Nutrition and Fluids
Taking Aspiration Precautions
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Safety
- Assess the patient’s level of consciousness before feeding him or her.
- Identify obstructions and medication side effects that cause difficulty swallowing.
- Suspect dysphagia or aspiration if the patient complains of having the sensation of food sticking in the throat and makes repeated attempts to swallow.
- Place any patient at risk of dysphagia or aspiration on NPO status until a swallowing evaluation determines that the dysphagia poses no substantial risk to the patient.
- Comply with the mandate of The Joint Commission that any patient admitted with a stroke diagnosis be screened for aspiration before he or she ingests an oral diet.
- To evaluate for silent aspiration, use pulse oximetry when administering oral fluids. A drop in oxygen saturation of greater than or equal to 2% from the patient’s baseline is diagnostic of aspiration.
Equipment
(Roll cursor over items to see labels)
Foods with texture
Oral hygiene supplies
Pulse oximeter
Suction equipment
Tongue blade
Penlight
Towel
Clean gloves
Antiseptic hand gel
Thickening agent
PrintableDelegation
Assessment of a patient’s risk for aspiration and determination of the patient’s position to prevent aspiration cannot be delegated to nursing assistive personnel (NAP). However, NAP may feed patients after receiving instruction on aspiration precautions. Be sure to inform NAP of the following:
- Explain that the patient must be positioned upright or in the high-Fowler’s position during and after feeding, according to medical restrictions.
- Instruct NAP to use aspiration precautions while feeding patients who need assistance.
- Instruct NAP to report to you immediately if the patient has any onset of coughing or gagging, a wet voice, or pocketing of food.
Preparation
- Assess the patient’s knowledge of aspiration risk.
- Perform a nutritional assessment.
- Assess the patient’s mental status, including alertness, orientation, and ability to follow simple commands, such as opening the mouth and sticking out the tongue.
- Determine if the patient is at increased risk for aspiration, and assess for signs and symptoms of dysphagia. Use a dysphagia screening tool for this assessment if one is available.
- Formally refer any patient at risk for aspiration to a speech and language pathologist (SLP) for a dysphagia evaluation.
- Assess the patient’s oral health. Check the patient’s level of dental hygiene, missing teeth, or poorly fitting dentures. Apply clean gloves to make this oral health assessment if needed.
- Observe the patient during mealtime for signs of dysphagia, such as coughing, dyspnea, or drooling. Note if the patient is fatigued during and at the end of a meal.
Follow-up
- Continually evaluate the at-risk patient’s ability to cough and manage oral secretions. Monitor the patient’s ability to swallow foods and fluids of different textures and viscosities without choking.
- Weigh the patient daily or weekly.
- Monitor the patient’s I&O, calorie count, and food intake per the health care provider’s order.
- Monitor the pulse oximetry readings for high-risk patients while they are eating.
Documentation
- Document assessment findings, patient’s tolerance of liquids and food textures, amount of assistance required, position during the meal, absence or presence of any symptoms of dysphagia during the meal, fluid intake, and amount eaten.
- Report any patient coughing, gagging, choking, or swallowing difficulties to the health care provider.
- Document pulse oximeter readings during the meal.
Review Questions
1. Which patient is least at risk for dysphagia?
A 22-year-old patient with a traumatic brain injury (TBI) sustained during combat - A 40-year-old woman undergoing stroke rehabilitation who had been smoking and taking oral contraceptives
- A 76-year-old patient with dementia
A 55-year-old patient with pancreatic cancer who is receiving palliative care
INCORRECT. The risk of dysphagia is elevated in any patient with generalized muscle weakness, altered mental status, or neurological impairment of the swallowing mechanism. Such conditions are more common among older adults, but any patient with a TBI is at increased risk for dysphagia, regardless of age or mechanism of injury.
INCORRECT. The risk of dysphagia is elevated in any patient with generalized muscle weakness, altered mental status, or neurological impairment of the swallowing mechanism, such as stroke. This patient is at increased risk for dysphagia; however, the factors contributing to the stroke are irrelevant to this risk.
INCORRECT. The risk of dysphagia is elevated in any patient with generalized muscle weakness, altered mental status, or neurological impairment of the swallowing mechanism, such as dementia.
CORRECT. The risk of dysphagia is elevated in any patient with generalized muscle weakness, altered mental status, or neurological impairment of the swallowing mechanism. Pancreatic cancer is not ordinarily associated with such conditions. Chemotherapeutic agents may cause dysphagia; this patient, however, is receiving only palliative care.
2. What would the nurse instruct nursing assistive personnel (NAP) to report while feeding any patient on aspiration precautions?
INCORRECT. The nurse would instruct NAP to report the onset of coughing in any patient on aspiration precautions. NAP might or might not be asked to report the amount of food ingested.
CORRECT. The nurse would instruct NAP to report the onset of coughing in any patient on aspiration precautions.
INCORRECT. The nurse would instruct NAP to report the onset of coughing in any patient on aspiration precautions. NAP might or might not be asked to report the patient’s appetite.
INCORRECT. The nurse would instruct NAP to report the onset of coughing in any patient on aspiration precautions. NAP might or might not be asked to report the patient’s food preferences.
3. What is the most effective way of preventing aspiration?
- Observe the patient closely for coughing, gagging, choking, and voice alteration.
- Monitor oxygen saturation with pulse oximetry.
- Put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist.
- Watch for subtle signs that aspiration may have occurred, such as lack of speech, depressed alertness, wet quality to the voice, difficulty controlling secretions, and absence of a gag reflex.
INCORRECT. All of the choices listed are steps that reduce the risk of aspiration. Bedside observation, however, is insufficient. The most important precaution to prevent aspiration is to put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist.
INCORRECT. All of the choices listed are steps that reduce the risk of aspiration. Monitoring the patient’s oxygenation is useful in detecting silent aspiration; nevertheless, the most important precaution to prevent aspiration is to put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist.
CORRECT. All of the choices listed are steps that reduce the risk of aspiration. The most important precaution to prevent aspiration, however, is to put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist.
INCORRECT. All of the choices listed are steps that reduce the risk of aspiration. Bedside observation, however, is insufficient. The most important precaution to prevent aspiration is to put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist.
4. Which food item would not be given to a patient on a dysphagia diet?
- Egg salad sandwich on wheat bread
- Biscuits and gravy with scrambled eggs
- Chicken noodle soup
- Rice pudding
INCORRECT. All of the foods listed may be eaten by a patient on a dysphagia diet except the chicken noodle soup. The liquid portion of the soup is not viscous enough to form a soft bolus in the mouth.
INCORRECT. All of the foods listed may be eaten by a patient on a dysphagia diet except the chicken noodle soup. The liquid portion of the soup is not viscous enough to form a soft bolus in the mouth.
CORRECT. All of the foods listed may be eaten by a patient on a dysphagia diet except the chicken noodle soup. The liquid portion of the soup is not viscous enough to form a soft bolus in the mouth.
INCORRECT. All of the foods listed may be eaten by a patient on a dysphagia diet except the chicken noodle soup. The liquid portion of the soup is not viscous enough to form a soft bolus in the mouth.
5. Why would the nurse provide special instructions to nursing assistive personnel (NAP) before feeding a patient with dysphagia?
- To reduce the risk of aspirating food or fluids
- To ensure that an accurate intake measurement is reported
- To encourage the patient to eat more of the food items on the meal tray
- To ensure that the NAP knows which foods to avoid when feeding the patient
CORRECT. The nurse gives special instructions before the NAP feeds a patient with dysphagia because such teaching reduces the risk that the patient will aspirate food or fluids.
INCORRECT. Recording I&O accurately will have no effect in preventing aspiration, but the NAP may still need to monitor I&O if ordered.
INCORRECT. Encouraging the patient to eat will have no effect in preventing aspiration, although encouraging adequate intake is always warranted.
INCORRECT. The nurse gives special instructions before the NAP feeds a patient with dysphagia because such teaching reduces the risk that the patient will aspirate food or fluids. The nurse will ensure that the meal served to the patient is appropriate; it is not the NAP’s responsibility to determine which foods to avoid.
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