Stress overload
Defining Characteristics
Demonstrates increased feelings of anger; demonstrates increased feelings of impatience; reports a feeling of pressure; reports a feeling of tension; reports difficulty in functioning; reports excessive situational stress (e.g., rates stress level as 7 or above on a 10-point scale); reports increased feelings of anger; reports increased feelings of impatience; reports negative impact from stress (e.g., physical symptoms, psychological distress, feeling of being sick or of going to get sick); reports problems with decision-making
Related Factors (r/t)
Inadequate resources (e.g., financial, social, education/knowledge level); intense stressors (e.g., family violence, chronic illness, terminal illness); multiple coexisting stressors (e.g., environmental threats/demands, physical threats/demands, social threats/demands); repeated stressors (e.g., family violence, chronic illness, terminal Illness)
Client Outcomes
Client Will (Specify Time Frame)
• Review the amounts and types of stressors in daily living
• Identify stressors that can be modified or eliminated
• Mobilize social supports to facilitate lower stress levels
• Reduce stress levels through use of health promoting behaviors and other strategies
Nursing Interventions
• Assist client in identification of stress overload during vulnerable life events.
• Listen actively to descriptions of stressors and the stress response.
• In younger adult women, assess interpersonal stressors.
• Categorize stressors as modifiable or nonmodifiable.
• Help clients distinguish among short-term, chronic, and secondary stressors.
• Provide information as needed to reduce stress responses to acute and chronic illnesses.
• Explore possible therapeutic approaches such as cognitive-behavioral therapy, biofeedback, neurofeedback, acupuncture, pharmacological agents, and complementary and alternative therapies.
• Help the client to reframe his or her perceptions of some of the stressors.
• Assist the client to mobilize social supports for dealing with recent stressors.
• With children, nurses should work with parents to help them to reduce children’s stressors.
• Help children to manage their feelings related to self-concept.
• Help children to deal with bullies and other sources of violence in schools and neighborhoods.
• Help young children to identify and mitigate the experience of “feeling sick.”
• Help children to manage the complexities of chronic illnesses.
Risk for Sudden Infant Death Syndrome
Risk Factors
Delayed prenatal care; infant overheating; infant overwrapping; infants placed to sleep in the prone position; infants placed to sleep in the side-lying position; bed sharing; lack of prenatal care; postnatal infant smoke exposure; prenatal infant smoke exposure; soft underlayment (loose articles in the sleep environment)
Client Outcomes
Client Will (Specify Time Frame)
• Explain appropriate measures to prevent SIDS
• Demonstrate correct techniques for positioning and blanketing the infant, protecting the infant from harm
Nursing Interventions
• Position the infant supine to sleep; do not position in the prone position or side-lying position.
• Lightly clothe the infant for sleep. Avoid overbundling and overheating the infant. The infant should not feel hot to touch.
• Provide the infant a certain amount of time in prone position while the infant is awake and observed. Change the direction that your baby lies in the crib from one week to the next; and avoid too much time in car seats, carriers, and bouncers.
• Consider offering the infant a pacifier during sleep times.
Use electronic respiratory or cardiac monitors to detect cardiorespiratory arrest only if ordered.
• Treat the parent with respect and caring.
• Encourage pregnant American Indian mothers to avoid drinking alcoholic beverages and to avoid wrapping infants in excessive blankets or clothing.
• Encourage African American mothers to find alternatives to bed sharing or placing infants for sleep on adult beds, sofas, or cots, and to avoid placing pillows, soft toys, and soft bedding in the sleep environment.
Client/Family Teaching and Discharge Planning
• Teach families to position infants to sleep on their back rather than in the prone position or side position.
• Teach the parents the need for observed “tummy time.”
• Recommend the following infant care practices to parents:
Infants should not be put to sleep on soft surfaces such as waterbeds, sofas, or soft mattresses.
Avoid placing soft materials in the infant’s sleeping environment such as pillows, quilts, and comforters. Do not use sheepskins under a sleeping infant.
Avoid the use of loose bedding, such as blankets and sheets.
• Teach parents the need to obtain a new crib that conforms to the safety standards of the Federal Safety Commission.
• Teach parents not to place the infant in an adult bed to sleep, or a sofa chair or other soft surface. Infants should sleep in a crib.
• Teach parents not to sleep with an infant, especially if alcohol or medications/illicit drugs are used by the parents.
• Recommend an alternative to sleeping with an infant; parents might consider placing the infant’s crib near their bed to allow for more convenient breastfeeding and parent contact.
• Teach parents to avoid overbundling and overheating the infant.
• Teach the need to stop smoking during pregnancy and to not smoke around the infant. Smoking is a risk factor for SIDS.
• Recommend that parents with infants in child care make it very clear to the employees that the infant must always be placed in the supine position to sleep, not prone or in a side-lying position.
Suggest speaking with a physician about genetic counseling if there is a family history of SIDS or if parents have lost an infant to SIDS.
Involve family members in learning and practicing rescue techniques, including treatment of choking, breathing, and cardiopulmonary resuscitation (CPR). Initiate referral to formal training classes.
Risk for Suffocation
Risk Factors
Discarding refrigerators without removing doors; eating large mouthfuls of food; hanging a pacifier around infant’s neck; household gas leaks; inserting small objects into airway; leaving children unattended in water; low-strung clothesline; pillow placed in infant’s crib; playing with plastic bags; propped bottle placed in infant’s crib; smoking in bed; use of fuel-burning heaters not vented to outside; vehicle warming in closed garage
Client Outcomes
Client Will (Specify Time Frame)
• Undertake appropriate measures to prevent suffocation
• Demonstrate correct techniques for emergency rescue maneuvers (e.g., Heimlich maneuver, rescue breathing, cardiopulmonary resuscitation [CPR]) and describe situations that require them
Nursing Interventions
• Counsel families on the following for care of an infant:
Position infants on their back to sleep; do not position them in the prone or side-lying position.
Obtain a new crib that conforms to the safety standards of the Federal Safety Commission.
Place the infant in the crib only to sleep, not on an adult bed, sofa, chair, or playpen.
Avoid use of loose bedding such as blankets and sheets for sleeping. If blankets are used, they should be tucked in around the crib mattress so the infant’s face is less likely to become covered by bedding. The blanket should end at the level of the infant’s chest.
• Assess for signs and symptoms of abuse such as Munchausen syndrome by proxy (MSBP).
• Conduct risk factor identification, noting special circumstances in which preventive or protective measures are indicated. Note the presence of environmental hazards, including the following: plastic bags/cribs with slats wider than 2 inches/ill-fitting crib mattresses that can allow the infant to become wedged between the mattress and crib/pillows in cribs/abandoned large appliances such as refrigerators, dishwashers, or freezers/clothing with cords or hoods that can become entangled/bibs, pacifiers on a string, drapery cords, pull-toy strings.
• Counsel families to evaluate household furniture for safety, including large dressers, televisions, and appliances that may need to be anchored to the wall, to prevent the child from climbing on the furniture, and it falling forward and suffocating the child.
• Counsel families to not serve these foods to the child younger than 4 years of age: nuts, hot dogs, popcorn, pretzels, chips, chunks of meat, hard pieces of fruit or vegetables, raisins, whole grapes, hard candies, and marshmallows.
• Counsel families to keep the following items away from infants and toddlers: balloons, coins, marbles, toys with small parts or toys that can be compressed to fit entirely into a child’s mouth (small balls, pen or marker caps, small button-type batteries, medicine syringes).
• Stress water and pool safety precautions, including vigilant, uninterrupted parental supervision.
• Underscore the necessity of not allowing children to play with or near electric garage doors and of keeping garage door openers out of the reach of young children.
• For adolescents, watch for signs of depression that could result in suicide by suffocation.
• Assess the status of the swallow reflex. Offer appropriate foods and beverages accordingly.
• Use care in pillow placement when positioning frail elderly clients who are on bed rest.
• Recognize that elderly clients in depression may use hanging, strangulation, and suffocation as a means of suicide.
• Assess the home for potential safety hazards in systems that are not likely to be fixed (e.g., faulty pilot lights or gas leaks in gas stoves, carbon monoxide release from heating systems, kerosene fumes from portable heaters).
• Assist the family in having these areas assessed and making appropriate safety arrangements (e.g., installing detectors, making repairs).
Client/Family Teaching and Discharge Planning
• Recommend that families who are seeking day care or in-home care for children, geriatric family members, or at-risk family members with developmental or functional disabilities inspect the environment for hazards and examine the first aid preparation and vigilance of providers.
• Ensure family members learn and practice rescue techniques, including treatment of choking and lack of breathing, as well as CPR.
Risk for Suicide
Related Factors (r/t)
Buying a gun; changing a will; giving away possessions; history of prior suicide attempt; impulsiveness; making a will; marked changes in attitude; marked changes in behavior; marked changes in school performance; stockpiling medicines; sudden euphoric recovery from major depression
Demographic
Age (e.g., elderly people, young adult males, adolescents); divorced; male gender; race (e.g., white, Native American); widowed
Psychological
Childhood abuse; family history of suicide; guilt; homosexual youth; psychiatric disorder; psychiatric illness; substance abuse
Situational
Adolescents living in nontraditional settings (e.g., juvenile detention center, prison, halfway house, group home); economic instability; institutionalization; living alone; loss of autonomy; loss of independence; presence of gun in home; relocation; retired
Client Outcomes
Client Will (Specify Time Frame)
• Maintain connectedness in relationships
• Disclose and discuss suicidal ideas if present; seek help
• Express decreased anxiety and control of impulses
• Talk about feelings; express anger appropriately
• Refrain from using mood-altering substances
• Obtain no access to harmful objects
Nursing Interventions
NOTE: Before implementing interventions in the face of suicidal behavior, nurses should examine their own emotional responses to incidents of suicide to ensure that interventions will not be based on countertransference reactions.
• Assess for suicidal ideation when the history reveals the following: depression, substance abuse; bipolar disorder, schizophrenia, anxiety disorders, post-traumatic stress disorder, dissociative disorder, eating disorders, substance use disorders, antisocial or other personality disorders; attempted suicide, current or past; recent stressful life events (divorce and/or separation, relocation, problems with children); recent unemployment; recent bereavement; adult or childhood physical or sexual abuse; gay, lesbian, or bisexual gender orientation; family history of suicide, history of chronic trauma.
• Assess all medical clients and clients with chronic illnesses, traumatic injuries, or pain for their perception of health status and suicidal ideation.
• Assess the client’s ability to enter into a no-suicide contract. Contract (verbally or in writing) with the client for no self-harm if the client is appropriate for a contract; recontract at appropriate intervals.
• Be alert for warning signs of suicide: making statements such as, “I can’t go on,” “Nothing matters anymore,” “I wish I were dead”; becoming depressed or withdrawn; behaving recklessly; getting affairs in order and giving away valued possessions; showing a marked change in behavior, attitudes, or appearance; abusing drugs or alcohol; suffering a major loss or life change.
• Take suicide notes seriously and ask if a note was left in any previous suicide attempts. Consider themes of notes in determining appropriate interventions.
• Question family members regarding the preparatory actions mentioned.
• Determine the presence and degree of suicidal risk. A number of questions will elicit the necessary information: Have you been thinking about hurting or killing yourself? How often do you have these thoughts and how long do they last? Do you have a plan? What is it? Do you have access to the means to carry out that plan? How likely is it that you could carry out the plan? Are there people or things that could prevent you from hurting yourself? What do you see in your future a year from now? Five years from now? What do you expect would happen if you died? What has kept you alive up to now?
• Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks.
• Develop a positive therapeutic relationship with the clients; do not make promises that may not be kept.
Refer for mental health counseling and possible hospitalization if evidence of suicidal intent exists, which may include evidence of preparatory actions (e.g., obtaining a weapon, making a plan, putting affairs in order, giving away prized possessions, preparing a suicide note).
• Assign a hospitalized client to a room located near the nursing station.
• Search the newly hospitalized client and the client’s personal belongings for weapons or potential weapons and hoarded medications during the inpatient admission procedure, as appropriate. Remove dangerous items.
• Limit access to windows and exits unless locked and shatterproof, as appropriate.
• Monitor the client during the use of potential weapons (e.g., razor, scissors).
• Increase surveillance of a hospitalized client at times when staffing is predictably low (e.g., staff meetings, change of shift report, periods of unit disruption).
If imminent suicide is suspected or an attempt has occurred, call for assistance and do not leave the client alone.
• Place the client in the least restrictive, safe, and monitored environment that allows for the necessary level of observation. Assess suicidal risk at least daily and more frequently as warranted.
• Consider strategies to decrease isolation and opportunity to act on harmful thoughts (e.g., use of a sitter).
• Explain suicide precautions and relevant safety issues to the client and family (e.g., purpose, duration, behavioral expectations, and behavioral consequences).
Refer for treatment and participate in the management of any psychiatric illness or symptoms that may be contributing to the client’s suicidal ideation or behavior.
Verify that the client has taken medications as ordered (e.g., conduct mouth checks after medication administration).
Maintain increased surveillance of the client whenever use of an antidepressant has been initiated or the dose increased. Antidepressant medications take anywhere from 2 to 6 weeks to achieve full efficacy.
• Involve the client in treatment planning and self-care management of psychiatric disorders.
• Explore with the client all circumstances and motivations related to the suicidality. Listen to the client’s own views on his or her problems.
• Explore with the client all perceived consequences that could act as a barrier to suicide (e.g., effect on family, religious beliefs).
• Keep discussion oriented to the present and future.
• Discuss plans for dealing with suicidal ideation in the future (e.g., how to identify precipitating factors, whom to contact, where to go for help, how to respond to desire for self-harm).
• Assist the client in identifying a network of supportive persons and resources (e.g., clergy, family, care providers).
Refer family members and friends to local mental health agencies and crisis intervention centers if the client has suicidal ideation or a suspicion of suicidal thoughts exists.
Document client behavior in detail to support outpatient commitment or an overnight psychiatric observation program for an actively suicidal client.
• Utilize cognitive-behavioral techniques that help the client to modify thinking styles that promote depression, hopelessness, and a belief that suicide is a valid means of escaping the current situation.
• Engage the client in group interventions that can be useful to address recurrent suicide attempts.
• With the client’s consent, facilitate family-oriented crisis intervention. Family-oriented crisis intervention can clarify stresses and allow assessment of family dynamics.
• Involve the family in discharge planning (e.g., illness/medication teaching, recognition of increasing suicidal risk, client’s plan for dealing with recurring suicidal thoughts, community resources).
Before discharge from the hospital, ensure that the client has a supply of ordered medications, has a plan for outpatient follow-up, understands the plan or has a caregiver able and willing to follow the plan, and has the ability to access outpatient treatment.
In the event of successful suicide, refer the family to a therapy group for survivors of suicide.
• See the care plans for Risk for self-directed Violence, Hopelessness, and Risk for Self-Mutilation.
• The preceding interventions may be appropriate for pediatric clients.
• Use brief self-report measures to improve clinical management of at-risk cases.
• Recognize that the developmental issues of childhood and adolescence may heighten suicide risks and involve different issues from those with adults. Assess specific stressors for the adolescent client.
• Assess for exposure to suicide of a significant other.
• Be alert to the presence of school victimization around lesbian, gay, bisexual, and transgender issues and be prepared to advocate for the client.
• Evaluate for the presence of self-mutilation and related risk factors. Refer to care plan for Risk for Self-Mutilation for additional information.
• Be aware that complete overlap does not exist between suicidal behavior and self-mutilation. The motivation may be different (ending life rather than coping with difficult feelings), and the method is usually different.
• Involve the adolescent in multimodal treatment programs.
• Before discharge from the hospital, ensure that the client’s parent has a supply of ordered medications, has a plan for outpatient follow-up, has a caregiver who understands the plan or is able and willing to follow the plan, and has the ability to access outpatient treatment.
• Parental education groups can influence suicide risk factors.
• Support the implementation of school-based suicide prevention programs.
• Evaluate the older client’s mental and physical health status and financial stressors.
• Explore with client any concerns or pressures (physical and financial) regarding ability to secure support of medical care, especially perceived pressures about being a burden on family.
• Conduct a thorough assessment of clients’ medications.
• When assessing suicide risk factors, incorporate a higher degree of risk for older men and for some older adults who have lost a loved one in the previous year.
• Explore triggers of and barriers to suicidal behavior, with particular attention to real and perceived losses (e.g., professional role, health).
• An older adult who shows self-destructive behaviors should be evaluated for dementia.
• Anticipate overall responsiveness to treatment, but monitor for early relapse.
Advocate for the older client with other professionals in securing treatment for suicidal states. Primary care physicians have been noted to underrecognize and undertreat older adult clients with depression.
• Encourage physical activity in older adults.
Refer older adults in primary care settings for care management.
• Consider telephone contacts as an effective intervention for suicidal older adults.
• Assess for the influence of cultural beliefs, norms, and values on the individual’s perceptions of suicide.
• Identify and acknowledge the stresses unique to culturally diverse individuals.
• Identify and acknowledge unique cultural responses to stressors in determining sensitive interventions to prevent suicide.
• Encourage family members to demonstrate and offer caring and support to each other.
• Validate the individual’s feelings regarding concerns about the current crisis and family functioning.
• Communicate the degree of risk to family and caregivers; assess the family and caregiving situation for ability to protect the client and to understand the client’s suicidal behavior. Provide the family and caregivers with guidelines on how to manage self-harm behaviors in the home environment.
• If the client’s suicidal ideation intensifies, or if a suicide plan with access to means becomes evident, institute an emergency plan for mental health intervention
• Counsel parents and homeowners to restrict unauthorized access to potentially lethal prescription drugs and firearms within the home.
• Identify the client’s concerns and implement interventions to address the consequences of disability in a client with medical illness. Refer to the care plans for Hopelessness and Powerlessness.
Refer for homemaker or psychiatric home health care services for respite, client reassurance, and implementation of a therapeutic regimen.
If the client is on psychotropic medications, assess the client’s and family’s knowledge of medication administration and side effects. Teach as necessary.
Evaluate the effectiveness and side effects of medications and adherence to the medication regimen. Review with the client and family all medications kept in the home; encourage discarding of old prescriptions. Monitor the amount of medications ordered/provided by the physician; limiting the amount of medications to which the client has access may be necessary.
Client/Family Teaching and Discharge Planning
• Establish a supportive relationship with family members.
• Explain all relevant symptoms, procedures, treatments, and expected outcomes for suicidal ideation that is illness based (e.g., depression, bipolar disorder).
• Teach the family how to recognize that the client is at increased risk for suicide (changes in behavior and verbal and nonverbal communication, withdrawal, depression, or sudden lifting of depression).
• Provide written instructions for treatments and procedures for which the client will be responsible.
• Instruct the client in coping strategies (assertiveness training, impulse control training, deep breathing, progressive muscle relaxation).
• Role play (e.g., say, “Tell me how you will respond if a friend asks why you were in the hospital”).
• Teach cognitive-behavioral activities, such as active problem solving, reframing (reappraising the situation from a different perspective), or thought stopping (in response to a negative thought, picturing a large stop sign and replacing the image with a prearranged positive alternative). Teach the client to confront his or her own negative thought patterns (or cognitive distortions), such as catastrophizing (expecting the very worst), dichotomous thinking (perceiving events in only one of two opposite categories), or magnification (placing distorted emphasis on a single event).
• Provide the client and family with phone numbers of appropriate community agencies for therapy and counseling. NAMI is an excellent resource for client and family support.
Delayed Surgical Recovery
Extension of the number of postoperative days required to initiate and perform activities that maintain life, health, and well-being
Defining Characteristics
Difficulty in moving about; evidence of interrupted healing of surgical area (e.g., red, indurated draining, immobilized); fatigue; loss of appetite with nausea; loss of appetite without nausea; perception that more time is needed to recover; postpones resumption of work/employment activities; requires help to complete self-care; report of discomfort; report of pain
Related Factors (r/t)
Extensive surgical procedure; obesity; pain; postoperative surgical site infection; preoperative expectations; prolonged surgical procedure
Client Outcomes
Client Will (Specify Time Frame)
• Have surgical area that shows evidence of healing: no redness, induration, draining, or immobility
• State that appetite is regained
• State that no nausea is present
• Demonstrate ability to move about
• Demonstrate ability to complete self-care activities
• State that no fatigue is present
• State that pain is controlled or relieved after nursing interventions
• Resume employment activities/activities of daily living (ADLs)
Nursing Interventions
• Perform a thorough assessment of the client, including risk factors. Allow time to be with the client.
• Assess for the presence of medical conditions and treat appropriately before surgery. If the client is diabetic, maintain normal blood glucose levels before surgery.
• Carefully assess client’s use of dietary supplements such as feverfew, ginkgo biloba, garlic, ginseng, ginger, valerian, kava, St. John’s wort, ephedra (Ma huang or metabolite), and echinacea. It is recommended that all clients be advised to stop all dietary supplements at least 1 week before major surgical or diagnostic procedures.
• Assess and treat for depression and anxiety in a client complaining of continuing fatigue after surgery.
• Play music of the client’s choice preoperatively, intraoperatively, and postoperatively.
• Consider using healing touch and other mind-body-spirit interventions such as stress control and imagery in the perianesthesia setting.
• Use warmed cotton blankets to reduce heat loss during surgery.
• Use careful aseptic technique when caring for wounds.
• Suggest the use of a semipermeable dressing and suction drainage for selected orthopedic clients.
• Clients should be allowed to shower after surgery to maintain cleanliness if not contraindicated because of the presence of pacemaker wires.
• Promote early ambulation and deep breathing. Consider use of a transcutaneous electrical nerve stimulation (TENS) unit for pain relief.
• The client should be provided with a complete, balanced therapeutic diet after the immediately postoperative period (24 to 48 hours).
• Provide 20-minute foot and hand massage (5 minutes to each extremity), 1 to 4 hours after a dose of pain medication.
Carefully consider the use of alternative therapy with a physician’s order, such as application of aloe vera or aqueous cream to promote wound healing.
• Consider the use of noetic therapies: stress management, imagery, and touch therapy.
• Encourage the client to use prayer as a form of spiritual coping if this is comfortable for the client.
• See the care plans for Anxiety, Acute Pain, Fatigue, Risk for deficient Fluid Volume, Risk for Perioperative Positioning Injury, Impaired physical Mobility, and Nausea.
Client/Family Teaching and Discharge Planning
• Provide preoperative teaching by a nurse to decrease postoperative problems of anxiety, pain, nausea, and lack of independence.
• Provide preoperative information in verbal and written form.
• Teach systematic muscle relaxation for pain relief.
• Provide individualized teaching plans for the client with an ostomy. Consider basic needs: (1) maintenance of a pouching seal for a consistent, predictable wear time; (2) maintenance of peristomal skin integrity; and (3) social and professional support of the client.
Impaired Swallowing
Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function
Defining Characteristics
Abnormality in esophageal phase by swallow study; acidic-smelling breath; bruxism; complaints of “something stuck”; epigastric pain; food refusal; heartburn or epigastric pain; hematemesis; hyperextension of head (e.g., arching during or after meals); nighttime awakening; nighttime coughing; observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing/choking); odynophagia; regurgitation of gastric contents (wet burps); repetitive swallowing; unexplained irritability surrounding mealtime; volume limiting; vomiting; vomitus on pillow
Oral Phase Impairment
Abnormality in oral phase of swallow study; choking, coughing, or gagging before a swallow; drooling; food falls from mouth; food pushed out of mouth; inability to clear oral cavity; incomplete lip closure; lack of chewing; lack of tongue action to form bolus; long meals with little consumption; nasal reflux; piecemeal deglutition; pooling in lateral sulci; premature entry of bolus; sialorrhea; slow bolus formation; weak suck resulting in inefficient nippling
Pharyngeal Phase Impairment
Abnormality in pharyngeal phase by swallowing study; altered head position; choking, coughing, or gagging; delayed swallow; food refusal; gurgly voice quality; inadequate laryngeal elevation; multiple swallows; nasal reflux; recurrent pulmonary infections; unexplained fevers
Related Factors (r/t)
Behavioral feeding problems; conditions with significant hypotonia; congenital heart disease; failure to thrive; history of tube feeding; mechanical obstruction (e.g., edema, tracheostomy tube, tumor); neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, facial paralysis); protein energy malnutrition; respiratory disorders; self-injurious behavior; upper airway anomalies
Neurological Problems
Achalasia; acquired anatomic defects; cerebral palsy; cranial nerve involvement; developmental delay; esophageal defects; gastroesophageal reflux disease; laryngeal abnormalities; laryngeal defects; nasal defects; nasopharyngeal cavity defects; oropharynx abnormalities; prematurity; tracheal defects; traumas; traumatic head injury; upper airway anomalies
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate effective swallowing without signs of aspiration (see defining characteristics above)
• Remain free from aspiration (e.g., lungs clear, temperature within normal range)
Nursing Interventions
If the client has impaired swallowing, do not feed orally until an appropriate diagnostic workup is completed.
Ensure proper nutrition by consulting with a physician regarding alternative nutrition and hydration when oral nutrition is not safe/adequate.
Refer to a speech-language pathologist for bedside evaluation, and videofluoroscopy or fiberoptic endoscopic evaluation of swallowing (FEES) to determine swallowing problems and solutions as soon as oral and/or pharyngeal dysphagia is suspected.
To manage impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist.
Observe the following feeding guidelines:
Prior to giving oral feedings, determine the client’s readiness to eat (e.g., alert, able to hold head erect, follow instructions, move tongue in mouth, and manage oral secretions).
Monitor client during oral feedings and provide cueing as needed to ensure client follows swallowing guidelines/aspiration precautions recommended by speech language pathologist or dysphagia specialist. NOTE: General aspiration precautions include: sit at 90 degrees for all oral feedings; take small bites/sips, slow rate, no straws. However, strategies for individual clients will be determined via bedside and/or instrumental swallowing evaluation performed by dysphagia specialist.
If older client or client with GERD, ensure client is kept in an upright posture for an hour after eating.
• During meals and all oral intake, observe for signs associated with swallowing problems such as coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or delay in swallowing, watering eyes, nasal discharge, wet or gurgly voice, decreased ability to move the tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech.
Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing; 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 is present, remove all food from the oral cavity, stop feedings, and consult with speech and language pathologist and dysphagia team.
If signs of aspiration or pneumonia are present, auscultate lung sounds after feeding. Note new onset of crackles or wheezing, and note elevated temperature.
• Watch for signs of malnutrition and dehydration and keep a record of food intake.
Evaluate nutritional status daily. Weigh the client weekly to help evaluate nutritional status. If the client is not adequately nourished, work with the dysphagia team to determine whether the client needs therapeutic feeding only or needs enteral feedings until the client can swallow adequately.
• If client is not eating a sufficient amount of food, recognize that the immune system may be impaired with resultant increased risk of infection.
Document and notify the physician and dysphagia team of changes in medical, nutritional, or swallowing status.
Work with the client on swallowing exercises prescribed by the dysphagia team.
• If needed, provide meals in a quiet environment away from excessive stimuli, such as a community dining room for some clients who are easily distracted.
For many adult clients, if recommended by the speech therapist, avoid the use of straws if recommended by the speech pathologist.
• Recognize that the client can aspirate oral feedings, even if there are no symptoms of coughing or distress.
• Ensure that oral hygiene is maintained.
• Check the oral cavity for proper emptying after the client swallows and after the client finishes the meal. Provide oral care at the end of the meal. It may be necessary to manually remove food from the client’s mouth. If this is the case, use gloves and keep the client’s teeth apart with a padded tongue blade.
• Praise the client for successfully following directions and swallowing appropriately.
• Keep the client in an upright position for 45 minutes to an hour after a meal.
• Recognize that impaired swallowing may be caused by the medications the client is taking. Side effects of medications include xerostomia (antidepressants, anticholinergics, antihistamines, bronchodilators, antineoplastic, anti-parkinson), CNS depression (anticonvulsants, benzodiazepines, antispasmodics, antidepressants, antipsychotics), myopathy (corticosteroids, lipid-lowering agents, colchicines), and esophageal sphincter tone decrease (antihistamines, diuretics, opiates, antipsychotics, antihypertensives, anticholinergics).
If client has a tracheostomy, ask for referral to speech pathologist for swallowing studies before attempting to feed. After evaluation, the decision should be made to have cuff either inflated or deflated when client eats.
Refer to speech-language pathologist (or dysphagia specialist), and a dietitian for a child who has difficulty swallowing and symptoms such as difficulty manipulating food, delayed swallow response, and pocketing of a bolus of food.
Consult with speech-language pathologist or dysphagia specialist regarding modifications to nipple; appropriate positioning and feeding strategies; and other therapeutic activities deemed most appropriate based on bedside and instrumental swallowing evaluation.
The following are general feeding guidelines. Specific strategies to eliminate aspiration and maximize intake should be individualized and determined by swallowing specialist through bedside and instrumental swallowing assessment.
In preterm infant, provide opportunities for patterned nonnutritive sucking (NNS).
In preterm infant, alter nipple flow rate to one that is easily managed by infant to facilitate intake while achieving physiological stability.
Avoid feeding-induced apnea in preterm infant by pacing (offer respiratory break after 3 to 5 sucks).
Watch for indicators of aspiration and physiological instability during feeding: coughing, a change in vocal quality or wet vocal quality, perspiration and color changes, sneezing, apnea, and/or increased heart rate and breathing.
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.
Observe infant’s behavior and cues and adjust feeding to promote a safe pleasurable feeding experience while eliminating aspiration and maximizing intake.
• Recognize that being elderly does not necessarily result in dysphagia, but having medical problems including such things as cerebrovascular and other neurological disease along with chronic medical problems can result in dysphagia.
Evaluate medications the client is taking, especially if elderly. Consult with the pharmacist for assistance in monitoring for incorrect doses and drug interactions that could result in dysphagia.
• Recognize that the elderly client with dementia needs a longer time to eat.
• For the client with dementia, hydration and nutrition can be optimized using the following techniques:
Encourage six small meals and hydration breaks per day.
Offer foods that are sweet, spicy, or sour to increase sensory input.
Allow clients to touch food, and self-feed, with their hands if necessary.
Eliminate from the tray or table nonfoods such as salt and pepper, or anything that can be distracting.
Keep desserts out of sight until the end of the meal.
Offer finger foods to the client who has trouble holding still to eat.
Allow clients to eat immediately when they come for the meal.
• Recognize that the client with advanced dementia, who is unable to swallow, may or may not benefit from enteral tube feedings.
Client/Family Teaching and Discharge Planning
Teach the client and family exercises prescribed by the dysphagia team.
Teach the client a systematic method of swallowing effectively as prescribed by the dysphagia team.
• Educate the client, family, and all caregivers about rationales for food consistency and choices.
• Teach the family how to monitor the client to prevent and detect aspiration during eating.