A nurse is preparing to feed a client who has dysphagia and left-sided facial weakness following the surgical resection of a brain tumor. Arrange the following nursing actions in the correct chronological sequence to prevent aspiration and promote safe swallowing. All options must be used.
- 1Elevate the head of the bed to a 90-degree angle.
- 2Place a small amount of food on the right side of the client's oral cavity.
- 3Instruct the client to flex the neck and tuck the chin against the chest.
- 4Inspect the left buccal cavity for any pocketed food after swallowing.
- 5Maintain the client in an upright seated position for at least 30 minutes.
Answer
The sequence must prioritize immediate airway protection through initial positioning, utilize the client's intact neurological function for feeding, apply a protective swallowing maneuver, verify complete swallowing, and finally maintain post-meal aspiration precautions.
Feeding a client with dysphagia and unilateral weakness requires a strict, chronological approach centered entirely on airway protection. The nurse must first establish safe positioning (high-Fowler's). Next, food is placed specifically on the unaffected side to maximize mechanical control of the bolus. The client then utilizes a compensatory swallowing technique (chin-tuck) to anatomically protect the airway. Immediate post-swallow assessment is critical to check for pocketing on the weak side. Finally, upright post-meal positioning is maintained for an extended period to prevent reflux and delayed aspiration.
Step-by-Step Solution
Key Concept
Aspiration prevention and safe feeding techniques for clients with dysphagia and unilateral neurological weakness.