Nursing Diagnosis: Impaired Swallowing Application of NANDA, NOC, NIC

Nursing Diagnosis: Impaired Swallowing
Roslyn Fine and Betty J. Ackley

NANDA Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics:

Oral phase impairment

Lack of tongue action to form bolus; weak suck resulting in inefficient nippling; incomplete lip closure; food pushed out of mouth; slow bolus formation; food falls from mouth; premature entry of bolus; nasal reflux; inability to clear oral cavity; long meals with little consumption; coughing, choking, or gagging before a swallow; abnormality in oral phase of swallow study; piecemeal deglutition; lack of chewing; pooling in lateral sulci; sialorrhea or drooling

Pharyngeal phase impairment

Altered head positions; inadequate laryngeal elevation; food refusal; unexplained fevers; delayed swallow; recurrent pulmonary infections; gurgly voice quality; nasal reflux; choking, coughing, or gagging; multiple swallows; abnormality in pharyngeal phase by swallowing study

Esophageal phase impairment

Heartburn or epigastric pain; acidic smelling breath; unexplained irritability surrounding mealtime; vomitous on pillow; repetitive swallowing or ruminating; regurgitation of gastric contents or set burps; bruxism; nighttime coughing or awakening; observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing, or choking); hyperextension of head, arching during or after meals; abnormality in esophageal phase by swallow study; odynophagia; food refusal or volume limiting; complaints of "something stuck"; hematemesis; vomiting

Related Factors: Congenital deficits; upper airway anomalies; failure to thrive; protein energy malnutrition; conditions with significant hypotonia; respiratory disorders; history of tube feeding; behavioral feeding problems; self-injurious behavior; neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, or facial paralysis); mechanical obstruction (e.g., edema, tracheotomy tube, or tumor); congenital heart disease; cranial nerve involvement; neurological problems; upper airway anomalies; laryngeal abnormalities; achalasia; gastroesophageal reflux disease; acquired anatomic defects; cerebral palsy; internal or external traumas; tracheal, laryngeal, esophageal defects; traumatic head injury; developmental delay; nasal or nasopharyngeal cavity defects; oral cavity or oropharynx abnormalities; premature infants

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Swallowing Status

·         Swallowing Status: Esophageal Phase, Oral Phase, Pharyngeal Phase

Client Outcomes

·         Demonstrates effective swallowing without choking or coughing

·         Remains free from aspiration (e.g., lungs clear, temperature within normal range)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Aspiration Precautions

·         Swallowing Therapy

Nursing Interventions and Rationales

·         Determine client's readiness to eat. Client 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 advisable to withhold oral feeding and use enteral feeding for nourishment (McHale et al, 1998). Cognitive deficits can result in aspiration even if able to swallow adequately (Poertner, Coleman, 1998).

·         If new onset of swallowing impairment, ensure that client receives a diagnostic workup. There are multiple causes of swallowing impairment, some of which are treatable (Schechter, 1998).

·         Assess ability to swallow by positioning examiner's thumb and index finger on client's laryngeal protuberance. Ask client to swallow; feel larynx elevate. Ask client 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. Normally the time taken for the bolus to move from the point at which the reflex is triggered to the esophageal entry (pharyngeal transit time) is (1 second (Logeman, 1983). Cardiovascular accident (CVA) clients with prolonged pharyngeal transit times (prolonged swallowing) have a greatly increased chance of developing aspiration pneumonia (Johnson, McKenzie, Sievers, 1993). Clients can aspirate even if they have an intact gag reflex (Baker, 1993; Lugger, 1994).

·         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 (Baker, 1993; Lugger, 1994).

·         If client has impaired swallowing, refer to a speech pathologist for bedside evaluation as soon as possible. Ensure that client is seen by a speech pathologist within 72 hours after admission if client has had a CVA. Speech pathologists specialize in impaired swallowing. Early referral of CVA clients 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 (Scott, 1998). Research demonstrates that a program of diagnosis and treatment of dysphagia in acute stroke management decreases the incidence of pneumonia (AHCPR, 1999).

·         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 client learn to swallow safely and maintain a good nutritional status (Poertner, Coleman, 1998).

·         If client 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 client who cannot adequately swallow results in aspiration and possibly death. Enteral feedings via PEG tube are generally preferable to nasogastric tube feedings because studies have demonstrated that there is increased nutritional status and possibly improved survival rates (Bath, Bath, Smithard, 2000).

·         If client has an intact swallowing reflex, attempt to feed. Observe the following feeding guidelines:

• Position client upright at a 90-degree angle with the head flexed forward at a 45-degree angle (Galvan, 2001). This position forces the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration.
• Ensure client is awake, alert, and able to follow sequenced directions before attempting to feed. As the client becomes less alert the swallowing response decreases, which increases the risk of aspiration.
• Begin by feeding client one-third teaspoon of applesauce. Provide sufficient time to masticate and swallow.
• Place food on unaffected side of tongue.
• During feeding, give 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").

·         Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing, which may indicate silent aspiration; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a change in respiratory patterns. If any of these signs are present, put on gloves, remove all food from oral cavity, stop feedings, and consult with a speech and language pathologist and a dysphagia team. These are signs of impaired swallowing and possible aspiration (Baker, 1993; Galvan, 2001).

·         If 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 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 client on the basis of progression in swallowing and ensuring that the client is nourished and hydrated.

·         Avoid providing liquids until client is able to swallow effectively. Add a thickening agent to liquids to obtain a soft consistency that is similar to nectar, honey, or pudding, depending on degree of swallowing problems. Liquids can be easily aspirated; thickened liquids form a cohesive bolus that the client can swallow with increased efficiency (Langmore, Miller, 1994; Poertner, Coleman, 1998).

·         Preferably use prepackaged thickened liquids, or use a viscosometer to ensure appropriate thickness. Often staff members overthicken liquids, resulting in decreased palatability with decreased intake. Using prepackaged thickened liquids can increase intake, which increases hydration and nutrition (Goulding, Bakheit, 2000; Boczko, 2000).

·         Work with client on swallowing exercises prescribed by dysphagia team (e.g., touching palate with tongue, stimulating tonsillar arch and soft palate with a cold metal examination mirror [thermal stimulation], labial/lingual range of motion exercises). Swallowing exercises can improve the client's ability to swallow (Langmore, Miller, 1994). Exercises need to be done at intervals necessitating nursing involvement (Poertner, Coleman, 1998).

·         For many adult clients, 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 (Travers, 1999).

·         Provide meals in a quiet environment away from excessive stimuli such as a community dining room. A noisy environment can be an aversive stimulus and can decrease effective mastication and swallowing. Talking and laughing while eating increases the risk of aspiration (Galvan, 2001).

·         Ensure that there is adequate time for client to eat. Clients with swallowing impairments often take two to four times longer than others to eat, if being fed. Often, food is offered rapidly to speed up the task, and this can increase the chance of aspiration (Poertner, Coleman, 1998).

·         Have suction equipment available during feeding. If choking occurs and suctioning is necessary, discontinue oral feeding until client is safely assessed with a videofluoroscopic swallow study and fiberoptic endoscopic evaluation of swallowing (FEES), whichever client can safely tolerate. Suctioning may be necessary if the client is choking on food and could aspirate.

·         Check oral cavity for proper emptying after client swallows and after client finishes meal. Provide oral care at end of meal. It may be necessary to manually remove food from client's mouth. If this is the case, use gloves and keep client's teeth apart with a padded tongue blade. Food may become pocketed in the affected side and cause stomatitis, tooth decay, and possible later aspiration.

·         Praise client for successfully following directions and swallowing appropriately. Praise reinforces behavior and sets up a positive atmosphere in which learning takes place.

·         Keep client in an upright position for 30 to 45 minutes after a meal. An upright position ensures that food stays in the stomach until it has emptied and decreases the chance of aspiration following meals (Galvan, 2001).

·         Watch 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 (Murray, Brzozowski, 1998) It could also indicate the presence of pneumonia (Galvan, 2001). Clients with dysphagia are at serious risk for aspiration pneumonia (Langmore, 1994).

·         Watch for signs of malnutrition and dehydration. Keep a record of food intake. A food intake record will allow the nurse, speech and language pathologist, and dietician to determine the adequacy of nutritional intake (Beadle, Townsend, Palmer, 1995). Malnutrition is common in dysphagic clients (Galvan, 2001). Clients with dysphagia are at serious risk for malnutrition and dehydration, which can lead to aspiration pneumonia resulting from depressed immune function and weakness, lethargy, and decreased cough (Langmore, 1999).

·         Weigh client weekly to help evaluate nutritional status.

·         Evaluate nutritional status daily. If not adequately nourished, work with dysphagia team to determine whether client needs to avoid oral intake (NPO) with therapeutic feeding only or needs enteral feedings until client can swallow adequately. Enteral feedings can maintain nutrition if client is unable to swallow adequate amounts of food (Grant, Rivera, 1995).

·         If client has a tracheotomy, ask for a diagnostic workup for adequacy of swallowing before attempting to feed, and ensure all staff members know appropriate feeding technique. Aspiration is common in clients with tracheotomies, and care must be used in feeding (Murray, Brzozowski, 1998). See care plan for Risk for Aspiration.

Pediatric

·         Refer to physician children with difficult swallowing and symptoms such as difficulty manipulating food, delayed swallow response, and pocketing a bolus of food. Research has indicated that structural deficits should be corrected by surgery (e.g. pyloric stenosis, neurological disorders that involve cranial nerve pathways, and structures resulting in swallowing changes such as brain injury and cerebral palsy [Rosenthal, Sheppard, Lotze, 1995]). Respiratory and gastrointestinal system disorders (GERD) and esophagitis can affect swallowing and nutrition. These systemic disorders are diagnosed by a physician and treated with medications.

·         When feeding an infant or child, place the infant/child in a 90 degree position with head slightly flexed. Change consistency of diet as needed, and use a curly straw for young children to facilitate a chin tuck, which helps improve swallowing ability.

·         Give oral motor stimulation that increases oral-sensory awareness by waking the mouth with exercises that focus on temperature, taste, and texture. Many of these infants require supplemental tube feedings as well as special nipples or bottles to boost oral intake.

·         For infants with poor sucking and swallowing:

o  Support the cheeks and jaw to increase sucking skills. Pace or rhythmically move the bottle, which encourages better coordination of suck-swallow-breath synchrony.

o  Work with dietitian. Some infants may need a high-calorie formula so that food volume may be decreased (which requires infant to expend less energy) while nutritional requirements are met (Klein, Tracey, 1994). Some infants may also need to have their tongue brushed, which promotes tongue stimulation (tongue tip and tongue lateralization), lip seal, and lip pursing.

o  Watch for indicators of aspiration: coughing, a change in web vocal quality while feeding, perspiration and color changes during feeding, sneezing, and increased heart rate and breathing.

o  Watch for warning signs of reflux: sour-smelling breath after eating, sneezing, lack of interest in feeding, crying and fussing extraordinarily when feeding, pained expressions when feeding, and excessive chewing and swallowing after eating (Johnson, McGonigel, Kaufman, 1991).

Many premature and medically fragile children are surviving as a result of technological advances and sustaining growth and respiratory deficits from an underlying dysphagia diagnosis. They present with limited food intake at a time when extra calories are essential for faster growth and lung repair. Some infants may need to work harder to breathe and develop a decreased tolerance for food intake. They also demonstrate inconsistent arousal and poor/uncoordinated suck-swallow-breath synchrony. Many of these infants require supplemental tube feedings, as well as special nipples or bottles to boost oral intake.

Geriatric

·         Evaluate medications client is presently taking, especially if elderly. Consult with the pharmacist for assistance in monitoring for incorrect doses and drug interactions that could result in dysphagia. Dysphagia is more prevalent in the elderly than in younger persons because of the coexistence of a variety of neurological, neuromuscular, or oncological conditions (Kosta, Mitchell, 1998). Most elderly clients take numerous medications, which when taken individually can slow motor function, cause anxiety and depression, and reduce salivary flow. When taken together, these medications can interact, resulting in impaired swallowing function. Drugs that reduce muscle tone for swallowing and can cause reflux include calcium channel blockers and nitrates. Drugs that can reduce salivary flow include antidepressants, antiparkinsonism drugs, antihistamines, antispasmodics, antipsychotic agents or major tranquilizers, antiemetics, antihypertensives, and drugs for treating diarrhea and anxiety (Sonies, 1992; Sliwa, Lis, 1993; Schechter, 1998).

Client/Family Teaching

·         Teach client and family exercises prescribed by dysphagia team.

·         Teach client a step-by-step method of swallowing effectively.

·           Educate client, family, and all caregivers about rationales for food consistency and choices. It is common for family members to disregard necessary dietary restrictions and give client inappropriate foods that predispose to aspiration (Poertner, Coleman, 1998).

·         Teach family how to monitor client to prevent aspiration during eating.