Impaired Swallowing

NANDA-I Definition: Abnormal functioning of the swallowing mechanism associated with

deficits in oral, pharyngeal, or esophageal structure or function
Impaired swallowing can be a temporary or permanent complication that can be life threatening.
Aspiration of food or fluid is the most serious complication. Impaired swallowing can be caused
by a structural problem, interruption or dysfunction of neural pathways, decreased strength or
excursion of muscles involved in mastication, facial paralysis, or perceptual impairment.
Swallowing difficulties are a common complaint among older adults, in those individuals who
have had a stroke, suffered head trauma, have head or neck cancer, or experience progressive
neurological diseases like Parkinson's disease, multiple sclerosis, and amyotrophic lateral
sclerosis. Dysphagia severity rating scales are available to guide extent of modification in diet
plan.
Common Related Factors
Neuromuscular:
Decreased or absent gag reflex
Decreased strength or excursion of muscles involved in mastication

Perceptual impairment

Facial paralysis (cranial nerves VII, IX, X, XII)

Mechanical:
Edema
Tracheostomy tube

Tumor

Fatigue
Limited awareness
Reddened, irritated oropharyngeal cavity (stomatitis)
Defining Characteristics
Observed evidence of difficulty in swallowing (coughing, choking, stasis of food in oral cavity)
Verbalized difficulty swallowing
Complaints of "something stuck" in throat
Abnormality in swallow study
Evidence of aspiration

Common Expected Outcomes

Patient exhibits ability to safely swallow, as evidenced by absence of aspiration, no evidence of

coughing or choking during eating/drinking, no stasis of food in oral cavity after eating, and
ability to ingest foods/fluid.
Patient verbalizes appropriate maneuvers to prevent choking and aspiration: positioning during
eating, type of food tolerated, and safe environment.
Patient and caregiver verbalize emergency measures to be enacted should choking occur.
NOC Outcomes

Swallowing Status
Risk Control

Self-Care: Eating

NIC Interventions

Aspiration Precautions
Swallowing Therapy

Ongoing Assessment
Assess for presence of gag and cough reflexes.
The lungs are normally protected against aspiration by reflexes such as cough or gag. When
reflexes are depressed, patient is at increased risk for aspiration.
Assess strength of facial muscles.
Cranial nerves VII, IX, X, and XII regulate motor function in the mouth and pharynx.
Coordinated function of muscles innervated by these nerves is necessary to move a bolus of food
from the front of the mouth to the posterior pharynx for controlled swallowing.
Assess coughing or choking during eating and drinking.
These signs indicate aspiration risk.
Assess ability to swallow small amount of water.
If aspirated, little or no harm to patient occurs.
Assess for residual food in mouth after eating.
Pocketed food may be easily aspirated at a later time.
Assess regurgitation of food or fluid through nares.
Regurgitation indicates a decreased ability to swallow food or fluids and an increased risk for
aspiration.
Assess results of swallowing studies as ordered.
A video-fluoroscopic swallowing study may be indicated to determine nature and extent of any
oropharyngeal swallowing abnormality, which aids in designing interventions.

Therapeutic Interventions
For the hospitalized or home care patient:
Before mealtime, provide adequate rest periods.
Fatigue can further contribute to swallowing impairment.

Remove or reduce environmental stimuli (e.g., television, radio).

With distractions removed, the patient can concentrate on swallowing.
Provide oral care before feeding. Clean and insert dentures before each meal.
Optimal oral care facilitates appetite and eating.
If swallowing study was completed, consult with speech pathologist regarding level of dysphagia
severity and implications for meal planning.
Levels on rating scales can range from minimal dysphagia, in which no change in diet is
required, to mild-moderate dysphagia, in which specific swallow techniques and a modified diet
may be indicated, to severe dysphagia, in which nothing by mouth is recommended.
Place suction equipment at bedside, and suction as needed.
With impaired swallowing reflexes, secretions can rapidly accumulate in the posterior pharynx
and upper trachea, increasing risk for aspiration.
If decreased salivation is a contributing factor:
Before feeding, give the patient a lemon wedge, pickle, or tart-flavored hard candy.
Use artificial saliva.
Moistening and use of tart flavors stimulate salivation, lubricate food, and enhance ability to
swallow.
Maintain the patient in high-Fowler's position with head flexed slightly forward during meals.
Upright position facilitates gravity flow of food or fluid through alimentary tract. Aspiration is
less likely to occur with head tilted slightly forward (position narrows airway).
Encourage intake of food that the patient can swallow; provide frequent small meals and
supplements. Use thickening agents as recommended by a speech pathologist.
Thickened foods with consistency of pudding, cooked cereal, and semisolid food are easier for
the patient to manage in the mouth and pharynx for controlled swallowing. Thin foods are most
difficult; gravy or sauce added to dry foods facilitates swallowing.
Instruct the patient to (1) hold food in mouth, (2) close lips, (3) think about swallowing, and then
(4) swallow.
Proper instruction and focused concentration on specific steps reduces risks.
Instruct the patient not to talk while eating. Provide verbal cueing as needed.
Concentration must be focused on swallowing.
Encourage the patient to chew thoroughly, eat slowly, and swallow frequently, especially if extra
saliva is produced. Provide patient with direction or reinforcement until he or she has swallowed
each mouthful.
Such directions assist in keeping one's focus on the task.
Identify food given to the patient before each spoonful if the patient is being fed.
Knowledge of consistency of food to expect can prepare the patient for appropriate chewing and
swallowing technique.
Proceed slowly, giving small amounts; whenever possible, alternate servings of liquids and
solids.
This technique helps prevent foods from being left in the mouth.
Encourage a high-calorie diet that includes all food groups, as appropriate. Avoid milk and milk
products.
Dairy products can lead to thickened secretions.
If patients pouch food to one side of their mouth, encourage them to turn their head to the
unaffected side and manipulate the tongue to paralyzed side.

Foods placed in unaffected side of mouth facilitate more complete chewing and movement of
food to back of mouth, where it can be swallowed. These strategies aid in cleaning out residual
food.
If patient has had a stroke, place food in back of mouth, on unaffected side, and gently massage
unaffected side of throat.
Massage helps stimulate act of swallowing.
Place whole or crushed pills in custard or gelatin. (First ask a pharmacist which pills should not
be crushed.) Substitute medication in elixir form as indicated.
Mixing some pills with foods helps reduce risk for aspiration.
Encourage the patient to feed self as soon as possible.
With self-feeding, the patient can control the volume of a food bolus and the timing of each bite
to facilitate effective swallowing.
If oral intake is not possible or is inadequate, initiate alternative feedings (e.g., nasogastric
feedings, gastrostomy feedings, or hyperalimentation).
Optimal nutrition is a patient need.
Follow-up:
Initiate dietary consultation for calorie count and food preferences.
Dietitians have a greater understanding of the nutritional value of foods and may be helpful in
guiding treatment.

Education/Continuity of Care
Discuss with and demonstrate the following to the patient or caregiver:
Avoidance of certain foods or fluids
Upright position during eating

Allowance of time to eat slowly and chew thoroughly

Provision of high-calorie meals

Use of fluids to help facilitate passage of solid foods

Monitoring of patient for weight loss or dehydration

Both the patient and caregiver may need to be active participants in implementing the treatment
plan to optimize safe nutritional intake.
Teach patient/caregiver exercises to enhance muscular strength of face and tongue to enhance
swallowing.
Muscle strengthening can facilitate greater chewing ability and positioning of food in mouth.
Facilitate home care aide or meal provision, if needed.
Homebound patients may require additional assistance to maintain adequate nutrition.
Demonstrate to the patient, caregiver, or family what should be done if the patient aspirates (e.g.,
chokes, coughs, becomes short of breath). For example, use suction, if available, and the
Heimlich maneuver if the patient is unable to speak or breathe. If liquid aspiration, turn the
patient three-fourths prone with head slightly lower than chest. If patient has difficulty breathing,
call the Emergency Medical System (9-1-1).

Respiratory aspiration requires immediate action by the caregiver to maintain the airway and
promote effective breathing and gas exchange. Being prepared for an emergency helps prevent
further complications.
Encourage family members or caregiver to seek out cardiopulmonary resuscitation (CPR)
instruction.
Mastery of emergency measures may provide confidence to both the patient and caregiver.