Risk for aspiration

Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00039
Nanda label: Risk for aspiration
Diagnostic focus: Aspiration

As a nurse, you should be aware of the risks of aspiration and how to prevent it. Aspiration is when food, liquid, or other material enters the respiratory tract instead of the gastrointestinal tract. It can lead to pneumonia and other complications. The nursing diagnosis “Risk for Aspiration” is used to evaluate the risk of aspiration in a patient. In this article, we will discuss the definition, risk factors, at-risk populations, associated conditions, suggested use, alternative NANDA nursing diagnoses, usage tips, NOC Outcomes, evaluation objectives and criteria, NIC Interventions, and Nursing activities for this diagnosis. We will also answer five frequently asked questions about Risk for Aspiration.

NANDA Nursing Diagnosis Definition

Risk for Aspiration, as defined by NANDA International, is “at risk for entry of oral, gastric, or intestinal contents into the tracheobronchial tree, which may result in airway obstruction, respiratory compromise, and/or pneumonia.”

Risk Factors

There are several factors that can put a person at risk of aspiration. These include decreased level of consciousness, neurological deficit, impaired swallowing, poor positioning or support during eating, certain medications, advanced age, certain medical conditions, and anxiety that could cause choking during eating.

At Risk Population

The following populations may be at an increased risk for aspiration due to a variety of risk factors: infants and children, the elderly, people who have had a stroke or head injury, people with neuromuscular disorders, and those with cognitive disabilities.

Associated Conditions

Several conditions may be associated with aspiration. These include choking, dysphasia, dysphagia, gastritis, nausea, GERD, and mucosal irritation.

Suggestions of Use

Nurses can use this nursing diagnosis to assess the risk of aspiration in patients with any of the above-listed risk factors or associated conditions.

Suggested Alternative NANDA Nursing Diagnoses

Other related NANDA International nursing diagnoses that may also be applicable include Impaired Swallowing, Risk for Aspiration Pneumonia, Risk for Limited Fluid Volume, and Alteration in Oral Mucous Membrane.

Usage Tips

When assessing the risk of aspiration, nurses should use standard precautions and protective equipment, such as gloves and masks. Nurses should also question the patient about their swallowing abilities and risk factors, such as level of consciousness, medical conditions, medications, etc.

NOC Outcomes

Nurses should monitor the clinical manifestations associated with Risk for Aspiration, and below are some of the Nursing Outcome Classification (NOC) outcomes associated with this diagnosis:

• Breathing Pattern: Uninterrupted rate and depth of respirations, free from dyspnea.
• Airway Clearance: Effective clearance of upper airway secretions
• Swallow Function: Safe swallow function, free from aspiration.

Evaluation Objectives and Criteria

Nurses can use the following objectives and criteria to evaluate the efficacy of interventions to reduce the risk of aspiration in patients:

• Breathing Pattern: Patient has an uninterrupted rate and depth of respirations without dyspnea.
• Airway Clearance: Patient is able to effectively clear upper airway secretions.
• Swallow Function: Patient is able to swallow food and liquid safely and without aspiration.

NIC Interventions

Depending on the individual patient's needs and risk factors, nurses may use the following Nursing Interventions Classification (NIC) interventions for risk of aspiration:

• Positioning: Promote optimal airway alignment and protect airway patency while eating.
• Oral Hygiene: Provide oral hygiene care before, during, and after meals to reduce aspiration risk.
• Nutritional Management: Provide patient-specific nutrition therapy to reduce aspiration risk.
• Aerosol & Oxygen Therapy: Provide aerosol and oxygen therapy to reduce inflammation and improve airway clearance.
• Swallowing Training/Therapy: Provide swallowing training and/or therapy to improve muscular control and reduce aspiration risk.

Nursing Activities

Nurses must also provide continual assessments, monitoring of vital signs, and administer the appropriate interventions to reduce the risk of aspiration in patients.

Conclusion

Risk for Aspiration is a nursing diagnosis that is used to assess the risk of aspiration in a patient. Nurses must be aware of the risk factors, at-risk populations, associated conditions, suggested use, alternative NANDA nursing diagnoses, usage tips, NOC Outcomes, evaluation objectives and criteria, NIC Interventions, and Nursing activities for this diagnosis. With these considerations, nurses can provide effective care and reduce the risk of aspiration in patients.

FAQs

1. What is the definition of Risk for Aspiration? Risk for Aspiration, according to NANDA International, is defined as “at risk for entry of oral, gastric, or intestinal contents into the tracheobronchial tree, which may result in airway obstruction, respiratory compromise, and/or pneumonia.”
2. What are the risk factors for Risk for Aspiration? Some of the risk factors for Risk for Aspiration include decreased level of consciousness, neurological deficit, impaired swallowing, poor positioning or support during eating, certain medications, advanced age, certain medical conditions, and anxiety that could cause choking during eating.
3. What populations are at an increased risk for Risk for Aspiration? At-risk populations for Risk for Aspiration include infants and children, the elderly, people who have had a stroke or head injury, people with neuromuscular disorders, and those with cognitive disabilities.
4. What nursing interventions can help reduce the risk of aspiration? Nurses can use the following Nursing Interventions Classification (NIC) interventions to reduce the risk of aspiration: Positioning, Oral Hygiene, Nutritional Management, Aerosol & Oxygen Therapy, and Swallowing Training/Therapy.
5. What are some of the NOC outcomes associated with Risk for Aspiration? Some of the Nursing Outcome Classification (NOC) outcomes associated with Risk for Aspiration are Breathing Pattern, Airway Clearance, and Swallow Function.