Susceptible to entry of gastrointestinal secretions, oropharyngeal secretions. solids, or fluids into the tracheobronchial passages, which may compromise health.

NANDA-I approved*

Pathophysiologic

Related to reduced level of consciousness secondary to:

Presenile dementia

Head injury

Cerebrovascular accident

Parkinson's disease

Alcohol- or drug-induced

Coma

Seizures

Anesthesia

Related to depressed cough/gag reflexes

Related to increased intragastric pressure secondary to:

Lithotomy position

Ascites

Obesity

Enlarged uterus

Related to impaired swallowing or decreased laryngeal and glottic reflexes secondary to:

Ineffective Airway Clearance *

Barrier to elevating upper body*

Achalasia

Cerebrovascular accident

Myasthenia gravis

Catatonia

Muscular dystrophy

Esophageal strictures

Debilitating conditions

Multiple sclerosis

Scleroderma

Parkinson's disease

Guillain-Barré syndrome

Related to tracheoesophageal fistula

Related to impaired protective reflexes secondary to:

Increased gastric residue*

Decreased gastrointestinal motility*

Difficulty swallowing*

Facial/oral/neck surgery or trauma

Paraplegia or hemiplegia

Treatment Related

Related to depressed laryngeal and glottic reflexes secondary to:

Enteral nutrition tube displacement*

Tracheostomy/endotracheal tube

Sedation

Tube feedings

Related to impaired ability to cough secondary to:

Wired jaw

Imposed prone position

Situational (Personal, Environmental)

Inadequate knowledge of modifiable factors*

Related to inability/impaired ability to elevate upper body

Related to eating when intoxicated

Maturational

Premature

Related to impaired sucking/swallowing reflexes

Neonate

Related to decreased muscle tone of inferior esophageal sphincter

Older Adult

Related to poor dentition

AUTHOR'S NOTE

Risk for Aspiration is a clinically useful diagnosis for people at high risk for aspiration because of reduced level of consciousness, structural deficits, mechanical devices, and neurological and gastrointestinal disorders. People with swallowing difficulties often are at risk for aspiration; the nursing diagnosis Impaired Swallowing should be used to describe a client with difficulty swallowing who also is at risk for aspiration. Risk for Aspiration should be used to describe people who require nursing interventions to prevent aspiration, but do not have a swallowing problem.

Key Concepts

General Considerations

• Central nervous system (CNS) depression interferes with the protective mechanism of the sphincters.
• Nasogastric and endotracheal tubes cause incomplete closure of the esophageal sphincters and depress the gag and cough reflexes.
• Difficulty swallowing is a disturbing symptom that occurs in the vast majority of palliative care patients. In fact, swallowing disorders are part of the natural process of the end of life, irrespective of the etiology (Goldsmith & Cohen, 2020).
• The risk of aspiration is high with corresponding pneumonia.
• Food and eating is an important social event. Swallowing dysfunction can negatively impact social interaction, communication, intimacy, food consumption, and nutrition (Goldsmith & Cohen, 2020).
• The volume and characteristics of the aspirated contents influence morbidity and mortality. Food particles can cause mechanical blockage. Gastric juice erodes alveoli and capillaries and causes chemical pneumonitis.

Pediatric Considerations

• A proportionately oversized airway diameter in infants and small children increases the risk of aspiration of foreign objects (Hockenberry & Wilson, 2014).
• Children, especially toddlers, have a natural curiosity, seek attractive objects, and frequently put things in their mouth. Children cannot comprehend danger to self or others.
• Common household objects and food items that are aspirated include balloons (toy rubber balloons are the leading cause of choking deaths from children's products), baby powder, hot dogs, candy, nuts, grapes, and small batteries.
• Children with certain congenital anomalies (e.g., tracheoesophageal fistula, cleft palate, gastroesophageal reflux) are at greater risk for aspiration.

Level 1 Fundamental Focused Assessment

Subjective Data

Assess for Related Factors

History of a problem with swallowing or aspiration

Presence or history of (see Pathophysiologic Related Factors)

Objective Data

Assess for Related Factors

Ability to swallow, chew, feed self

Neuromuscular impairment:

Mechanical obstruction:

Perceptual patterns/awareness

Level of consciousness

Condition of oropharyngeal cavity

Nasal regurgitation

Hoarseness

Aspiration

Coughing 1 or 2 seconds after swallowing

Dehydration

Apraxia (problem with the motor coordination of speech)

The individual will not experience aspiration as evidenced by the following indicators:

• Relate measures to prevent aspiration.
• Name foods or fluids that are high risk for causing aspiration.

The parent will reduce opportunities for aspirations as evidenced by the following indicators:

• Remove small objects from child's reach.
• Inspect toys for removable small objects.
• Discourage the child from putting objects in his or her mouth.

Level 1 Fundamental Focused Interventions

Assess Causative or Contributing Factors

Refer to Related Factors.

Ensure a consult with speech-language pathologist is initiated.

R:Speech-language pathologists (SLPs) are expert in assessment and management of oropharyngeal swallowing disorders.

Reduce the Risk of Aspiration in Individuals with Decreased Strength, Decreased Sensorium, or Autonomic Disorders

• Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated.

R:There is evidence that a sustained supine position (zero-degree head-of-bed elevation) increases gastroesophageal reflux and the probability for aspiration (American Association of Critical Care Nurses, 2016).

• Use sedatives as sparingly as feasible

R:Sedation causes reduced cough and gag reflexes. It can impair the person's ability clear oropharyngeal secretions and refluxed gastric contents (American Association of Critical Care Nurses, 2016).

• Maintain a side-lying position if not contraindicated by injury.
• If the client cannot be positioned on the side, open the oropharyngeal airway by lifting the mandible up and forward and tilting the head backward. (For a small infant, hyperextension of the neck may not be effective.)
• Assess for position of the tongue, ensuring it has not dropped backward, occluding the airway.
• Keep the head of the bed elevated, if not contraindicated by hypotension or injury.
• Maintain good oral hygiene. Clean teeth and use mouthwash on cotton swab; apply petroleum jelly to lips; removing encrustations gently.
• Clear secretions from mouth and throat with a tissue or gentle suction.
• Reassess frequently for obstructive material in mouth and throat.
• Reevaluate frequently for good anatomic positioning.
• Maintain side-lying position after feedings.

R:Regurgitation is often silent in people with decreased sensorium or depressed mental states.

• Positions are maintained to reduce aspiration.

R:Increased intragastric pressure can contribute to regurgitation and aspiration. Causes include bolus tube feedings, obstructions, obesity, pregnancy, and autonomic dysfunction.

Individuals with Gastrointestinal Tubes and Feedings

• Confirm that tube placement has been verified by radiography or aspiration of greenish fluid (check hospital/organizational policy for preferred method).

R:Verifying correct placement of feeding tubes is done most reliably by radiography. Aspiration of green-colored fluid or gastric aspirant with a pH of 6.5 or lower is also reliable.

• Observe for a change in length of the external portion of the feeding tube, as determined by movement of the marked portion of the tube (American Association of Critical Care Nurses, 2016).

If there is a doubt about the tube's position, request an x-ray.

• Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated.

R:This helps to prevent reflux by use of reverse gravity.

• Aspirate for residual contents before each feeding for tubes positioned gastrically.
• Measure gastric residual volumes (GRVs) every 4 hours in critically ill person. Delay tube feeding if GRV is greater than 150 mL.

R:Gastric distention predisposes to regurgitation.

• Regulate gastric feedings using an intermittent schedule, allowing periods for stomach emptying between feeding intervals. Monitored for tolerance to enteral feedings by noting abdominal distention, complaints of abdominal pain, observing for passage of flatus and stool at 4-hour intervals. Report abnormal finding promptly (American Association of Critical Care Nurses, 2016).
• Avoid bolus feedings in those at high risk for aspiration.

R:To administer an entire 4-hour volume of formula over a period of a few minutes is more likely to predispose to regurgitation of gastric contents than is the steady administration of the same volume over a period of 4 hours (American Association of Critical Care Nurses, 2016).

For an Older Adult with Difficulties Chewing and Swallowing (See Impaired Swallowing)

Initiate Health Teaching and Referrals, as Indicated

• Instruction causes and prevention of aspiration.
• Maintain oral hygiene to prevent pneumonia related to oral bacteria aspiration.
• Have the family demonstrate tube-feeding technique.
• Contact a community nursing agency with a referral for an urgent home assessment.
• Teach the Heimlich or abdominal thrust maneuver to remove aspirated foreign bodies.

R:The risk of aspiration increases after discharge due to less supervision.