The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.
Which action by the UAP should the nurse recognize indicates the need for additional teaching?
A.
Places food on the unaffected side of the mouth.
B.
Raises the head of the bed to 80 degrees.
C.
Positions the head with the chin tilted slightly downward.
D.
Allows 30 minutes of rest before feeding.
The Correct Answer and Explanation is:
The correct answer is B. Raises the head of the bed to 80 degrees.
Explanation:
When caring for a client who has had a cerebrovascular accident (CVA), also known as a stroke, one of the primary concerns is the risk of aspiration. Aspiration occurs when food, liquid, or saliva is inhaled into the lungs instead of being swallowed correctly, leading to potential respiratory complications such as pneumonia.
Option B: Raises the head of the bed to 80 degrees
This action suggests raising the head of the bed to a very high angle. While elevating the head of the bed is crucial to reduce the risk of aspiration, 80 degrees is excessively steep and can lead to discomfort for the client. This angle may also cause the client to slouch forward or tilt the head back, increasing the risk of aspiration rather than preventing it. The optimal bed elevation is typically around 30 to 45 degrees, which helps maintain a safe position for swallowing without causing strain or discomfort.
Option A: Places food on the unaffected side of the mouth
Placing food on the unaffected side of the mouth is an appropriate action. This method ensures that the client uses the stronger, more functional side of the mouth to chew and swallow, reducing the risk of food entering the airway.
Option C: Positions the head with the chin tilted slightly downward
Positioning the head with a slight chin-down or chin-tuck posture is recommended for clients at risk of aspiration. This technique helps close off the airway and makes it easier to swallow safely by reducing the chance of food or liquid entering the trachea.
Option D: Allows 30 minutes of rest before feeding
Allowing the client to rest before feeding is also a good practice. Resting helps ensure that the client is less fatigued, which can improve their ability to chew and swallow effectively, thereby minimizing the risk of aspiration.
In summary, while elevating the head of the bed is a crucial step in preventing aspiration, doing so at 80 degrees is too steep and could increase the risk of complications. The nurse should provide additional teaching to ensure that the head of the bed is raised to a more appropriate angle of 30 to 45 degrees.