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?
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- 1. Managing Aspiration Risk for Clients with Dysphagia
- 2. Managing Aspiration Risk for Clients With vomiting
- 3. Proper Feeding Tube Placement and Techniques
- 4. Managing Aspiration Risk for Clients with Endotracheal Intubation
- 5. Managing Postoperative Aspiration Risk
- 6. Providing Client and family discharge education
- See also
- References and Sources
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. Aspiration syndromes include all conditions in which foreign substances are inhaled into the lungs. Most commonly, aspiration syndromes involve oral or gastric contents associated with gastroesophageal reflux, swallowing dysfunction, neurological disorders, and structural abnormalities (Mikita & Sharma, 2022).
The act of swallowing is divided into the following four discrete phases.
- Oral preparatory phase. This phase begins when foods and liquids are placed into the mouth, mixed with saliva, and formed into a bolus.
- Oral propulsive phase. This phase consists of moving the bolus into the pharynx, triggering the reflex swallow, which is the major component of the pharyngeal phase.
- Pharyngeal phase. During this phase, the larynx elevates and closes at the level of the epiglottis, aryepiglottic folds, and true and false vocal cords. The laryngeal reflex during the pharyngeal phase of swallowing acts as a protective mechanism against direct or indirect aspiration.
- Esophageal phase. This phase is initiated when the bolus passes through the relaxed cricopharyngeal muscle and enters the esophagus.
Aspiration may occur when foreign substances enter the hypopharynx, either before the relaxation of the cricopharyngeal muscle or before the closing of the laryngeal sphincters. Direct aspiration is the aspiration of a food bolus while swallowing, whereas indirect aspiration is the reflex of food from the stomach into the esophagus and pulmonary system (Mikita & Sharma, 2022).
There are four types of aspiration syndromes. Aspiration of gastric acid causes a chemical pneumonitis which has also been called Mendelson syndrome. The aspiration of bacteria from oral and pharyngeal areas causes aspiration pneumonia. Aspiration of oil (mineral oil or vegetable oil) causes exogenous lipoid pneumonia, an unusual form of pneumonia. Aspiration of a foreign body may cause an acute respiratory emergency and, in some cases, may predispose the client to bacterial pneumonia (Gamache & Soo, 2021).
The primary focus in caring for at-risk clients is prevention, which involves measures like positioning clients 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 Care Plans and Management
A comprehensive nursing care plan and management should be implemented to minimize the potential for aspiration pneumonia or other complications. The management of an acute aspiration event includes conservative management and cautious observation. Collaborating with the interdisciplinary team and following evidence-based guidelines is crucial for optimal client outcomes.
Nursing Problem Priorities
The following are the nursing priorities for clients with aspiration risk:
- Dysphagia and absent reflexes management. Identifying dysphagia and managing an absent swallow reflex.
- Management of vomiting. Prevention of risk and positioning during vomiting.
- Managing clients with feeding tubes and delayed stomach emptying. Proper tube insertion and feeding, and identification of delayed stomach emptying.
- Prevention of aspiration in intubated clients. Management and prevention of aspiration in prolonged intubated clients.
- Prevention of aspiration pneumonia and other complications. Interventions to prevent the development of aspiration pneumonia.
- Managing the risk of aspiration in post-operative clients. Aspiration as a postoperative complication is common but it can be avoided and managed.
Assessment is required in order to distinguish possible problems that may have led to aspiration as well as name any episode that may occur during nursing care.
- Noisy breathing
- Clubbing of fingernails
- Increased work of breathing, flaring, or retractions
- Globus hystericus
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with aspiration risk based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The client will maintain a clear airway, free of signs of aspiration.
- The client will identify causative and risk factors.
- The client will demonstrate techniques to prevent and/or correct aspiration.
- The caregivers will demonstrate appropriate feeding techniques.
- The caregivers will display proper tube care for intubated clients.
Nursing Interventions and Actions
1. Managing Aspiration Risk for Clients with Dysphagia
Dysphagia is a condition in which disruption of the swallowing process interferes with the client’s ability to eat. It can result in aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. The goals of dysphagia treatment are to maintain adequate nutritional intake for the client and to maximize airway protection (Paik & Moberg, 2022).
1.1. Assessing swallowing ability and risk factors for dysphagia
Evaluate swallowing ability by assessing for the following: coughing, choking, throat clearing, gurgling or “wet” voice during or after swallowing, residual food in the 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. The client may report coughing or choking or the abnormal sensation of food sticking in the back of the throat or upper chest when they are trying to swallow; however, some of these presentations can be quite subtle or even absent (Paik & Moberg, 2022).
Inspect the client’s oral cavity and pharynx.
Inspect the client’s oral cavity and pharynx for mucosal integrity and dentition, and examine the soft palate for position and symmetry during phonation and at rest. Evaluate pharyngeal elevation by placing two fingers on the larynx and assessing movement during a volitional swallow; this technique helps to identify the presence or absence of key laryngeal protective mechanisms (Paik & Moberg, 2022).
Review results of swallowing studies as ordered.
For high-risk clients, the performance of a videofluoroscopic swallowing study may be indicated to determine the nature and the extent of any swallowing abnormality. It is designed to study the anatomy and physiology of the oral, pharyngeal, and esophageal stages of deglutition (the action or process of swallowing). It is considered the standard for identifying clients who have the potential to develop pneumonia and for diagnosing aspiration and swallowing problems (Paik & Moberg, 2022).
Assess the gag reflex.
The gag reflex is elicited by stroking the pharyngeal mucosa with a tongue depressor. Testing for the gag reflex is helpful, but the absence of the reflex does not necessarily indicate that a client is unable to swallow safely. Pulling the palate to one side during testing of the gag reflex indicates weakness of the muscles of the contralateral palate and suggests unilateral bulbar pathology (Paik & Moberg, 2022).
Assess the client’s level of consciousness, developmental age, and mental status.
Assess the client’s level of alertness and cognitive status because they can impact the safety of swallowing and the ability to learn compensatory measures. Young children and clients with neurologic or psychiatric disorders are at increased risk for aspiration but might not be able to describe symptoms or report choking episodes (Warshawsky & Mosenifar, 2020).
Perform a reflex cough test.
The laryngeal cough reflex protects the laryngeal aditus from significant aspiration and reduces the risk of respiratory complications, such as aspiration pneumonia. A 20% solution of L-tartaric acid is dissolved in two mL of sterile normal saline. Using a nasal nebulizer, the client inhales the solution, which stimulates cough receptors and initiates the laryngeal cough reflex (Paik & Moberg, 2022).
Observe the client directly during the swallowing process.
The final step in the physical examination is direct observation of the act of swallowing; at a minimum, the nurse may watch the client while they drink a few ounces of water. After the swallow, observe the client for one minute or more to see if a delayed cough response is present (Paik & Moberg, 2022).
1.2. Preventing a client with dysphagia from aspiration
Inform the healthcare provider or other healthcare professionals instantly of the noted decrease in cough/gag reflexes or difficulty in swallowing.
Early intervention protects the client’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. The basic pathogenesis of any aspiration event involves impaired swallowing and any condition that reduces the client’s gag reflex (Gamache & Soo, 2021).
Place the client in a sitting or upright position before, during, and after mealtimes.
Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck their chin toward the chest as they swallow will help prevent aspiration. If the client is receiving an enteral tube feeding, the nurse must elevate the head of the bed at least 30 degrees to prevent aspiration.
Rotate the client’s head to the affected side when swallowing.
This technique closes the pyriform sinus on the affected side, directing food down the opposite, stronger side. This posture also adds external pressure on the damaged vocal cord and moves it toward the midline, improving airway closure (Paik & Moberg, 2022).
Provide the client with a dysphagia diet as indicated.
The dysphagia diet can be classified according to viscosity. Level I includes pudding, crushed potato, and ground meat. Level II consists of curd-type yogurt, orange juice (mixed with 3% thickener), cream soup, and thin soup with starch. Level III has tomato juice, fluid-type yogurt, and thick, fluid rice. Level IV contains water and orange juice. A uniform and viscous bolus of food or beverage enables the client with a delayed swallow reflex to control mastication and transport. It also allows the client to swallow with less risk of aspirating residue material (Paik & Moberg, 2022).
Provide foods with consistency that the client 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 clients with dysphagia. Liquids can be thickened by various thickening agents. Many commercially available, starch-based food thickeners are used to increase the consistency of food, and pre-thickened water, juice, coffee, and other products are available (Paik & Moberg, 2022).
Allow the client 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. As the client’s swallowing function improves, their dysphagic diet may be advanced to the next level of soft and semisolid foods with regular consistencies. Recommend to the client that they alternate bites with sips, bite or sip size, and the number of swallows per size (Paik & Moberg, 2022).
For clients with reduced cognitive abilities, eliminate distracting stimuli during mealtimes. Tell the client 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. By paying attention to their eating process, the client can take smaller bites, chew thoroughly, and control the timing and coordination of their swallowing muscles.
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. The client may also tilt their head to the strong side because the bolus tends to be directed down the stronger side in the oral cavity and in the pharynx (Paik & Moberg, 2022).
Offer liquids after food is eaten. Provide food choices rich in water content.
Ingesting food and fluids together increases swallowing difficulties. Adequate fluid intake can be achieved through simple interventions, such as systematically offering the client preferred liquids or foods with high fluid content, such as pureed fruits, and vegetables, hot cereals, custards, and puddings, and having an adequate number of supervised staff to help the client drink while properly positioned (Paik & Moberg, 2022).
Encourage the client to perform exercise techniques.
Exercises are used to increase muscle tone and augment pharyngeal swallow. Indirect exercises strengthen the swallowing muscles while direct exercises can be performed while swallowing. Tongue exercises are used to facilitate the manipulation of the bolus and its propulsion through the oral cavity. Jaw exercises help to facilitate the rotatory movements of mastication. Respiratory exercises, such as resistive straw sucking, coughing, and incentive spirometry, are recommended to improve respiratory strength (Paik & Moberg, 2022).
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 clients with impaired swallowing. Speech and language therapists should assess clients with risks for or symptoms of dysphagia, particularly those who require tracheostomy and ventilation (Paik & Moberg, 2022).
Assist with tactile-thermal stimulation (TTS).
TTS can be used to increase the speed of swallow. TTS involves the application of cold by rubbing the bilateral anterior facial arch with a laryngeal mirror that has been placed on ice. The purpose is to sensitize the area of the oral cavity where the swallow is triggered (Paik & Moberg, 2022).
Insert a nasogastric tube (NGT) as indicated for the client’s feeding.
NGT feeding is a commonly used method of enteral feeding. In clients with a short-term life expectancy, NGT feeding is a more appropriate route for enteral nutrition. Insertion is an easy, quick, and a relatively noninvasive procedure. However, many clients find the NGT uncomfortable and repeatedly pull the tube out, which results in interrupted feeding and potential malnutrition (Paik & Moberg, 2022).
2. Managing Aspiration Risk for Clients With vomiting
Vomiting with the possible aspiration of gastric contents is a well-known clinicopathological phenomenon. Sequelae associated with aspiration include pulmonary obstruction, chemical pneumonitis, secondary infection of airways or lung parenchyma, and possible death. Prevention is the primary goal when caring for clients at risk for aspiration.
Assess the client’s level of consciousness.
The risk of aspiration is indirectly related to the level of consciousness of the client. Aspiration of small amounts of material from the oral cavity is not uncommon, particularly during sleep; however, disease as a result of aspiration does not occur in a healthy person because the material is cleared by the mucociliary tree and the macrophages. Witnessed aspiration of large volumes occurs occasionally; however, small-volume clinically silent aspiration is more common.
Assess for the presence of nausea or vomiting.
Nausea or vomiting places clients 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. Vomiting is an important reflex, which may be provoked by many conditions that can be classified as visceral (stomach distention or traction on abdominal organs), pharmacological (any recreational drugs with emetic properties), metabolic (pregnancy, uremia), central nervous system or psychological (seasickness, panic, anorexia) (Novomesky et al., 2018).
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. Aspiration may occur if the client cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. This hazard is increased if the client has a distended abdomen, is supine, or has the upper extremities immobilized in any manner.
Assess risk factors contributing to vomiting.
Dangers of vomiting may occur due to anesthesia, diseases, and emetic medications. Inhalation of stomach contents into the lungs with sequelae such as pneumonitis, bronchopneumonia, atelectasis, and lung abscess may occur during anesthesia (Khan et al., 2018).
Position clients 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. When vomiting, people can normally protect their airways by sitting up or turning on their side and coordinating breathing, coughing, gagging, and glottic reflexes.
Assist in removing an oral airway when the gag reflex returns.
If the client has active reflexes, an oral airway should not be inserted. However, if an airway is in place, it should be pulled out the moment the client gags so as not to stimulate the pharyngeal gag reflex and promote vomiting and aspiration.
Administer antiemetics as indicated.
Prevention of vomiting can be achieved by proper pre-medication with esomeprazole or metoclopramide, which speeds up gastric emptying. Side effects range from more common (mild headaches and dizziness) to rare (anaphylaxis and hypersensitivity).
3. Proper Feeding Tube Placement and Techniques
Misplaced feeding tubes are associated with many potentially serious complications. Minimizing placement errors during insertion and ongoing use reduces the complication rate and improves client outcomes.
3.1. Assessing feeding tube placement
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, older adult clients have decreased esophageal motility, which delays esophageal emptying. When combined with the weaker gag reflex of older adults, aspiration is at higher risk.
Identify risk factors for dislodgement of the feeding tube.
Even when an NG tube is positioned properly during initial placement, it may become dislocated during use. NG tubes can migrate proximally to the initial placement site with coughing, suctioning, vomiting, repositioning the client, ambulation, and failure of the securement method or device. Consequently, the tube position must be reconfirmed for as long as the tube is in place (Judd, 2020).
Assess tube placement every four hours and before administering feedings or medications.
Based on current guidelines, nurses must reassess tube placement every four hours before administering enteral feedings and medications. Nurses must rely on secondary methods for frequent bedside confirmation of continued correct placement. These methods should be research-based, taught in nursing schools, and used by nurses to verify placement without additional cost or unnecessary exposure of the client to radiation (Judd, 2020).
Observe food particles in tracheal secretions in clients with tracheostomies.
Food should never be present in the tracheobronchial passages. It signifies aspirated material. Pulmonary complications from gastric intubation can occur because coughing and clearing of the pharynx are impaired. Aspiration pneumonia occurs when regurgitated stomach contents or enteral feedings from an improperly positioned feeding tube are instilled into the pharynx or the trachea or when oral secretions are aspirated.
Utilize capnography for ongoing assessments before administering feedings and medications.
Use capnography, if available, to detect any release of carbon dioxide from the tube. This would suggest placement in the tracheobronchial tree rather than the stomach. The nurse attaches a carbon dioxide detector to the end of the tube. A solar change on the detector indicates whether carbon dioxide is present. Feeding should be stopped immediately and an X-ray must be then obtained (Judd, 2020).
Measure the pH of the tube aspirate with pH strips.
The fasting pH of gastric fluid is usually five or less and the pH of both respiratory and small bowel secretions is typically six or more. But the reliability of pH testing has limitations. It cannot be used to distinguish between gastric and esophageal placement because ph is altered if the aspirated fluid is mixed with saliva or gastric reflux. In order to ensure reliable results from a pH test, the tube feeding should be stopped for one hour before testing (Judd, 2020).
Avoid using the auscultatory or bubbling method when checking for tube placement.
Research has revealed that some once-common methods should no longer be used- specifically, the auscultatory (air bolus) method and the bubbling method. Studies showed that nurses were unable to distinguish variations in the sound of an air bubble entering the lungs, esophagus, stomach, or small intestine, and little research has been conducted to investigate the accuracy of the bubbling method (Judd, 2020).
3.2. Feeding clients with nasogastric (NG) or gastrostomy tubes
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. Small bowel fluids are likely to be bile-stained. Immediately after radiographic confirmation, the nurse marks the tube’s exit site from the nose or mouth and documents the incremental length also at the nose or mouth. Any change in the length of the external portion of the tube will alert clinicians to possible tube migration (Judd, 2020).
Test sputum with glucose oxidase reagent strips.
Significant amounts of glucose in sputum may be indicative of aspiration. To detect aspiration, researchers in a study used urinary test paper via the glucose oxidase method to detect sugar in the oral and tracheal secretions. The test paper is applied to the tip of the tube after suctioning the oral cavity or tracheostomy (Sakisaka et al., 2022).
Check residuals before feeding, or every four hours if feeding is continuous. Hold feedings if the number of residuals is large, and notify the healthcare provider.
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 one hour. Recent research shows that gastric residual volumes between 250 and 500 mL did not increase the incidence of vomiting, aspiration, or pneumonia.
Elevate the head of the bed to 30 to 45 degrees while feeding the client and for one hour afterward, if feeding is intermittent. Turn off the feeding before lowering the head of the bed. Clients with continuous feedings should be in an upright position.
Upright positioning reduces aspiration by decreasing the reflux of gastric contents. This position is maintained at least one hour after completion of an intermittent tube feeding and is maintained whenever possible for clients receiving continuous feedings. A reverse Trendelenburg position can be considered when it is not possible or advisable to elevate the head of the client’s bed.
Stop continuous feeding temporarily when turning or moving the client.
When turning or moving a client, it is difficult to keep the head elevated to prevent regurgitation and possible aspiration. However, according to a study, the practice of continuing or withholding enteral feedings during the repositioning of clients who are critically ill and mechanically ventilated varies among nurses and is not necessarily research-based. Results from a study suggest that this technique does not seem to reduce the incidence of aspiration in clients who are mechanically ventilated.
Provide liquid formulas that aid in the prevention of aspiration.
A liquid formula used in research containing ingredients fermented by lactic acid bacteria and having a pH of 4.0 was fed to the clients in the study. The low pH and low molecular weight due to the fermentation by lactic acid bacteria are thought to contribute to gastric clearance without gelation in the stomach. The use of this formula completely eliminated the episodes of aspiration pneumonia in clients in the study (Sakisaka et al., 2022).
3.3. Managing delayed gastric emptying
Identify factors that cause delayed gastric emptying.
A full stomach can cause aspiration because of increased intragastric or extragastric pressure. The following may delay emptying of the stomach: intestinal obstruction; increased gastric secretions in GERD; increased gastric secretions during anxiety; stress, or pain; and abdominal distention due to paralytic ileus, ascites, peritonitis; the use of opioids or sedatives, severe illness, or vaginal delivery.
Ensure accurate placement of feeding tubes.
During nasal insertion, the tip of the tube should be directed toward the back of the nose, through the esophagus, and into the stomach, and is further advanced through the pylorus into the small intestine if warranted. Fluoroscopic techniques may be used to visually direct feeding tubes into the stomach, duodenum, or jejunum.
If the tube is clogged, clear the obstruction as indicated.
If it is difficult to instill or withdraw contents from a feeding tube, several declogging steps can be taken, including warm water irrigation, milking the tube, infusing digestive enzymes, and employing mechanical declogging devices. Cola and cranberry juice are not advocated because their acidic nature has been shown to worsen formula clogs by causing the precipitation of proteins. Feeding tubes are more successfully unclogged when intervention is initiated immediately after the obstruction is noted.
Irrigate the feeding tube routinely.
The nurse must maintain the tube’s patency to avoid abdominal distention, which can precipitate delayed emptying. To maintain patency, the tube is irrigated with water after every feeding and medication delivery and every four to six hours during continuous feedings, or if the tube is set to gravity drainage or suction. Sterile saline or water or tap water can be used as irrigants, depending on the client’s electrolyte levels and ability to fight infection.
4. Managing Aspiration Risk for Clients with Endotracheal Intubation
Prolonged endotracheal intubation or tracheostomy can depress the laryngeal and glottic reflexes because of disuse. Nosocomial bacterial pneumonia caused by aspiration is common, and the major pathogens involved are hospital-acquired flora through oropharyngeal colonization. Selection and colonization of gram-negative organisms in the oropharynx, sedation, and intubation of the client’s airways are important pathogenic factors in nosocomial pneumonia.
Assess the level of consciousness.
The primary risk factor of aspiration is indirectly related to a decreased level of consciousness. Aspiration of small amounts of material from the oral cavity is not uncommon, particularly during sleep; however, disease as a result of aspiration does not occur in healthy persons because the material is cleared by the mucociliary tree and the macrophages.
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. Signs and symptoms of pulmonary complications include coughing during the administration of foods or medications, difficulty clearing the airway, tachypnea, and fever.
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 clients with diminished levels of consciousness. Pulmonary infiltrates on chest X-ray films indicate some level of aspiration has already occurred. Clients with chemical pneumonitis may present with an acute onset or abrupt development of symptoms within a few minutes to two hours of the aspiration event, as well as respiratory distress and rapid breathing, audible wheezing, and cough with pink or frothy sputum (Gamache & Soo, 2021).
Monitor the effectiveness of the cuff in clients 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. Maintain endotracheal cuff pressures at an appropriate level (greater than 20 cm H2O but less than 30 cm H2O), and ensure that secretions are cleared from above the cuff before it is deflated. This is to prevent leakage of secretions from around the cuff into the lower respiratory tract. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.
Keep the suction machine available when feeding high-risk clients. If aspiration does occur, suction immediately.
A client with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubation. Mortality is closely tied to the volume of fluid a client aspirates. By promptly suctioning the airway, exposure to contaminants can be reduced and the risk of hypoxia can be lowered (Say, 2018).
In clients with artificial airways:
- Perform oral suctioning as needed.
Suctioning reduces the volume of oropharyngeal secretions and reduces aspiration risk. Properly suctioning the airway is equally important when other indications for suction, such as low oxygen saturation, are present. Aspiration is a preventable emergency, and having a suction unit ready in high-risk situations is the single most important thing to prevent a life-threatening situation (Say, 2018).
- Brush teeth twice a day, and swab mouth with sponge applicators every two to four hours between brushing.
Oral care reduces the risk of ventilator-associated pneumonia by decreasing the number of microorganisms in aspirated oropharyngeal secretions. Due to poor oral hygiene, saliva contaminated with an increased quantity of multiple bacteria species can harbor microbes that if colonized and aspirated may result in bacterial pneumonia (Remijn et al., 2022).
Administer antibiotics as prescribed.
Antibiotics are indicated for aspiration pneumonia. However, for aspiration pneumonitis, early presumptive antibiotics are not recommended. This practice is believed to lead to the selection of more resistant organisms. Antibiotics are administered if pneumonitis fails to resolve within 48 hours, if the client has a small-bowel obstruction, and if clients are taking antacids due to the potential for gastric colonization with microorganisms (Gamache & Soo, 2021).
Monitor the length of time of endotracheal intubation.
Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the trachea lining. The swallowing reflexes are depressed because of prolonged disuse and the mechanical trauma produced by the tube can increase the risk of aspiration, microaspiration, and subsequent ventilator-associated pneumonia.
5. Managing Postoperative Aspiration Risk
Keep the preoperative client on nothing per orem (NPO) before surgery.
During surgery, clients are often given general anesthesia, which can cause a suppression of the protective reflexes that prevent food and fluids from entering the lungs. To reduce stomach contents, no solid or semisolid food should be taken within six hours of a planned operation (Khan et al., 2018). Clients who underwent surgical procedures along the esophageal area also may remain on NPO until X-ray studies confirm that there are no leaks, obstruction, or evidence of pulmonary aspiration.
Supervise or aid the client with oral intake. Never give oral fluids to a comatose client.
Supervision helps identify abnormalities early and allows the implementation of strategies for safe swallowing. Withholding fluids and foods as needed prevents aspiration. Additionally, the aspiration of stomach contents into the lung during induction, preoperatively or immediately postoperatively is a common cause of avoidable anesthetic death. This may follow active vomiting in the presence of a depressed laryngeal protective mechanism, or in circumstances that overwhelm the normal mechanism (Khan et al., 2018).
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. According to a study, the incidence of aspiration pneumonia was reduced by using intensified oral hygiene instruction in combination with a free water protocol. Good oral hygiene in the free water protocol is an important condition to ensure that the oral cavity is as free as possible from pathogens before water consumption (Remijn et al., 2022).
Place the client in an upright position during feedings.
Postoperative clients may also receive tube feedings after major surgery. These clients should be positioned with the head of the bed at 30 degrees or higher during feedings and for 30 to 45 minutes after tube feedings. Clients receiving oral feedings are positioned with the head of the bed in an upright position for 30 to 45 minutes after feeding. For clients with NG or gastrostomy tubes, the placement of the tube and residual gastric volume must be checked before each feeding.
Ensure that suction equipment is available at all times.
If the client cannot cough up or expectorate secretions manually, the client’s respiratory tract needs to be suctioned. Care is taken to protect the suture lines during suctioning. If a tracheostomy tube is in place, suctioning is performed through the tube. The client may also be instructed on the use of Yankauer suction (tonsil-tip suction) to remove oral secretions.
Administer antacids as prescribed.
Antacids such as magnesium trisilicate and sodium citrate may be given 30 to 60 minutes before surgery or sodium bicarbonate just before induction. H2-blockers such as cimetidine given intravenously increase the pH of gastric fluid and reduce the volume (Khan et al., 2018).
Apply cricoid pressure as indicated.
Cricoid pressure is a technique that has become part of rapid sequence intubation to prevent aspiration of gastric contents. Correctly applied compression of the esophagus between the cricoid cartilage and the vertebrae will obstruct the esophagus. The pressure must be firm. Pressure should not be applied during active vomiting as there is a possibility of rupturing the esophagus due to the pressure generated below the cricoid ring (Khan et al., 2018).
Position the client in a head-down or lateral position prior to surgery.
This used to be the treatment recommended and still has much to commend it. It is difficult to aspirate vomit against gravity. A 15” head-down tilt does not make intubations difficult, whereas the lateral position does. If used properly it is very safe; the worst complication is that vomit will soil the nasopharynx and spill over the anesthetist. This position increases the risk of regurgitation following administration of a muscle relaxant (Khan et al., 2018).
6. Providing Client and family discharge education
Clients who recover from aspiration pneumonia generally do not require additional outpatient care, except for adherence to measures to prevent further aspiration episodes. Clients can be discharged from the hospital after clinical improvement and stability and radiographic improvement (Gamache & Soo, 2021).
Assess the client 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. Older adults with aspiration pneumonia often develop a hospitalization-associated disability that can lead to physical decline. Most clients with aspiration pneumonia, particularly older adults, have dysphagia and difficulty with oral intake and malnutrition (Momosaki, 2017).
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. However, crushing or dispersing tablets with no modification to their release profile can in itself create difficulties due to taste and stability. Furthermore, tablets and capsules are relatively inexpensive with respect to acquisition costs, and switching to other formulations frequently results in an increase in cost (Wright et al., 2020).
For clients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management.
Continuity of care can prevent unnecessary stress for the client and family and can facilitate successful management in the home setting. Bed rest in the acute phase induces muscle loss, mobility decline, and activities of daily living decline. Hospital-associated disability can lead to cognitive disorders, other complications, the extension of hospitalization, difficulty in returning home, quality of life decline, and death (Momosaki, 2017).
Establish emergency and contingency plans for the care of clients.
The clinical safety of clients between visits is a primary goal of home care nursing. Aspiration pneumonia is frequently fatal among older adults. Therefore rehabilitative management is necessary, including early physical therapy and pulmonary and dysphagia rehabilitation to potentially improve the clinical outcomes of geriatric clients with aspiration pneumonia (Momosaki, 2017).
Educate the client and family on the need for proper positioning.
Upright positioning decreases the risk of aspiration. Clients with altered consciousness should be positioned in a semirecumbent position with the head of the bed at a 30 to 45-degree angle. This reduces the risk of aspiration leading to pneumonia (Gamache & Soo, 2021).
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. The clinical presentation of both aspiration pneumonia and pneumonitis ranges from mildly ill and ambulating to critically ill, with signs and symptoms of septic shock and/or respiratory failure (Gamache & Soo, 2021).
Demonstrate 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. Portable suction units at home must always be on, charged, and ready to go. Regular testing of the suction kit is critical because this kit is part of the first response when an aspiration emergency occurs (Say, 2018).
Refer the client to a home health nurse, rehabilitation specialist, or occupational therapist as indicated.
The use of consultants may be required to ensure outcomes are achieved. Early rehabilitation might prevent ADL decline during hospitalization. A study showed that hospital-based physical therapy helps to reduce 30 days hospital readmission rate of acutely ill older adults with pneumonia and declining physical function (Momosaki, 2017).
Provide education about rehabilitation nutrition at home.
Almost all clients with aspiration pneumonia have dysphagia and oral intake difficulty and are likely to develop malnutrition. Malnourished older adults admitted to rehabilitation units are likely to be discharged with moderate malnutrition, low, physical function, and poor health-related quality of life. Early initiation of oral intake after hospital admission with aspiration pneumonia is recommended. A study showed that early oral intake was associated with earlier hospital discharge with oral intake in hospitalized older adults with pneumonia (Momosaki, 2017).
Instruct the client and family members about oral care.
Oral care is frequently combined with dysphagia rehabilitation as preparation for oral intake after aspiration pneumonia. In the hospital, clients are typically nil by mouth. However, nil by mouth or NPO after aspiration pneumonia leads to worsened oral cavity clearance and poor oral hygiene. Oral care might reduce oral bacteria count, which is associated with pneumonia onset, and may prevent the recurrence of pneumonia (Momosaki, 2017).
Teach the client and family members compensatory techniques that can be done at home.
For clients with known swallowing dysfunction, helpful compensatory techniques to reduce aspiration include a soft diet reducing the bite-size, nectar-thick, or honey-thickened liquids, keeping the chin tucked and the head turned, and repeated swallowing (Gamache & Soo, 2021).
Provide instructions about feeding in a client discharged with a feeding tube.
Feedings and medications should always be given with the client in a semi-Fowler position, and the client’s head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least one hour after completion of an intermittent tube feeding and is maintained whenever possible for clients receiving continuous feedings. Before and after intermittent tube feeding and medication administration, at least 30 mL of water should be given to ensure patency and to decrease the chance of bacterial growth.
Provide accessible information about home care needs for the client and caregivers.
Family members who will be active in the client’s home care are encouraged to participate in education sessions. Available printed information about the equipment, the formula, and the procedure is may be reviewed and provided. Arrangements are made to obtain the equipment and formula and have it ready for use before the client’s discharge.
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.
References and Sources
Here are some recommended materials and sources for aspiration risk:
- Cheever, K. H., & Hinkle, J. L. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
- Gamache, J., & Soo, G. W. (2021, October 12). Aspiration Pneumonitis and Pneumonia: Overview of Aspiration Pneumonia, Predisposing Conditions for Aspiration Pneumonia, Pathophysiology of Aspiration Pneumonia. Medscape Reference. Retrieved June 4, 2023, from https://emedicine.medscape.com/article/296198-overview#a1
- Judd, M. (2020). Confirming nasogastric tube placement in adults. Nursing, 50(4). https://journals.lww.com/nursing/Abstract/2020/04000/Confirming_nasogastric_tube_placement_in_adults.13.aspx?context=LatestArticles
- Khan, K., Ali, M., Shamim, A., Paul, D., & Chakravarty, C. (2018). Vomiting and aspiration during per-operative and post-operative period – A life threatening condition. KYAMC Journal, 8(2). https://www.banglajol.info/index.php/KYAMCJ/article/view/35703
- Mikita, C. P., & Sharma, G. D. (2022, October 24). Aspiration Syndromes: Background, Etiology, Epidemiology. Medscape Reference. Retrieved June 3, 2023, from https://emedicine.medscape.com/article/1005303-overview#a4
- Momosaki, R. (2017). Rehabilitative management for aspiration pneumonia in elderly patients. Rehabilitative management for aspiration pneumonia in elderly patients, 18(1). https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.25
- Novomesky, F., Janik, M., Hajek, M., Krajcovic, J., & Straka, L. (2018). Vomiting and aspiration of gastric contents: a possible life-threatening combination in underwater diving. Diving and Hyperbaric Medicine, 48(1). https://pubmed.ncbi.nlm.nih.gov/29557100/
- Paik, N., & Moberg, E. A. (2022, January 31). Dysphagia: Practice Essentials, Background, Anatomy. Medscape Reference. Retrieved June 4, 2023, from https://emedicine.medscape.com/article/2212409-overview
- Remijn, L., Sanchez, F., Heijnen, B. J., Windsor, C., & Speyer, R. (2022). Effects of Oral Health Interventions in People with Oropharyngeal Dysphagia: A Systematic Review. Journal of Clinical Medicine, 11(12). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9225542/
- Sakisaka, M., Yoshii, D., Sakisaka, M., & Inomata, Y. (2022, June). Modulation of tube feeding protocol to prevent aspiration pneumonia in gastroesophageal reflux. Clinical Nutrition Open Science, 43. https://www.sciencedirect.com/science/article/pii/S2667268522000262
- Say, S. D. (2018, October 22). The Importance of Suction in Pulmonary Aspiration Emergencies. SSCOR BLOG. Retrieved June 6, 2023, from https://blog.sscor.com/the-importance-of-suction-in-pulmonary-aspiration-emergencies
- Warshawsky, M. E., & Mosenifar, Z. (2020, October 20). Foreign Body Aspiration: Background, Pathophysiology, Etiology. Medscape Reference. Retrieved June 4, 2023, from https://emedicine.medscape.com/article/298940-overview#a4
- Wright, D. J., Smithard, D. G., & Griffith, R. (2020). Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility? Geriatrics, 5(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7151233/