SKILL 30-3

Aspiration Precautions

Basic / Nutrition and Fluids / Taking Aspirations Precautions

Aspiration is the inhalation of oropharyngeal secretions into the lower respiratory tract. Secretions build up in the back of the oropharynx as a result of gastroesophageal reux or dysphagia (impairment in swallowing). When pathogenic bacteria colonize the secretions, 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 patients poor prognosis, increasing 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 difculty. Conditions associated with silent aspiration include local weakness/incoordination of the pharyngeal muscles, reduced laryngopharyngeal sensation, impaired ability to reexively cough, and low levels of neurotransmitters (e.g., substance P and dopamine) (Ramsey and others, 2005). Characteristics of dysphagia that are most predictive of aspiration 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 transit; incomplete oral clearance; regurgitation; pharyngeal pooling; and inability to speak consistently.

NUTRITIONAL IMPLICATIONS OF DYSPHAGIA

Dysphagia often causes a decrease in food intake, which then results 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 difculty in consuming an adequate volume of solids or liquids. Dietary intake may be affected for long periods of time, and the malnutrition that occurs is secondary to insufcient protein, calorie, and micronutrient intake (Ebersole and others, 2008). This signicantly impedes a patients recovery from illness.

DYSPHAGIA SCREENING
Dysphagia is typically identied by using one of three types of diagnostic 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 conduct a more thorough test. The comprehensive testing involves assessment of cranial nerves and swallowing trials using a variety of texture-modied liquids and solids. The third diagnostic technique is use of videouoroscopy. A patient assumes a sitting position and swallows radiopaque materials of different liquid and food textures. The videouoroscope shows swallow physiology. Nurses and RDs initially screen for dysphagia in patients believed to be at risk. There are many dysphagia screening tools with similar characteristics (Fig. 30-6). The Registered Dietitian Dysphagia 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, difculty 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).

BOX 30-3

Causes of Dysphagia
Obstructive Benign peptic stricture Lower esophageal ring Candidiasis Head and neck cancer Inammatory masses Trauma/surgical resection Anterior mediastinal masses Cervical spondylosis Other Gastrointestinal or esophageal resection Rheumatological disorders Connective tissue disorders Vagotomy
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Neurogenic Stroke Cerebral palsy Guillain-Barr syndrome Multiple sclerosis Amyotrophic lateral sclerosis (Lou Gehrig disease) Diabetic neuropathy Parkinsons disease Myogenic Myasthenia gravis Aging Muscular dystrophy Polymyositis

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

When assessing patients during a meal, use caution. It is important to rst assess the patients consciousness level, posture, ability to cooperate, and gross oral motor function (Metheny, 2007). After 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 difculties 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 others, 2003). When a patient has difculty swallowing, referral for a more comprehensive examination is necessary (Box 30-4). The assessment includes observation of the patient eating a range of food textures and consistencies, resulting in a comprehensive description of the phases of swallowing and a judgment of degree of dysfunction 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 function, protective reexes, and respiratory status. Treatment recommendations 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 evidence on research studies involving interventions for preventing aspiration pneumonia in older adults. Positioning changes, dietary interventions, oral hygiene, pharmacological therapies, and electrical stimulation have all been tested. The benet of these therapies is inconclusive. However, Skill 30-3 includes approaches 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 modications. Liquid or pureed foods are sometimes the only consistency tolerated by patients with mechanical disorders that cause dysphagia, but this is not always the most appropriate choice for individuals with oropharyngeal 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.

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SKILL 30-3

BOX 30-4

Criteria for Dysphagia Referral

Facial weakness Tongue weakness Difculty 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 movements If any of the above is present, the patient may have swallowing problems and may need referral to a speech-language pathologist.

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 surgical 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

In October 2002 the American Dietetic Association published the National Dysphagia Diet Task Forces (NDDTFs) 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), honeylike liquids (viscosity of honey), and spoon-thick liquids (viscosity of pudding) (Table 30-4).

TABLE 30-4
Stage Dysphagia Puree

Stages of National Dysphagia Diet

Examples Smooth hot cereals cooked to a pudding consistency Mashed potatoes Pureed meat Pureed pasta or rice Pureed vegetable Yogurt Cooked cereals Dry cereals moistened with milk Canned fruit (excluding pineapple) Moist ground meat Well-cooked noodles in sauce/gravy Well-cooked, diced vegetables Moist breads (with butter, jelly, etc.) Well-moistened cereals Peeled soft fruits (peach, plum, kiwi) Tender, thin-sliced meats Baked potato (without skin) Tender, cooked vegetables No restrictions

Description Uniform Pureed Cohesive Puddinglike texture

Delegation Considerations
The assessment of patients 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.
Dysphagia Mechanically Altered Moist Soft textured Easily forms a bolus

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
Dysphagia Advanced Regular foods (with the exception of very hard, sticky, or crunchy foods)

Regular

All foods

STEP
ASSESSMENT 1 Perform a nutritional assessment (see Skill 30-1).

RATIONALE
Patients with aspiration from dysphagia alter their eating patterns or choose foods that do not provide adequate nutrition (White and others, 2008). Some patients show symptoms of poor lip and tongue control. Patients at risk include those who have neurological or neuromuscular diseases and those who have had trauma to or surgical procedures of the oral cavity or throat. Detects abnormal eating patterns such as frequent clearing of throat, coughing after swallowing, prolonged eating time. Fatigue increases risk for aspiration.

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. 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).

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

STEP
4 Ask patient about any trouble with chewing or swallowing

RATIONALE
Be alert for coughing, dyspnea, or drooling that suggest difculty handling food, especially thin liquids. Some patients need to have an assessment performed by a radiologist or speech-language pathologist (White and others, 2008). Identifying patient as dysphagic reduces risk for his or her receiving oral nutrients without supervision (Nowlin, 2006).

various textures of food. 5 Report signs and symptoms of dysphagia to the health care provider. 6 Place an identication on patients chart or Kardex indicating that dysphagia/aspiration risk is present. Option: Some facilities use different-colored meal trays to signify patients at risk for aspiration. NURSING DIAGNOSES

Disturbed sensory perception (gustatory)

Impaired swallowing

Risk for aspiration

Individualize related factors based on patients condition or needs.

PLANNING 1 Expected outcomes following completion of procedure: Patient will not exhibit signs or symptoms of aspiration. Patient maintains stable weight. IMPLEMENTATION 1 Perform hand hygiene. 2 Provide thorough oral hygiene, including brushing of tongue, before meal.
3 Apply pulse oximeter to patients nger. 4 5 6

Interventions for preventing aspiration are successful. Patient is able to maintain oral intake.

7 8 9 10 11 12 13 14

Position patient upright in bed or sitting at a 90-degree angle in a chair (Loeb and others, 2003). Using penlight and tongue blade, gently inspect mouth for pockets of food. Have patient assume a chin-tuck position. Begin by having patient try sips of water. Monitor for swallowing and respiratory difculties continuously. If patient tolerates water, offer a larger volume of water, then different consistencies of foods and liquids. Add thickener to thin liquids to create the consistency of mashed potatoes. Place 12 to 1 teaspoon of food on unaffected side of mouth, allowing utensils to touch the mouth or tongue. Provide verbal cueing while feeding. Remind patient to chew and think about swallowing. Observe for coughing, choking, gagging, and drooling; suction airway as necessary. During feeding do not rush a patient. Allow time for adequate chewing and swallowing. Ask patient to remain sitting upright for at least 30 to 60 minutes after the meal. Help patient to perform hand hygiene and mouth care. Return patients tray to appropriate place, and perform hand hygiene.

Prevents transmission of microorganisms. Tongue coating is associated with accumulation of bacterial cells in the saliva and aspiration pneumonia, especially in patients without dentures (Abe and others, 2007). Studies have suggested that oxygen desaturation and hypoxia occur with aspiration (White and others, 2008). Position aims to prevent gastric reux and reduces occurrence of aspiration. Pockets of food in the mouth indicate difculty swallowing. Chin-tuck or chin-down position helps reduce aspiration (Huang and others, 2006). Introducing liquids and foods of different textures assesses patients ability to swallow safely. Gradual increase in types and textures, coupled with constant monitoring, ensures patient is able to eat safely (White and others, 2008). Thin liquids can be easily aspirated (White and others, 2008). Provides a tactile cue to begin eating. Keeps patient focused on swallowing and minimizes distractions (Metheny, 2007). Indicates dysphagia and risk for aspiration. Ensures oral cavity is empty between swallows. Reduces the risk for gastroesophageal reux, which causes aspiration (Ebersole and others, 2008; Nowlin, 2006). Mouth care after meals helps prevent dental caries. Reduces spread of microorganisms.

EVALUATION 1 Observe patients ability to ingest foods of various textures and thicknesses. 2 Monitor patients food and uid intake.
3 Monitor pulse oximetry readings. 4 Weigh patient weekly.

Indicates whether aspiration risk is increased with thin liquids. Some patients avoid certain types and textures of food that are difcult to swallow. The occurrence of desaturation indicates aspiration. Determines if weight is stable and reects adequate caloric level.

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SKILL 30-3

Unexpected Outcomes
1 Patient coughs, gags, complains of food stuck in throat, or has pockets of food in mouth.

Related Interventions
Patient may require a swallowing evaluation by a licensed speech pathologist or videouoroscopy. 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. Change consistency and texture of food (see Table 30-4). Consult with dietitian on increasing frequency of meals or providing oral nutritional supplements.

2 Patient avoids certain textures of food. 3 Patient experiences weight loss.

Recording and Reporting

Document in patients chart: patients tolerance of liquids and food textures, amount of assistance required, position during meal, absence or presence of any symptoms of dysphagia, uid intake, and amount eaten. Report any coughing, gagging, choking, or swallowing difculties to nurse in charge or health care provider.

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 because of an increased incidence of dysphagia and gastroesophageal reux. Older adults with stroke and Parkinsons 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. Enteral feedings are sometimes necessary, but there is still a risk for aspiration (Ebersole and others, 2008).

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).

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