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Difficulty: MediumBasic Care and Comfort

A nurse is developing a feeding and basic care plan for a geriatric client who has right-sided hemiparesis and severe dysphagia following an ischemic stroke. Which specific intervention should the nurse include to promote safe swallowing and minimize the risk of aspiration?

  1. Instruct the client to flex their chin slightly downward toward the chest when swallowing.Answer
  2. B
    Maintain the client in a semi-Fowler's position at a 30-degree angle during meal consumption.
  3. C
    Delegate the continuous monitoring of the client's initial meal to the unlicensed assistive personnel (UAP).
  4. D
    Document the client's frequent coughing during oral intake as an expected, age-related decline in the gag reflex.

Answer

Instruct the client to flex their chin slightly downward toward the chest when swallowing.
The correct intervention utilizes the chin-tuck maneuver, a vital compensatory strategy for clients with dysphagia. Flexing the chin downward toward the chest physically narrows the opening to the airway (larynx) and widens the vallecular space. This structural shift helps prevent food or liquid from passively falling into the trachea and causing aspiration, ensuring basic safety and comfort during nutrition intake.

Step-by-Step Solution

1
Analyze the client's clinical presentation and risks.
The client has right-sided weakness and severe dysphagia post-stroke, placing them at an exceptionally high risk for airway compromise (aspiration) during meals.
Identifying specific neurological deficits allows the nurse to prioritize targeted, evidence-based feeding interventions over routine care.
2
Evaluate standard basic care interventions for dysphagia and aspiration prevention.
Safe feeding protocols require maximum upright positioning (90 degrees), placing food on the unaffected side of the mouth, avoiding thin liquids/straws, and using compensatory swallowing techniques.
Evidence-based practice guidelines dictate specific positional and mechanical strategies to actively protect the airway when physiological reflexes are impaired.
3
Select the option that correctly implements a protective swallowing strategy.
The chin-tuck maneuver is identified as the correct physiological intervention to prevent aspiration.
Tucking the chin downward physically narrows the airway entrance (larynx), directing the food bolus safely backward into the esophagus rather than down the trachea.

Key Concept

Aspiration Precautions and Dysphagia Management
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Topics

Basic Care and Comfort

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