00103 Deterioration Of Swallowing

Domain 2: nutrition
Class 1: ingestion
Diagnostic Code: 00103
Nanda label: swallow deterioration
Diagnostic focus: swallowing
Approved 1986 • Revised 1998, 2017, 2020 • Level of evidence 3.2

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « deterioration of swallow >

Definite characteristics

First stage: oral

  • Abnormal oral phase in a swallowing study
  • Bruxism
  • PRIORA PRIGINATION TO DEGLUTION
  • Cold water swallowing
  • cough prior to swallowing
  • Babeo
  • Foods fall out of the mouth
  • Food are expelled from the mouth
  • Nausea prior to swallowing
  • Deterioration of the ability to empty oral cavity
  • Inappropriate consumption for a long time of food
  • Incomplete closure of the lips
  • Inadequate chewing
  • Incidence of wet rumor twice in 30 seconds
  • I hook the ineffective nipple
  • ineffective suction
  • Nasal reflux
  • Fractional swallowing
  • Bolus stagnation in the lateral grooves
  • Premature entry of the bolus
  • Prolonged duration in the formation of bolus
  • Inefficiency of the action of the tongue to form the bolus

Second stage: pharyngeal

  • Abnormal pharyngeal phase in a swallowing study
  • Alteration in the position of the head
  • Chargement
  • cough
  • Delay in swallowing
  • Fever of unknown etiology
  • Rejection of food
  • Nausea sensation
  • Gorto Voice Quality
  • Inadequate larynx elevation
  • Nasal reflux
  • Recurrent pulmonary infection
  • Repetitive swallows

Third stage: esophageal

  • Abnormal esophageal phase in a swallowing study
  • Breath with acid smell
  • Difficulty in swallowing
  • Epigastralgia
  • Rejection of food
  • Stomach burning
  • Hematemesis
  • Hyperextension of the head
  • Night awakening
  • Night cough
  • Odinophagy
  • Regurgitation
  • Repetitive swallows
  • Express “have something stuck”
  • Inganeable irritability in the hours close to meals
  • Volume limitation
  • Vomiting
  • Vomiting on the pillow

Related factors

  • ATTACTION OF ATTENTION
  • Food behavior problems
  • Malnutrition in relation to proteins and energy
  • Autolesive behavior

Risk population

  • People with a history of enteral nutrition
  • Older adults
  • Premature infants

Associated problems

  • Acquired anatomical defects
  • Cerebral lesions
  • Cerebral paralysis
  • Problems with important hypotonia
  • Congenital heart disease
  • Commitment of the Cranial Parisle
  • Disabilities of development
  • Alichasia esophageal
  • Gastroesophageal reflux
  • Laringe diseases
  • Mechanical obstruction
  • Nasal defects
  • Nasopharyngeal cavity defects
  • Neurological problems
  • Neuromuscular diseases
  • Anomaly of the oropharyngeal cavity
  • Pharmacological preparations
  • Prolonged Intubation
  • Respiratory disorders
  • Tracheal defect
  • Trauma
  • Authental Way Anomaly
  • Dysfunction of the vocal strings

Suggestions of use

The deterioration of swallowing could be associated with various medical diseases (for example, cerebral palsy, vascular stroke, Parkinson’s disease, neoplasms that affect the brain, reconstructive surgery of the head and neck, and reduction of consciousness caused by anesthesia or other causes). It could also be related to the Suggested alternative diagnostics

Other examples

  • Identify the emotional or psychological factors that interfere with swallowing
  • Tolerates food intake without choking or bronchaspirar
  • It does not have deterioration of facial muscles or throat, swallowing, language movements, or nauseous reflex

NIC Interventions

  • Vomiting management: prevention and mitigation of vomiting
  • Position: Deliberate placement of the patient, or from his body, to improve physiological and psychological well -being
  • Precautions to avoid bronchoaspiration: prevention or minimization of risk factors in a patient with possibilities of bronchaspiration
  • Deglution therapy: facilitation of swallowing and prevention of complications derived from a deterioration of swallowing
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions

Nursing Activities

Valuations

  • Assess the level of family comfort
  • (NIC) Precautions to avoid aspiration: monitor the level of consciousness, the tusigen reflex, the nauseous reflection and the ability to swallow
  • (NIC) swallowing therapy:
    • Monitor the patient’s language movements while eat
    • Monitor the signs and symptoms of aspiration
    • Monitor the closure of the lips while eats, baby and deglute
    • Check your mouth to verify food storage after eating
    • Monitor body hydration (intake, elimination, cutaneous turgidity and mucous membranes)

Patient and family education

  • (NIC) swallowing therapy:
    • Instruct the patient to reach with the tongue the food particles that are on the lips and in the chin
    • Instruct the patient and the caretaker on emergency measures in case of suffocation

Collaboration activities

  • Consult with the nutritionist what foods can be easily swallowed
  • (NIC) Precautions to avoid aspiration: ask for medications in the form of a tonic
  • (NIC) swallowing therapy:
    • Collaborate with other members of the Health Team (Occupational Therapist, Pathologist of Language and Nutriologist) to provide continuity to the patient rehabilitation plan
    • Collaborate with the Language Therapist to instruct the patient’s family on the exercise regime for swallowing

Others

  • Remove the patient during the episodes of suffocation
  • (NIC) Precautions to avoid aspiration:
    • Place in a straight position of 90 degrees, or as straight as possible
    • Keep the tracheal tube inflated
    • Have the suction system at hand
    • feed in small amounts
    • Avoid liquids or use thickening agents
    • Cut food into small pieces
    • Break or crush the pills before administering them
  • (NIC) swallowing therapy:
    • Provide oral care, when required
    • Provide or use auxiliary devices, when necessary
    • Avoid the use of drinking straws
    • Help the patient place the head flexed forward when preparing to swallow (put the chin)
    • Help the patient to place the food on the back of the mouth and on the unf affected side

At home

  • The above activities can be used or adapted for use at home
  • (NIC) swallowing therapy:
    • Teach the family or the caregiver to place, feed and monitor the patient

Babies and Children

  • Evaluate the presence of structural defects (for example, pyloric stenosis) that could interfere with swallowing; consult a doctor if necessary
  • For babies, hold the jaw and cheeks to facilitate suction

Older people

  • Recognize that dysphagia is not a normal change due to age
  • Allow adequate time to eat; Do not hurry the patient
  • Evaluate the denture
  • Identify the medications that the patient takes and that could cause difficulties when swallowing