A nurse is preparing to assist a client who has dysphagia and right-sided facial weakness with a meal. Arrange the following nursing actions in the correct chronological sequence to ensure safe oral intake and prevent aspiration. All options must be used.
- 1Elevate the head of the bed to a 90-degree high-Fowler's position.
- 2Place a small spoonful of food on the left side of the client's mouth.
- 3Instruct the client to tilt their chin downward toward the chest to swallow.
- 4Assess the oral cavity for any pocketed or unswallowed food.
- 5Maintain the client in a sitting position for 30 to 45 minutes.
Answer
First, elevate the head of the bed. Second, place food on the left side. Third, instruct the client to tuck their chin. Fourth, assess for pocketed food. Finally, maintain an upright position.
Safe oral feeding for a client with dysphagia and hemiparesis requires a systematic approach prioritizing airway protection. Upright positioning must occur before any food is introduced. Food is then placed on the unaffected side to maximize control, followed by a chin-tuck maneuver to physically protect the airway during the swallow. Immediate post-swallow assessment ensures clearance, and prolonged upright positioning prevents subsequent reflux or delayed aspiration.
Step-by-Step Solution
Key Concept
Aspiration precautions and feeding techniques for clients with dysphagia and unilateral facial weakness.
Estimated Time:1m 30s