00039 Aspiration Risk

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00039
Nanda label: aspiration risk
Diagnostic focus: aspiration
Approved 1988 • Revised 2013, 2017, 2020 • Level of evidence 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis “aspiration risk” is defined as: susceptible to the penetration of gastrointestinal secretions, oropharyngeal, solid or liquid in the tracheobronchial tree, which can compromise health. P>

Risk factors

  • Barriers for the elevation of the upper body
  • Decrease in gastrointestinal motility
  • Difficulty in swallowing
  • Revelation of the enteral nutrition probe
  • Insufficient knowledge of modifiable factors
  • Increase in gastric residue
  • Ineffective cleaning of the airways

Risk population

  • Older adults
  • Premature infants

Associated problems

  • Chronic obstructive pulmonary disease
  • Severe condition
  • Decrease in the level of consciousness
  • Gastric emptying delay
  • Decrease in the nauseous reflex
  • Enteral nutrition
  • Facial surgery
  • Facial trauma
  • Head and neck neoplasms
  • Incompetence of the lower esophageal sphincter
  • Increased intragastric pressure
  • Jaw fixing techniques
  • Medical devices
  • Neck surgery
  • Neck trauma
  • Neurological diseases
  • Oral surgical procedure
  • Oral trauma
  • Pharmacological preparations
  • Pneumonia
  • stroke
  • Therapeutic regime

Suggestions of use

The most specific diagnosis should always be used, in which the patient meets the necessary defining characteristics. The risk of injury should not be used if the patient presents the defining characteristics or risk factors of aspiration. If the etiology of aspiration risk is deterioration of swallowing, both diagnoses could be adequate.

Suggested alternative diagnostics

NOC Results

note : For the results of specific etiologies (risk factors), consult the following diagnoses: acute confusion, chronic confusion, ineffective infant feeding pattern, deterioration of physical mobility, deficit of the Self -care: feeding and deterioration of swallowing.

  • Deglution status: Safety in the passage of liquids and solids of the mouth to the stomach
  • Respiratory status: permeability of the respiratory tract: open and clear tracheobronchial tree to perform the gas exchange
  • Respiratory status: ventilation: input and output of the lungs
  • Precautions to avoid aspiration: personal actions aimed at preventing the passage of solid and liquid particles to the lung

Evaluation objectives and criteria

  • It will not suffer aspiration, as evidenced by the prevention of aspiration, the state of swallowing not affected and the respiratory state: ventilation
  • Demonstrate aspiration prevention, as the following indicators prove (specify from 1 to 5: never, sometimes, sometimes, often or usually):
    • Avoid risk factors
    • Eat and drink upright
    • Choose liquids and food from the appropriate consistency
    • Select food according to your swallowing capacity

Other examples

The patient will be able to:

  • Prove that swallowing has improved
  • Tolerate intake and oral secretions without aspirating
  • Tolerate enteral food without aspirating
  • Vesicular murmur preserved in auscultation and always open airways
  • Maintain the appropriate strength and muscle tone

NIC Interventions

  • Change of position: place the patient or part of his body in a certain way to promote physiological and psychological well -being
  • Respiratory control and monitoring: Patient data collection and analysis to ensure the permeability of the respiratory tract and an appropriate gas exchange
  • Teaching: Child Safety: Security instructions in the first year of life
  • Management of respiratory tract: facilitate the permeability of the respiratory system
  • Vomit management: prevention and relief of vomiting
  • Precautions to avoid aspiration: prevention or minimization of risk factors in a patient at risk of aspiration
  • swallow therapy: facilitate swallowing and prevent complications derived from swallowing alterations

Nursing Activities

Valuations

  • Check the gastric residue before food and medication administration
  • Pulmonary auscultation before and after food
  • Monitor the appearance of signs of bronchaspiration during feeding: cough, drowning, inability to swallow saliva, cyanosis, wheezing or fever
  • Check the placement of the enteral probe before food and medication administration
  • Evaluate whether the family feels comfortable with feeding, aspiration, patient positioning, etc.
  • (NIC) Precautions to avoid bronchaspiration:
    • Monitor level of consciousness, reflections of cough and vomiting, and swallowing capacity
    • Monitor the pulmonary state (for example, before and after feeding, and before and after administering medications)

Patient and family education

  • Teach the family of food and swallowing techniques
  • Teach the family to use the vacuum cleaner to eliminate secretions
  • Review with the patient and his family the signs and symptoms of aspiration, as well as preventive measures
  • Help the family prepare an emergency plan in case the patient suffers an aspiration at home

Collaboration activities

  • Communicate any color change in lung secretions that resemble food or food preparation
  • Request a consultation to occupational therapy
  • Refer to a home services agency to get home nursing help
  • (NIC) Precautions to avoid aspiration: suggest a consultation with a language specialist, if necessary

Others

  • Give the patient enough time to swallow
  • Place an aspiration catheter next to the bed and aspire during meals, if necessary
  • Implicate the family during food intake
  • Provide support and encouragement
  • If possible, place the patient in Fowler’s position, high or medium, during food and an hour later; Use the lateral recumbency if the previous one is contraindicated
  • Place patients who cannot sit and raise the head of the bed as much as possible, during and after meals
  • Administer positive reinforcers in the patient’s attempts to swallow by himself
  • If necessary, use a syringe to feed the patient
  • Vary the consistency of food to discover which ones are better tolerate
  • For patients with tracheostomy or endotracheal tube, inflate the ball during and after eating, as well as during probe diet and an hour later
  • (NIC) Precautions to avoid aspiration:
    • Keep the bed header high for 30 to 45 minutes after meals
    • Cut food into small pieces
    • Give small amounts of food every time
    • Avoid liquids or use thickeners
    • Take or crush the pills
    • Request medications in the form of syrup

At home

  • Teach family caregivers to use the suction equipment

Babies and Children

  • Choose toys appropriate to the child’s age, without small or removable parts; Do not offer balloons to young children
  • Avoid certain foods, such as nuts, gum, grapes and small candies
  • Teach parents not to support the bottle
  • In newborns with a leporino lip or cleft palate, consult feeding techniques in a pediatric nursing book
  • In normal newborns, keep in mind that they frequently regurgate when fed; put them erect and make them erets often during feeding; Place them in lateral recumbency

Older people

  • Weak elders may require case management to live independently; channel when necessary and if there are adequate services
  • Modified swallowing studies may be required to ensure that you can safely swallow, especially after a stroke