Impaired Swallowing Care Plan

Impaired Swallowing NANDA-I Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function Impaired swallowing can be a temporary or permanent complication that can be life threatening. Aspiration of food or fluid is the most serious complication. Impaired swallowing can be caused by a structural problem, interruption or dysfunction of neural pathways, decreased strength or excursion of muscles involved in mastication, facial paralysis, or perceptual impairment. Swallowing difficulties are a common complaint among older adults, in those individuals who have had a stroke, suffered head trauma, have head or neck cancer, or experience progressive neurological diseases like Parkinson's disease, multiple sclerosis, and amyotrophic lateral sclerosis. Dysphagia severity rating scales are available to guide extent of modification in diet plan. Common Related Factors Neuromuscular:  Decreased or absent gag reflex  Decreased strength or excursion of muscles involved in mastication 

Perceptual impairment

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Facial paralysis (cranial nerves VII, IX, X, XII)

Mechanical:  Edema  Tracheostomy tube 

Tumor

Fatigue Limited awareness Reddened, irritated oropharyngeal cavity (stomatitis) Defining Characteristics Observed evidence of difficulty in swallowing (coughing, choking, stasis of food in oral cavity) Verbalized difficulty swallowing Complaints of "something stuck" in throat Abnormality in swallow study Evidence of aspiration

Common Expected Outcomes

Patient exhibits ability to safely swallow, as evidenced by absence of aspiration, no evidence of coughing or choking during eating/drinking, no stasis of food in oral cavity after eating, and ability to ingest foods/fluid. Patient verbalizes appropriate maneuvers to prevent choking and aspiration: positioning during eating, type of food tolerated, and safe environment. Patient and caregiver verbalize emergency measures to be enacted should choking occur. NOC Outcomes  

Swallowing Status Risk Control

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Self-Care: Eating

NIC Interventions  

Aspiration Precautions Swallowing Therapy

Ongoing Assessment Assess for presence of gag and cough reflexes. The lungs are normally protected against aspiration by reflexes such as cough or gag. When reflexes are depressed, patient is at increased risk for aspiration. Assess strength of facial muscles. Cranial nerves VII, IX, X, and XII regulate motor function in the mouth and pharynx. Coordinated function of muscles innervated by these nerves is necessary to move a bolus of food from the front of the mouth to the posterior pharynx for controlled swallowing. Assess coughing or choking during eating and drinking. These signs indicate aspiration risk. Assess ability to swallow small amount of water. If aspirated, little or no harm to patient occurs. Assess for residual food in mouth after eating. Pocketed food may be easily aspirated at a later time. Assess regurgitation of food or fluid through nares. Regurgitation indicates a decreased ability to swallow food or fluids and an increased risk for aspiration. Assess results of swallowing studies as ordered. A video-fluoroscopic swallowing study may be indicated to determine nature and extent of any oropharyngeal swallowing abnormality, which aids in designing interventions.

Therapeutic Interventions For the hospitalized or home care patient: Before mealtime, provide adequate rest periods. Fatigue can further contribute to swallowing impairment.

Remove or reduce environmental stimuli (e.g., television, radio). With distractions removed, the patient can concentrate on swallowing. Provide oral care before feeding. Clean and insert dentures before each meal. Optimal oral care facilitates appetite and eating. If swallowing study was completed, consult with speech pathologist regarding level of dysphagia severity and implications for meal planning. Levels on rating scales can range from minimal dysphagia, in which no change in diet is required, to mild-moderate dysphagia, in which specific swallow techniques and a modified diet may be indicated, to severe dysphagia, in which nothing by mouth is recommended. Place suction equipment at bedside, and suction as needed. With impaired swallowing reflexes, secretions can rapidly accumulate in the posterior pharynx and upper trachea, increasing risk for aspiration. If decreased salivation is a contributing factor:  Before feeding, give the patient a lemon wedge, pickle, or tart-flavored hard candy.  Use artificial saliva. Moistening and use of tart flavors stimulate salivation, lubricate food, and enhance ability to swallow. Maintain the patient in high-Fowler's position with head flexed slightly forward during meals. Upright position facilitates gravity flow of food or fluid through alimentary tract. Aspiration is less likely to occur with head tilted slightly forward (position narrows airway). Encourage intake of food that the patient can swallow; provide frequent small meals and supplements. Use thickening agents as recommended by a speech pathologist. Thickened foods with consistency of pudding, cooked cereal, and semisolid food are easier for the patient to manage in the mouth and pharynx for controlled swallowing. Thin foods are most difficult; gravy or sauce added to dry foods facilitates swallowing. Instruct the patient to (1) hold food in mouth, (2) close lips, (3) think about swallowing, and then (4) swallow. Proper instruction and focused concentration on specific steps reduces risks. Instruct the patient not to talk while eating. Provide verbal cueing as needed. Concentration must be focused on swallowing. Encourage the patient to chew thoroughly, eat slowly, and swallow frequently, especially if extra saliva is produced. Provide patient with direction or reinforcement until he or she has swallowed each mouthful. Such directions assist in keeping one's focus on the task. Identify food given to the patient before each spoonful if the patient is being fed. Knowledge of consistency of food to expect can prepare the patient for appropriate chewing and swallowing technique. Proceed slowly, giving small amounts; whenever possible, alternate servings of liquids and solids. This technique helps prevent foods from being left in the mouth. Encourage a high-calorie diet that includes all food groups, as appropriate. Avoid milk and milk products. Dairy products can lead to thickened secretions. If patients pouch food to one side of their mouth, encourage them to turn their head to the unaffected side and manipulate the tongue to paralyzed side.

Foods placed in unaffected side of mouth facilitate more complete chewing and movement of food to back of mouth, where it can be swallowed. These strategies aid in cleaning out residual food. If patient has had a stroke, place food in back of mouth, on unaffected side, and gently massage unaffected side of throat. Massage helps stimulate act of swallowing. Place whole or crushed pills in custard or gelatin. (First ask a pharmacist which pills should not be crushed.) Substitute medication in elixir form as indicated. Mixing some pills with foods helps reduce risk for aspiration. Encourage the patient to feed self as soon as possible. With self-feeding, the patient can control the volume of a food bolus and the timing of each bite to facilitate effective swallowing. If oral intake is not possible or is inadequate, initiate alternative feedings (e.g., nasogastric feedings, gastrostomy feedings, or hyperalimentation). Optimal nutrition is a patient need. Follow-up: Initiate dietary consultation for calorie count and food preferences. Dietitians have a greater understanding of the nutritional value of foods and may be helpful in guiding treatment.

Education/Continuity of Care Discuss with and demonstrate the following to the patient or caregiver:  Avoidance of certain foods or fluids  Upright position during eating 

Allowance of time to eat slowly and chew thoroughly

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Provision of high-calorie meals

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Use of fluids to help facilitate passage of solid foods

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Monitoring of patient for weight loss or dehydration

Both the patient and caregiver may need to be active participants in implementing the treatment plan to optimize safe nutritional intake. Teach patient/caregiver exercises to enhance muscular strength of face and tongue to enhance swallowing. Muscle strengthening can facilitate greater chewing ability and positioning of food in mouth. Facilitate home care aide or meal provision, if needed. Homebound patients may require additional assistance to maintain adequate nutrition. Demonstrate to the patient, caregiver, or family what should be done if the patient aspirates (e.g., chokes, coughs, becomes short of breath). For example, use suction, if available, and the Heimlich maneuver if the patient is unable to speak or breathe. If liquid aspiration, turn the patient three-fourths prone with head slightly lower than chest. If patient has difficulty breathing, call the Emergency Medical System (9-1-1).

Respiratory aspiration requires immediate action by the caregiver to maintain the airway and promote effective breathing and gas exchange. Being prepared for an emergency helps prevent further complications. Encourage family members or caregiver to seek out cardiopulmonary resuscitation (CPR) instruction. Mastery of emergency measures may provide confidence to both the patient and caregiver.