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Nursing Care Plan for Aspiration

Pathophysiology

Aspiration occurs when something enters into the lungs that is not air. This sometimes causes aspiration pneumonia, but not always. For example, the patient has a gag reflex, causing coughing, or the cilia lining the lungs are able to sweep out the aspirated item. If the patient aspirates a secretion that has a high bacterial count they will likely get aspiration pneumonia. The difference physiologically speaking is that pneumonia will be treated with antibiotics.

Etiology

This is likely caused by someone losing their gag reflex, but can also be caused by inability to clear secretions/emesis, as well as from a position or medication (such as a sedative medication). Someone with dysphagia, no matter the cause is at high risk for aspiration.

Desired Outome

Patent airway, oxygenation maintenance, prevention of further complications such as pneumonia.

Aspiration Nursing Care Plan

Subjective Data:

Shortness of breath

 

Difficulty breathing

 

Chest pain

Objective Data:

Coughing

 

Low oxygen saturation

 

Tachypnea/Dyspnea

 

Blue lips/fingers

 

Lung sounds: Crackles and/or diminished

 

Putrid or frothy sputum


Nursing Interventions and Rationales:

  1. AIRWAY PROTECTION Maintain a patent airway

    • Legit the number one thing. Everything else in this care plan is good too but this trumps it all when it comes to priorities.

      Prevention is key, but since this patient has already slipped substances past the epiglottis (AKA royal lung guard) everything that applies to prevention (NPO, head of bed greater than 30 degrees, oral hygiene, etc.) is even more important to prevent further complications.

      Intubation: Be prepared to intubate, not because the patient will for sure be intubated, but because not being prepared is costly (like someones life kind of cost).

      Suction: Lastly have suction ready. You should always have suction ready no matter the patient’s chief complaint, but especially for a patient with aspiration.

      Oxygen: Have all the stuff for oxygen ready. Monitor their oxygen levels. If they dip low (<94%) help them out with oxygen. Key note here: have a full tank of oxygen ready to go on their bed incase you need to rush them off somewhere due to emergent situations. These patients are high risk for low oxygenation.

  2. Suction when necessary
    • Have the suction ready to go to help keep the airway clear and increase the surface area for oxygen absorption.
  3. Perform a Swallow Screen

    • This is a simple, nurse initiated test that should really be performed on any patient that is not NPO.

      Checking the patient’s ability to swallow gives the nurse so much information about how to proceed with the plan of care.

      For example: That fever they have, is not going to be treated via oral Tylenol if they cannot swallow. Doctors WILL order this- you will not give it because you are awesome and have checked the patient’s ability to swallow. Then you will beg for IV Tylenol and get an order for rectal Tylenol because it is cheaper and the standard of care. After you and the patient cry it out for a minute, you will administer the Tylenol in the no go zone with the promise of blankets as a reward for breaking the fever.

      If they do not pass the swallow screen the patient will be NPO, or they should be anyway.
  4. Acquire a chest X-ray
    • A chest x-ray helps to differentiate the patient with aspiration as to whether they have acquired pneumonia or not.

      The results of the x-ray determine the patient’s plan of care (meaning pneumonia treatment or not).

      As a nurse, it is important to monitor for s/s of aspiration and to inform the doctor if you suspect aspiration has occurred so the team can assess the need for an x-ray.
  5. Laboratory testing: Venous or Arterial Blood gas Complete Blood Count (CBC) Sputum culture/Blood culture
    • The goal of the blood gas is to monitor the patient PaCO2/PCO2 and their PaO2/PO2

      The goal of the CBC is to monitor White Blood Cells (WBC)

      Sputum culture/blood cultures will be not helpful right away but after they result can change the antibiotics that the patient is receiving.
  6. Antibiotics- if indicated (Clindamycin or Metronidazole)
    • This may be used as prophylaxis, or because the patient developed pneumonia.

      Clindamycin: most commonly used for aspiration pneumonia.

      Metronidazole: used in conjunction with clindamycin to offer further coverage.
  7. Assess respiratory function: Auscultate lung sounds Monitor O2 saturation Assess skin color (are they blue?) Assess depth, rate, regularity of breathing as well as symmetry of chest rise and fall
    • This should be done on every patient. But just like for a patient who has stroke like symptoms, you will be checking neuro function more frequently, a patient with aspiration needs to have their respiratory functions assess more frequently. The frequency is based on each patient and the situation-use clinical judgement here.

References

Date Published - May 30, 2017
Date Modified - Jun 28, 2017