# A nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who has been experiencing progressive muscle weakness and difficulty swallowing. Which nursing intervention should be the highest priority to ensure client safety?

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## 문제

A nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who has been experiencing progressive muscle weakness and difficulty swallowing. Which nursing intervention should be the highest priority to ensure client safety?

## 보기

1. Assess swallowing ability and implement aspiration precautions **✔ 정답**
2. Encourage range of motion exercises to maintain muscle strength
3. Provide emotional support and counseling resources
4. Monitor for signs of depression and suicidal ideation

**정답: 1**

## 해설

Assessing swallowing ability and implementing aspiration precautions is the highest priority for ALS safety, as aspiration is the most immediate life-threatening risk. Other options like exercise, emotional support, and depression monitoring are important but not urgent.

## 심화 해설

Priority Setting and Airway Protection in ALS

When caring for a client with amyotrophic lateral sclerosis (ALS), the progressive degeneration of both upper and lower motor neurons leads to predictable clinical deterioration, including severe dysphagia [4]. The pathophysiology of dysphagia in ALS is directly linked to the disruption of the swallowing central pattern generator (CPG) located in the medulla oblongata, a process that creates a severe form of neurogenic dysphagia [2]. As the disease advances, particularly when brainstem involvement is significant, the risk of aspiration and subsequent suffocation becomes the most immediate threat to life and quality of life [3].

Applying the nursing process, the initial step is assessment, but for a client with a known, progressive swallowing difficulty, assessment must be immediately paired with intervention to ensure safety. According to the airway-breathing-circulation (ABC) prioritization framework, maintaining a patent airway is the highest physiological need. The intervention "Assess swallowing ability and implement aspiration precautions" directly addresses the risk of aspiration pneumonia and acute airway obstruction, which are the leading causes of mortality in ALS [3][4]. A structured, trajectory-based nursing approach, such as the Chronic Illness Trajectory Framework (CITF), emphasizes proactive management of predictable complications like dysphagia to mitigate anxiety and improve clinical outcomes [1]. This framework supports the principle that early and continuous assessment of swallowing, coupled with immediate safety modifications (e.g., positioning, diet texture alteration), is a cornerstone of care.

While encouraging range of motion exercises, providing emotional support, and monitoring for depression are all important components of a holistic care plan for ALS, they address secondary or tertiary needs. Rehabilitation strategies, including exercise, are valuable for preserving autonomy and joint function but are contraindicated if they induce fatigue that could further compromise an already unsafe swallow [4]. Similarly, psychological support and depression screening are critical for quality of life, yet a client who aspirates and develops respiratory distress faces an immediate, life-threatening physiological crisis that supersedes psychosocial concerns on the hierarchy of needs. The nurse's immediate priority must be to secure the airway by rigorously evaluating the swallow mechanism and enforcing precautions to prevent aspiration.References (research sources)

- [1]The Application Value of Nursing Interventions Based on the Chronic Illness Trajectory Framework in Patients With Amyotrophic Lateral Sclerosis.Research articleZhen J, Liu Q, Xue X, Hao F, Zhang S, Liu N, Li Z, Chen J, Cheng J. (2026) · DOI: 10.1155/nri/1280057

- [2]Pathophysiology and Etiology of Brainstem-Related Dysphagia.Research articleD'Alatri L, Marchese MR, Tizio A, Galli J. (2025) · DOI: 10.3390/audiolres15060153

- [3]Aspiration prevention surgeries for adult patients with brainstem malignant gliomas: illustrative cases.Research articleIkeda K, Saito K, Sasaki N, Kobayashi K, Nagane M. (2025) · DOI: 10.3171/case25284

- [4]Rehabilitation in Amyotrophic Lateral Sclerosis: Recommendations for Clinical Practice and Further Research.GuidelineGratzer A, Gdynia N, Sasse N, Beese R, Winterholler C, Bauer Y, Schröter C, Gdynia HJ. (2025) · DOI: 10.3390/jcm14238590

## 임상 시나리오

ALS Dysphagia & Airway SafetyPreventing Aspiration in Progressive Neurological Decline
In ALS, the swallowing central pattern generator in the medulla is disrupted, causing severe neurogenic dysphagia. Aspiration pneumonia and airway obstruction are the leading causes of mortality.

The ABC framework mandates airway protection as the highest priority. Immediate interventions include a bedside swallow assessment, positioning the client upright (90 degrees) for all oral intake, and ensuring suction equipment is set up and functional.

CautionDo not rely solely on the gag reflex to assess swallowing safety; it is often absent in healthy adults and is a poor predictor of aspiration risk in ALS. A formal speech-language pathology evaluation is essential.

## 핵심 개념

- **Neurogenic Dysphagia** — Swallowing difficulty caused by neurological damage to the central pattern generator in the medulla oblongata, leading to a high risk of aspiration.
- **ABC Prioritization** — A triage framework prioritizing Airway, Breathing, and Circulation as the most immediate physiological needs for survival.
- **Aspiration Precautions** — Safety interventions such as positioning, diet modification, and suction setup to prevent food or fluids from entering the airway.
- **Chronic Illness Trajectory Framework (CITF)** — A nursing model that guides proactive, phase-based management of predictable complications in progressive conditions like ALS.
- **Amyotrophic Lateral Sclerosis (ALS)** — A progressive neurodegenerative disease affecting upper and lower motor neurons, leading to muscle weakness, paralysis, and respiratory failure.

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