Risk for Impaired Swallowing | Nursing Care Plan for Cerebrovascular Accident

Nursing diagnosis: Risk for Impaired Swallowing

Risk factors may include

Neuromuscular or perceptual impairment

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Swallowing Status

Demonstrate feeding methods appropriate to individual situation, with aspiration prevented.

Maintain desired body weight.

Nursing intervention with rationale:

1. Review individual pathology and ability to swallow, noting extent of paralysis, clarity of speech, facial and tongue involvement, ability to protect airway and episodes of coughing or choking; presence of adventitious breath sounds and amount and character of oral secretions. Weigh periodically, as indicated.

Rationale: Nutritional interventions, including choice of feeding route, are determined by these factors.

2. Have suction equipment available at bedside, especially during early feeding efforts.

Rationale: Timely intervention may limit amount and untoward effect of aspiration.

3. Place client in upright position during and after feeding, as appropriate.

Rationale: Uses gravity to facilitate swallowing and reduces risk of aspiration.

4. Provide oral care based on individual need prior to meal.

Rationale: Clients with dry mouth require a moisturizing agent, such as artificial saliva or alcohol-free mouthwash, before and after eating; clients with excess saliva will benefit from use of a drying agent, such as lemon or glycerin swabs, before meal and a moisturizing agent afterward.

5. Season food with herbs, spices, and lemon juice according to client’s preference, within dietary restrictions.

Rationale: Increases salivation, improving bolus formation and swallowing effort.

6. Serve foods at customary temperature and water always chilled.

Rationale: Lukewarm temperatures are less likely to stimulate salivation, so foods and fluids should be served cold or warm as appropriate. Note: Water is the most difficult to swallow.

7. Stimulate lips to close or manually open mouth by light pressure on lips or under chin, if needed.

Rationale: Aids in sensory retraining and promotes muscular control.

8. Place food of appropriate consistency in unaffected side of mouth.

Rationale: Provides sensory stimulation (including taste), which may increase salivation and trigger swallowing efforts, enhancing intake. Food consistency is determined by individual deficit. For example: Clients with decreased range of tongue motion require thick liquids initially, progressing to thin liquids, whereas clients with delayed pharyngeal swallow will handle thick liquids and thicker foods better. Note: Pureed food is not recommended because client may not be able to recognize what is being eaten. Most milk products, peanut butter, syrup, and bananas are avoided because they produce mucus and are sticky.

9. Touch parts of the cheek with tongue blade or apply ice to weak tongue.

Rationale: Can improve tongue movement and control necessary for swallowing and inhibits tongue protrusion.

10. Feed slowly, allowing 30 to 45 minutes for meals.

Rationale: Feeling rushed can increase stress and level of frustration, may increase risk of aspiration, and may result in client’s terminating meal early.