Friday, 26 March 2010

IMPAIRED SWALLOWING AND ASPIRATION PRECAUTIONS

Patients may experience impaired swallowing as a result of several specific problems. The first of these, oropharyngeal dysphagia, is impaired swallowing associated with deficits in oral and pharyngeal structure or function. These patients are at especially high risk for aspiration, and many of them experience silent aspiration. Patients at risk for oropharyngeal dysphagia include those with:
  • nervous system damage such as stroke, head injury, or spinal cord injury
  • neuromuscular diseases such as muscular dystrophy and cerebral palsy
  • progressive neurologic disease such as Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, and dementia
  • facial, oral, or neck surgery or trauma
  • head and neck cancer.
Patients who were intubated for more than 3 days are also at risk for oropharyngeal dysphagia.
The second impaired swallowing problem is associated with esophageal dysphagia and aspiration risk due to:
  • gastroesophageal reflux disease
  • esophageal dysmotility or structural abnormality
  • delayed gastric emptying
  • nasogastric tubes.
Finally, impaired swallowing can be associated with tracheostomy or ventilation support due to:
  • decreased sensation of the oral and pharyngeal cavities
  • decreased sensation of food or fluids penetrating the laryngeal vestibule and aspirating (dropping below the level of the vocal cords)
  • decreased ability to cough aspirated material off the vocal cords
  • decreased laryngeal elevation and airway closure.
Equipment
Meal tray, call bell, wall suction or portable suction apparatus, suction kit, gloves, protective eyewear, pulse oximeter.
Implementation
  • Explain the procedure to the patient and his family.
  • Wash your hands, and put on gloves and protective eyewear, if indicated, prior to suctioning the patient or providing mouth care


Managing impaired swallowing due to oropharyngeal dysphagia

Managing impaired swallowing due to esophageal dysphagia

Managing impaired swallowing due to tracheostomy or endotracheal tube

Managing a patient with a feeding tube

Impaired swallowing due to speaking valve trials


Special considerations
Monitor the patient for signs and symptoms of swallowing problems and aspiration, including:
  • coughing before, during, or after eating
  • wet or gurgling voice
  • increased chest congestion after eating
  • multiple swallows on one mouthful or washing down food with liquids
  • complaints of food getting stuck or painful swallowing
  • unexplained changes in amount or rate of eating
  • drooling or spitting food out of the mouth
  • difficulty breathing during meals
  • leakage from the tracheostomy site
  • low-grade fevers shortly after meals
  • weight loss and poor oral intake
  • recurrent pneumonias
  • increased white blood cell counts.
Patient teaching
  • Train the family to feed the patient, and supervise them as needed.
  • Teach family members the abdominal thrust maneuver.
  • Teach family members how to use suction equipment as needed.
Complications
Patients with impaired swallowing are more likely to experience airway obstruction and aspiration during meals. Aspiration may result in pneumonitis or pneumonia. Difficulty swallowing may result in decreased oral intake and eventually lead to dehydration and malnutrition.
Documentation
Record the amount of intake, the patient's food preferences, progress with meals, and any techniques effective in helping the swallowing process. Document the effectiveness of the family's assistance. Record any complications that arise and the interventions used to correct them.