Assignment: Aspiration pneumonia.
The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching?
· 1″| have to remember to raise my chin slightly upward when | swallow.” (56%)
Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg, elderly, neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease), include the following:
· Swallowing 2 times before taking another bite of food. This clears food from the pharynx.
· Thickening liquids to assist swallowing
· Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing.
· Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract, decreases gastroesophageal reflux, and helps decrease risk for aspiration.
· Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later.
· Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth.
(Option 1) Positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in some clients with
dysphagia due to its facilitating closure of the epiglottis to help prevent tracheal aspiration.
Teaching clients who are susceptible to aspiration about swallowing techniques, positioning, avoidance of over-the-counter cold
preparation medications (cause drowsiness and dry mouth), oral care, and smoking cessation can decrease the risk for aspiration
The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential
complication during hospitalization? Select all that apply.
· 1.Add a thickening agent to the fluids
· 2. Avoid administering sedating medications before meals
· 3. Place the client in an upright position during meals
· 5. Teach the client to flex the neck while swallowing
Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response and
provides a medium for bacterial growth. At-risk conditions include cognitive changes (eg, dementia, head injury, stroke, sedation),
difficulty swallowing, compromised gag reflex, and tube feeding.
Aspiration-prevention measures include:
· Thicken liquids (eg, to nectar or honey consistency) for clients with dysphagia; thin liquids are more difficult to control whenswallowing (Option 1).
· Ensure that the client is fully awake before eating. The nurse should time the administration of sedating medications (eg, opioids, benzodiazepines) to avoid sedation during meals (Option 2).
· Elevate the head of the bed to 90 degrees during and for 30 minutes after meals, and never place the head of the bed lower than 30 degrees (Option 3).
· Encourage clients to facilitate swallowing by flexing the neck (chin to chest) (Option 5).
· Administer prescribed antiemetics (eg, ondansetron) as needed to prevent vomiting.
· Monitor for coughing, gagging, and pocketing food.
(Option 4) Performing strict handwashing and limiting sick visitors are important infection-control measures; however, they do not
prevent noninfectious aspiration pneumonia. Assignment: Aspiration pneumonia.
Measures for preventing aspiration pneumonia include administering medications to prevent vomiting, avoiding mealtime sedation,
maintaining head-of-bed elevation at 30 degrees or more (90 degrees during and 30 minutes after meals), and encouraging neck
flexion while swallowing. Clients with dysphagia should receive thickened liquids and be monitored for coughing, gagging, and
The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the
nurse make to evaluate if a complication from the mannitol is occurring?
· 1. Auscultate breath sounds to assess for crackles (49%)
Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function.
(Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication.
(Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of
(Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area.
Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.
Aclient is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, “That’s weird, didn’t even feel nauseated.” Which action by the nurse is the most appropriate?
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