The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply.

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Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes (eg, dementia, head injury, stroke, sedation), difficulty swallowing, compromised gag reflex, and tube feeding. Aspiration-prevention measures include: Thicken liquids (eg, to nectar or honey consistency) for clients with dysphagia; thin liquids are more difficult to control when swallowing (Option A). Ensure that the client is fully awake before eating. The nurse should time the administration of sedating medications (eg, opioids, benzodiazepines) to avoid sedation during meals (Option B). Elevate the head of the bed to 90 degrees during and for 30 minutes after meals, and never place the head of the bed lower than 30 degrees (Option C). Encourage clients to facilitate swallowing by flexing the neck (chin to chest) (Option E). Administer prescribed antiemetics (eg, ondansetron) as needed to prevent vomiting. Monitor for coughing, gagging, and pocketing food. (Option D) Performing strict handwashing and limiting sick visitors are important infection-control measures; however, they do not prevent noninfectious aspiration pneumonia. Educational objective: Measures for preventing aspiration pneumonia include administering medications to prevent vomiting, avoiding mealtime sedation, maintaining head-of-bed elevation at 30 degrees or more (90 degrees during and 30 minutes after meals), and encouraging neck flexion while swallowing. Clients with dysphagia should receive thickened liquids and be monitored for coughing, gagging, and pocketing food.

The Nurse Is Caring for a Client at Risk for Aspiration