Friday, November 26, 2010

Risk for Aspiration

Risk for Aspiration

NANDA Definition
At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages

Discussion of the Problem
Aspiration of stomach contents into the lungs is a serious complication that can cause pneumonia and result in the following clinical picture: tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and finally death.  It can occur when the protective airway reflexes and decreased or absent due to either one or more of the following: seizure activity, decreased level of consciousness, nausea and vomiting in patient with decreased LOC, swallowing disorders, cardiac arrest, silent aspiration head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, postanesthesia effects from surgery or diagnostic tests, use of tube feedings for nutrition, endotracheal intubation, radical neck surgery, laryngectomy, parenteral/enteral feeding or mechanical ventilation. In addition to this, oropharyngeal secretions, or solids or fluids could also enter tracheobronchial passages due to decreased coughing, gag, and glottic reflexes. Prevention is the primary goal when caring for patients at risk for aspiration. Evidence confirms that one of the main preventive measures for aspiration is placing at-risk patients in a semirecumbent position. Other measures are compensating for absent reflexes, assessing feeding tube placement, identifying delayed stomach emptying, and managing effects of prolonged intubation.

Nursing Interventions Classification (NIC)
  • Airway Management
  • Aspiration Precautions

Nursing Outcomes Classification (NOC)
  • Respiratory Status: Airway Patency
  • Respiratory Status: Ventilation
  • Risk Control
  • Risk Detection

Goal and Objectives
  • Patient will be free of signs of aspiration and the  risk of aspiration is decreased
  • Patient will expectorate clear secretions and be free of aspiration.
  • Patient will maintain a patent airway with clear breath sounds clear

Subjective and Objective Data
[Not appropriate; existence of signs and symptoms ascertains an actual diagnosis.]

Risk Factors
  • Anesthesia or medication administration
  • Copious and thick secretions
  • Decreased gastrointestinal motility or delayed gastric emptying
  • Depressed cough and gag reflexes
  • Edema formation (surgical manipulation and lymphatic accumulation)
  • Facial, oral, or neck surgery or trauma
  • Impaired swallowing
  • Increased abdominal pressure
  • Presence of gastrointestinal tubes, bolus tube feedings
  • Presence of tracheostomy or endotracheal tube
  • Reduced level of consciousness
  • Situations hindering elevation of upper body

Assessment (Dx)
  • Assess cough and gag reflexes. A diminished cough or gag reflex increases the risk of aspiration.

  • Assess level of consciousness. The primary risk factor of aspiration is decreased level of consciousness.

  • Observe swallowing ability:
    1. Assess for coughing or ability to clear throat after swallowing.
    2. Check for residual food in mouth after eating. Tidbits of food can be easily aspirated at a later time.
    3. Monitor for regurgitation of food or fluid through nares.
    4. Assess for choking during and after drinking or eating. Choking indicates aspiration.

  • Assess for presence of nausea or vomiting.

  • Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds noting for crackles and rhonchi. Aspiration of small amounts can happen with sudden onset of respiratory distress or without coughing particularly in patients with diminished levels of consciousness.

  • Auscultate bowel sounds to assess for gastrointestinal motility. Reduced 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. Aspiration is a higher when reduce esophageal motility is combined with the weaker gag reflex of elderly patients.

  • 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.

  • Note characteristics of sputum tracheal aspirate. Explore development of dyspnea, cough, tachypnea, and cyanosis. Signs and symptoms of respiratory distress or presence of formula in tracheal secretions imply aspiration.

Therapeutic Interventions (Tx)
  • Assist in oral care after meals. This eliminates residuals and reduces pocketing of food that can be aspirated.

  • Maintain upright position for 30 to 45 minutes after feeding. The upright position assists the gravitational flow of food or fluid as it passes the alimentary tract. Position patient in right side-lying position if the head of the bed cannot be elevated because of the patient’s condition. This is to facilitate passage of stomach contents into the duodenum.

  • Offer foods with consistency that patient can swallow. Cut foods into small pieces. Use thickening agents as appropriate. Most easily swallowed semisolid foods are pudding and hot cereal.

  • Position patient at 90-degree angle, whether in bed or in a chair or wheelchair when feeding or eating. To maintain position, use cushions or pillows. It is of primary importance the proper positioning of patients with swallowing difficulties during feeding or eating.

  • Position patients who have a decreased level of consciousness on their sides. Proper positioning protects the airway. It can decrease the risk of aspiration. Comatose patients need regular log-rolling or turning to facilitate drainage of secretions.

  • Put whole or crushed pills in soft foods (e.g., banana). Validate with a pharmacist which pills should not be crushed.

  • Remove disturbing stimuli during mealtimes for patients with diminished cognitive ability. This facilitates concentration on chewing and swallowing.

  • Suction oral, nasal cavities and ET/tracheostomy tube. Note amount, color, and consistency of secretions. Keep suction setup available (in both hospital and home settings) and use as needed. It keeps secretions from obstructing airway, once swallowing ability is impaired and patient cannot blow nose. Changes in characteristics of secretions may signify developing complications that needs further evaluation or management.

  • In patients with nasogastric (NG) or gastrostomy tubes:
    1. Validate placement of nasoenteral feeding tubes. Tube position can be checked by x-ray, affirmation of pH of 0–5 of the gastric fluid withdrawn through tube, or gurgling sound heard upon auscultation when air is injected. Misplacement of nasoenteral feeding tubes may cause aspiration of enteral formula. Patients at high risk include those who are obtunded, intubated, those who have had a cerebrovascular accident or stroke, surgery of the head or neck and upper GI system. Note: The reliability of the pH method is decreased if antacids or other medications have been given within the past 4 hours. In addition when assessing tube placement through auscultation, air sounds can be transmitted to the epigastrium even if the tube is malpositioned.

    1. Check residuals before feeding. Withold feedings if residuals are high then refer to the physician. Large amount of gastric residuals (>50% of previous hour’s intake) implies delayed gastric emptying, may potentiate an incompetent esophageal sphincter, can cause distention of the stomach consequently leading to vomiting and aspiration.

    1. Add dye or blue food coloring to enteral formula as indicated. Helps identify aspiration of enteral formula if found out in sputum or lung secretions. Note: Avoid use of methylene blue dye, which may cause false-positive occult blood or guaiac test when checking for GI bleeding.

    1. Maintain head of bed raised at 30–45 degrees when feeding and at least 1 hour after feeding. Reduces risk of regurgitation or gastric reflux and aspiration.

    1. Observe indicators of NG tube intolerance such as diminish gag reflex, high risk of aspiration, and frequent removal of NG tubes. For patient’s safety, the health care workers should consider surgically placed feeding tube or percutaneous endoscopic gastrostomy (PEG).

·         Check serial ABGs, pulse oximetry and chest x-ray. Accumulation of secretions or presence of atelectasis may cause pneumonia. It entails more aggressive therapeutic actions and management.

·         Refer to speech pathologist, occupational therapist as appropriate. Dysphagia assessment can be done by a speech pathologist that helps determine the need for modified barium swallow.

·         Resume oral intake with care. Changes in muscle mass or strength and nerve innervations increase possibility of aspiration.

Educative (Edx)
·         Discuss to patient and significant others the need for proper positioning. This reduces the risk of aspiration.

·         Encourage caregiver to watch out for signs and symptoms of aspiration. This helps in appropriately evaluating high-risk conditions and determining when to call for help and further evaluation.

·         Encourage patient to chew thoroughly and eat slowly during meals. Instruct patient not to talk while eating.

·         Encourage swallowing, if patient is able. Avoids pooling of oral secretions, reducing risk of aspiration.

Instruct or demonstrate on suctioning techniques to prevent accumulation of secretions in the oral cavity. Avoids pooling of oral secretions, reducing risk of aspiration. It also prevents complications.

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