Nursing Care Plan for Newborn Baby Risk for Aspiration

Aspiration NCLEX Review Care Plans

Nursing Study Guide on Aspiration

Aspiration happens when the swallowed food, liquid, or strange object goes into the airway and respiratory tract instead of the digestive tract. Aspiration can too occur when stomach contents regurgitate from the tum into the throat and enter the airway.

Aspiration is different from choking in terms of airway blockage. In aspiration, the airway is only partially blocked; however, in that location is a full blockage of airway when a person chokes.

Dysphagia or difficulty of swallowing is the about common cause of aspiration. Dysphagia can be a temporary status, or a symptom of a serious medical condition such as neurological disorders (e.g., cerebral palsy, Parkinson'southward disease, etc.) or cancer (e.g. mouth cancer, esophageal cancer, etc.).

Signs and Symptoms of Aspiration

1. General Signs and Symptoms

feeling that there is something stuck in the throat
difficulty of swallowing
pain triggered past trying to consume
coughing while or afterward eating/ drinking
wet-sounding or gurgling vocalisation when eating or talking
feeling congested while or subsequently eating/drinking
increased salivation
heartburn or chest discomfort
shortness of breath
fatigue
frequent pneumonia
trouble chewing
sudden fever within 30 minutes of eating

2. Aspiration Symptoms in Infants and Children

Aside from the signs and symptoms to a higher place, the post-obit may be observed in pediatric patients suffering from aspiration:

weak sucking
sudden apnea or tachypnea while or after feeding
facial grimace
ruby face and/or watery eyes while or afterwards feeding
breathing noises like wheezing subsequently feeding
frequent respiratory infections

In some cases of aspiration, there may exist no immediate signs and symptoms noted. The aspiration may not be realized until complications like pneumonia occurs.

Causes and Gamble Factors of Aspiration

Aspiration tin happen due to reduced tongue control. This results to failure of triggering the swallowing reflex. An abnormal swallow reflex due to a neurological disorder may also lead to aspiration.

Throat surgeries and response to certain medications tin too issue to dysphagia-related aspiration. Dysphagia becomes more likely to occur as a person grows older, thus aspiration is common in elderly patients.

A number of medical weather condition may put a person at risk for aspiration. These include:

acid reflux
seizures
blackout
cancer in any part of the upper digestive system, such as the mouth, throat, and esophagus
head and cervix injuries
stroke
eating and drinking as well fast
dental problems
oral cavity sores
cancer handling of the cervix or throat (radiotherapy or chemotherapy)
feeding tubes
breathing machines
cognitive disorders (due east.g., dementia)
neurological disorders (east.one thousand., Parkinson's disease)
frequent airsickness
muscular disorders (e.g., spinal muscular atrophy)
impaired mental condition or consciousness
lung disease
delayed growth in children
fissure palate in children
Down syndrome

Complications of Aspiration

If left untreated, aspiration may lead to the following serious medical conditions:

1. Aspiration pneumonia. Aspirating bacteria from swallowed nutrient, liquid, object, vomit, or saliva may pb to an infection in the lungs.

2. Pulmonary edema and respiratory distress. Liquid that enters the lungs may pb to the congestion of air sacs, which tin can cause difficulty of animate and respiratory distress.

3. Malnutrition, dehydration, and weight loss in children

Diagnosis of Aspiration

Physical test – to bank check for the signs and symptoms of dysphagia and aspiration
Imaging – the following imaging tests may be ordered by the physician every bit needed:
X-rays and bronchoscopy – to check the extent of aspiration in the respiratory tract
Modified barium consume (MBS) – to visualize the pharynx and esophagus equally the patient swallows food and liquids mixed with barium
Fiber-optic endoscopic evaluation of swallowing (FEES) – an endoscopy of the pharynx and esophagus by inserting a thin tube into a numbed nose
Pharyngeal manometry – the insertion of a catheter into a numbed nose towards the pharynx to mensurate the pressure in the upper digestive tract as the patient swallows

Handling for Aspiration

one. Management of the underlying medical condition. Aspiration can be treated by means of managing its medical cause. For case, giving medications to end or command acid reflux tin resolve dysphagia and prevent aspiration.

2. Referral to a speech-language pathologist (SLP) or voice communication and language therapy (SALT) team. An SLP or Common salt squad can assistance make up one's mind swallowing issues and create a treatment plan to improve swallowing, manage dysphagia, and prevent aspiration.

3. Surgery. In severe or recurrent cases of aspiration, a surgical intervention may be required. The surgery involves creating a flap closure to prevent nutrient, liquid, or other strange bodies to enter the airways.

iv. Repositioning. An unconscious patient can be turned on one side to prevent aspiration.

Prevention of Aspiration

The healthcare provider can advise the following actions to preclude aspiration:

1. Eat and drinkable slowly and chew nutrient thoroughly.

2. Ensure correct posture when eating or drinking. Information technology is ideal to sit upright while eating or drinking, or at to the lowest degree lift oneself using a wedge pillow. Practice not eat or drink while lying apartment. Stand or sit down upright at to the lowest degree xxx minutes afterward eating or drinking.

3. Feed the infant on an angled position and not when he/she is lying down.

4. Avert distractions while eating or drinking, such as watching TV or talking on the phone.

5. Cutting food in smaller pieces.

vi. Avoid eating dry out food, or increase its moisture by ways of calculation sauce.

seven. Maintain proper dental hygiene and have regular dental check-ups.

8. Cease smoking.

ix. In patients with feeding tubes, check the placement of the tube first before starting the feed. Ensure to take time in administering the feed.

Nursing Care Plans for Aspiration

Nursing Care Programme ane

Nursing Diagnosis: Risk for Aspiration related to decreased ability to consume secondary to multiple sclerosis

Desired Outcome: The patient will exist able to avoid whatever aspiration or developing aspiration pneumonia.

Interventions	Rationale
Assess airway patency.	Maintaining an open and clear airway is vital to retain airway clearance and reduce the hazard for aspiration.
Appraise the patient's ability to cough out secretions.	Multiple sclerosis features neuromuscular weakness and may limit the patient'due south ability to clear the airway.
Refer the patient to SLP or speech and language therapy (Table salt) squad.	MS can diminish or reduce the patient'due south power to swallow. The patient can aspirate, which can crusade respiratory issues. The SALT team are specialists in assessing the ability to consume and recommending diet, thickness of liquids to drink, and techniques to improve the ability to eat.
Encourage a Fowler's position when the patient is eating/ feeding the patient.	To foreclose food or liquid to be aspirated into the airways and lungs.
Follow the SLP or SALT squad's advice on the appropriate nutrition of the patient as well as the proper thickness of the drinks.	To prevent nutrient or liquid to be aspirated into the airways and lungs.

Nursing Intendance Plan 2

Nursing Diagnosis: Risk for Imbalanced Diet: Less Than Body Requirements related to dysphagia and aspiration

Desired Outcome: The patient will either regain normal swallowing capacity or be able to improve nutrition by tube feeding. He/she will also obtain agreement of food options to support nutrition supplementation.

Interventions	Rationales
Certificate the patient's weight. Weight the patient daily in the mornings.	Weight loss can be measured accurately with a patient's actual weight rather than by estimate. The patient's weight is also an platonic tool in the cess of a person's nutritional requirements.
Beginning the patient on a nutrient diary and assess caloric intake.	A record of what the patient eats can help direct handling.
Assess what the patient can safely eat and drink.	Patients with dysphagia and aspiration may be able to tolerate thickened liquids and pureed food. Assessing what the patient can tolerate volition help support diet and arrange nutrient choices to go bachelor.
Promote a semi or full Fowler's position during feeding.	An upright position or elevating the caput to at least xxx degrees aids in swallowing and reduces the risk for aspiration.
Refer the patient to the dietitian and/or nutritionist.	A dietitian can help the medical team appraise the patient'south nutritional condition and recommend food options that will supplement the patient's nutritional gaps.
Refer to oral communication and linguistic communication therapy.	Spoken communication and language therapists appraise the patient's ability to swallow safely and tin can recommend food and food texture that is safety for the patient to eat/drink.
Weigh the patient regularly and document readings.	The patient's weight will help in the evaluation of the patient'due south progress.
Explain nutrition and the patient's personal nutritional needs.	Agreement the importance of maintaining proper nutrition will encourage the patient to become proactive in adhering to the handling plan.
Hash out the nutritional recommendation of the team, nutritionist, and dietitian to the patient. Follow the recommended type of diet and thickness of fluids.	An explanation of the new food choices and the recommended type of diet and fluids to support the patient's nutritional requirements will promote compliance to treatment.

Nursing Care Plan 3

Ineffective Airway Clearance related to dysphagia and aspiration as evidenced by difficulty of swallowing and shortness of jiff

Desired Upshot: The patient volition be able to establish improved airway patency and airway clearance as evidenced by respiratory rates between 12 to twenty breaths per minutes, oxygen saturation within the target range (as gear up by the dr.), and verbalize ease of breathing.

Intervention	Rationale
Assess the patient's vital signs and characteristics of respirations at least every 4 hours. Assess for signs of hypoxia.	To aid in creating an accurate diagnosis and monitor effectiveness of medical handling. Early signs of hypoxia include irritability, confusion, headache, restlessness, and pallor.
Place the patient on a side-lying position.	To promote drainage of saliva from the oral cavity through gravity, while preventing aspiration, especially in children.
Ask the patient to cough.	To facilitate removal of food, liquid or foreign object from the airways.
Suction equally needed.	To assist articulate liquid that the patient has aspirated.
Elevate the caput of the bed and assist the patient to assume semi-Fowler'south position.	Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.

Other possible nursing diagnoses:

Take a chance for Infection (aspiration pneumonia)

Chance for Dehydration
Risk for Failure to Thrive (in infants and children)
Anxiety
Fatigue

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An testify-based guide to planning care . St. Louis, MO: Elsevier. Purchase on Amazon

Gulanick, G., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, Northward. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative intendance . St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier. Purchase on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an data resource simply and is not to be used or relied on for whatever diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used equally a substitute for professional diagnosis and treatment.

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