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Impaired Swallowing Nursing Diagnosis Care Plan: Comprehensive Guide

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What is Dysphagia?

Dysphagia, clinically referred to as impaired swallowing, is characterized by difficulties in moving food or liquid from the mouth to the stomach. This condition necessitates more time and effort during the swallowing process. Impaired swallowing arises from the malfunction of muscles and nerves critical for food passage through the throat and esophagus. Dysphagia can manifest as a temporary inconvenience or a persistent, even life-threatening, complication.

Recent medical discourse has refined the distinction between ‘dysphagia’ and ‘swallowing impairment.’ Dysphagia, in a subjective context, describes a patient’s perception of swallowing difficulty. Symptoms may include the sensation of food obstruction, choking, or coughing during swallowing episodes. Conversely, swallowing impairment denotes objective, clinically observable dysfunctions in the deglutition process, as identified by healthcare professionals (Rameau et al., 2022).

A significant risk associated with impaired swallowing is aspiration, where food or fluids enter the airway. This can be triggered by structural anomalies, disruptions in neural pathways, diminished muscle strength involved in chewing, facial paralysis, or sensory-perceptual deficits. Swallowing muscles can weaken due to age or inactivity, making dysphagia a common concern among older adults and individuals recovering from stroke, head trauma, head and neck cancer, or progressive neurological conditions such as multiple sclerosis, amyotrophic lateral sclerosis (ALS), and Parkinson’s disease. While more prevalent in older populations, dysphagia can affect individuals of any age.

The act of swallowing, or deglutition, is a complex process divided into four distinct phases:

  • Preparatory Phase: This initial phase occurs in the oral cavity and involves mastication, where food is chewed and mixed with saliva to form a bolus. The bolus is then prepared for transit into the pharynx and esophagus.
  • Oral Phase: During this phase, the tongue propels the bolus from the oral cavity into the pharynx.
  • Pharyngeal Phase: This is a critical phase where food passes through the pharynx and into the esophagus. Respiration is momentarily halted and coordinated with swallowing to prevent aspiration, as both breathing and swallowing utilize the pharynx, but not simultaneously.
  • Esophageal Phase: In the final phase, the bolus is transported down the esophagus to the stomach through peristaltic contractions.

Understanding these phases is crucial for healthcare professionals to accurately diagnose and manage impaired swallowing, ensuring patient safety and nutritional well-being. Effective nursing care plans are essential to address the complexities of dysphagia and improve patient outcomes.

Alt text: Four phases of swallowing illustrated with diagrams showing food bolus movement through mouth, pharynx, and esophagus, highlighting preparatory, oral, pharyngeal, and esophageal stages for nursing education on dysphagia.

Causes

Swallowing problems are multifaceted, with a range of underlying causes that dictate treatment strategies. The origin of dysphagia can often be categorized into neurological and non-neurological disorders.

Neurological Causes:

  • Central Nervous System (CNS) disorders: Conditions affecting the brain and spinal cord can significantly impair swallowing function. These include:

    • Stroke (Cerebrovascular Accident)
    • Traumatic Brain Injury (TBI)
    • Parkinson’s Disease
    • Multiple Sclerosis (MS)
    • Amyotrophic Lateral Sclerosis (ALS)
    • Cerebral Palsy
    • Dementia

  • Peripheral Nervous System (PNS) disorders: Disorders impacting the nerves outside the CNS can also lead to dysphagia:

    • Neuromuscular junction disorders:
      • Myasthenia Gravis
      • Lambert-Eaton Myasthenic Syndrome
    • Myopathy:
      • Muscular Dystrophy
      • Polymyositis
    • Peripheral neuropathy:
      • Diabetic Neuropathy
      • Guillain-Barré Syndrome

Non-Neurological Causes and Other Disorders:

  • Head and neck local structural lesions: Physical obstructions or abnormalities in the head and neck area can impede swallowing:

    • Head and Neck Cancer
    • Esophageal strictures or tumors
    • Pharyngeal pouches
    • Cervical spine disorders
    • Zenker’s Diverticulum

  • Poor general medical condition: Systemic illnesses and general debilitation can contribute to swallowing difficulties:

    • Age-related muscle weakness (Sarcopenia)
    • Connective tissue diseases (e.g., Scleroderma)
    • Respiratory diseases (e.g., COPD)
    • Medication side effects (e.g., anticholinergics)

  • Unknown etiology: In some cases, the cause of dysphagia remains unidentified despite thorough investigation.

Identifying the specific cause of impaired swallowing is crucial for developing targeted interventions and effective nursing care plans. A detailed medical history, physical examination, and diagnostic tests are essential to determine the etiology and guide appropriate management strategies.

Signs and Symptoms

Recognizing the signs and symptoms of dysphagia is vital for early intervention and effective management. Patients with impaired swallowing may exhibit a variety of indicators, ranging from subtle to overt difficulties. Common signs and symptoms include:

  • Sensation of food sticking in the throat: Patients often report a feeling that food is trapped or not passing down smoothly.
  • Coughing or choking when eating or drinking: This is a significant indicator of aspiration risk, occurring as the airway attempts to clear food or liquid.
  • Coughing at rest or between feedings: Suggests possible aspiration of saliva or residual food, even when not actively eating.
  • Changes in taste: Altered taste perception can be related to nerve damage or changes in oral mucosa.
  • Excessive oral secretions: Increased saliva production or difficulty managing saliva can indicate impaired oral motor control.
  • Wet or gurgling voice during or after eating: A change in voice quality suggests that liquid or food may be pooling in the larynx.
  • Change in vocal quality while eating: Similar to a wet voice, this may indicate material in the larynx.
  • Regurgitation of food or fluids, including nasal regurgitation: Food or liquid returning up the esophagus or through the nose signals swallowing dysfunction.
  • Pocketing food in the mouth: Food remaining in the cheeks or under the tongue after swallowing attempts indicates oral phase difficulties.
  • Delayed swallowing initiation: Hesitation or a noticeable delay in starting the swallow reflex is a sign of impairment.
  • Fatigue during meals: Increased effort and energy expenditure during eating can lead to exhaustion.
  • Difficulty chewing: Problems breaking down food in the mouth suggests issues with mastication muscles.
  • Uncoordinated chewing or swallowing: Lack of synchrony between chewing and swallowing phases points to neuromuscular dysfunction.
  • Acute or chronic weight loss: Unexplained weight loss can be a consequence of reduced food intake due to swallowing difficulties.
  • Wet, gurgling sounds with respiration: Noisy breathing may indicate aspiration and the presence of fluids in the airway.
  • Sneezing or coughing while eating: These reflexes can be triggered by food or liquid entering the nasal passages or airway.
  • Prolonged mealtimes: Taking significantly longer than usual to complete meals can be a compensatory strategy due to slow or inefficient swallowing.
  • Inability to manage saliva: Drooling or difficulty controlling saliva in the mouth.
  • Aspiration or risk of aspiration: Leading to coughing or respiratory issues, including pneumonia.
  • Drooling or food leakage from the mouth: Loss of food or saliva from the mouth due to poor lip closure or oral control.

Nurses play a critical role in recognizing these signs and symptoms, conducting thorough assessments, and developing appropriate nursing care plans to mitigate the risks associated with impaired swallowing. Early detection and intervention are key to preventing complications and improving patient outcomes.

Alt text: Illustration of a person coughing while eating, emphasizing coughing as a key symptom of dysphagia and the importance of nursing assessment for swallowing difficulties.

Nursing Care Plans and Management

Nursing care plans for patients with dysphagia are essential for providing structured, individualized care. These plans encompass a detailed assessment of the patient’s medical history, nutritional status, and the underlying cause of their swallowing impairment. This comprehensive approach ensures that interventions are targeted and effective, addressing the specific needs and risks of each patient. The primary goals of these care plans are to promote patient safety, prevent aspiration, and maintain optimal nutritional status.

Nursing Problem Priorities

When addressing impaired swallowing, nurses prioritize the following key areas to ensure patient well-being and safety:

  1. Airway protection: Maintaining a patent airway is the paramount concern. Preventing aspiration of food, fluids, or secretions into the lungs is crucial to avoid respiratory complications such as aspiration pneumonia.
  2. Nutritional support: Dysphagia can significantly impact a patient’s ability to eat and drink adequately, leading to malnutrition and dehydration. Providing appropriate nutritional support is essential to meet the patient’s metabolic needs and promote healing.
  3. Client and family education: Empowering patients and their families or caregivers with knowledge and skills to manage dysphagia is vital for long-term success. Education includes safe swallowing techniques, dietary modifications, and recognizing signs of potential complications.

These priorities guide the nursing assessment, diagnosis, interventions, and evaluation processes, ensuring a holistic and patient-centered approach to managing impaired swallowing.

Nursing Assessment

A thorough nursing assessment is the cornerstone of effective care for patients with dysphagia. It involves gathering both subjective and objective data to identify the nature and extent of swallowing impairment, potential underlying causes, and associated risks.

Assess for the following subjective and objective data:

  • The sensation of food sticking: Inquire if the patient feels food is getting stuck in their throat. This subjective report can indicate issues with bolus propulsion, esophageal sphincter relaxation, mucosal integrity, or esophageal conditions. It may also suggest repeated reflux.
  • Changes in taste: Note any alterations in taste perception reported by the patient. Taste changes can be linked to neurogenic factors, oral or pharyngeal mucosa alterations, medications, chemotherapy, or radiation therapy.
  • Coughing with food or liquid before, during, and after swallowing: Observe and document when coughing occurs in relation to swallowing. Coughing can be a sign of aspiration, but it may also be related to pre-existing pulmonary disease.
  • Cough at rest/between feedings: Assess for coughing episodes when the patient is not eating or drinking. This may indicate aspiration of residual food or saliva.
  • Excessive oral secretions: Evaluate the amount and consistency of oral secretions. Increased secretions can be due to poor sensation, overproduction, thick secretions, or difficulty managing normal saliva.
  • Acute or chronic weight loss: Monitor weight trends and investigate any recent or ongoing weight loss. Weight loss may signal inadequate nutrition intake, increased metabolic needs, or underlying conditions like depression or undiagnosed cancer.
  • Change in vocal quality while eating: Listen for any changes in the patient’s voice during meals. A wet or hoarse voice can suggest the presence of food or liquid in the larynx.
  • Wet or gurgling sounds with respiration: Auscultate lung sounds and note any wet or gurgling sounds. These sounds indicate the presence of fluids or food in the pharynx or larynx, suggesting ineffective clearing mechanisms.
  • Fatigue: Assess for fatigue reported by the patient, especially during or after meals. Fatigue can be a significant factor affecting meal intake and swallowing efficiency.

This comprehensive assessment provides critical information for formulating a relevant nursing diagnosis and developing an individualized nursing care plan.

Nursing Diagnosis

Following a comprehensive assessment, formulating a nursing diagnosis is crucial for addressing the specific challenges associated with impaired swallowing. While nursing diagnoses provide a valuable framework for care planning, it is important to recognize that clinical judgment and expertise are paramount in tailoring care to each patient’s unique needs.

For patients with dysphagia, a primary nursing diagnosis to consider is:

  • Impaired Swallowing related to neuromuscular impairment, mechanical obstruction, or cognitive deficits as evidenced by (select from defining characteristics):
    • Observed evidence of difficulty in swallowing (e.g., coughing, choking, gagging).
    • Change in voice quality or speech (e.g., hoarseness, gurgling voice).
    • Abnormal pharyngeal or laryngeal movement.
    • Delayed swallowing.
    • Incomplete oral clearance (pocketing food).
    • Regurgitation.
    • Food avoidance.
    • Weight loss.
    • Excessive drooling.

This nursing diagnosis provides a clear statement of the patient’s problem and its potential causes, guiding the development of targeted nursing interventions and actions.

Nursing Goals

Establishing clear and measurable goals is essential for evaluating the effectiveness of the nursing care plan. Goals for patients with impaired swallowing should be patient-centered and focused on improving safety, nutrition, and quality of life. Example goals include:

  • The client will demonstrate safe swallowing techniques with minimal or no episodes of coughing, choking, or aspiration during and after meals, within the next [specify time frame].
  • The client will maintain or achieve a stable weight, appropriate for their body composition and health status, by [specify date], indicating adequate nutritional intake.
  • The client will effectively communicate their needs and preferences related to meals and swallowing, utilizing established communication strategies, throughout their plan of care.
  • The client will remain free from complications associated with dysphagia, such as aspiration pneumonia, throughout their hospitalization or care period.
  • The client and their caregivers will verbalize understanding of dietary modifications, safe swallowing techniques, and signs and symptoms of potential complications, prior to discharge or by [specify date].

These goals provide direction for nursing interventions and serve as benchmarks to measure progress and adjust the care plan as needed.

Nursing Interventions and Actions

Therapeutic nursing interventions and actions for patients with dysphagia are multifaceted and aim to improve swallowing safety, nutritional intake, and overall quality of life. These interventions are tailored to the individual patient’s needs based on the comprehensive nursing assessment and established goals.

1. Dysphagia Assessment

A thorough and ongoing assessment of swallowing function is paramount. This includes identifying the underlying cause of dysphagia and evaluating the patient’s cognitive and communication abilities, which can significantly impact their ability to adhere to dietary recommendations and swallowing strategies.

Assessing the ability to swallow and the potential for aspiration

  • Determine the client’s mental status. If the client is unable to care for self, oral hygiene must be provided by nursing personnel. A patient’s level of consciousness and cognitive function directly affect their ability to self-feed and follow swallowing instructions. Cognitive impairment can increase aspiration risk. If self-care is compromised, nurses must provide oral hygiene and feeding assistance.

    • Nursing Diagnosis Consideration: Bathing/Hygiene Self-care deficit may be applicable for patients with cognitive or physical limitations affecting self-care.

  • Assess for pharyngeal reflex. Evaluate the pharyngeal reflex to assess swallowing mechanics. Palpate hyoid bone, thyroid notch, and cricoid ring while the patient performs a dry swallow. Normal swallow involves a 2-2.5 cm elevation of these structures (Speyer et al., 2021). Reduced elevation may indicate impaired pharyngeal phase.

  • Ask the client to cough; test for a gag reflex on both sides of the posterior pharyngeal wall (lingual surface) with a tongue blade. Do not rely on the presence of a gag reflex to determine when to feed. Eliciting cough and gag reflexes helps assess airway protection mechanisms. However, the absence of a gag reflex is not a reliable indicator of aspiration risk, and its presence does not guarantee safe swallowing. Clinical judgment and further assessment are necessary before initiating oral feeding.

  • Check for coughing or choking during eating and drinking. Directly observe the patient during meals for signs of coughing or choking. These are strong indicators of aspiration. Differentiate between coughing before, during, and after swallowing, as each may suggest different phases of swallowing impairment or underlying pulmonary issues. Coughing at rest may indicate chronic pulmonary conditions or reflux.

  • Assess the ability to swallow a small amount of water. Administer a small amount of water (e.g., teaspoon) to assess initial swallowing ability. Water is often used for initial screening as small amounts aspirated are generally less harmful. The Toronto Bedside Swallowing Screening Test (TOR-BSST) uses water swallows to assess dysphagia risk. A positive screen necessitates referral for a comprehensive swallowing assessment.

  • Check for residual food in the mouth after eating. Inspect the oral cavity after meals for pocketed food. Residual food poses a delayed aspiration risk. Oral phase dysphagia is often associated with poor bolus control, leading to food retention in the mouth. Drooling, food leakage, and difficulty initiating swallowing may also be present.

  • Check for food or fluid regurgitation through the nares. Observe for nasal regurgitation, indicating impaired swallowing and increased aspiration risk. Pharyngeal phase dysphagia can manifest as delayed swallow reflex, reduced pharyngeal closure causing nasal regurgitation, decreased epiglottic movement, and reduced laryngeal elevation. Patients may report globus sensation, nasal regurgitation, aspiration, or reflux.

  • Implement or assist in swallowing studies, as indicated. Utilize bedside swallowing tests to evaluate swallowing function. The Volume Viscosity Swallowing Test (VVST) and Gugging Swallowing Screen test (GUSS) are examples of bedside tests using different volumes and viscosities of food and liquids to mimic real-life swallowing scenarios. These tests help assess swallowing safety and guide dietary modifications.

  • Evaluate the results of swallowing studies as ordered. Interpret results from instrumental swallowing evaluations such as video-fluoroscopic swallowing study (VFSS) or modified barium swallow study (MBSS). VFSS is considered the gold standard for diagnosing oropharyngeal dysphagia and aspiration. It allows visualization of swallowing mechanics and peristalsis under fluoroscopy, aiding in targeted intervention planning.

  • Determine the client’s readiness to eat. The client needs to be alert, able to follow instructions, hold the head erect, and able to move the tongue in the mouth. Assess pre-feeding readiness. Patients must be alert, able to follow directions, maintain head control, and have adequate tongue movement for safe oral intake. If these criteria are not met, enteral feeding may be necessary to prevent aspiration and ensure nutritional needs are met. Cognitive deficits can also increase aspiration risk, even with adequate swallowing mechanics.

  • Classify food given to the client before each spoonful if the client is being fed. Communicate food consistency before each spoonful when assisting with feeding. This prepares the patient for appropriate chewing and swallowing. The International Dysphagia Diet Standardization Initiative (IDDSI) provides a framework for classifying food textures and liquid viscosities. Modified textures, such as purees with gelling agents, may reduce aspiration risk in moderate to severe dysphagia.

  • Evaluate nutritional status. Assess for malnutrition, a common comorbidity in dysphagia. Use nutritional assessment tools like the Short Nutritional Assessment Questionnaire or Mini Nutritional Assessment Form. Detailed nutritional evaluation helps identify existing deficits and guide nutritional support strategies.

  • Observe the ability to eat and drink. Monitor eating and drinking abilities, noting any difficulties with chewing or swallowing. Pain from oral mucositis or other conditions can impair swallowing. Swallowing capabilities can fluctuate throughout the day and be affected by medications or activities. Observe for changes in vocal quality, coughing, wet respirations, and fatigue during meals, which are significant indicators of swallowing dysfunction.

  • Note the client’s oral hygiene practices. Evaluate oral hygiene habits. Poor oral hygiene is a significant risk factor for aspiration pneumonia in dysphagia patients. Oropharyngeal colonization by respiratory pathogens is a key factor in aspiration pneumonia development.

  • Monitor the client’s fluid status to determine if adequate. Assess hydration status. Dehydration can exacerbate dysphagia by causing dry mucous membranes and reducing saliva production, hindering bolus formation and swallowing.

  • Utilize validated patient-reported measures, as applicable. Incorporate patient-reported outcome measures (PROMs) such as the Swallowing Quality of Life questionnaire (SWAL-QOL), Dysphagia Handicap Index (DHI), or MD Anderson Dysphagia Inventory (MDADI). PROMs enhance patient-centered care, improve communication, and facilitate goal setting by incorporating the patient’s perspective on their swallowing difficulties and quality of life.

Performing physical examination

  • Evaluate the strength of facial muscles. Assess facial muscle strength, crucial for oral phase swallowing. Cranial nerves V, VII, IX, X, and XII control muscles involved in chewing and swallowing. Examine for facial asymmetries and test cranial nerve function to rule out neurological deficits affecting swallowing.

  • Observe for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new crackles or wheezing, and note elevated temperature. Notify the healthcare provider as needed. Monitor for aspiration pneumonia signs. Auscultate lungs for new crackles or wheezing post-feeding. Elevated temperature, increased white blood cell count, and changes in sputum may indicate aspiration pneumonia. Older adults are particularly vulnerable due to age-related physiological changes. Promptly report any signs of aspiration pneumonia to the healthcare provider.

  • Weigh the client weekly. Regularly monitor weight to track nutritional status. Weekly weighing helps detect weight loss, a sign of inadequate nutritional intake or increased metabolic demands, which may be related to dysphagia severity or underlying conditions.

  • Assess the oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Assess the severity of ulcerations involving the intraoral soft tissues, including the palate, tongue, gums, and lips. Refer to a healthcare provider or specialist as appropriate. Conduct daily oral cavity examinations. Inspect for lesions, discoloration, edema, bleeding, exudate, or dryness. Document the severity of ulcerations on the palate, tongue, gums, and lips. Oral findings can indicate local or systemic disease, drug side effects, or trauma. Tooth loss affects oral anatomy and swallowing mechanics. Refer abnormalities to a healthcare provider or specialist for further evaluation and management.

  • Inspect for any indication of infection, and culture lesions as needed. Refer to a healthcare provider, nurse, or specialist as appropriate. Assess for oral infections. Inspect for signs of infection and culture lesions if indicated. Early detection and treatment of oral infections are crucial. Dysphagia due to oral mucositis can worsen oral lesions and systemic symptoms.

    • Severe mucositis manifestations: Be aware of severe mucositis signs:
      • Candidiasis: White, cottage cheese-like patches on tongue, buccal mucosa, palate.
      • Herpes simplex: Painful, itching vesicles that crust over.
      • Bacterial infections: Wartlike, yellowish-brown plaques (Gram-positive) or creamy, yellow-white patches on red ulcers (Gram-negative).
      • Systemic symptoms: Fevers, chills, rigors indicating systemic response to infection.

  • Check for mechanical agents such as ill-fitting dentures or chemical agents such as constant exposure to tobacco that could create or develop trauma to oral mucous membranes. Identify potential irritants. Assess for ill-fitting dentures or chemical irritants like tobacco. Eliminate causative agents for stomatitis. Denture use can increase oral microorganism proliferation, leading to denture stomatitis, especially with poor hygiene.

  • Inspect the status of the oral mucosa; including the tongue, lips, gums, saliva, teeth, and mucous membranes. Perform a comprehensive oral mucosal assessment using a tongue blade to visualize all areas. Identify inflammation, infection, or mucositis. Early detection and management of oral health issues are essential to prevent complications.

  • Assess the tone, strength, and mobility of the tongue. Evaluate tongue function. Assess tongue tone and strength by resistance against a tongue blade. Assess mobility through non-articulatory and articulatory praxis tasks. Tongue strength and mobility are crucial for bolus control and oral phase swallowing.

  • Examine after removal of dental appliances. Use a moist, padded tongue blade to pull back the cheeks and tongue gently. Examine oral mucosa after denture removal. Lesions may be hidden or irritated by dentures. Caregivers should be educated on the importance of these assessments.

  • Assess the client’s chewing ability if possible. Evaluate chewing ability, particularly for solids, to identify choking risk. Tools like the Test of Mastication and Swallowing of Solids (TOMASS) can be used.

  • Include mealtime observation during the clinical swallowing evaluation (CSE). Incorporate mealtime observation into CSE. This is especially valuable for cognitively impaired patients where swallowing difficulties may fluctuate with attention, fatigue, or environment. Observe self-feeding ability, need for adaptive utensils, meal duration, and fatigue. Standardized CSEs like McGill Ingestive Skills Assessment (MISA) and Dysphagia Disorder Survey (DDS) may be used during mealtime observation.

2. Protecting and Strengthening the Airway

Dysphagia increases the risk of aspiration, where food or secretions enter the airway. Aspiration can lead to respiratory complications, including aspiration pneumonia. Protecting the airway is a primary nursing priority.

  • Before mealtime, provide adequate rest periods. Ensure patients are rested before meals. Fatigue exacerbates swallowing difficulties. Eating requires sustained coordination of oropharyngeal muscles, respiration, and cognitive functions.

  • Eliminate any environmental stimuli (e.g., TV, radio) Minimize distractions during meals. A quiet environment enhances concentration on swallowing. Patients with dysphagia expend significant energy focusing on swallowing, and reducing stimuli can improve mealtime safety and intake.

  • Assist the client in eating as needed. Provide feeding assistance and supervision. Patients with dysphagia may need help with feeding to conserve energy and ensure adequate nutrient intake. Observation during meals is crucial for safety.

  • Provide oral care before and after feeding. Clean and insert dentures before each meal. Implement meticulous oral care. Oral hygiene before meals stimulates appetite. Oral care before and after meals, including denture cleaning, reduces oral bacteria and decreases aspiration pneumonia risk, especially in stroke patients and nursing home residents. Strict oral care routines are essential.

  • If the client has impaired swallowing, consult a speech pathologist for bedside evaluation as soon as possible. Ensure that the client is seen by a speech pathologist within 72 hours after admission if the client has had a cerebrovascular accident (CVA). Refer to a speech pathologist (SLP) promptly. SLPs specialize in dysphagia management. Early SLP referral, particularly within 72 hours of admission for stroke patients, and early nutritional support initiation improve outcomes, reduce hospital stay, and lower healthcare costs. Stroke patients should be screened for malnutrition risk within 48 hours of admission, ideally within 24 hours (Oliveira et al., 2022).

  • For impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, healthcare provider, and radiologist who work together. Utilize a multidisciplinary dysphagia team. A team approach involving nurses, SLPs, dietitians, physicians, and radiologists optimizes dysphagia management. The team develops and implements safe swallowing strategies and nutritional plans. Patients at risk for or experiencing malnutrition require individualized nutritional therapy by a dietitian in collaboration with the team.

  • Place suction equipment at the bedside, and suction as needed. Ensure suction availability. Have suction equipment readily available at the bedside to manage secretions and aspiration events. For emergencies, portable non-invasive suction devices like LifeVac are available. These devices are easy to use and can quickly remove airway obstructions during choking episodes.

  • Practice swallowing maneuvers with the client as indicated. Implement swallowing maneuvers under SLP guidance. Swallowing maneuvers are behavioral techniques to improve swallowing safety and effectiveness. The Mendelsohn maneuver, which involves prolonging laryngeal elevation during swallowing, can be effective but may cause fatigue in older adults and is best for cognitively and physically capable patients.

  • Promote oral sensory stimulation. Utilize oral sensory stimulation techniques. Sensory stimulation, such as cold or tactile input, can enhance oral awareness and trigger the swallowing reflex, improving the transition from the oral to pharyngeal phase.

  • Assist the client in performing head and neck range-of-motion (ROM) exercises. Encourage head and neck ROM exercises. Exercises are active interventions to strengthen swallowing muscles. Head and neck ROM exercises, including cervical flexion strengthening (Shaker exercise), improve hyoid and laryngeal elevation, increase upper esophageal sphincter opening, reduce pharyngeal residue, and improve dysphagia symptoms.

  • Promote oropharyngeal exercise for older adults. Implement oropharyngeal exercises, particularly for older adults. Age-related tissue elasticity loss can benefit from targeted exercises. Tongue strengthening exercises improve tongue propulsion and pressure against the palate, enhancing swallowing function. Tongue exercises improve swallowing phase timing and food intake in older adults.

Aspiration precautions

  • Position the client upright at a 90-degree angle with the head flexed forward at a 45-degree angle. Position patients upright during meals. Upright positioning at 90 degrees with a 45-degree chin tuck optimizes swallowing mechanics by closing the trachea and opening the esophagus, reducing aspiration risk. Chin tuck posture is a common and effective postural modification that slows bolus passage and protects the airway, especially for patients with premature bolus spillage (Umay et al., 2022).

  • Ensure the client is awake, alert, and able to follow sequenced directions before attempting to feed. Verify alertness and cognitive readiness before feeding. Patients must be awake, alert, and able to follow instructions for safe oral intake. Reduced alertness impairs swallowing reflexes and increases aspiration risk. Clinical observation of posture, alertness, respiratory secretions, and saliva management is essential before feeding.

  • Begin by feeding the client one-third teaspoon of applesauce. Provide sufficient time to masticate and swallow. Start with small, controlled feedings. Begin with a small amount of puree consistency food like applesauce (e.g., 1/3 teaspoon). Allow ample time for chewing and swallowing. Pureed foods and thickened liquids are often recommended initially to minimize aspiration risk. Texture modification, such as pureeing and minced textures, and thickened liquids like nectar, honey, and pudding consistencies are commonly used for chronic dysphagia in older adults.

  • Place food on the unaffected side of the tongue. Position food strategically in the mouth. Place food on the stronger, unaffected side of the tongue, particularly for patients with unilateral weakness. This aids in bolus control and reduces the risk of food entering the airway. Oral phase dysphagia symptoms include oral residue, drooling, and difficulty with lip closure, chewing, and tongue movements.

  • During feeding, give the client-specific directions (e.g., “Open your mouth, chew the food completely, and when you are ready, tuck your chin to your chest and swallow”). Provide clear, step-by-step swallowing instructions. Give specific verbal cues during feeding, such as “Open your mouth,” “Chew thoroughly,” and “Tuck your chin and swallow.” Clear instructions and focused attention improve swallowing safety. Mealtime assistance and verbal prompting enhance nutritional intake in older adults. Ensure thorough chewing and frequent swallowing. Provide continuous direction and reinforcement until each mouthful is swallowed.

  • Maintain the client in a high-Fowler position with the head flexed slightly forward during meals. Maintain upright positioning during and after meals. Keep patients in a high-Fowler’s position with slight chin tuck during meals to minimize aspiration risk. Upright positions, ideally 60 to 90 degrees (supine position), and sitting upright after meals utilize gravity to protect the airway and aid esophageal transit.

  • Observe for uncoordinated chewing or swallowing; coughing shortly after eating or delayed coughing, which may mean silent aspiration; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than one second in swallowing; or a variation in respiratory patterns. If any of these signs are present, put on gloves, eliminate all food from the oral cavity, end feedings, and consult with a speech and language pathologist and a dysphagia team. Monitor for aspiration signs during and after meals. Observe for signs of swallowing difficulty, including uncoordinated movements, coughing (immediate or delayed), pocketing, wet voice, sneezing, delayed swallow initiation (>1 second), or changes in breathing pattern. Silent aspiration may occur without immediate cough. If aspiration signs are noted, stop feeding immediately, clear the oral cavity, and consult with the SLP and dysphagia team. Age-related swallowing changes often lead to altered eating habits, including reduced volume, texture modifications, and prolonged meal times.

  • Place whole or crushed pills in custard, gelatin, or yogurt. (First, ask a pharmacist which pills should not be crushed.) Substitute medication in an elixir form as indicated. Administer medications safely. Administer pills with food vehicles like custard, gelatin, or yogurt to ease swallowing and reduce aspiration risk. Consult a pharmacist before crushing any medications. Elixir or liquid forms of medication may be substituted when appropriate. Yogurt is often preferred for crushed medications as it minimally affects dissolution rates compared to other vehicles.

  • Keep the client upright for 30 to 45 minutes after a meal. Maintain upright position post-meal. Keep patients upright for 30 to 45 minutes after meals. Upright positioning post-meal ensures gastric emptying and reduces reflux and aspiration risk. Elevating the head while lying down and remaining upright for at least 30 minutes post-meal are recommended for patients with gastroesophageal reflux.

3. Providing Adequate Nutritional Support

Dysphagia can lead to malnutrition, dehydration, and increased morbidity and mortality. Ensuring adequate nutritional support is a critical component of dysphagia management.

  • If the client has impaired swallowing, do not feed until an appropriate diagnostic workup is completed. Ensure proper nutrition by consulting with a for enteral feedings, preferably a PEG tube in most cases. Withhold oral feeding until swallowing is assessed. Do not initiate oral feeding until a dysphagia workup is completed to prevent aspiration. Ensure adequate nutrition, often via enteral feeding, preferably percutaneous endoscopic gastrostomy (PEG) tube for long-term needs. Nasogastric tubes are suitable for short-term feeding (2-4 weeks), while PEG tubes are preferred for long-term enteral nutrition (>28 days).

  • Before feeding, provide the client a lemon wedge, pickle, or tart-flavored hard candy or use artificial saliva if decreased salivation is a contributing factor. Stimulate salivation pre-feeding. Stimulate saliva production before meals with lemon wedges, pickles, tart candy, or artificial saliva if dry mouth is a factor. Saliva moistens food, lubricates the oral cavity, and facilitates swallowing. Age-related changes often include decreased taste and salivary rheology.

  • Advance slowly, giving small amounts; whenever possible, alternate servings of liquids and solids. Introduce foods gradually in small portions. Advance diet textures slowly, starting with small portions and alternating liquids and solids to prevent oral residue. Portion control and alternating consistencies aid in swallowing and reduce food pooling. Modified eating strategies include smaller portions, increased meal frequency, bite-sized pieces, avoiding difficult-to-chew foods, and drinking liquids with meals.

  • Incorporate a texture-modified diet or thickened liquid administration as appropriate. Implement texture-modified diets and thickened liquids. Texture-modified diets and thickened liquids are key interventions for safe swallowing. The IDDSI framework provides standardized texture and viscosity levels. Pureed diets with gelling agents can reduce aspiration risk in moderate to severe dysphagia.

  • Encourage a high-calorie diet that involves all food groups, as appropriate. Improve the nutrient density in the diet. Promote nutrient-dense, high-calorie diets. Encourage a balanced, high-calorie diet with all food groups. Enhance nutrient density by fortifying foods. Increased nutrient density improves nutritional intake without affecting satiety and enhances satisfaction with texture-modified diets. Adding medium-chain triglyceride oil, protein powders, and nutritious foods increases nutrient intake and improves nutritional status.

  • Provide nutritious snacks. Offer nutritious snacks between meals. Snacks increase overall nutritional intake. Older adults with dysphagia often prefer snacks, suggesting their benefit in improving nutrition. ESPEN guidelines recommend snacks to boost nutritional intake.

  • If client pouches food to one side of their mouth, encourage them to turn their heads to the unaffected side and manipulate the tongue to the paralyzed side. Address food pocketing with postural strategies. If food pocketing occurs, instruct patients to turn their head to the unaffected side and use their tongue to move food to the stronger side for swallowing. These strategies aid in clearing oral residue. Cervical flexion exercises can also reduce pharyngeal residue.

  • If the client tolerates single-textured foods such as pudding, hot cereal, or strained baby food, advance to a soft diet with guidance from the dysphagia team. Avoid foods that are difficult to chew. Also, avoid sticky foods such as peanut butter and white bread. Progress diet texture based on tolerance and SLP recommendations. Advance diet texture gradually from single-texture purees to soft diets under dysphagia team guidance. Avoid difficult-to-chew or sticky foods like peanut butter and white bread. Texture modification is crucial for aspiration prevention, but long-term use can lead to nutrient deficiencies and reduced quality of life.

  • Encourage the client to feed self as soon as possible. Promote self-feeding when appropriate. Encourage self-feeding to allow patients to control bolus size and pace, promoting effective swallowing. Self-feeding mimics normal eating patterns and is preferred over assisted feeding when possible.

  • If oral intake is not possible or is inadequate, initiate alternative feedings (e.g., nasogastric feedings, gastrostomy feedings, or hyperalimentation). Implement alternative feeding methods if oral intake is insufficient. If oral intake is inadequate, initiate alternative nutrition, such as nasogastric (NG) tube, gastrostomy tube, or parenteral nutrition. NG and PEG tubes significantly reduce aspiration pneumonia and ensure adequate nutrition. These methods are indicated for severe dysphagia, high aspiration risk, or malnutrition risk.

  • For many adult clients, avoid using straws if recommended by a speech pathologist. Limit straw use. Avoid straws unless specifically recommended by an SLP. Straws can increase aspiration risk by delivering a bolus of liquid quickly and reducing oral control.

  • Praise the client for successfully following directions and swallowing appropriately. Provide positive reinforcement. Praise and encourage patients for following swallowing strategies and directions. Positive reinforcement promotes learning and a positive mealtime experience. For older adults, physical and social support during meals, including encouragement and emotional support, improve mealtime satisfaction.

  • Refer the client to the dietitian for instructions on maintaining a well-balanced diet. Consult a dietitian for dietary guidance. Refer patients to a dietitian for personalized dietary plans. Dietitians provide specialized nutritional management for dysphagia patients.

  • Administer oral nutritional supplements (ONS) as indicated. Use oral nutritional supplements (ONS) as needed. ONS are effective in optimizing nutritional intake and are cost-effective for patients at malnutrition risk. ONS increase protein intake and serum albumin levels in older adults.

  • Administer IV fluids as added support to oral nutrition. Consider IV fluids for hydration support. IV fluids can provide short-term hydration support, especially for patients transitioning back to oral intake. Parenteral hydration can supplement enteral nutrition, as adequate fluid intake is crucial for healing and well-being.

  • Refer the client with stroke for a dysphagia rehabilitation program. Refer stroke patients to dysphagia rehabilitation. Dysphagia in stroke patients increases mortality, morbidity, and reduces quality of life. Early dysphagia rehabilitation is recommended to improve outcomes and reduce complications like malnutrition, dehydration, and aspiration pneumonia.

4. Providing Oral Hygiene

Maintaining excellent oral hygiene is crucial in dysphagia management to reduce the risk of aspiration pneumonia and improve overall oral health.

  • Stop the use of a toothbrush and flossing. Modify oral hygiene practices if mucositis is present. If oral mucositis is present, discontinue toothbrush and flossing to prevent tissue damage. Use foam swabs (Toothettes) or sterile cotton swabs for gentle cleansing. Rinse mouth with alcohol-free mouthwash at least four times daily.

  • Provide gentle oral care for the client with oral mucositis. Implement gentle oral care for mucositis. Use foam swabs to moisten oral mucosa, remove debris, and clean the mouth, especially for edentulous patients. Avoid using foam swabs to clean teeth if platelet count is low due to bleeding risk. Foam swabs are not effective for plaque removal on teeth.

  • Maintain the inside of the mouth moist with frequent sips of water and salt water rinses. Keep oral mucosa moist. Frequent sips of water and saline rinses maintain oral moisture, promoting natural cleansing and preventing mucosal drying, which can lead to fissures and lesions. Artificial saliva, dry mouth gums, and honey can also be used for lubrication.

  • Provide scrupulous oral care to critically ill clients. Provide rigorous oral care for critically ill patients. Critically ill patients often have high oral bacterial colonization, increasing nosocomial pneumonia risk. Implement protocols using 0.12% chlorhexidine for oral care in intensive care units.

  • Ensure that removable dentures are cleaned daily and meticulously. Maintain denture hygiene. Clean dentures daily. Dentures can harbor microorganisms. Mechanical cleaning with a soft brush and non-abrasive toothpaste three times daily is recommended. Weekly immersion in 0.5% sodium hypochlorite (for non-metallic dentures) or 0.12% chlorhexidine for 10 minutes is also advised.

  • If whitish plaques are evident in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red base that bleeds, suspect a fungal infection and contact the healthcare provider for follow-up. Recognize and manage oral candidiasis. Suspect oral candidiasis (thrush) if whitish plaques are present that can be rubbed off, leaving a red, bleeding base. Common causes include antibiotic or steroid use, HIV, diabetes, and immunosuppression. Treat with antifungal agents and maintain daily oral cleaning with a soft brush or chlorhexidine.

  • Give local antimicrobial agents as ordered. Administer prescribed antimicrobial agents. Local antimicrobial agents like Mycostatin, nystatin, and Mycelex Troche may be prescribed for oral infections. Nystatin is often the preferred choice for oral candidiasis due to its effectiveness, low side effects, and cost-effectiveness.

  • Provide mucosal protectants as indicated. Use mucosal protectants. Mucosal protectants like Gelclair and Zilactin coat oral mucosa, protecting nerve endings and allowing for more comfortable eating and speaking.

  • Offer alternative methods for oral mucositis as recommended. Consider alternative therapies for mucositis. Herbal medicines and honey can be used for mucositis due to their anti-inflammatory, antioxidant, and wound-healing properties. Ginger extract has analgesic compounds that can help manage pain associated with mucositis.

5. Providing Client and Family Education

Comprehensive education for patients and caregivers is essential for successful dysphagia management at home. This includes instruction on safe swallowing techniques, dietary modifications, and recognition of complications.

  • Discuss and demonstrate the following to the client or caregiver:

    • Avoidance of certain foods or fluids: Identify specific foods and liquids to avoid based on individual needs and swallowing assessment.
    • Upright position during eating: Emphasize maintaining an upright posture during all meals and snacks.
    • Allowance of time to eat slowly and chew thoroughly: Instruct on the importance of slow eating, thorough chewing, and taking small bites.
    • Provision of high-calorie meals: Educate on strategies to increase calorie intake with modified diets, including nutrient-dense foods and supplements.
    • Use of fluids to help facilitate the passage of solid foods: Explain how liquids can be used to wash down solids and improve swallowing efficiency, if appropriate for the patient.
    • Monitoring of the client for weight loss or dehydration: Teach how to monitor for signs of weight loss and dehydration and when to seek medical advice.

    Active participation from patients and caregivers is crucial for treatment plan adherence and optimal outcomes. Regular evaluation of oral health, swallowing, and chewing function is important.

  • Discuss the importance of exercise to enhance the muscular strength of the face and tongue to enhance swallowing. Educate on swallowing exercises. Explain the benefits of facial and tongue exercises to improve swallowing strength and coordination. Tongue-strengthening exercises improve swallowing function. Oropharyngeal exercises enhance bolus formation and control, reducing aspiration risk.

  • Educate the client, family, and all caregivers about rationales for food consistency and choices. Explain dietary modifications and rationales. Educate patients and caregivers about the reasons behind dietary restrictions and texture modifications to prevent aspiration. Family members may inadvertently offer inappropriate foods, so clear education is essential. Discuss potential unconscious dietary modifications patients may make, such as reducing solid food intake or prolonging meal times, and emphasize the importance of healthcare professional supervision.

  • Educate the client and family about the importance of dysphagia rehabilitation program. Inform about dysphagia rehabilitation programs. Educate patients and families about the benefits of dysphagia rehabilitation programs. Education enhances disease acceptance and improves communication within the family and with caregivers.

Educating about oral care and hygiene

  • Plan and implement a meticulous mouth care regimen after each meal regularly and every four hours while awake. Establish a consistent oral care routine. Teach and implement a regular oral care regimen after each meal and every 4 hours while awake to prevent plaque and bacterial buildup. Patients with oral catheters or oxygen therapy may require more frequent care. Regular oral hygiene reduces aspiration pneumonia and improves cough reflex sensitivity.

  • Increase the frequency of oral hygiene by rinsing with one of the suggested solutions between brushings and once during the night especially if signs of mild stomatitis (dryness and burning; mild erythema and edema along mucocutaneous junction) occur. Increase oral hygiene frequency if stomatitis develops. If mild stomatitis occurs, increase oral hygiene frequency, including rinses between brushings and at night. Chlorhexidine mouthwash can be more effective than brushing alone in preventing ventilator-associated pneumonia.

  • Provide systemic or topical analgesics as prescribed. Administer analgesics for oral pain. Prescribed systemic or topical analgesics provide pain relief, improving comfort and enabling better food and fluid intake, communication, and sleep. Topical analgesics like phenytoin, morphine, doxepin, and sucralfate can be used.

  • Discontinue flossing if it causes pain. Use a pediatric toothbrush or a soft-bristled toothbrush to avoid mucosal trauma. Modify oral hygiene tools for comfort. If flossing causes pain, discontinue it. Use a pediatric or extra-soft toothbrush to minimize mucosal trauma. Thinning oral mucosa increases pain sensitivity. If unable to use a toothbrush or floss, use soft cloths, cotton swabs, or mouthwash for frequent rinsing.

  • Explain that topical analgesics can be administered as “swish and swallow” or “swish and spit” 15 to 20 minutes before meals, or painted on each lesion immediately before mealtime. Instruct on topical analgesic use. Explain how to use topical analgesics as swish and swallow or swish and spit solutions 15-20 minutes before meals or apply directly to lesions before eating for optimal pain control. Hold solution in mouth for several minutes before expectorating.

  • Explain the use of topical protective agents. Educate about mucosal protectants. Explain the use of topical protective agents that coat lesions and promote healing.

  • Use tap water or normal saline to provide oral care; do not use commercial mouthwashes containing alcohol or hydrogen peroxide. Also, do not use lemon-glycerin swabs. Recommend appropriate oral care solutions. Advise using tap water or normal saline for oral care. Avoid alcohol-based mouthwashes, hydrogen peroxide, and lemon-glycerin swabs, as they can irritate or dry oral mucosa. Alcohol dries mucosa, hydrogen peroxide is irritating and tastes unpleasant, and lemon-glycerin swabs can erode tooth enamel and reduce salivary amylase.

Instructing about appropriate nutritional practices
  • Encourage a diet high in protein and vitamins. Recommend a nutrient-rich diet. Advise a diet high in protein and vitamins to support healing and overall health.
  • Serve foods and fluids lukewarm or cold. Serve food at appropriate temperatures. Serve foods and fluids lukewarm or cold to minimize irritation, especially with mucositis.
  • Serve frequent small meals or snacks spaced throughout the day. Promote frequent, small meals. Recommend frequent, small meals or snacks throughout the day to improve intake and reduce fatigue.
  • Encourage soft foods (e.g., mashed potatoes, puddings, custards, and creamy cereals). Suggest soft food choices. Encourage soft foods like mashed potatoes, puddings, custards, and creamy cereals that are easier to swallow.
  • Encourage the use of straw. (Note: This is contradictory to previous advice to limit straw use. This may be context-dependent and requires clarification with SLP recommendations. In general, straw use is often discouraged unless specifically recommended by an SLP for certain patients.) [Re-evaluate and clarify the recommendation on straw use based on individual patient needs and SLP guidance. Generally, straws are often avoided due to aspiration risks unless specifically indicated.]
  • Encourage peach, pear, apricot nectars, and fruit drinks instead of citrus juices. Recommend less acidic beverages. Suggest less acidic fruit drinks like peach, pear, and apricot nectars instead of citrus juices, which can irritate oral mucosa.

Dietary modifications are key compensatory strategies for dysphagia. Modifications include adjusting volume, viscosity, bolus size, and texture.

  • Instruct the client to avoid alcohol or hydrogen peroxide-based commercial products for mouth care and to avoid other irritants to the oral cavity (e.g., tobacco, spicy foods). Advise avoiding oral irritants. Instruct patients to avoid alcohol and hydrogen peroxide-based mouthwashes and other oral irritants like tobacco and spicy foods, which can further irritate oral mucosa and increase discomfort. Acidic foods should also be avoided.
Instructing the client and caregiver on home care

  • Lightly brush all surfaces of the teeth, gums, and tongue with a soft-bristled nylon or foam brush. Floss smoothly. Teach proper home oral hygiene techniques. Instruct on gentle brushing of teeth, gums, and tongue with a soft brush and smooth flossing to remove debris and stimulate circulation. Nurses should encourage proper oral hygiene. Soft cloths or foam swabs can be used if toothbrushing is too painful.

  • Remove and brush dentures properly after meals as necessary. Have loose-fitting dentures adjusted. Educate on denture care. Instruct on proper denture removal and cleaning after meals. Ensure dentures fit well to prevent irritation and trauma. Ill-fitting dentures can increase microorganism proliferation and risk of denture stomatitis.

  • Rinse the mouth thoroughly during and after brushing. Emphasize thorough rinsing. Advise thorough mouth rinsing during and after brushing to remove food particles and reduce infection risk. Non-medicated rinses like sodium bicarbonate and saline can help prevent mucositis.

  • Include food items with each meal that require chewing. Incorporate chewing exercises through diet. Include foods requiring chewing with each meal to stimulate gingival tissue and circulation. Tongue strengthening exercises also improve swallowing.

  • Educate the client on how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and healing. Teach self-monitoring skills. Educate patients on self-oral cavity inspection and monitoring for infection, complications, and healing signs. Build on existing knowledge to create an individualized home care plan. Education and information are first-line rehabilitation methods.

  • Educate the client and caregiver about the appropriate positioning during mealtimes. Instruct on proper mealtime positioning at home. Teach patients and caregivers about proper positioning during meals. Orally fed patients should sit upright, and non-orally fed patients should be at a minimum 30-45 degree reclining position to facilitate bolus flow and protect the airway.

  • Explain the advantages and disadvantages of texture modification and thickeners. Discuss pros and cons of texture modification and thickeners. Explain the benefits and drawbacks of texture modification and thickeners. While they prevent aspiration risk, long-term use can lead to nutrient deficiencies and reduced quality of life. Newer xanthan gum-based thickeners are more palatable and amylase-resistant compared to starch-based thickeners.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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References and Sources

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