Aspiration Precautions

The nurse is caring for a client and suspects dysphagia. Which are the general symptoms of aspiration?

Drop in oxygen saturation while eating Pocketing food Wheezing breath sounds Coughing or choking while drinking

A nurse is caring for a client with prescribed aspiration precautions. What is the main concern when a client has pockets of food remaining in the mouth after eating?

Eventually, the pocket of food may be aspirated into the airway.

A nurse is caring for an older adult client who is retired but very active in the community. The client exercises daily and enjoys cooking healthy meals with their partner. Is this client at risk for aspiration?

No, because the client has no risk factors for aspiration.

A nurse is caring for a client admitted with left-sided weakness and facial drooping for 3 days. Which nursing actions will protect the client's airway while eating and drinking? Select all that apply.

Position the client upright when eating. Avoid talking to the client while they are eating. Do not provide a straw for drinking.

A nurse is caring for a client who has just returned from the post-anesthesia care unit (PACU) after a surgical procedure. The client is arousable but very drowsy and slurs words when asking for water. Which action by the nurse is most appropriate?

Withhold all food and fluids until the client is awake and alert.

A nurse is planning care for a client with a decreased level of consciousness. Which should be included in the plan of care? Select all that apply.

Primary interventions should be aimed at preventing aspiration. Problem analysis would be risk for aspiration due to impaired level of consciousness.

The nurse is making care assignments for several clients. Which clients may have difficulty swallowing and require aspiration precautions? Select all that apply.

A client who had a stroke An adolescent client who had surgical removal of traumatized tissue in the neck A client with muscular dystrophy A client with Parkinson's disease

John Mays (preferred pronouns: he/him/his) was recently admitted after a stroke. He has right-sided weakness and facial drooping. Click to select appropriate versus inappropriate actions taken by the nurse to prevent aspiration.

Appropriate Action: Use a feeding rate and bite size that matches John's tolerance. Encourage John to raise his left hand up if he is having difficulty swallowing or needs to stop. Place John on NPO status if he coughs, gags, or feels he still has food in his throat after swallowing. Provide verbal cues to John while he is chewing and swallowing. Obtain a baseline oxygen saturation because a decrease may indicate aspiration. Between bites, look in John's mouth to see if there are pockets of food remaining. Inappropriate Action: Encourage John to clear his throat and cough between bites to avoid the need for suctioning. Ask John to speak between bites to assess for a wet voice. Encourage John to look forward and tilt his head slightly up while swallowing. Provide John with only small bites of food and sips of thin liquids between bites.

A nurse is caring for a client with prescribed aspiration precautions. Specify which actions are appropriate versus inappropriate for this client.

Appropriate Steps: Assess the client for aspiration symptoms after all meals Ensure that the meal tray includes the appropriately prescribed diet. Delegate client feeding assistance to the unlicensed assistive personnel (UAP). Before feeding, be sure the client is awake, alert, and oriented. Before feeding, elevate the head of the bed to 90 degrees. Inappropriate Steps: Ask the client's partner to supervise eating. After feeding, ask the UAP to assess for aspiration symptoms. After feeding, lower the head of the bed to 30 degrees.

A nurse is caring for several clients at risk for aspiration. Which information should the nurse consider when planning care? Select all that apply.

Aspiration means that food or water enters the trachea instead of the stomach. The body is not functioning properly when aspiration occurs. Aspiration can be silent without common

A nurse is caring for a toddler with cerebral palsy who has limited communication and impaired mobility of the lips and tongue. Which instructions should be provided to the toddler's caregiver? Select all that apply.

Assure correct positioning when feeding. Thicken liquids to prescribed consistency. Monitor weight daily to ensure adequate intake. Provide small, easy to swallow bites.

The nurse is caring for a client with an increased risk for aspiration. Which actions should the nurse take? Select all that apply. ​

Avoid mixing foods of different textures in the same mouthful. ​ Monitor oxygen saturation during feeding. Maintain an upright position for at least 30 minutes after a meal. ​ Position the client upright (45-90 degrees) during feedings. ​

Feeding a client who is prescribed aspiration precautions _______ be delegated to an assistive personnel.

Can

A nurse is caring for an older adult client with muscular dystrophy in the emergency department (ED). The client's speech is abnormal, and lip and tongue movements appear delayed. The client has lost 7 pounds in the past 2 weeks. Secretions are thick, and the skin appears rough and dry. Which is the priority action taken by the nurse?

Place the client on nothing by mouth (NPO) status and notify the healthcare provider.

A nurse is caring for a client who has just finished eating. While talking to the nurse, the client's voice sounds "wet" and gurgling. Which action should the nurse take first?

Place the client on nothing by mouth (NPO) status.

A nurse is caring for a client with Parkinson's disease who is not prescribed aspiration precautions. The client appears to have no difficulties with eating or drinking. Why might the nurse remain concerned about aspiration risk?

Silent aspiration is common with neurologic disorders. Decreased sensation can cause silent aspiration. Some aspiration may be occurring even without obvious signs.