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An elderly client with a history of stroke exhibits coughing and a change in voice tone immediately after swallowing a sip of water. What is the priority nursing intervention?
An elderly client with a history of stroke exhibits coughing and a change in voice tone immediately after swallowing a sip of water. What is the priority nursing intervention?
- Document the event in the client's medical record.
- Assess the client's lung sounds for adventitious breath sounds.
- Immediately notify the provider of potential aspiration. (correct)
- Encourage the client to continue drinking slowly.
A nurse is preparing to administer an intermittent enteral feeding to a client with a nasogastric tube. What is the MOST reliable method to use to verify correct tube placement immediately prior to initiating the feeding?
A nurse is preparing to administer an intermittent enteral feeding to a client with a nasogastric tube. What is the MOST reliable method to use to verify correct tube placement immediately prior to initiating the feeding?
- Check the pH of aspirated gastric contents. (correct)
- Measure the exposed length of the nasogastric tube.
- Auscultate over the epigastric area while injecting 30 mL of air.
- Observe the client for coughing, choking, or cyanosis during a test bolus.
A client with dysphagia is ordered a diet of honey-thick liquids. Which statement indicates the client understands this dietary modification?
A client with dysphagia is ordered a diet of honey-thick liquids. Which statement indicates the client understands this dietary modification?
- "I should drink all liquids through a straw to prevent choking."
- "I need to avoid thin liquids like broth or juice." (correct)
- "My beverages will be slightly thicker than normal water."
- "I can have ice cream and gelatin, because they are easy to swallow."
A nurse is caring for a client who is at high risk for aspiration. What is the MOST critical action to include in the client's plan of care?
A nurse is caring for a client who is at high risk for aspiration. What is the MOST critical action to include in the client's plan of care?
A nurse is educating a client and their family about aspiration precautions at home. Which statement by the family indicates a need for FURTHER teaching?
A nurse is educating a client and their family about aspiration precautions at home. Which statement by the family indicates a need for FURTHER teaching?
A client with an endotracheal tube is receiving continuous enteral feedings. The nurse notes that the client is coughing frequently and has new-onset wheezing. What is the nurse's INITIAL action?
A client with an endotracheal tube is receiving continuous enteral feedings. The nurse notes that the client is coughing frequently and has new-onset wheezing. What is the nurse's INITIAL action?
Which nursing intervention is MOST important when feeding a client with advanced Alzheimer's disease to prevent aspiration?
Which nursing intervention is MOST important when feeding a client with advanced Alzheimer's disease to prevent aspiration?
A nurse is caring for a client receiving enteral feedings who reports feeling nauseous. What is the nurse's FIRST action?
A nurse is caring for a client receiving enteral feedings who reports feeling nauseous. What is the nurse's FIRST action?
A nurse is preparing to administer oral medications to a client with a history of dysphagia. Which intervention is MOST appropriate to ensure safe medication administration?
A nurse is preparing to administer oral medications to a client with a history of dysphagia. Which intervention is MOST appropriate to ensure safe medication administration?
What is the PRIMARY reason for providing frequent oral care to a client who is on aspiration precautions?
What is the PRIMARY reason for providing frequent oral care to a client who is on aspiration precautions?
A client is receiving enteral feedings via a gastrostomy tube. The nurse auscultates the client's lungs and notes coarse crackles bilaterally. What is the nurse's PRIORITY action?
A client is receiving enteral feedings via a gastrostomy tube. The nurse auscultates the client's lungs and notes coarse crackles bilaterally. What is the nurse's PRIORITY action?
What is the CORRECT position for a client receiving continuous enteral feeding to minimize the risk of aspiration?
What is the CORRECT position for a client receiving continuous enteral feeding to minimize the risk of aspiration?
Which assessment finding would indicate that a client on aspiration precautions may be aspirating?
Which assessment finding would indicate that a client on aspiration precautions may be aspirating?
A client with dysphagia has a new order for thickened liquids. Which of the following liquids would be MOST appropriate to offer?
A client with dysphagia has a new order for thickened liquids. Which of the following liquids would be MOST appropriate to offer?
A nurse is caring for a client who is at risk for aspiration. Which of the following interventions is MOST appropriate to delegate to a nursing assistant?
A nurse is caring for a client who is at risk for aspiration. Which of the following interventions is MOST appropriate to delegate to a nursing assistant?
What is the nurse's PRIMARY responsibility in preventing aspiration for clients receiving tube feedings?
What is the nurse's PRIMARY responsibility in preventing aspiration for clients receiving tube feedings?
A nurse is caring for a group of clients. Which client is at the HIGHEST risk for aspiration?
A nurse is caring for a group of clients. Which client is at the HIGHEST risk for aspiration?
Which nursing intervention is MOST effective in preventing aspiration during oral feeding of a client with a history of stroke?
Which nursing intervention is MOST effective in preventing aspiration during oral feeding of a client with a history of stroke?
A nurse is caring for a client with Parkinson's disease who has difficulty swallowing. Which dietary modification is MOST appropriate for this client?
A nurse is caring for a client with Parkinson's disease who has difficulty swallowing. Which dietary modification is MOST appropriate for this client?
A client receiving enteral feedings develops diarrhea. Which action should the nurse take FIRST?
A client receiving enteral feedings develops diarrhea. Which action should the nurse take FIRST?
Which of the following is the MOST reliable method for confirming the correct placement of a nasogastric tube immediately after insertion?
Which of the following is the MOST reliable method for confirming the correct placement of a nasogastric tube immediately after insertion?
A client with aspiration pneumonia is prescribed an oral diet. Which intervention is MOST important for the nurse to implement during meal times?
A client with aspiration pneumonia is prescribed an oral diet. Which intervention is MOST important for the nurse to implement during meal times?
What is the PRIMARY reason for limiting conversation during meal times with a client who is at risk for aspiration?
What is the PRIMARY reason for limiting conversation during meal times with a client who is at risk for aspiration?
Which situation requires the nurse to IMMEDIATELY discontinue an enteral feeding?
Which situation requires the nurse to IMMEDIATELY discontinue an enteral feeding?
A client with dysphagia is being discharged home. Which referral is MOST important for the nurse to include in the discharge plan?
A client with dysphagia is being discharged home. Which referral is MOST important for the nurse to include in the discharge plan?
Before initiating an enteral feeding, the nurse aspirates 50 mL of gastric residual volume. What is the appropriate nursing action?
Before initiating an enteral feeding, the nurse aspirates 50 mL of gastric residual volume. What is the appropriate nursing action?
A client with a nasogastric tube is receiving continuous enteral feedings. The nurse notes that the client's abdomen is distended and firm. What is the nurse's INITIAL action?
A client with a nasogastric tube is receiving continuous enteral feedings. The nurse notes that the client's abdomen is distended and firm. What is the nurse's INITIAL action?
A client with a history of aspiration pneumonia is ordered to receive medications via a nasogastric tube. Which nursing intervention is MOST important to prevent aspiration during medication administration?
A client with a history of aspiration pneumonia is ordered to receive medications via a nasogastric tube. Which nursing intervention is MOST important to prevent aspiration during medication administration?
A nurse is providing discharge instructions to a client with dysphagia. Which statement by the client indicates an UNDERSTANDING of aspiration precautions?
A nurse is providing discharge instructions to a client with dysphagia. Which statement by the client indicates an UNDERSTANDING of aspiration precautions?
What is the MOST appropriate intervention to prevent aspiration in an infant with gastroesophageal reflux (GERD) who is receiving intermittent bolus feedings?
What is the MOST appropriate intervention to prevent aspiration in an infant with gastroesophageal reflux (GERD) who is receiving intermittent bolus feedings?
A client with a tracheostomy tube is receiving mechanical ventilation and continuous enteral feedings. What is the MOST important intervention to prevent aspiration?
A client with a tracheostomy tube is receiving mechanical ventilation and continuous enteral feedings. What is the MOST important intervention to prevent aspiration?
Which of the following interventions is MOST appropriate for minimizing the risk of aspiration in a client receiving intermittent nasogastric feedings?
Which of the following interventions is MOST appropriate for minimizing the risk of aspiration in a client receiving intermittent nasogastric feedings?
Flashcards
Aspiration
Aspiration
Inadvertent passage of solids/liquids into the lungs, leading to complications like pneumonia or airway obstruction.
Aspiration Precautions
Aspiration Precautions
Elevating the head of the bed during feedings or head elevated to at least 30 degrees when administering enteral feeding.
RN Role in Aspiration Precautions
RN Role in Aspiration Precautions
Includes Registered Nurses ensuring assessment, communication, and education regarding aspiration precautions.
Allergy Verification
Allergy Verification
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Client Identification
Client Identification
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Client Education
Client Education
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Aspiration Risk Factors
Aspiration Risk Factors
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Interprofessional Collaboration (Aspiration)
Interprofessional Collaboration (Aspiration)
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High-Fowler's Position
High-Fowler's Position
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Oral Cavity Assessment
Oral Cavity Assessment
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Modified Diet
Modified Diet
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Pausing During Feeding
Pausing During Feeding
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Minimize Distractions
Minimize Distractions
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Monitoring Swallowing
Monitoring Swallowing
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Close Supervision
Close Supervision
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Enteral Feeding Tube Placement
Enteral Feeding Tube Placement
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Action for Vomiting (Enteral)
Action for Vomiting (Enteral)
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Ensuring Client Safety (Position)
Ensuring Client Safety (Position)
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Discuss Findings
Discuss Findings
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Aspiration Precautions Protocol
Aspiration Precautions Protocol
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Infant Feeding
Infant Feeding
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Enteral Feeding Complications
Enteral Feeding Complications
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Oral Nutrition Complications
Oral Nutrition Complications
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Indications of Aspiration
Indications of Aspiration
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Documentation Elements (Aspiration)
Documentation Elements (Aspiration)
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Study Notes
- Aspiration is the accidental entry of solids or liquids into the lungs, potentially causing choking, respiratory distress, pneumonia, or death.
- Aspiration can occur during enteral feeding or due to swallowing difficulties (dysphagia) with oral intake.
- Aspiration precautions are implemented for clients at risk of aspiration.
- Precautions for enteral feedings include elevating the head of the bed during feedings and verifying tube placement regularly.
- For dysphagia, precautions include feeding assistance and monitoring for choking or severe coughing.
- The RN assesses and communicates about aspiration precautions and educates personnel and family on aspiration signs and interventions.
Safety Considerations
- Determine allergies, especially food allergies, to prevent allergic reactions.
- Verify client identification to ensure the correct procedure for the correct client.
- Use standard and infection control precautions to prevent the transmission of infectious organisms.
Equipment Needed
- Nonsterile gloves and other personal protective equipment (PPE)
- Toothbrush or mouth swabs
- Prepared food and liquids, adaptive utensils, and washcloths/napkins for oral nutrition
- Formula, syringe or pump, tubing, water for flush, and measuring tape for enteral nutrition
Step-by-Step Guide for Aspiration Precautions
- Review the client’s medical record for allergies, medical history, medications, and lab values to identify safety concerns and relevant conditions.
- Obtain necessary supplies to ensure preparedness.
- Provide privacy to maintain client confidentiality.
- Introduce yourself to the client to promote a therapeutic relationship.
- Perform hand hygiene and apply PPE to prevent infection.
- Identify the client using two identifiers to ensure correct procedure.
- Confirm the client’s allergy status to prevent allergic reactions.
- Educate the client about the procedure to decrease anxiety and promote understanding.
- Evaluate the client for aspiration risk factors like dementia, dysphagia, retained food, neuromuscular disorders, head/neck surgery, intubation, poor oral care, enteral feeding tubes, vomiting, or high residual volumes.
- Collaborate with the team to determine diet modifications or tests for chewing/swallowing disorders to optimize nutrition and minimize aspiration risk.
- Position the client in high-Fowler’s position (90°) during eating, or elevate the head of the bed to at least 30° during enteral feeding to facilitate effective swallowing.
- Check the mouth for denture placement and oral cavity defects, as poor dentition is a dysphagia risk factor.
- Cut food into small pieces or provide a modified diet (thickened liquids, pureed, minced, or chopped) in collaboration with providers/dietitians.
- Allow extra time for chewing and swallowing to prevent retained food.
- Minimize conversation and distractions during oral intake to improve concentration and coordination.
- Check for swallowing difficulty after each bite and stop feeding if present, notifying the provider.
- Supervise feeding closely, watching for coughing, choking, voice changes, or cyanosis, and notify the provider.
- For enteral feedings, verify tube placement before initiating or every 4 hours to prevent aspiration.
- If vomiting occurs during enteral feeding, discontinue feeding and ensure airway clearance; notify the provider.
- Ensure the client is in a safe position with the head of bed elevated before leaving the room.
- Discuss findings with the client to decrease anxiety and promote involvement in care.
Client Considerations
- Clients at increased risk for aspiration should be placed on an aspiration precautions protocol.
- Aspiration precaution protocols can include interprofessional assessment, alerts in the medical record, bedside suction, posted signs, head of bed elevation, one-to-one supervision, staff education, and frequent oral care.
- Infants with laryngeal or craniofacial disorders, reflux, or prematurity are at risk, thus slow bolus feedings and cue-based feeding are recommended.
Interventions for Unexpected Outcomes
- For enteral nutrition- If aspiration is suspected, notify the provider and request radiographic assessment of tube placement. For nausea or vomiting, ensure an upright position and notify the provider if persistent.
- For oral nutrition- If aspiration is suspected, discontinue feeding, maintain an upright position, implement emergency procedures, and notify the provider.
- Indications of aspiration include choking, hoarseness, coughing, altered breath sounds, declining oxygen saturation, cyanosis, gurgling, or regurgitation.
Documentation
- Accurately document assessment findings, interventions, client position and response, feeding details (amount, method, type), percentage of meal eaten, and liquid intake in the client's medical record.
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