Risk for Aspiration (Aspiration Pneumonia) Nursing Diagnosis & Care Plan

Aspiration happens when foreign material reaches the trachea and lungs, and it turns into chemical pneumonitis or aspiration pneumonia fast. Your job with at-risk patients is prevention: keep them upright, confirm swallow and gag reflexes, verify feeding tube placement, watch for delayed gastric emptying, and keep suction ready. This care plan covers the assessments and interventions you will actually use.

What is Aspiration?

Aspiration is the entry of foreign objects or substances into the trachea and lungs, which can lead to aspiration pneumonia or chemical pneumonitis. Acute and chronic conditions both raise the risk: post-anesthesia effects, altered consciousness, and artificial airway devices. Most aspiration involves oral or gastric contents tied to gastroesophageal reflux, swallowing dysfunction, neurological disorders, and structural abnormalities.

Swallowing moves through four phases.

• Oral preparatory phase. Food and liquid enter the mouth, mix with saliva, and form a bolus.
• Oral propulsive phase. The bolus moves into the pharynx and triggers the reflex swallow, the major component of the pharyngeal phase.
• Pharyngeal phase. The larynx elevates and closes at the epiglottis, aryepiglottic folds, and true and false vocal cords. This laryngeal reflex protects against direct and indirect aspiration.
• Esophageal phase. The bolus passes through the relaxed cricopharyngeal muscle and enters the esophagus.

Aspiration occurs when foreign material enters the hypopharynx before the cricopharyngeal muscle relaxes or before the laryngeal sphincters close. Direct aspiration is aspiration of a food bolus while swallowing. Indirect aspiration is reflux of food from the stomach into the esophagus and pulmonary system.

There are four aspiration syndromes. Aspiration of gastric acid causes a chemical pneumonitis, also called Mendelson syndrome. Aspiration of bacteria from oral and pharyngeal areas causes aspiration pneumonia. Aspiration of oil (mineral or vegetable) causes exogenous lipoid pneumonia, an unusual form. Aspiration of a foreign body can cause an acute respiratory emergency and may predispose the patient to bacterial pneumonia.

Prevention drives the care: position the patient semi-recumbent, compensate for absent reflexes, confirm feeding tube placement, identify delayed gastric emptying, and manage the effects of prolonged intubation.

Nursing Care Plans and Management

Build the plan to minimize the chance of aspiration pneumonia and other complications. Managing an acute aspiration event means conservative management and close observation. Work with the interdisciplinary team and follow evidence-based guidelines.

Nursing Problem Priorities

1. Dysphagia and absent reflexes. Identify dysphagia and manage an absent swallow reflex.
2. Vomiting. Prevent it and position the patient correctly when it happens.
3. Feeding tubes and delayed gastric emptying. Insert and feed properly, and catch delayed emptying.
4. Intubated patients. Manage and prevent aspiration during prolonged intubation.
5. Aspiration pneumonia. Intervene to prevent it.
6. Postoperative patients. Aspiration is a common but avoidable postoperative complication.

Nursing Assessment

Assess to identify problems that could cause aspiration and to catch any event during care.

• Fever
• Tachypnea
• Wheezing
• Crackles
• Noisy breathing
• Cough
• Congestion
• Clubbing of fingernails
• Increased work of breathing, flaring, or retractions
• Cyanosis
• Hypoxemia
• Stridor
• Irritability
• Globus hystericus

Nursing Diagnosis

After assessing, formulate nursing diagnoses that address the aspiration risk based on your clinical judgment and the patient's condition. Diagnostic labels organize care but vary in use across settings. Examples include:

1. Risk for aspiration as evidenced by impaired swallowing reflex
2. Risk for aspiration as evidenced by improper positioning during feeding
3. Risk for aspiration as evidenced by impaired oral motor control (drooling, food pocketing in the cheeks, inability to close the lips)
4. Risk for aspiration as evidenced by improper feeding tube placement

Nursing Goals

Goals and expected outcomes may include:

• The patient will maintain a clear airway, free of signs of aspiration.
• The patient will identify causative and risk factors.
• The patient will demonstrate techniques to prevent or correct aspiration.
• The caregivers will demonstrate appropriate feeding techniques.
• The caregivers will demonstrate proper tube care for intubated patients.

Nursing Interventions and Actions

1. Managing Aspiration Risk in Patients with Dysphagia

Dysphagia disrupts swallowing and interferes with eating. It can cause aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. The goals are adequate nutrition and maximum airway protection.

1.1. Assessing swallowing ability and dysphagia risk

**Evaluate swallowing by assessing for coughing, choking, throat clearing, a gurgling or wet voice during or after swallowing, residual food in the mouth, and regurgitation of food or fluid through the nares.**Impaired swallowing raises aspiration risk. The patient may report coughing, choking, or food sticking in the throat or upper chest, but these signs can be subtle or absent.

**Inspect the oral cavity and pharynx.**Check mucosal integrity and dentition, and examine the soft palate for position and symmetry during phonation and at rest. Assess pharyngeal elevation by placing two fingers on the larynx and feeling for movement during a volitional swallow. This identifies whether the key laryngeal protective mechanisms are working.

**Review swallowing studies as ordered.**For high-risk patients, a videofluoroscopic swallowing study defines the nature and extent of any swallowing abnormality. It studies the anatomy and physiology of the oral, pharyngeal, and esophageal stages of swallowing and is the standard for identifying patients at risk for pneumonia and for diagnosing aspiration.

**Assess the gag reflex.**Elicit it by stroking the pharyngeal mucosa with a tongue depressor. An absent gag reflex does not by itself mean the patient cannot swallow safely. The palate pulling to one side during testing indicates weakness of the contralateral palatal muscles and suggests unilateral bulbar pathology.

**Assess level of consciousness, developmental age, and mental status.**Alertness and cognition affect both the safety of swallowing and the ability to learn compensatory measures. Young children and patients with neurologic or psychiatric disorders are at higher risk and may not be able to describe symptoms or report choking.

**Perform a reflex cough test.**The laryngeal cough reflex protects against significant aspiration and lowers the risk of respiratory complications. Dissolve a 20% solution of L-tartaric acid in 2 mL of sterile normal saline; the patient inhales it through a nasal nebulizer, which stimulates cough receptors and triggers the reflex.

**Observe the patient directly during swallowing.**At a minimum, watch the patient drink a few ounces of water. After the swallow, observe for one minute or more to catch a delayed cough response.

1.2. Preventing aspiration in patients with dysphagia

**Notify the provider immediately of any decrease in cough or gag reflexes or difficulty swallowing.**Early intervention protects the airway. Keep anyone at high risk NPO (nothing by mouth) until evaluation is complete. The basic mechanism of aspiration is impaired swallowing plus any condition that reduces the gag reflex.

**Position the patient sitting or upright before, during, and after meals.**Sitting upright, preferably out of bed in a chair, with the chin tucked toward the chest during swallowing helps prevent aspiration. For enteral tube feeding, elevate the head of the bed at least 30 degrees.

**Rotate the patient's head to the affected side when swallowing.**This closes the pyriform sinus on the affected side and directs food down the stronger side. It also adds external pressure on the damaged vocal cord and moves it toward the midline, improving airway closure.

**Provide a dysphagia diet as indicated.**The dysphagia diet is classified by viscosity. Level I includes pudding, crushed potato, and ground meat. Level II includes curd-type yogurt, orange juice mixed with 3% thickener, cream soup, and thin soup with starch. Level III includes tomato juice, fluid-type yogurt, and thick fluid rice. Level IV includes water and orange juice. A uniform, viscous bolus lets a patient with a delayed swallow reflex control mastication and transport and swallow with less risk of aspirating residue.

**Provide foods with a consistency the patient can swallow. Use thickening agents if recommended by a speech pathologist or dietician.**Thickened semisolid foods such as pudding and hot cereal are easiest to swallow and least likely to be aspirated. Liquids and thin foods like creamed soups are the hardest. Many starch-based commercial thickeners and pre-thickened water, juice, and coffee are available.

**Have the patient chew thoroughly and eat slowly.**Well-chewed food cut into small pieces swallows more easily. As swallowing improves, advance the diet to soft and semisolid foods of regular consistency. Have the patient alternate bites with sips and control bite or sip size and the number of swallows.

**For patients with reduced cognition, remove distractions during meals and tell them not to talk while eating.**Concentration must stay on chewing and swallowing. Talking and eating at once opens the airway. Focused eating means smaller bites, thorough chewing, and better timing of the swallow.

**Place medication and food on the strong side of the mouth when there is unilateral weakness or paresis.**Careful placement promotes chewing and successful swallowing. The patient can also tilt the head to the strong side, since the bolus tends to travel down the stronger side.

**Offer liquids after food. Provide foods rich in water content.**Taking food and fluids together increases swallowing difficulty. Reach adequate fluid intake by offering preferred liquids or high-water foods such as pureed fruits and vegetables, hot cereals, custards, and puddings, with enough staff to help the patient drink while properly positioned.

**Encourage swallowing exercises.**Exercises increase muscle tone and augment the pharyngeal swallow. Indirect exercises strengthen the swallowing muscles; direct exercises are done while swallowing. Tongue exercises help manipulate and propel the bolus, jaw exercises facilitate the rotary movements of mastication, and respiratory exercises such as resistive straw sucking, coughing, and incentive spirometry improve respiratory strength.

**Consult a speech pathologist as appropriate.**A speech pathologist performs a dysphagia assessment, determines the need for videofluoroscopy or a modified barium swallow, and sets specific techniques to prevent aspiration. This is especially important for patients who need tracheostomy and ventilation.

**Assist with tactile-thermal stimulation (TTS).**TTS increases the speed of the swallow by applying cold, rubbing the bilateral anterior facial arch with a laryngeal mirror chilled on ice, to sensitize the area where the swallow is triggered.

**Insert a nasogastric tube (NGT) as indicated for feeding.**NGT feeding is a common, quick, relatively noninvasive method of enteral feeding and is appropriate for patients with a short-term life expectancy. Many patients find the NGT uncomfortable and pull it out, which interrupts feeding and risks malnutrition.

2. Managing Aspiration Risk in Patients with Vomiting

Vomiting with aspiration of gastric contents can cause pulmonary obstruction, chemical pneumonitis, secondary infection of the airways or lung parenchyma, and death. Prevention is the primary goal.

**Assess level of consciousness.**Aspiration risk is inversely related to level of consciousness. Aspiration of small amounts from the oral cavity is common, especially during sleep, but a healthy person clears it through the mucociliary tree and macrophages. Large-volume aspiration is witnessed occasionally, but small-volume silent aspiration is more common.

**Assess for nausea or vomiting.**Nausea and vomiting put the patient at high risk, especially with reduced consciousness. Antiemetics may be needed. Vomiting can be provoked by visceral causes (stomach distention, traction on abdominal organs), pharmacologic causes (drugs with emetic properties), metabolic causes (pregnancy, uremia), and central or psychological causes (motion sickness, panic, anorexia).

**Note new abdominal distention or increased rigidity.**These can signal paralytic or mechanical obstruction and a higher likelihood of vomiting and aspiration. Aspiration is more likely when the patient cannot coordinate the protective glottic, laryngeal, and cough reflexes, and the hazard rises with a distended abdomen, a supine position, or immobilized upper extremities.

**Assess risk factors for vomiting.**Anesthesia, disease, and emetic medications all contribute. Inhalation of stomach contents during anesthesia can cause pneumonitis, bronchopneumonia, atelectasis, and lung abscess.

**Position patients with decreased consciousness on their side.**This rescue positioning drains secretions out of the mouth instead of down the pharynx. An alert patient normally protects the airway by sitting up or turning to the side and coordinating breathing, coughing, gagging, and glottic reflexes.

**Remove an oral airway when the gag reflex returns.**Do not insert an oral airway in a patient with active reflexes. If one is in place, pull it the moment the patient gags so it does not stimulate the pharyngeal gag reflex and provoke vomiting and aspiration.

**Administer antiemetics as indicated.**Prevent vomiting with esomeprazole or metoclopramide, which speeds gastric emptying. Side effects range from common (mild headache, dizziness) to rare (anaphylaxis, hypersensitivity).

3. Proper Feeding Tube Placement and Technique

Misplaced feeding tubes cause serious complications. Minimizing placement errors during insertion and use lowers the complication rate.

3.1. Assessing feeding tube placement

**Auscultate bowel sounds to assess GI motility.**Reduced motility raises aspiration risk as fluid and food build up in the stomach. Older adults have decreased esophageal motility, which delays emptying, and combined with a weaker gag reflex, raises the risk further.

**Identify risk factors for tube dislodgement.**Even a properly placed NG tube can migrate with coughing, suctioning, vomiting, repositioning, ambulation, or failure of the securement device. Reconfirm tube position for as long as the tube is in place.

**Assess tube placement every 4 hours and before feedings or medications.**Current guidelines call for reassessing placement every 4 hours before enteral feedings and medications. Use research-based secondary methods for frequent bedside confirmation that add no cost and no radiation exposure.

**Observe for food particles in tracheal secretions in patients with tracheostomies.**Food should never be in the tracheobronchial passages; it signifies aspirated material. Aspiration pneumonia occurs when regurgitated stomach contents or feedings from a misplaced tube reach the pharynx or trachea, or when oral secretions are aspirated.

**Use capnography before feedings and medications.**Capnography detects carbon dioxide release from the tube, which suggests placement in the tracheobronchial tree rather than the stomach. Attach a carbon dioxide detector to the end of the tube; a color change indicates CO2. Stop feeding immediately and obtain an X-ray.

**Measure the pH of the tube aspirate with pH strips.**Fasting gastric fluid pH is usually 5 or less; respiratory and small bowel secretions are typically 6 or more. The test has limits: it cannot distinguish gastric from esophageal placement, and saliva or reflux alters the reading. For reliable results, stop the feeding for 1 hour before testing.

**Avoid the auscultatory and bubbling methods for checking placement.**Research shows the auscultatory (air bolus) and bubbling methods should no longer be used. Nurses cannot reliably distinguish the sound of air entering the lungs, esophagus, stomach, or small intestine.

3.2. Feeding patients with nasogastric or gastrostomy tubes

**Check placement before feeding using tube markings, X-ray (most accurate), pH of gastric fluid, and color of aspirate.**A displaced tube can deliver feeding into the airway. Chest X-ray verification is the most reliable. Gastric aspirate is usually green, brown, clear, or colorless, with a pH between 1 and 5; small bowel fluid is usually bile-stained. After radiographic confirmation, mark the tube's exit site at the nose or mouth and document the external length so any change flags possible migration.

**Test sputum with glucose oxidase reagent strips.**Significant glucose in sputum can indicate aspiration. Apply the test paper to the tip of the tube after suctioning the oral cavity or tracheostomy.

**Check residuals before feeding, or every 4 hours during continuous feeding. Hold feedings for large residuals and notify the provider.**Large residuals indicate delayed gastric emptying and can distend the stomach, causing reflux emesis. Feedings are often held if the residual volume is greater than 50% of the amount to be delivered in 1 hour. Recent research shows gastric residual volumes between 250 and 500 mL did not increase vomiting, aspiration, or pneumonia.

**Elevate the head of the bed to 30 to 45 degrees during feeding and for 1 hour afterward with intermittent feeding. Turn off the feeding before lowering the head of the bed. Keep patients on continuous feeding upright.**Upright positioning reduces aspiration by decreasing reflux. Maintain it for at least 1 hour after an intermittent feeding and whenever possible during continuous feeding. Consider reverse Trendelenburg when elevating the head of the bed is not advisable.

**Stop continuous feeding temporarily when turning or moving the patient.**It is hard to keep the head elevated during repositioning. Practice varies among nurses and is not always research-based, and one study suggests pausing does not clearly reduce aspiration in mechanically ventilated patients.

**Provide liquid formulas that help prevent aspiration.**A research formula containing ingredients fermented by lactic acid bacteria, with a pH of 4.0, cleared the stomach without gelation and eliminated aspiration pneumonia episodes in the study group.

3.3. Managing delayed gastric emptying

**Identify causes of delayed gastric emptying.**A full stomach can cause aspiration through increased intragastric or extragastric pressure. Emptying is delayed by intestinal obstruction; increased gastric secretions from GERD, anxiety, stress, or pain; abdominal distention from paralytic ileus, ascites, or peritonitis; opioids or sedatives; severe illness; or vaginal delivery.

**Ensure accurate feeding tube placement.**During nasal insertion, direct the tip toward the back of the nose, through the esophagus, into the stomach, and further through the pylorus into the small intestine if warranted. Fluoroscopy can guide the tube into the stomach, duodenum, or jejunum.

**Clear a clogged tube as indicated.**Declogging steps include warm water irrigation, milking the tube, infusing digestive enzymes, and mechanical declogging devices. Avoid cola and cranberry juice; their acidity worsens formula clogs by precipitating proteins. Tubes unclog more easily when you act immediately.

**Irrigate the tube routinely.**Maintain patency to avoid distention, which can delay emptying. Irrigate with water after every feeding and medication and every 4 to 6 hours during continuous feeding, or if the tube is on gravity drainage or suction. Use sterile water, tap water, or saline depending on the patient's electrolytes and ability to fight infection.

4. Managing Aspiration Risk in Patients with Endotracheal Intubation

Prolonged intubation or tracheostomy depresses the laryngeal and glottic reflexes through disuse. Nosocomial aspiration pneumonia is common, driven by hospital flora through oropharyngeal colonization. Colonization with gram-negative organisms, sedation, and airway intubation are key pathogenic factors.

**Assess level of consciousness.**Aspiration risk is inversely related to level of consciousness. Small-amount aspiration during sleep is common but cleared in healthy people by the mucociliary tree and macrophages.

**Monitor respiratory rate, depth, and effort. Note dyspnea, cough, cyanosis, wheezing, or fever.**Catch aspiration early to prevent further events and start lifesaving treatment. Pulmonary signs include coughing during feedings or medications, difficulty clearing the airway, tachypnea, and fever.

**Assess pulmonary status for aspiration. Auscultate breath sounds for crackles and rhonchi, and monitor chest X-rays as ordered.**Small-amount aspiration can present with sudden respiratory distress or without coughing, especially with diminished consciousness. Pulmonary infiltrates on X-ray indicate aspiration has already occurred. Chemical pneumonitis can develop within a few minutes to two hours, with respiratory distress, rapid breathing, audible wheezing, and a cough producing pink or frothy sputum.

**Monitor cuff effectiveness in patients with endotracheal or tracheostomy tubes.**An ineffective cuff raises aspiration risk. Work with the respiratory therapist to verify cuff pressure. Keep endotracheal cuff pressure greater than 20 cm H2O but less than 30 cm H2O, and clear secretions from above the cuff before deflating it to prevent leakage into the lower respiratory tract. Routine deflation is not recommended because of the risk of aspiration and hypoxia.

**Keep suction available when feeding high-risk patients, and suction immediately if aspiration occurs.**Aspiration needs immediate suctioning and may need further lifesaving intervention such as intubation. Mortality tracks the volume aspirated, so prompt suctioning reduces exposure to contaminants and the risk of hypoxia.

In patients with artificial airways:

• **Perform oral suctioning as needed.**This reduces oropharyngeal secretions and aspiration risk. Having a suction unit ready in high-risk situations is the single most important step to prevent a life-threatening event.
• **Brush teeth twice a day and swab the mouth with sponge applicators every 2 to 4 hours between brushing.**Oral care reduces ventilator-associated pneumonia by cutting the microorganisms in aspirated oropharyngeal secretions. Poor hygiene lets saliva harbor bacteria that, if aspirated, cause pneumonia.

**Administer antibiotics as prescribed.**Antibiotics are indicated for aspiration pneumonia. For aspiration pneumonitis, early presumptive antibiotics are not recommended because they select for resistant organisms. Give antibiotics if pneumonitis fails to resolve within 48 hours, if there is small-bowel obstruction, or if the patient takes antacids, given the risk of gastric colonization.

**Monitor the duration of endotracheal intubation.**Endotracheal intubation should last no longer than 14 to 21 days, after which consider a tracheostomy to reduce irritation and trauma to the trachea. Depressed swallowing reflexes and mechanical trauma from the tube raise the risk of aspiration, microaspiration, and ventilator-associated pneumonia.

5. Managing Postoperative Aspiration Risk

**Keep the preoperative patient NPO before surgery.**General anesthesia suppresses the protective reflexes that keep food and fluid out of the lungs. Take no solid or semisolid food within 6 hours of a planned operation. Patients who had esophageal procedures may stay NPO until X-rays confirm no leaks, obstruction, or aspiration.

**Supervise or assist with oral intake. Never give oral fluids to a comatose patient.**Supervision catches problems early and supports safe swallowing. Aspiration of stomach contents during induction or immediately before or after surgery is a common cause of avoidable anesthetic death, often from active vomiting against a depressed laryngeal protective mechanism.

**Provide oral care before and after meals.**Care before meals reduces oral bacterial counts; care after eating removes residual food that could be aspirated later. One study reduced aspiration pneumonia by combining intensified oral hygiene with a free water protocol.

**Position the patient upright during feedings.**Position postoperative patients on tube feeding with the head of the bed at 30 degrees or higher during feeding and for 30 to 45 minutes afterward. Position patients on oral feeding upright for 30 to 45 minutes after eating. For NG or gastrostomy tubes, check placement and residual gastric volume before each feeding.

**Keep suction equipment available at all times.**Suction the respiratory tract if the patient cannot cough up secretions, protecting the suture lines. With a tracheostomy in place, suction through the tube. The patient can also use Yankauer (tonsil-tip) suction for oral secretions.

**Administer antacids as prescribed.**Antacids such as magnesium trisilicate and sodium citrate may be given 30 to 60 minutes before surgery, or sodium bicarbonate just before induction. IV H2-blockers such as cimetidine raise gastric pH and reduce volume.

**Apply cricoid pressure as indicated.**Cricoid pressure is part of rapid sequence intubation to prevent aspiration of gastric contents. Firm compression of the esophagus between the cricoid cartilage and the vertebrae obstructs the esophagus. Do not apply it during active vomiting, since the pressure generated below the cricoid ring can rupture the esophagus.

**Position the patient head-down or lateral before surgery.**It is hard to aspirate vomit against gravity. A 15-degree head-down tilt does not make intubation difficult, whereas the lateral position does. Used properly it is very safe, though it increases the risk of regurgitation after a muscle relaxant is given.

6. Patient and Family Discharge Education

Patients who recover from aspiration pneumonia usually need no extra outpatient care beyond adherence to prevention measures. Discharge them after clinical and radiographic improvement and stability.

**Assess the patient's and family's willingness and cognitive ability to learn and cope with swallowing and feeding disorders.**Food and feeding habits are often tied to cultural values, so acknowledging or adjusting to them improves compliance and family coping. Older adults with aspiration pneumonia often develop a hospitalization-associated disability that leads to physical decline, and most have dysphagia, difficulty with oral intake, and malnutrition.

**Place whole or crushed pills in soft foods such as custard. Verify with a pharmacist which pills cannot be crushed.**Mixing pills with food reduces aspiration risk, but crushing tablets can create taste and stability problems and crushing the wrong tablet alters its release profile.

**For high-risk patients, get complete information from the discharging institution on its management.**Continuity of care prevents stress and supports success at home. Acute-phase bed rest causes muscle loss and decline in mobility and activities of daily living, which can lead to cognitive disorders, complications, longer stays, and death.

**Establish emergency and contingency plans.**Patient safety between visits is a primary goal of home care. Aspiration pneumonia is frequently fatal in older adults, so rehabilitative management, including early physical therapy and pulmonary and dysphagia rehabilitation, can improve outcomes.

**Teach the family proper positioning.**Upright positioning decreases aspiration risk. Position patients with altered consciousness semi-recumbent with the head of the bed at a 30 to 45-degree angle.

**Teach the signs and symptoms of aspiration.**This helps the family assess high-risk situations and know when to call for evaluation. Aspiration pneumonia and pneumonitis range from mildly ill and ambulating to critically ill with septic shock or respiratory failure.

**Demonstrate suctioning techniques.**Respiratory aspiration needs prompt action to maintain the airway and gas exchange. Keep portable home suction units on, charged, and ready, and test the kit regularly, since it is the first response in an aspiration emergency.

**Refer to a home health nurse, rehabilitation specialist, or occupational therapist as indicated.**Consultants help achieve outcomes, and early rehabilitation can prevent decline in activities of daily living during hospitalization. Hospital-based physical therapy helps reduce the 30-day readmission rate for acutely ill older adults with pneumonia.

**Teach rehabilitation nutrition at home.**Nearly all patients with aspiration pneumonia have dysphagia and oral intake difficulty and are likely to develop malnutrition. Early oral intake after admission is recommended and is associated with earlier discharge.

**Teach the family oral care.**Oral care often pairs with dysphagia rehabilitation to prepare for oral intake. Keeping patients NPO after aspiration pneumonia worsens oral cavity clearance and hygiene. Oral care reduces the oral bacterial count tied to pneumonia onset and may prevent recurrence.

**Teach compensatory techniques for home.**For known swallowing dysfunction, useful techniques include a soft diet, reduced bite size, nectar-thick or honey-thickened liquids, keeping the chin tucked and the head turned, and repeated swallowing.

**Provide feeding instructions for a patient discharged with a feeding tube.**Give feedings and medications with the patient in a semi-Fowler position and the head elevated at least 30 to 45 degrees to reduce reflux and aspiration. Maintain this for at least 1 hour after an intermittent feeding and whenever possible during continuous feeding. Before and after intermittent feeding and medications, give at least 30 mL of water to ensure patency and decrease bacterial growth.

**Provide accessible home care information for the patient and caregivers.**Encourage family members active in home care to attend education sessions. Review and provide printed information on the equipment, formula, and procedure, and arrange to have equipment and formula ready before discharge.