Impaired swallowing Nursing Diagnosis & Nursing Care Plan
IMPAIRED SWALLOWING
Impaired swallowing is defined by Nanda as an abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.
A good swallowing reflex is one of the factors that permits proper eating and absorption of nutrients needed by the body. However, some cases have impairment in swallowing wherein it prevents a person from meeting the nutritional requirements needed by the body. Impaired swallowing means there is an abnormal functioning of the swallowing mechanism which may be associated with deficits in oral, pharyngeal, or esophageal structure or function.
Impaired swallowing is a very difficult disorder because it will affect the eating pattern of a person. It affects the muscles necessary during eating and swallowing which will aid in further digestion and absorption of ingested food. In this case, having impairment in swallowing increases the risk for aspiration of food. It is highly expected and should always be prevented because it may cause complications to the patient. The aspiration of food or fluid is 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.
Defining characteristics:
First Stage: Oral
- Abnormal oral phase of swallow study
- Choking prior to swallowing
- Coughing prior to swallowing
- Drooling
- Food falls from mouth
- Food pushed out of mouth
- Gagging prior to swallowing
- Inability to clear oral cavity
- Incomplete lip closure
- Inefficient nippling
- Inefficient suck
- Insufficient chewing
- Nasal reflux
- Piecemeal deglutition
- Pooling of bolus in lateral sulci
- Premature entry of bolus
- Prolonged bolus formation
- Prolonged meal time with insufficient consumption
- Tongue action ineffective in forming bolus
Second Stage: Pharyngeal
- Abnormal pharyngeal phase of swallow study
- Alteration in head position
- Choking
- Coughing
- Delayed swallowing
- Fevers of unknown etiology
- Food refusal
- Gagging sensation
- Gurgly voice quality
- Inadequate laryngeal elevation
- Nasal reflux
- Recurrent pulmonary infection
- Repetitive swallowing
Third Stage: Esophageal
- Abnormal esophageal phase of swallow study
- Acidic-smelling breath
- Bruxism
- Difficulty swallowing
- Epigastric pain
- Food refusal
- Heartburn
- Hematemesis
- Hyperextension of head
- Nighttime awakening
- Nighttime coughing
- Odynophagia
- Regurgitation
- Repetitive swallowing
- Reports “something stuck”
- Unexplained irritability surrounding mealtimes
- Volume limiting
- Vomiting
- Vomitus on pillow
Related Factors
Congenital Deficits
- Behavioral feeding problem
- Conditions with significant hypotonia
- Congenital heart disease
- Failure to thrive
- History of enteral feeding
- Mechanical obstruction
- Neuromuscular impairment
- Protein-energy malnutrition
- Respiratory condition
- Self-injurious behavior
- Upper airway abnormality
Neurological Problems
- Achalasia
- Acquired anatomic defects
- Brain injury (e.g., cerebrovascular impairment, neurological illness, trauma, tumor)
- Cerebral palsy
- Cranial nerve involvement
- Developmental delay
- Esophageal reflux disease
- Laryngeal abnormality
- Laryngeal defect
- Nasal defect
- Nasopharyngeal cavity defect
- Neurological problems
- Oropharynx abnormality
- Prematurity
- Tracheal defect
- Trauma
- Upper airway anomaly
Nursing Assessment
| Assessment | Rationale |
| 1. Assess the patient’s ability to swallow by letting him/her to swallow. | · It will let the nurse determine the extent of swallowing mechanism of the patient. |
| 2. Observe for coughing or choking during eating and drinking. | · It signals the nurse for signs which indicates aspiration. |
| 4. Observe for signs associated with swallowing problems | · It will give better interventions |
| 5. Assess ability to swallow a small amount of water. | · This is to test the risk of occurrence of aspiration |
| 6. Check for food or fluid backflow | · This increase or signals risk for aspiration |
| 7. Determine and assess patient’s readiness to eat. | · It will ready the mental and physical ability of the patient to try eating without the presence of aspiration |
Desired Outcomes
- Patient shows ability to swallow safely as manifested by absence of aspiration, no coughing or choking during eating/drinking, no food stasis in the oral cavity after eating, ability to ingest foods/fluids normally and easily.
- Patient determines different emergency measures when choking occurs.
Nursing Interventions/Rationale
| Interventions | Rationale |
| For hospitalized or home care patients: | |
| 1. Encourage small, frequent feedings and rest in between periods | · This will not let the patient be exhausted with such activities including eating |
| 2. Render oral care before feeding. | · It promotes better appetite |
| 3. Place suction equipment at the bedside, and suction as needed. | · This will ready the nurse and patient when there is presence of aspiration or drooling of saliva |
| 4. Proper positioning of the patient when eating | · To prevent aspiration through correct positioning |
| 5. Instruct the patient not to talk while eating. | · It will let the patient concentrate in eating |
| 6. Alternately give servings of liquids and solids to the patient | · This technique helps prevent foods from being left in the mouth. |
| 7. If the patient had a stroke, place food on the unaffected side | · It permits chewing on the unaffected side and prevents letting the food in the affected side which may cause aspiration. |
| 10. Encourage the patient to feed himself/herself as soon as possible. | · It promotes sense of independence and motivation in practicing good swallowing techniques |
| 11. If oral intake is not possible or in inadequate, initiate alternative feedings | · This will maintain proper nutrition at all means |
| 12. Praise patient for successfully following directions and swallowing appropriately. | · Praise reinforces behavior and sets up a positive atmosphere in which learning takes place. |
| Collaborative | |
| 1. Refer to a dietitian for calorie count and food preferences if needed | · This will guide the patients to have a better food choices with the correct caloric content |
| 2. If patient has impaired swallowing, consult a speech pathologist or therapist | · It will help them to have immediate intervention of the problem |