Cues Nursing Background Goals and Objectives Nursing interventions Evaluation

diagnosis Knowledge and rationale

Subjective: Imbalance Nutritional NOC: Swallowing status NIC: Swallowing The patient w
A day after his nutrition: imbalance is therapy able to:
admission, the less than caused by Goal: 1. Maintain
patient body inability of After 1-2 weeks of The nurse will: adequate
complained of requiremen the body to nursing interventions the hydration/nut
difficulty of t related to absorb patient will be able to 1. Determine n with optimu
swallowing difficulty of certain Demonstrates effective client's safety and
swallowing nutrients or swallowing without readiness to efficiency of
Objective: result from a choking or coughing eat. Client swallowing
The patient’s poor diet. needs to be function on P.
attending Based on alert, able to intake withou
physician ordered: the Objectives: follow overt signs an
 NGT nutrients in After nursing instructions, symptoms of
insertion short or interventions the patient hold head aspiration
 Intubation excess will be able to: erect, and able 2.Utilize
 Transferre supply, 1. Client will to move tongue compensatory
d to ICU imbalances maintain in mouth. strategies with
create adequate  If one of these optimum safe
unpleasant hydration/nutriti factors is and efficiency
side effects on with optimum missing, it may swallowing
and safety and be advisable to function on P.
conditions efficiency of withhold oral intake withou
that could swallowing feeding and use overt signs an
lead to function on P.O. enteral feeding symptoms of
serious intake without for nourishment
disease. overt signs and (McHale et al,
symptoms of 1998).
Many aspiration Cognitive
patients 2. Client will utilize deficits can
with GBS compensatory result in
experience strategies with aspiration even
difficulty optimum safety if able to
swallowing and efficiency of swallow
because the swallowing adequately
nerves that function on P.O. (Poertner,
control the intake without Coleman,
muscles for overt signs and 1998).
swallowing symptoms of
become 2. If new onset of
affected by swallowing
the impairment,
syndrome. ensure that
Difficulty client receives a
swallowing diagnostic
(dysphagia) workup.
can be a  There are
dangerous multiple causes
condition, of swallowing
especially impairment,
when a some of which
patient’s are treatable
immune (Schechter,
system is 1998).
compromise
d (such as in 3. Assess ability to
GBS) swallow by
positioning
examiner's
thumb and
index finger on
client's
laryngeal
protuberance.
Ask client to
swallow; feel
larynx elevate.
Ask client to
cough; test for a
gag reflex on
both sides of
posterior
pharyngeal wall
(lingual surface)
with a tongue
blade. Do not
rely on
presence of gag
reflex to
determine
when to feed.
 Normally the
time taken for
the bolus to
move from the
point at which
the reflex is
triggered to the
esophageal
entry
(pharyngeal
transit time) is
(1 second
(Logeman,
1983).
 Cardiovascular
accident (CVA)
clients with
prolonged
pharyngeal
transit times
(prolonged
swallowing)
have a greatly
increased
chance of
developing
aspiration
pneumonia
(Johnson,
McKenzie,
Sievers, 1993).
Clients can
aspirate even if
they have an
intact gag
reflex (Baker,
1993; Lugger,
1994).

4. Observe for
signs associated
with swallowing
problems (e.g.,
coughing,
choking, spitting
of food,
drooling,
difficulty
handling oral
secretions,
double
swallowing or
major delay in
swallowing,
watering eyes,
nasal discharge,
wet or gurgly
voice,
decreased
ability to move
tongue and lips,
decreased
 mastication of
food, decreased
ability to move
food to the
back of the
pharynx, slow
or scanning
speech).
 These are all
signs of
swallowing
impairment
(Baker, 1993;
Lugger, 1994).

5. If client has
impaired
swallowing,
refer to a
speech
pathologist for
bedside
evaluation as
soon as
possible. Ensure
that client is
seen by a
speech
pathologist
within 72 hours
after admission
if client has had
a CVA.
 Speech
pathologists
specialize in
impaired
swallowing.
Early referral of
CVA clients to a
speech
pathologist,
along with
early initiation
of nutritional
support, results
in decreased
length of
 hospital stay,
shortened
recovery time,
and reduced
overall health
costs (Scott,
1998). Research
demonstrates
that a program
of diagnosis
and treatment
of dysphagia in
acute stroke
management
decreases the
incidence of
pneumonia
(AHCPR, 1999).

6. If client has
impaired
swallowing, do
not feed until
an appropriate
diagnostic
workup is
completed.
Ensure proper
nutrition by
consulting with
physician for
enteral
feedings,
preferably a
PEG tube in
most cases.
 Feeding a client
who cannot
adequately
swallow results
in aspiration
and possibly
death. Enteral
feedings via
PEG tube are
generally
preferable to
nasogastric
 tube feedings
because studies
have
demonstrated
that there is
increased
nutritional
status and
possibly
improved
survival rates
(Bath, Bath,
Smithard,
2000).

7. Watch for
uncoordinated
chewing or
swallowing;
coughing
immediately
after eating or
delayed
coughing, which
may indicate
silent
aspiration;
pocketing of
food; wet-
sounding voice;
sneezing when
eating; delay of
more than 1
second in
swallowing; or a
change in
respiratory
patterns. If any
of these signs
are present, put
on gloves,
remove all food
from oral cavity,
stop feedings,
and consult
with a speech
and language
pathologist and
 a dysphagia
team.
 These are signs
of impaired
swallowing and
possible
aspiration
(Baker, 1993;
Galvan, 2001).

8. Avoid providing
liquids until
client is able to
swallow
effectively. Add
a thickening
agent to liquids
to obtain a soft
consistency that
is similar to
nectar, honey,
or pudding,
depending on
degree of
swallowing
problems.
 Liquids can be
easily
aspirated;
thickened
liquids form a
cohesive bolus
that the client
can swallow
with increased
efficiency
(Langmore,
Miller, 1994;
Poertner,
Coleman,
1998).

9. For many adult

clients, avoid
using straws if
recommended
by speech
pathologist.
 Use of straws
can increase
the risk of
aspiration
because straws
can result in
spilling of a
bolus of fluid in
the oral cavity
as well as
decrease
control of
posterior
transit of fluid
to the pharynx
(Travers, 1999).

10. Ensure that

there is
adequate time
for client to eat.
 Clients with
swallowing
impairments
often take two
to four times
longer than
others to eat, if
being fed.
Often, food is
offered rapidly
to speed up the
task, and this
can increase
the chance of
aspiration
(Poertner,
Coleman,
1998).

11. Have suction

equipment
available during
feeding. If
choking occurs
and suctioning
is necessary,
discontinue oral
 feeding until
client is safely
assessed with a
videofluoroscop
ic swallow study
and fiberoptic
endoscopic
evaluation of
swallowing
(FEES),
whichever
client can safely
tolerate.
 Suctioning may
be necessary if
the client is
choking on food
and could
aspirate.

12. Check oral

cavity for
proper
emptying after
client swallows
and after client
finishes meal.
Provide oral
care at end of
meal. It may be
necessary to
manually
remove food
from client's
mouth. If this is
the case, use
gloves and keep
client's teeth
apart with a
padded tongue
blade.
 Food may
become
pocketed in the
affected side
and cause
stomatitis,
tooth decay,
 and possible
later aspiration.

13. Keep client in

an upright
position for 30
to 45 minutes
after a meal.
 An upright
position
ensures that
food stays in
the stomach
until it has
emptied and
decreases the
chance of
aspiration
following meals
(Galvan, 2001).