Aspiration Precautions

NUTRITIONAL IMPLICATIONS OF DYSPHAGIA

Dysphagia often causes a decrease in food intake, which then re-sults in malnutrition. Nutritional status changes as indicated by changes in skinfold thickness and albumin level are apparent in patients with dysphagia. In most instances this is due to diffi culty in consuming an adequate volume of solids or liquids. Dietary in-take may be affected for long periods of time, and the malnutrition that occurs is secondary to insuffi cient protein, calorie, and micro-nutrient intake (Ebersole and others, 2008). This signifi cantly impedes a patient’s recovery from illness.

DYSPHAGIA SCREENING

Dysphagia is typically identifi ed by using one of three types of di-agnostic techniques. An initial bedside swallow assessment is a cursory examination that you can administer with basic clinical swallowing training. If you suspect dysphagia, an extensively trained swallowing technician (e.g., speech pathologist) will con-duct a more thorough test. The comprehensive testing involves assessment of cranial nerves and swallowing trials using a variety of texture-modifi ed liquids and solids. The third diagnostic technique is use of videofl uoroscopy. A patient assumes a sitting position and swallows radiopaque materials of different liquid and food textures. The videofl uoroscope shows swallow physiology.

Nurses and RDs initially screen for dysphagia in patients be-lieved to be at risk. There are many dysphagia screening tools with similar characteristics (Fig. 30-6). The Registered Dietitian Dys-phagia Screening Tool, designed by Brody and others, uses medical record review, patient questioning, and observation of a meal. The screening tool includes observation of a patient at a meal for change in voice quality, posture and head control, percentage of meal consumed, eating time, drooling of liquids and solids, cough during/after a swallow, facial or tongue weakness, diffi culty with secretions, pocketing, and presence of voluntary and dry cough (Brody and others, 2002). All dysphagia screening tools assess holding food in mouth, leakage from mouth, coughing, choking, breathlessness, and quality of voice after swallowing (Runions and others, 2004).

Aspiration is the inhalation of oropharyngeal secretions into the lower respiratory tract. Secretions build up in the back of the oro-pharynx as a result of gastroesophageal refl ux or dysphagia (impair-ment in swallowing). When pathogenic bacteria colonize the se-cretions, the risk for aspiration pneumonia is high. Aspiration pneumonia can be a fatal complication, particularly in older adults. Dysphagia is a symptom or complication of a number of conditions (Box 30-3), particularly that of stroke. Dysphagia after a stroke is very common and is a marker of a patient’s poor prognosis, increas-ing the risks for pneumonia, malnutrition, persistent disability, prolonged hospital stay, and death (Martino and others, 2005). Cerebral, cerebellar, or brain stem strokes impair swallowing in a number of ways. Cerebral lesions interrupt voluntary control of chewing and movement of food down the esophagus (White and others, 2008). Lesions of the cerebral cortex impair facial, lip, and tongue motor control (Martino and others, 2005). Impairments in cognitive function such as concentration or selective attention also affect swallowing. Because stroke is common in older adults, age-related swallowing further adds to stroke-related dysphagia.

In some patients, aspiration from dysphagia occurs silently. This means that a patient will aspirate without any outward signs of swallowing diffi culty. Conditions associated with silent aspiration include local weakness/incoordination of the pharyngeal muscles, reduced laryngopharyngeal sensation, impaired ability to refl ex-ively cough, and low levels of neurotransmitters (e.g., substance P and dopamine) (Ramsey and others, 2005).

Characteristics of dysphagia that are most predictive of aspira-tion risk include the following (Nowlin, 2006):• A wet voice• Weak voluntary cough• Coughing or choking on food• Prolonged swallow• Combination of the above

Additional characteristics of dysphagia are a voice change after swallowing; abnormal lip closure and tongue movement; hoarse voice; slow, weak, imprecise, or uncoordinated speech; abnormal gag; abnormal volitional cough; delayed oral and pharyngeal tran-sit; incomplete oral clearance; regurgitation; pharyngeal pooling; and inability to speak consistently.

SKILL 30-3 Aspiration PrecautionsBasic / Nutrition and Fluids / Taking Aspirations Precautions

BOX 30-3 Causes of Dysphagia

NeurogenicStrokeCerebral palsyGuillain-Barré syndromeMultiple sclerosisAmyotrophic lateral sclerosis (Lou Gehrig disease)Diabetic neuropathyParkinson’s disease

MyogenicMyasthenia gravisAgingMuscular dystrophyPolymyositis

ObstructiveBenign peptic strictureLower esophageal ringCandidiasisHead and neck cancerInfl ammatory massesTrauma/surgical resectionAnterior mediastinal massesCervical spondylosis

OtherGastrointestinal or esophageal resectionRheumatological disordersConnective tissue disordersVagotomy

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Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

When assessing patients during a meal, use caution. It is impor-tant to fi rst assess the patient’s consciousness level, posture, ability to cooperate, and gross oral motor function (Metheny, 2007). Af-ter you determine that a patient is safe, test the patient with sips of water while observing for coughing or respiratory distress, voice changes, and laryngeal movement. Offer a small glass of water if the sip is cleared safely. Then, offer those without diffi culties in swallowing a larger volume of water, yogurt, and normal foods, again under constant monitoring. Patients who continue to have no problems then need to receive a normal diet, with monitoring of oral intake and respiratory status for 48 hours (Ramsey and oth-ers, 2003).

When a patient has diffi culty swallowing, referral for a more comprehensive examination is necessary (Box 30-4). The assess-ment includes observation of the patient eating a range of food textures and consistencies, resulting in a comprehensive descrip-tion of the phases of swallowing and a judgment of degree of dys-function and aspiration risk (Metheny, 2007; White and others, 2008). A speech-language pathologist performs the assessment. Clinical assessment focuses on oral-motor and oral-sensory func-tion, protective refl exes, and respiratory status. Treatment recom-mendations include alterations in the consistencies of foods and the use of swallowing therapies.

DYSPHAGIA TREATMENT

There is no one clear approach to prevent aspiration in patients. Metheny (2007) and White and others (2008) reviewed the evi-dence on research studies involving interventions for prevent-ing aspiration pneumonia in older adults. Positioning changes, dietary interventions, oral hygiene, pharmacological therapies, and electrical stimulation have all been tested. The benefi t of these therapies is inconclusive. However, Skill 30-3 includes ap-proaches used by researchers to minimize aspiration. A priority is the initiation of safe oral nutrition and hydration. Changes in food and/or liquid consistencies, elimination of oral intake, and initiation of tube feeding are common diet modifi cations. Liquid or pureed foods are sometimes the only consistency tolerated by pa-tients with mechanical disorders that cause dysphagia, but this is not always the most appropriate choice for individuals with oro-pharyngeal dysphagia. Patients with oropharyngeal dysphagia have more success with semisolid consistencies that are easy to chew. Foods with increased viscosity, such as the thickness of pudding, have to be thickened with a commercial thickener to decrease transit time and allow for protection of the airway (White and others, 2008). Maintain nothing by mouth (NPO) status if aspiration is present.

FIG 30-6 Screening assessment for dysphagic patients. SLT, Speech, language therapist. (From Dangerfi eld L, Sullivan R: Screening for and managing dysphagia after stroke, Nurs Times 95[19]:44, 1999.)



In October 2002 the American Dietetic Association published the National Dysphagia Diet Task Force’s (NDDTF’s) National Dysphagia Diet (2002). The diet comprises four levels: Dysphagia Puree, Dysphagia Mechanically Altered, Dysphagia Advanced, and Regular. There are also four levels of liquid consistencies: thin liquids (low viscosity), nectarlike liquids (medium viscosity), hon-eylike liquids (viscosity of honey), and spoon-thick liquids (viscos-ity of pudding) (Table 30-4).

Delegation ConsiderationsThe assessment of patient’s risk for aspiration and determination of positioning cannot be delegated to NAP. However, NAP may feed patients after receiving instruction in aspiration precautions. The nurse directs the NAP to:• Report to the nurse in charge, as soon as possible, any onset of

coughing, gagging, a wet voice, or pocketing of food.

Equipment❑ Chair or electric bed (to allow patient to sit upright)❑ Thickening agents as needed (rice, cereal, yogurt, gelatin,

commercial thickening agent)❑ Tongue blade❑ Oral hygiene supplies (see Chapter 17)❑ Pulse oximeter❑ Penlight

BOX 30-4 Criteria for Dysphagia Referral

Before referral:If the answer is yes to either of the following two questions, the referral at this time is not appropriate.• Is the patient unconscious or drowsy?• Is the patient unable to sit in an upright position for a reasonable

length of time?Please consider the next two questions before making the referral:• Is the patient near the end of life?• Does the patient have an esophageal problem that will require surgi-

cal intervention?When observing the patient or giving mouth care, look for the following:• Open mouth (weak lip closure)• Drooling liquids or solids• Poor oral hygiene/thrush

• Facial weakness• Tongue weakness• Diffi culty with secretions• Slurred, indistinct speech• Change in voice quality• Poor posture or head control• Weak involuntary cough• Delayed cough (up to 2 minutes after swallow)• General frailty• Confusion/dementia• No spontaneous swallowing movementsIf any of the above is present, the patient may have swallowing problems and may need referral to a speech-language pathologist.

SKILL 30-3

TABLE 30-4 Stages of National Dysphagia DietStage Description Examples

Dysphagia Puree

Uniform Smooth hot cereals cooked to a “pudding” consistency

Pureed Mashed potatoesCohesive Pureed meatPuddinglike

texturePureed pasta or ricePureed vegetableYogurt

Dysphagia Mechani-cally Al-tered

MoistSoft texturedEasily forms a

bolus

Cooked cerealsDry cereals moistened with

milkCanned fruit (excluding

pineapple)Moist ground meatWell-cooked noodles in

sauce/gravyWell-cooked, diced vegeta-

bles

Dysphagia Advanced

Regular foods (with the ex-ception of very hard, sticky, or crunchy foods)

Moist breads (with butter, jelly, etc.)

Well-moistened cerealsPeeled soft fruits (peach,

plum, kiwi)Tender, thin-sliced meatsBaked potato (without skin)Tender, cooked vegetables

Regular All foods No restrictions

STEP RATIONALE

ASSESSMENT 1 Perform a nutritional assessment (see Skill 30-1). Patients with aspiration from dysphagia alter their eating patterns

or choose foods that do not provide adequate nutrition (White and others, 2008).

2 Assess patients who are at increased risk for aspiration for signs and symptoms of dysphagia (see Box 30-4). Use a dysphagia screening tool if available.

Some patients show symptoms of poor lip and tongue control. Pa-tients at risk include those who have neurological or neuromus-cular diseases and those who have had trauma to or surgical procedures of the oral cavity or throat.

3 Observe patient during mealtime for signs of dysphagia. Allow patient to attempt to feed self. Note at end of meal if patient fatigues, has wet voice, or coughs after attempting to swallow (White and others, 2008).

Detects abnormal eating patterns such as frequent clearing of throat, coughing after swallowing, prolonged eating time. Fa-tigue increases risk for aspiration.



4 Ask patient about any trouble with chewing or swallowing various textures of food.

Be alert for coughing, dyspnea, or drooling that suggest diffi culty handling food, especially thin liquids.

5 Report signs and symptoms of dysphagia to the health care provider.

Some patients need to have an assessment performed by a radiolo-gist or speech-language pathologist (White and others, 2008).

6 Place an identifi cation on patient’s chart or Kardex indicating that dysphagia/aspiration risk is present. Option: Some facili-ties use different-colored meal trays to signify patients at risk for aspiration.

Identifying patient as dysphagic reduces risk for his or her receiving oral nutrients without supervision (Nowlin, 2006).

NURSING DIAGNOSES

STEP RATIONALE

• Disturbed sensory perception (gustatory) • Impaired swallowing • Risk for aspiration

Individualize related factors based on patient’s condition or needs.

PLANNING 1 Expected outcomes following completion of procedure:

• Patient will not exhibit signs or symptoms of aspiration. Interventions for preventing aspiration are successful.• Patient maintains stable weight. Patient is able to maintain oral intake.

IMPLEMENTATION 1 Perform hand hygiene. Prevents transmission of microorganisms. 2 Provide thorough oral hygiene, including brushing of tongue,

before meal.Tongue coating is associated with accumulation of bacterial cells in

the saliva and aspiration pneumonia, especially in patients without dentures (Abe and others, 2007).

3 Apply pulse oximeter to patient’s fi nger. Studies have suggested that oxygen desaturation and hypoxia oc-cur with aspiration (White and others, 2008).

4 Position patient upright in bed or sitting at a 90-degree angle in a chair (Loeb and others, 2003).

Position aims to prevent gastric refl ux and reduces occurrence of aspiration.

5 Using penlight and tongue blade, gently inspect mouth for pockets of food.

Pockets of food in the mouth indicate diffi culty swallowing.

6 Have patient assume a chin-tuck position. Begin by having patient try sips of water. Monitor for swallowing and respira-tory diffi culties continuously. If patient tolerates water, offer a larger volume of water, then different consistencies of foods and liquids.

Chin-tuck or chin-down position helps reduce aspiration (Huang and others, 2006). Introducing liquids and foods of different textures assesses patient’s ability to swallow safely. Gradual in-crease in types and textures, coupled with constant monitoring, ensures patient is able to eat safely (White and others, 2008).

7 Add thickener to thin liquids to create the consistency of mashed potatoes.

Thin liquids can be easily aspirated (White and others, 2008).

8 Place 1⁄2 to 1 teaspoon of food on unaffected side of mouth, allowing utensils to touch the mouth or tongue.

Provides a tactile cue to begin eating.

9 Provide verbal cueing while feeding. Remind patient to chew and think about swallowing.

Keeps patient focused on swallowing and minimizes distractions (Metheny, 2007).

10 Observe for coughing, choking, gagging, and drooling; suction airway as necessary.

Indicates dysphagia and risk for aspiration.

11 During feeding do not rush a patient. Allow time for adequate chewing and swallowing.

Ensures oral cavity is empty between swallows.

12 Ask patient to remain sitting upright for at least 30 to 60 minutes after the meal.

Reduces the risk for gastroesophageal refl ux, which causes aspiration (Ebersole and others, 2008; Nowlin, 2006).

13 Help patient to perform hand hygiene and mouth care. Mouth care after meals helps prevent dental caries. 14 Return patient’s tray to appropriate place, and perform hand

hygiene.Reduces spread of microorganisms.

EVALUATION 1 Observe patient’s ability to ingest foods of various textures and

thicknesses.Indicates whether aspiration risk is increased with thin liquids.

2 Monitor patient’s food and fl uid intake. Some patients avoid certain types and textures of food that are diffi cult to swallow.

3 Monitor pulse oximetry readings. The occurrence of desaturation indicates aspiration.

4 Weigh patient weekly. Determines if weight is stable and refl ects adequate caloric level.



Recording and Reporting• Document in patient’s chart: patient’s tolerance of liquids and

food textures, amount of assistance required, position during meal, absence or presence of any symptoms of dysphagia, fl uid intake, and amount eaten.

• Report any coughing, gagging, choking, or swallowing diffi cul-ties to nurse in charge or health care provider.

Teaching Considerations• Instruct family caregivers in ways to position patient and

the signs and symptoms of aspiration to observe (Huang and others, 2006).

• Consider language barriers when instructing patient and family (Riquelme, 2007).

SKILL 30-3

Unexpected Outcomes Related Interventions1 Patient coughs, gags, complains of food “stuck in throat,” or has pock-

ets of food in mouth.• Patient may require a swallowing evaluation by a licensed speech pa-

thologist or videofl uoroscopy.• Consider consultation with a speech therapist for swallowing exercises

and techniques to improve swallowing and reduce risk for aspiration.• Notify physician of any symptoms that occurred during meal and which

foods caused the symptoms.

2 Patient avoids certain textures of food. • Change consistency and texture of food (see Table 30-4).

3 Patient experiences weight loss. • Consult with dietitian on increasing frequency of meals or providing oral nutritional supplements.

• For high-risk patients, have an oral suction device available for family caregivers to use.

Gerontological Considerations• The risk for aspiration pneumonia is higher in older adults be-

cause of an increased incidence of dysphagia and gastroesopha-geal refl ux. Older adults with stroke and Parkinson’s disease and individuals with dementia are particularly at risk (Ebersole and others, 2008; White and others, 2008).

• Malnutrition occurs rapidly in older adults with dysphagia. En-teral feedings are sometimes necessary, but there is still a risk for aspiration (Ebersole and others, 2008).



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Aspiration Precautions