Nursing Manual

Fatal Four Topic: Aspiration

1. Decreased or absent protective airway reflexes such as occur in cerebral palsy.
2. Poor or underdeveloped oral motor skills that do not permit adequate chewing or swallowing.
3. Gastroesophogeal reflux disorder (GERD) which may cause aspiration of refluxed stomach contents.
4. Epileptic seizures.
5. Poor self-eating skills (food stuffing, rapid eating).
6. Inappropriate fluid consistency and/or food textures.
7. Inadequately trained staff assisting persons with eating (poor assisted eating technique and allowing poor positioning).
8. Medication side effects which decrease/relax voluntary muscles causing delayed swallowing or suppression of protective reflexes of gagging and coughing.
9. Impaired mobility may leave persons unable to properly position themselves for adequate swallowing.

Nursing assessment

Record Review/History

• Diagnosis of conditions such as cerebral palsy, epilepsy, GERD, dysphasia or hiatal hernia
• History of aspiration pneumonia
• Assisted by staff with eating or drinking
• History of choking, coughing, gagging while eating
• Modified food texture and fluid consistency
• Eating/swallowing evaluations and laboratory tests (barium swallow, pH study, etc.)
• Unexplained weight loss
• Taking medications that may decrease voluntary muscle coordination or cause decreased alertness
• Unsafe eating and drinking habits due to mental illness or behavior disorder

Assessment

• Gagging, choking, coughing with or shortly after meals
• Drooling
• Food falls out while eating

• Forceful ejection of food during swallow
• Smells of vomit or food after a meal
• Frequent emesis

• Positioning during meals, trunk, neck, head in proper alignment
• Positioning after meals in an upright position

• Elevated body temperature
• Abnormal lung sounds
• Rapid or labored respirations
• Wet respirations at mealtime

• Rapid eating, food stuffing, water seeking
• Impulsivity, distractibility at meals

Staff interview

• Reports of coughing, choking, gagging while or immediately after eating
• Reports that the individual will only eat for one or two special staff
• Reports that the individual takes unusually long to eat a meal
• Reports of meal refusals

• Is based on a professional assessment of the person's health care
  • Problems
  • Support needs
• Identifies:
  • Measurable and appropriate goals
  • Specific interventions
  • By whom and how frequently data will be monitored
• Refers to an individualized aspiration protocol that contains:
  • Risk factors for aspiration specific to the person.
  • Prevention strategies
  • Signs and symptoms of aspiration
  • Interventions
  • Reminders for the staff to call 911 if they believe the person appears gravely ill or they are concerned about their immediate health and safety.

Goals

• Respiratory rate within normal limits
• Breath sounds normal
• No instances of gagging, coughing, choking with eating
• No aspiration pneumonia
• No evidence of chronic lung changes on chest x-ray

Interventions

• Written plan for feeding or assisting person
• Food texture and liquid consistency per physician orders
• Liquid consistency with tooth brushing or administering medications
• Proper positioning during and after meals
• Swallowing evaluation as indicated/ordered
• Only trained staff to assist with eating
• Stop eating/assisting if person coughs, chokes or gags until improved
• Offer more frequent but smaller meals
• Slow pace of eating and decrease size of bites
• Avoid supine position after meals (best upright 30 minutes after eating)
• Head of bed elevated per orders (for individuals with GERD)
• Avoid food/fluid before bedtime
• Breath sounds assessment by nurse

Evaluation

• Analysis and review of interventions
• Review of person's and staff's training needs
• Review and continue to monitor person's response