Impaired Swallowing Nursing Diagnosis and Nursing Care Plan
This guide is about impaired swallowing, impaired swallowing nursing diagnosis, and impaired swallowing nursing care plan. It can be used to develop nursing interventions for educational purposes.
Impaired Swallowing
What is meant by impaired swallowing?
Dysphagia or impaired swallowing can be defined as the reduced capacity to swallow solids or liquids related to oral, pharyngeal, or esophageal damage. It is a condition that increases the risk of choking, aspiration, dehydration, and malnutrition.
Impaired swallowing can also be defined as difficulty swallowing — taking more time and effort to move food or liquid from your mouth to your stomach. Dysphagia can be painful. In some cases, swallowing is impossible.
Impaired swallowing involves more time and effort to transfer food or liquid from the mouth to the stomach. It occurs when the muscles and nerves that help move food through the throat and esophagus are not working right. It can be a temporary or permanent complication that can be fatal.
Aspiration of food or fluid can also occur possibly brought about by a structural problem, interruption or dysfunction of neural pathways, decreased strength or excursion of muscles involved in mastication, facial paralysis, or perceptual impairment. The swallowing muscles can become weak with age or inactivity. It is a common complaint among older adults, in those individuals who have had a stroke, suffered head trauma, have head or neck cancer, or experience progressive neurological diseases such as multiple sclerosis, amyotrophic lateral sclerosis, and Parkinson’s disease. Dysphagia can befall at any age, but it’s more prevalent in older adults. The causes of swallowing problems vary, and treatment depends on the cause.
Nursing Diagnosis
How do you assess difficulty in swallowing?
Assessment is necessary to determine potential problems that may have led to dysphagia as well as handle any difficulty that may appear during nursing care.
| Assessment | Rationales |
|---|---|
| Assess ability to swallow by positioning examiner’s thumb and index finger on patient’s laryngeal protuberance. Ask patient to swallow; feel larynx elevate. Ask patient 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. | The lungs are usually protected against aspiration by reflexes as cough or gag. When reflexes are depressed, the patient is at increased risk for aspiration. |
| Evaluate the strength of facial muscles. | Cranial nerves VII, IX, X, and XII control motor function in the mouth and pharynx. Coordinated function of muscles innervated by these nerves is necessary to move a bolus of food from the mouth to the posterior pharynx for controlled swallowing. |
| Check for coughing or choking during eating and drinking. | These signs indicate aspiration. |
| 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. |
| Assess ability to swallow a small amount of water. | If aspirated, little or no harm to the patient occurs. |
| Check for residual food in mouth after eating. | Pocketed food may be easily aspirated at a later time. |
| Check for food or fluid regurgitation through the nares. | Regurgitation indicated decreased ability to swallow food or fluids and an increased risk for aspiration. |
| Evaluate the results of swallowing studies as ordered. | A video-fluoroscopic swallowing study may be indicated to determine the nature and extent of any oropharyngeal swallowing abnormality, which aids in designing interventions. |
| Determine patient’s readiness to eat. Patient needs to be alert, able to follow instructions, hold head erect, and able to move tongue in mouth. | If one of these factors is missing, it may be desirable to withhold oral feeding and do enteral feeding for nourishment. Cognitive deficits can result in aspiration even if able to swallow adequately. |
Nursing Care Plan
What are the nursing interventions for dysphagia?
The following are the therapeutic nursing interventions for impaired swallowing:
| Nursing Interventions | Rationales |
|---|---|
| For hospitalized or home care patients: | |
| Before mealtime, provide for adequate rest periods. | Fatigue can further add to swallowing impairment. |
| Eliminate any environmental stimuli (e.g., TV, radio) | The patient can more concentrate when external stimuli are removed. |
| Provide oral care before feeding. Clean and insert dentures before each meal. | Optimal oral care promotes appetite and eating. |
| If patient has impaired swallowing, consult a speech pathologist for bedside evaluation as soon as possible. Ensure that patient is seen by a speech pathologist within 72 hours after admission if patient has had a CVA. | Speech pathologists specialize in impaired swallowing. Early referral of CVA patients 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. |
| For impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist who work together. | The dysphagia team can help the patient learn to swallow safely and maintain a good nutritional status. |
| Place suction equipment at the bedside, and suction as needed. | With impaired swallowing reflexes, secretions can rapidly accumulate in the posterior pharynx and upper trachea, increasing the risk of aspiration. |
| If patient 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 patient who cannot sufficiently swallow results in aspiration and possibly death. Enteral feedings via PEG tube are generally preferable to nasogastric tube feedings because studies have shown that there is increased nutritional status and possibly improved survival rates. |
If decreased salivation is a contributing factor:
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Moistening and use of tart flavors stimulate salivation, lubricate food, and improves the ability to swallow. |
| If patient has an intact swallowing reflex, attempt to feed. Observe the following feeding guidelines: | |
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This position allows the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration. |
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As the patient becomes less alert the swallowing response decreases, which increases the risk of aspiration. |
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Gravy or sauce added to dry foods facilitates swallowing. |
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Proper instruction and focused concentration on specific steps reduce risks. |
| Maintain the patient in high-Fowler’s position with the head flexed slightly forward during meals. | Aspiration is less likely to happen in this position. |
| Instruct the patient not to talk while eating. Provide verbal cueing as needed. | Concentration must be focus on the task. |
| 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 1 second in swallowing; or a variation in respiratory patterns. If any of these signs are present, put on gloves, eliminate all food from oral cavity, end feedings, and consult with a speech and language pathologist and a dysphagia team. | These are signs of impaired swallowing and possible aspiration. |
| Reassure the patient to chew completely, eat gently, and swallow frequently, especially if extra saliva is produced. Give the patient with direction or reinforcement until he or she has swallowed each mouthful. | Such directions assist in keeping one’s focus on the task. |
| Classify food given to the patient before each spoonful if the patient is being fed. | Knowledge of the consistency of food to expect can prepare the patient for appropriate chewing and swallowing technique. |
| Advance slowly, giving small amounts; whenever possible, alternate servings of liquids and solids. | This technique helps prevent foods from being left in the mouth. |
| Encourage high-calorie diet that involves all food groups, as appropriate. Avoid milk and milk products. | Dairy products can lead to thickened secretions. |
| If patients pouch food to one side of their mouth, encourage them to turn their head to the unaffected side and manipulate the tongue to the paralyzed side. | Foods placed on the unaffected side of the mouth promote more complete chewing and movement of food to the back of the mouth, where it can be swallowed. These strategies aid in cleaning out residual food. |
| If patient 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 such as hamburgers, corn, and pastas that are difficult to chew. Also, avoid sticky foods such as peanut butter and white bread. | The dysphagia team should determine the appropriate diet for the patient on the basis of progression in swallowing and ensuring that the patient is nourished and hydrated. |
| If the patient had a stroke, place food in the back of the mouth, on the unaffected side, and gently massage the unaffected side of the throat. | Massage aids stimulate the act of swallowing. |
| Place whole or crushed pills in custard or gelatin. (First, ask a pharmacist which pills should not be crushed.) Substitute medication in an elixir form as indicated. | Mixing some pills with foods helps reduce the risk for aspiration. |
| Encourage the patient to feed self as soon as possible. | With self-feeding, the patient can establish the volume of a food bolus and the timing of each bite to promote effective swallowing. |
| If oral intake is not possible or in inadequate, initiate alternative feedings (e.g., nasogastric feedings, gastrostomy feedings, or hyperalimentation). | Optimal nutrition is a patient need. |
| For many adult patients, 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. |
| Praise patient for successfully following directions and swallowing appropriately. | Praise reinforces behavior and sets up a positive atmosphere in which learning takes place. |
| Follow-up: | |
| Initiate a dietary consultation for calorie count and food preferences. | Dietitians have a greater understanding of the nutritional value of foods and may be helpful in guiding treatment. |
| More interventions: | |
| Keep patient in an upright position for 30 to 45 minutes after a meal. | An upright position guarantees that food stays in the stomach until it has emptied and decreases the chance of aspiration following meals. |
| Observe for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new crackles or wheezing, and note elevated temperature. Notify physician as needed. | The presence of new crackles or wheezing, an elevated temperature or white blood cell count, and a change in sputum could indicate aspiration of food. |
Discuss and demonstrate the following to the patient or caregiver:
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Both the patient and caregiver may need to be active participants in implementing the treatment plan to optimize safe nutritional intake. |
| Weigh patient weekly. | This is to help evaluate nutritional status. |
| Assess nutritional status regularly. If not adequately nourished, work with dysphagia team to determine whether patient needs to avoid oral intake (NPO) with therapeutic feeding only or needs enteral feedings until patient can swallow adequately. | Enteral feedings can maintain nutrition if patient is unable to swallow adequate amounts of food. |
| Discuss the importance of exercise to enhance the muscular strength of the face and tongue to enhance swallowing. | Muscle strengthening can facilitate greater chewing ability and positioning of food in the mouth. |
| Educate patient, family, and all caregivers about rationales for food consistency and choices. | It is common for family members to disregard necessary dietary restrictions and give patient inappropriate foods that predispose to aspiration. |
Impaired Swallowing Nursing Diagnosis and Nursing Care Plan Example
Nursing Care Plan 1
Head and Neck Cancer
Nursing Diagnosis: Impaired Swallowing related to mechanical obstruction status secondary to head and neck cancer as evidenced by repetitive swallowing, choking, coughing, and gagging.
Desired Outcome: The patient will maintain adequate nutrition and hydration as evidenced by maintained BMI, good skin turgor, moist mucous membranes, and appropriate urine output.
| Intervention | Rationale |
| Assess the cause and the degree of impairment by using the dysphagia screening test and by comparing the patient’s previous weight to the current weight. | To provide baseline data and determine the need for hydration and nutritional support. The dysphagia screening test also determines whether the patient has the capacity to feed solids and liquids. |
| Auscultate breath sounds and review laboratory results. | To monitor for aspiration and determine infection by observing the trends in the blood tests. |
| Provide a consistency of food and fluid that is easily swallowed. Avoid dairy products and chocolate. | To reduce the risk of aspiration or choking. Dairy products and chocolate thicken oral secretions and increase the risk of choking. |
| Position client appropriately when feeding and maintain strict aspiration precautions. | Placing the patient upright when feeding minimizes the risk of aspiration, maintaining airway patency. |
| Prepare the patient for possible diagnostic examinations such as the fiberoptic endoscopic evaluation of swallowing, the transnasal or esophageal endoscopy, or the barium swallow. | Diagnostic examinations aid the healthcare team in determining the extent of the swallowing disorder and helps in directing the course of treatment of the patient. |
| Administer tube feeding, parenteral nutrition, or hydration as ordered. | To meet body fluid and nutritional requirements. |
| Refer to the surgeon, gastroenterologist, or oncologist. | For specialized treatment that may improve swallowing ability, such as surgery, medications, and others. |
| Advise patient to avoid eating within 3 hours before sleeping at night and to elevate the head of the bed during sleep. | Eating before sleeping may cause gastric reflux and aspiration. Refraining from eating reduces the risk of this occurring. |
Nursing Care Plan 2
Parkinson’s Disease
Nursing Diagnosis: Impaired Swallowing related to neuromuscular impairment secondary to Parkinson’s disease as evidenced by choking, drooling, muscle rigidity, food pocketing, and aspiration.
Desired Outcome: The patient will be able to ingest an adequate amount of nutrients and maintain the ideal body weight.
| Intervention | Rationale |
| Assess the patient’s cognitive and sensory-perceptual status. | Impairment in cognitive or sensory-perceptual status affects the patient’s desire and ability to swallow safely and effectively. |
| Assess the cause and the degree of impairment by using the dysphagia screening test | Swallowing difficulties and choking are common in Parkinson’s disease. Producing baseline data will help in assessing in the future if the patient’s disorder is regressing or progressing. |
| Auscultate breath sounds and review laboratory results. | To monitor for aspiration and determine infection by observing the trends in the blood tests. |
| Note symmetry of facial structures and muscle tone and determine if there is any presence of muscle weakness. Place the food in the functioning side of the patient’s mouth. Modify diet and provide patient-preferred foods that are soft and require little chewing. Avoid thin liquids. | Placing the food in the functioning side of the patient’s mouth allows for sensory stimulation and taste and may trigger swallowing reflexes. Soft foods decrease the potential for choking or aspiration. |
| Cue client to chew and swallow as needed. | This enhances concentration and performance of swallowing. |
| Massage the sides of the trachea and neck. | Massaging these areas will stimulate swallowing. |
| Inspect oral cavity after each bite and have client check around cheeks with tongue for remaining food. | To monitor for food pocketing and minimize the risk of aspiration later on. |
| Keep client seated or upright during feeding and at least 30 minutes post-feeding. | Letting the patient lay down during eating or immediately after intake may cause regurgitation or aspiration. |
| Administer tube feeding, parenteral nutrition, or hydration as ordered. | To achieve adequate nutritional intake, and prevent malnutrition and dehydration. |
| Refer to ENT or speech pathology. | Referral to a specialist will let the patient learn specific techniques to enhance efforts and safety. |
