Risk for Aspiration | Nursing Care Plan for Total Nutritional Support

Nursing diagnosis: risk for Aspiration

Risk factors may include
Presence of GI tube, bolus tube feedings, medication administration
Increased intragastric pressure, delayed gastric emptying

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

Desired Outcomes/Evaluation Criteria—Client Will
Aspiration Prevention
Maintain clear airway, free of signs of aspiration.

Nursing intervention with rationale:
1. Confirm placement of nasoenteral feeding tubes. Determine feeding tube position in stomach by x-ray, confirm pH of 0 to 5 for the gastric fluid withdrawn through tube, or auscultate injected air before intermittent feedings. Observe for ability to speak and cough.
Rationale: Malplacement of nasoenteral feeding tubes may result in aspiration of enteral formula. Clients at particular risk include those who are intubated or obtunded and those who have had a cerebrovascular accident (CVA) or surgery of the head, neck, and upper GI system. Note: The reliability of the pH method is reduced if antacids or certain other medications have been given orally or via NG in the past 4 hours. In addition, when using auscultatory method to assess tube placement, air sounds can be transmitted to the epigastrium even if the tube is malpositioned in lung or proximal jejunum.

2. Maintain aspiration precautions during enteral feedings, such
as the following: Keep head of bed elevated at 30 to 45 degrees during feeding and for least 1 hour after feeding.
Rationale: Reduces risk of regurgitation or gastric reflux.

3. Inflate tracheostomy cuff during and for 1 hour after intermittent feeding. Interrupt continuous feeding when client is in prone position.
Rationale: Aspiration of enteral formulas is highly irritating to the lung parenchyma and may result in pneumonia and respiratory compromise.

4. Add blue food coloring to enteral formula, as indicated.
Rationale: Helps identify aspiration of enteral formula and tracheal esophageal fistula, if discovered in sputum or lung secretions. Note: Avoid use of methylene blue dye, which may cause false-positive guiac test when assessing for GI bleeding.

5. Monitor gastric residuals between or before bolus feedings (as previously noted in ND: imbalanced Nutrition: Less than Body Requirements).
Rationale: Presence of large gastric residuals may potentiate an incompetent esophageal sphincter, leading to vomiting and aspiration.

6. Note characteristics of sputum and tracheal aspirate. Investigate development of dyspnea, cough, tachypnea, and cyanosis. Auscultate breath sounds.
Rationale: Presence of formula in tracheal secretions or signs and symptoms reflecting respiratory distress suggests aspiration.

7. Note indicators of NG tube intolerance, such as absence of gag reflex, high risk of aspiration, and frequent removal of NG feeding tubes.
Rationale: May require consideration of surgically placed feeding tube, percutaneous endoscopic gastrostomy (PEG), or jejunostomy for client safety and consistency of enteral formula delivery.

8. Review abdominal x-ray if performed.
Rationale: Confirmation of placement of gastric feeding tube should be obtained by x-ray. Note: Injection of air boluses is no longer recommended.