Utilize this comprehensive nursing care plan and management guide to effectively provide care for patients at risk of developing aspiration pneumonia. Gain insights into essential nursing assessments, evidence-based interventions, goal setting, and accurate nursing diagnosis specific to aspiration. This guide will equip you with the necessary knowledge and strategies to optimize patient outcomes and prevent complications related to aspiration.
Table of contents
What is aspiration?
Aspiration occurs when foreign objects or substances enter the trachea and lungs, potentially leading to conditions like aspiration pneumonia or chemical pneumonitis. Both acute and chronic situations, such as post-anesthesia effects, altered consciousness, or the use of artificial airway devices, can increase the risk of aspiration. The primary focus in caring for at-risk patients is prevention, which involves measures like positioning patients in a semi-recumbent position, compensating for absent reflexes, assessing feeding tube placement, identifying delayed stomach emptying, and managing the effects of prolonged intubation.
Nursing Assessment and Rationales
Assessment is required in order to distinguish possible problems that may have lead to aspiration as well as name any episode that may occur during nursing care.
1. Assess the level of consciousness.
The primary risk factor of aspiration is decreased level of consciousness.
2. Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever.
Signs of aspiration should be identified as soon as possible to prevent further aspiration and to initiate treatment that can be life-saving.
3. Evaluate swallowing ability by assessing for the following: Coughing, choking, throat clearing, gurgling or “wet” voice during or after swallowing, residual food in mouth after eating, and regurgitation of food or fluid through the nares.
Impaired swallowing increases the risk of aspiration. There remains a need for valid and easy-to-use methods to screen for aspiration risk.
4. Review results of swallowing studies as ordered.
For high-risk patients, the performance of a videofluoroscopic swallowing study may be indicated to determine the nature and extent of any swallowing abnormality.
5. Assess for the presence of nausea or vomiting.
Nausea or vomiting places patients at great risk for aspiration, especially if the level of consciousness is compromised. Antiemetics may be required to prevent the aspiration of regurgitated gastric contents.
6. Observe food particles in tracheal secretions in patients with tracheostomies.
Food should never be present in the tracheobronchial passages. It signifies aspirated material.
7. Auscultate bowel sounds to assess for gastrointestinal motility.
Reduced gastrointestinal motility increases the risk of aspiration as fluids and food build up in the stomach. Further, elderly patients have a decrease in esophageal motility, which delays esophageal emptying. When combined with the weaker gag reflex of older patients, aspiration is at higher risk.
8. Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds and note for crackles and rhonchi. Monitor chest x-ray films as ordered.
Aspiration of small amounts can happen with sudden onset of respiratory distress or without coughing particularly in patients with diminished levels of consciousness. Pulmonary infiltrates on chest x-ray films indicate some level of aspiration has already occurred.
9. Monitor the effectiveness of the cuff in patients with endotracheal or tracheostomy tubes.
An ineffective cuff can increase the risk of aspiration. Work together with the respiratory therapist, as necessary, to verify cuff pressure.
10. In patients with nasogastric (NG) or gastrostomy tubes:
- 10.1. Check placement before feeding, using tube markings, x-ray study (most accurate), pH of gastric fluid, and color of aspirate as guides.
A displaced tube may erroneously deliver tube feeding into the airway. Chest x-ray verification of accurate tube placement is the most reliable. The gastric aspirate is usually green, brown, clear, or colorless, with a pH between 1 and 5.
- 10.2. Test sputum with glucose oxidase reagent strips.
Significant amounts of glucose in sputum may be indicative of aspiration.
- 10.3. Check residuals before feeding, or every 4 hours if feeding is continuous. Hold feedings if the amount of residuals are large, and notify the physician.
Large amounts of residuals indicate delayed gastric emptying and can cause distention of the stomach, leading to reflux emesis. The amount of residuals may vary depending on the volume and rate of infusion; however, the evaluation can be unreliable. Feedings are often held if the residual volume is greater than 50% of the amount to be delivered in 1 hour.
11. Assess the patient and family for willingness and cognitive ability to learn and cope with swallowing, feeding, and related disorders.
Food and feeding habits may be strongly tied to family cultural values. Acknowledgment and/or adjustment to cultural values can facilitate compliance and successful family coping.
12. Note the new onset of abdominal distention or increased rigidity of the abdomen.
Abdominal distention or rigidity can be associated with paralytic or mechanical obstruction and an increased likelihood of vomiting and aspiration.
Nursing Interventions and Rationales
The following are the therapeutic nursing interventions for aspiration risk:
1. Keep the suction machine available when feeding high-risk patients. If aspiration does occur, suction immediately.
A patient with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubation.
2. Inform the physician or other health care provider instantly of the noted decrease in cough/gag reflexes or difficulty in swallowing.
Early intervention protects the patient’s airway and prevents aspiration. Anyone identified as being at high risk for aspiration should be kept NPO (nothing by mouth) until further evaluation is completed.
3. Keep the head of the bed elevated when feeding and for at least a half-hour afterward.
Maintaining a sitting position after meals may help decrease aspiration pneumonia in the elderly.
4. Position patients with a decreased level of consciousness on their side.
This positioning (rescue positioning) decreases the risk of aspiration by promoting the drainage of secretions out of the mouth instead of down the pharynx, where they could be aspirated.
5. Supervise or aid the patient with oral intake. Never give oral fluids to a comatose patient.
Supervision helps identify abnormalities early and allows the implementation of strategies for safe swallowing. Withholding fluids and foods as needed prevents aspiration.
6. Provide foods with consistency that the patient can swallow. Use thickening agents if recommended by a speech pathologist or dietician.
Thickened semisolid foods such as pudding and hot cereal are most easily swallowed and less likely to be aspirated. Liquids and thin foods (e.g., creamed soups) are the most difficult for patients with dysphagia.
7. Allow the patient to chew thoroughly and eat slowly during meals.
Well-masticated food is easier to swallow, and food cut into small pieces may also be easier to swallow.
8. For patients with reduced cognitive abilities, eliminate distracting stimuli during mealtimes. Tell the patient not to talk while eating.
Concentration must be focused on chewing and swallowing. There is a higher risk for the airway to be opened when talking and eating at the same time.
9. During enteral feedings, position the patient with the head of bed elevated 30 to 40 degrees; maintain for 30 to 45 minutes after feeding.
Keeping the patient’s head elevated helps keep food in the stomach and decreases the incidence of aspiration
10. Place medication and food on the strong side of the mouth when unilateral weakness or paresis is present.
Careful food placement promotes chewing and successful swallowing.
11. Offer liquids after food is eaten.
Ingesting food and fluids together increases swallowing difficulties.
12. Place whole or crushed pills in soft foods (e.g., custard). Verify with a pharmacist which pills should not be crushed.
Mixing pills with food helps reduce the risk of aspiration.
13. Stop continuous feeding temporarily when turning or moving the patient.
When turning or moving a patient, it is difficult to keep the head elevated to prevent regurgitation and possible aspiration.
14. Provide oral care before and after meals.
Oral care before meals reduces bacterial counts in the oral cavity. Oral care after eating removes residual food that could be aspirated at a later time.
15. In patients with artificial airways:
- 15.1. Perform oral suctioning as needed.
Suctioning reduces the volume of oropharyngeal secretions and reduces aspiration risk.
- 15.2. Brush teeth twice a day, and swab mouth with sponge applicators every 2 to 4 hours between brushing.
Oral care reduces the risk of ventilator-associated pneumonia by decreasing the number of microorganisms in aspirated oropharyngeal secretions.
16. In patients with NG or gastrostomy tubes:
- 16.1. If ordered by a physician, put several drops of blue or green food coloring in tube feeding to help indicate aspiration. In addition, test the glucose in tracheobronchial secretions to detect aspiration of enteral feedings.
Colored secretions suctioned or coughed from the respiratory tract indicate aspiration.
- 16.2. Elevate the head of the bed to 30 to 45 degrees while feeding the patient and for 30 to 45 minutes afterward if feeding is intermittent. Turn off the feeding before lowering the head of the bed. Patients with continuous feedings should be in an upright position.
Upright positioning reduces aspiration by decreasing the reflux of gastric contents.
17. For patients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management.
Continuity of care can prevent unnecessary stress for the patient and family and can facilitate successful management in the home setting.
18. Establish emergency and contingency plans for the care of patients.
The clinical safety of patients between visits is a primary goal of home care nursing.
19. Educate the patient and family on the need for proper positioning.
Upright positioning decreases the risk of aspiration.
20. Educate about the signs and symptoms of aspiration.
The information helps in the appropriate assessment of high-risk situations and the determination of when to call for further evaluation.
21. Demonstrate on suctioning techniques to prevent the accumulation of secretions in the oral cavity.
Respiratory aspiration requires prompt action to maintain the airway and promote effective breathing and gas exchange.
22. Consult a speech pathologist, as appropriate.
A speech pathologist can be consulted to perform a dysphagia assessment that helps determine the need for videofluoroscopy or modified barium swallow and to establish specific techniques to prevent aspiration in patients with impaired swallowing.
23. Refer the patient to a home health nurse, rehabilitation specialist, or occupational therapist as indicated.
The use of consultants may be required to ensure outcomes are achieved.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
I see this is updated March 2022, but it doesn’t represent current recommendations at all. ASPEN discourages the use of gastric residual volume, use of blue dye to assess for aspiration, the glucose oxidase strips, etc. Might want to review current guidelines. https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0148607115621863
Hi CC, thanks for sharing. Will add your suggestions on the next update of this care plan.