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Risk for Aspiration

By Gil Wayne, BSN, R.N. - October 26, 2016  0

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Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion, solids, or fluids
into tracheobronchial passages.

Aspiration is breathing in a foreign object such as foods or liquids into the trachea and lungs and happens
when protective reflexes are reduced or jeopardized. An infection that develops after an entry of food,
liquid, or vomit into the lungs can result in aspiration pneumonia. Inhaling chemical fumes or breathing in
and choking on certain chemicals, even small amounts of gastric acids can damage lung tissue, resulting
in chemical pneumonitis. Many household and industrial chemicals can produce both an acute and a
chronic form of inflammation in the lungs which can place patients at risk for aspiration. Acute conditions,
like postanesthesia effects from surgery or diagnostic tests, happen predominantly in the acute care
setting. Chronic conditions, like altered consciousness from head injury, spinal cord injury, neuromuscular
weakness, hemiplegia, and dysphagia from stroke, use of tube feedings for nutrition, and artificial airway
devices such as tracheostomies, may be experienced in the home, rehabilitative, or hospital setting.

Prevention is the main goal when caring for patients at risk for aspiration. Evidence shows that one of the
principal precautionary measures for aspiration is placing at-risk patients in a semirecumbent position.
Other measures include compensating for absent reflexes, assessing feeding tube placement, identifying
delayed stomach emptying, and managing effects of prolonged intubation.

1. Risk Factors
2. Goals and Outcomes
3. Nursing Assessment
4. Nursing Interventions

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Risk Factors

Here are some factors that may be related to Risk for Aspiration:

Advanced age
Anesthesia or medication administration
Decreased gastrointestinal motility
Delayed gastric emptying
Depressed cough or gag reflex
Drug or alcohol intoxication
Facial, oral, or neck surgery or trauma
Impaired swallowing
Increased gastric residual
Presence of gastrointestinal tubes
Presence of tracheostomy or endotracheal tube
Reduced level of consciousness
Seizure activity
Situations hindering elevation of upper body
Tube feedings
Wired jaws

Goals and Outcomes

The following are the common goals and expected outcomes for Risk for Aspiration:

Patient is free of signs of aspiration and the risk of aspiration is decreased.

Patient expectorates clear secretions and is free of aspiration.
Patient maintains a patent airway with normal breath sounds.
Patient swallows and digests oral, nasogastric, or gastric feeding without aspiration.

Nursing Assessment

Assessment is required in order to distinguish possible problems that may have lead to aspiration as well
as name any episode that may occur during nursing care.

Assessment Rationales 
Assess level of consciousness. The primary risk factor of aspiration is decreased
level of consciousness.

Monitor respiratory rate, depth, and effort. Note Signs of aspiration should be identified as soon as
any signs of aspiration such as dyspnea, cough, possible to prevent further aspiration and to
cyanosis, wheezing, or fever. initiate treatment that can be life-saving.

Evaluate swallowing ability by assessing for the

following:

Impaired swallowing increases the risk for

Coughing, choking, throat clearing, gurgling or
aspiration. There remains a need for valid and
“wet” voice during or after swallowing
easy-to-use methods to screen for aspiration risk.
Residual food in mouth after eating
Regurgitation of food or fluid through the nares

For high-risk patients, performance of a

videofluoroscopic swallowing study may be
Review results of swallowing studies as ordered.
indicated to determine the nature and extent of
any swallowing abnormality.

Nausea or vomiting places patients at great risk

for aspiration, especially if the level of
Assess for presence of nausea or vomiting. consciousness is compromised. Antiemetics may
be required to prevent aspiration of regurgitated
gastric contents.

Food should never be present in the

Observe for food particles in tracheal secretions in
tracheobronchial passages. It signifies aspirated
patients with tracheostomies.
material.

Reduced gastrointestinal motility increases the

risk of aspiration as fluids and food build up in the
Auscultate bowel sounds to assess for stomach. Further, elderly patients have a decrease
gastrointestinal motility. in esophageal motility, which delays esophageal
emptying. When combined with the weaker gag
reflex of older patients, aspiration is at higher risk.

Assess pulmonary status for clinical evidence of Aspiration of small amounts can happen with
aspiration. Auscultate breath sounds noting for sudden onset of respiratory distress or without
crackles and rhonchi. Monitor chest x-ray films as coughing particularly in patients with diminished
ordered. levels of consciousness. Pulmonary infiltrates on

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 chest x-ray films indicate some level of aspiration
has already occurred.

An ineffective cuff can increase the risk of

Monitor the effectiveness of the cuff in patients
aspiration. Work together with the respiratory
with endotracheal or tracheostomy tubes.
therapist, as necessary, to verify cuff pressure.

In patients with nasogastric (NG) or gastrostomy tubes:

A displaced tube may erroneously deliver tube

Check placement before feeding, using tube feeding into the airway. Chest x-ray verification of
markings, x-ray study (most accurate), pH of accurate tube placement is most reliable. Gastric
gastric fluid, and color of aspirate as guides. aspirate is usually green, brown, clear, or colorless,
with a pH between 1 and 5.

Test sputum with glucose oxidase reagent Significant amounts of glucose in sputum may be
strips. indicative of aspiration.

Large amounts of residuals indicate delayed

gastric emptying and can cause distention of the
Check residuals before feeding, or every 4 stomach, leading to reflux emesis. The amount of
hours if feeding is continuous. Hold feedings if residuals may vary depending on the volume and
amount of residuals is large, and notify the rate of infusion; however, the evaluation can be
physician. unreliable. Feedings are often held if residual
volume is greater than 50% of the amount to be
delivered in 1 hour.

Food and feeding habits may be strongly tied to

Assess the patient and family for willingness and
family cultural values. Acknowledgment and/or
cognitive ability to learn and cope with swallowing,
adjustment to cultural values can facilitate
feeding, and related disorders.
compliance and successful family coping.

Nursing Interventions

The following are the therapeutic nursing interventions for Risk for Aspiration:

Interventions Rationales

Keep suction machine available when feeding A patient with aspiration needs immediate
high-risk patients. If aspiration does occur, suction suctioning and will need further lifesaving
immediately. interventions such as intubation. 
Inform the physician or other health care provider Early intervention protects the patient’s airway and
instantly of noted decrease in cough/gag reflexes prevents aspiration. Anyone identified as being at
or difficulty in swallowing. high risk for aspiration should be kept NPO
(nothing by mouth) until further evaluation is
completed.

Keep head of bed elevated when feeding and for at Maintaining a sitting position after meals may help
least a half hour afterward. decrease aspiration pneumonia in the elderly.

This positioning (rescue positioning) decreases

Position patients with a decreased level of the risk for aspiration by promoting the drainage
consciousness on their side. of secretions out of the mouth instead of down
the pharynx, where they could be aspirated.

Supervision helps identify abnormalities early and

Supervise or aid the patient with oral intake. Never allows implementation of strategies for safe
give oral fluids to a comatose patient. swallowing. Withholding fluids and foods as
needed prevents aspiration.

Thickened semisolid foods such as pudding and

Provide foods with consistency that the patient
hot cereal are most easily swallowed and less
can swallow. Use thickening agents if
likely to be aspirated. Liquids and thin foods (e.g.,
recommended by a speech pathologist or
creamed soups) are most difficult for patients
dietician.
with dysphagia.

Well-masticated food is easier to swallow, food

Allow the patient to chew thoroughly and eat
cut into small pieces may also be easier to
slowly during meals.
swallow.

Abdominal distention or rigidity can be associated

Note new onset of abdominal distention or
with paralytic or mechanical obstruction and an
increased rigidity of abdomen.
increased likelihood of vomiting and aspiration.

Concentration must be focused on chewing and

For patients with reduced cognitive abilities,
swallowing. There is a higher risk for the airway to
eliminate distracting stimuli during mealtimes. Tell
be opened when talking and eating at the same
the patient not to talk while eating.
time.

During enteral feedings, position patient with head

Keeping patient’s head elevated helps keep food in
of bed elevated 30 to 40 degrees; maintain for 30
stomach and decreases incidence of aspiration
to 45 minutes after feeding.

Place medication and food on the strong side of Careful food placement promotes chewing and
the mouth when unilateral weakness or paresis is successful swallowing.

present.

Ingesting food and fluids together increases

Offer liquids after food is eaten.
swallowing difficulties.

Place whole or crushed pills in soft foods (e.g.,

Mixing pills with food helps reduce risk for
custard). Verify with a pharmacist which pills
aspiration.
should not be crushed.

When turning or moving a patient, it is difficult to

Stop continual feeding temporarily when turning or
keep the head elevated to prevent regurgitation
moving patient.
and possible aspiration.

Oral care before meals reduces bacterial counts in

the oral cavity. Oral care after eating removes
Provide oral care before and after meals.
residual food that could be aspirated at a later
time.

In patients with artificial airways:

Suctioning reduces the volume of oropharyngeal

Perform oral suctioning as needed.
secretions and reduces aspiration risk.

Oral care reduces the risk for ventilator-associated

Brush teeth twice a day, and swab mouth with
pneumonia by decreasing the number of
sponge applicators every 2 to 4 hours between
microorganisms in aspirated oropharyngeal
brushing.
secretions.

In patients with NG or gastrostomy tubes:

 If ordered by physician, put several drops of

blue or green food coloring in tube feeding to
Colored secretions suctioned or coughed from the
help indicate aspiration. In addition, test the
respiratory tract indicate aspiration.
glucose in tracheobronchial secretions to
detect aspiration of enteral feedings.

Upright positioning reduces aspiration by

Elevate the head of bed to 30 to 45 degrees
decreasing reflux of gastric contents.
while feeding the patient and for 30 to 45
minutes afterward if feeding is intermittent.
Turn off the feeding before lowering the head
of bed. Patients with continuous feedings
should be in an upright position. 
 A speech pathologist can be consulted to perform
a dysphagia assessment that helps determine the
need for videofluoroscopy or modified barium
Consult a speech pathologist, as appropriate.
swallow and to establish specific techniques to
prevent aspiration in patients with impaired
swallowing.

For patients at high risk for aspiration, obtain Continuity of care can prevent unnecessary stress
complete information from the discharging for the patient and family and can facilitate
institution regarding institutional management. successful management in the home setting.

Establish emergency and contingency plans for Clinical safety of patient between visits is a
care of patient. primary goal of home care nursing.

Educate the patient and family the need for proper Upright positioning decreases the risk for
positioning. aspiration.

Information helps in appropriate assessment of

Instruct in signs and symptoms of aspiration. high-risk situations and determination of when to
call for further evaluation.

Respiratory aspiration requires prompt action to

Demonstrate on suctioning techniques to prevent
maintain the airway and promote effective
accumulation of secretions in the oral cavity.
breathing and gas exchange.

Refer the patient to a home health nurse,

Use of consultants may be required to ensure
rehabilitation specialist, or occupational therapist
outcomes are achieved.
as indicated.

See Also

You may also like the following posts and nursing diagnoses: 

Nursing Diagnosis: The Complete List – archive of different nursing diagnoses with their definition,
related factors, goals and nursing interventions with rationale.
The Ultimate Guide to Nursing Diagnosis – learn how to formulate nursing diagnoses correctly in this
easy-to-follow guide! 
1,000+ Nursing Care Plans List – the ultimate database of nursing care plans for different diseases and
conditions! Get the complete list!
What is a Nursing Care Plan? 9 Steps on How to Write a Care Plan – learn how to write an excellent
care plan. We explain the concepts and walk you through the steps.  
Other Nursing Diagnoses

Activity Intolerance
Acute Confusion
Acute Pain
Anxiety
Caregiver Role Strain
Constipation
Chronic Pain
Decreased Cardiac Output
Deficient Fluid Volume
Deficient Knowledge
Diarrhea
Disturbed Body Image
Disturbed Thought Processes
Excess Fluid Volume
Fatigue
Fear
Hopelessness
Hyperthermia
Hypothermia
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: More Than Body Requirements
Impaired Gas Exchange
Impaired Oral Mucous Membrane
Impaired Physical Mobility
Impaired Swallowing
Impaired Tissue (Skin) Integrity
Impaired Urinary Elimination
- Functional Urinary Incontinence
- Reflex Urinary Incontinence
- Stress Urinary Incontinence
- Urge Urinary Incontinence
Impaired Verbal Communication
Ineffective Airway Clearance
Ineffective Breathing Pattern
Ineffective Coping 
 Ineffective Therapeutic Regimen Management
Ineffective Tissue Perfusion
Latex Allergy Response
Powerlessness
Rape Trauma Syndrome
Risk for Aspiration
Risk for Bleeding
Risk for Falls
Risk for Infection
Risk for Injury
Risk for Unstable Blood Glucose Level
Self-Care Deficit
Urinary Retention

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Last updated on September 24, 2017

TAGS Nursing Diagnosis risk for aspiration

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Gil Wayne, BSN, R.N.

https://nurseslabs.com

Gil Wayne graduated in 2008 with a bachelor of science in nursing and during the same year, earned his license
to practice as a registered nurse. His drive for educating people stemmed from working as a community health

 nurse where he conducted first aid training and health seminars and workshops to teachers, community
members, and local groups. Wanting to reach a bigger audience in teaching, he is now a writer and contributor
for Nurseslabs since 2012 while working part-time as a nurse instructor. His goal is to expand his horizon in
nursing-related topics, as he wants to guide the next generation of nurses to achieve their goals and empower
the nursing profession.

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