Nursing Care Plan for Risk for Aspiration
Definition: A state in which an individual is at risk for entry of gastric secretions, oropharyngeal secretions, or exogenous food or fluids into tracheobronchial passages because of dysfunction of normal protective mechanisms.
- Impaired laryngeal sensation or reflex
Reduced level of consciousness
Immediately after extubation
- Impaired pharyngeal peristalsis or tongue function
Central nervous system dysfunction
Head or neck surgery
- Impaired laryngeal closure or elevation
Laryngeal nerve dysfunction
- Increased gastric volume
Delayed gastric emptying
- Increased intragastric pressure
Upper abdominal surgery
- Decreased lower esophageal sphincter pressure
Increased gastric acidity
- Decreased antegrade esophageal propulsion
Trendelenburg or supine position
Esophageal structural defects or lesions
- Normal breath sounds or no change in patient’s baseline breath sounds
- ABG values remain within patients’ baseline
- No evidence of gastric contents in lung secretions
Nursing Interventions and Rationale:
- Assess gastrointestinal function to rule out hypoactive peristalsis and abdominal distension.
- Position patient with head of bed elevated 30 degrees to prevent gastric reflux through gravity. If head elevation is contraindicated, position patients in right lateral decubitus position to facilitate passage of gastric contents accross the pylorus.
- Maintain patency and functioning of nasogastric suction apparatus to prevent accumulation of gastric contents.
- Provide frequent and scrupulous mouth care to prevent colonization of the oropharynx with bacteria and inoculation of the lower airways.
- Ensure that endotracheal/tracheostomy cuff is properly inflated to limit aspiration of oropharyngeal secretions.
- Treat nausea promptly; collaborate with physician on an order for antiemetic to prevent vomiting and resultant aspiration.
Additional interventions for patients receiving continuous or intermittent enteral tube feedings
- Position patients with head of bed elevated 45 degrees to prevent gastric reflux. If a head-down position becomes necessary at any time, interrupt the feeding 30 minutes before the position change.
- Check placement of feeding tube either by auscultation or radiographically at regular intervals (e.g., before administering intermittent feedings and after position changes, suctioning, coughing episodes or vomiting) to ensure proper placement of the tube.
- Instill blue food coloring to feeding solutions to assist with identification of gastric contents in pulmonary secretions.
- Monitor patients for signs of delayed gastric emptying to decrease potential for vomiting and aspiration
- For large-bore tubes, check residuals of tube feedings before intermittent feedings and every 4 hours during continuous feedings. Consider withholding feedings for residuals greater than 150% of the hourly rate (continuous feeding) or greater than 50% of the previous feeding (intermittent feeding).
- For small-bore tubes, observe abdomen for distention, palpate abdomen for hardness or tautness, and auscultate abdomen for bowel sounds.