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Dysphagia > Bedside Evaluation > Flashcards

Bedside Evaluation Flashcards

1
Q

Bedside Evaluation History (6)

A
  • Respiratory Status (ventilator, trach, pnemonia?)
  • History of Swallowing Problem (How long, what type, describe it, what type of food causes choking, and how often)
  • Nutritional Status (How do they get their nutrition, Do they have trouble with liquids, soft foods, or meat (we don’t need to know their food preferences)
  • Neurological Examination Results (any disorders that can cause swallowing issues)
  • Otolaryngologic Examination Results (any VF paralysis)
  • Dysphagia Symptoms

— What type of medications is the pt. on, do they reduce salivia, do they have dry mouth?

— Has the pt. had any other swallowing evals? (what is the outcome, did it help, what compensatory treatments did they learn?

— ask about symptoms

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2
Q

Observation of Patient (7)

A

1 Patient Posture (Do they have good tone, weakness, head falling forward)

2 Patient level of alertness (pt. must be alert and cooperative)

  • – Must be able to follow directions
  • – If the pt. can not produce a voice you cannot do a bedside exam, need to do a MBS, because you must be able to voice to see if a pt. is aspirating
  • – You can feel the swallow, even if they cannot voice, but you still have to do MBS
  • – Pt. w/ dementia, they may be alert, but not cooperative so you need to do a MBS

3 Patient management of their own secretions (Individuals who are drooling, frothing, and unable to handle secretions are very severe and should have a MBS)

4 Presence of congestion (May be a sign of pneumonia, refer for a modified if you cannot clear the congestion. Have the pt. try to clear the congestion and then say /a/, it could be due to excess mucus on the VF. If voice was clear after clearing throat you can do a bedside. If gurgly/wet voice continues, do MBS)

5 Presence of Tracheostomy tube & status (How long has the pt. had the trach?, we don’t do swallow studies on pts. who have been extubated unless it has been 24 hours, larynx needs to recover

6 Ability to follow directions

7 Correspondence of observation with information from chart & nursing staff ( ask the nurses about choking and talk to the family)

*** If pt. can’t do water (may have weak musculature) Thin liquids, water, is the most difficult to swallow (but water is safest to aspirate)

*** If pudding causes a problem (thicker consistencies maybe a pharyngeal issue, pharyngeal parastylsis issues, think about innervation what’s causing it?)

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3
Q

Patient Report (6)

A
  • Patients description of Problem ( a lot of pts. have trouble describing swallowing problems)
  • Onset of the problem
  • Course of the problem (has it gotten worse or better)
  • Management of various food consistencies (better with liquids, solids, soft foods, hardest consitency is water because it moves the fastest)
  • Localization of disorders
  • Presence of coughing (signifies aspiration, could be silent)
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4
Q

Oral Motor & Anatomy Exam

A
  • Anatomical Assessment
  • Functional Assessment of articulators
  • Areas to look at:

— Labial Functions

— Lingual Functions

— Soft Palate Functions

— Oral Reflexes

— Laryngeal Functions (diaodichokinetic rate /i/ /i/ /i/, or have pt. cough voluntarily)

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5
Q

Labial Functions

A
  • Lip spreading/rounding
  • Rapid alterations /i/, /u/
  • closure (tight closure, how long can they do it)
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6
Q

Lingual Functions

A
  • Lingual Functions
    1. Tongue tip /ta/

— Tongue Extension

— Rapid alternations (lateralize quickly)

— Tongue activation

— Diadochokinetic rate

  1. Posterior of the tongue /ka/ (therapy technique)

— Lift back of tongue & hold

— Diadochokinetic rate

— Sentence repetition

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7
Q

Soft Palate Reflexes

A
  • Sustain /a/
  • Rapid repetition /a/

*** Listen for hypernasality

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8
Q

Oral Reflexes (3)

A
  1. Palatal Reflex (elevation of the palate)

*** Say /a/ and watch bilateral movement

  • Junction of hard & soft palate
  • Junction of soft palate & uvula
    2. Gag Reflex
  • Base of tongue or posterior pharyngeal wall
    3. Swallow Reflex (tongue triggers swallow)
  • Base of anterior faucial pillar
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9
Q

Laryngeal Functions 1

  1. Voice Quality
  2. Diadochokinetic Rate
A
  1. Hoarse or breathy
    - Poor laryngeal closure, laryngeal function examination
  2. Does it sound breathy when they do /puh, tuh, kuh/?
    - Ask to patient to cough (voluntarily) is it strong or weak (can VF go together)
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10
Q

Laryngeal Functions 2

  1. Pitch
  2. Sustain /s/ & /z/
  3. Length of Phonation
A
  1. Slide voice up and down scale

— Evaluates external superior laryngeal nerve which triggers the swallow reflex

— Inability to change pitch

—– Cricothyroid

  • If pitch is monotone, we know that the cricothyroid muscle is impaired
  • Assess pitch if you think that the pt. has a pharyngeal phase issue (Same CN innercation for the cricothyroid as base of pharynx)
    2. How long?
    3. Measures respiratory capacity
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11
Q

Time swallow & up and downward excursion of larynx

A
  • Index finger at the base of the tongue
  • Middle finger on hyoid bone
  • Place 3rd finger on top thyroid cartilage
  • Place 4th finger on bottom thyroid cartilage
  • To assess initiation time (time bolus moves through oral cavity to initiation of swallow)
  • Normal Swallow time is between 1 & 2 seconds
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12
Q

Behavioral Assessment

A
  1. Memory (Dementia patient could have trouble with swallowing because they can’t remember how to do it)
  2. Self-Discipline
  3. Ability to Follow Directions
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13
Q

Food Assessment Materials 1 (6)

A
  • Size 00 laryngeal mirror
  • Metal spoon
  • Straw
  • Tongue blade
  • Suction machine (trachs and vents)
  • Blue food coloring (used with trachs and vents, allergies can be an issue, not used everywhere)
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14
Q

Food Assessment Materials 2 (food) (8)

A
  • Glass of H2O
  • Nectar thick liquids
  • Honey thick liquids
  • Applesauce (thin puree)
  • Pudding (thick puree)
  • Fruit cocktail or banana (mechanical soft)
  • Ground meat
  • Bread

*** You can thicken liquids if the pt. is at risk of aspirating (safer to aspirate water with thick it)

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15
Q

Bedside Swallow Test

What are you looking for? (3)

A
  • Using the tray of food, the SLP will determine:

— use of the lips, cheeks tongue to take in food and swallow it,

— watch for signs of aspiration,

— make recommendations about how the patient should eat (types of food and liquid, position, kinds of utensils

  • For each consistency you are making an assessment + taking notes
  • Start with the pts. original diet ( if pt. is on nectar thick liquids, start there.
  • Lots of aspiration, stop and switch to MBS
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16
Q

Clinical Signs of Aspiration (5)

A
  • Coughing and choking
  • Wet sounding voice- have pt. clear throat and get a baseline. Then have pt. swallow and try to produce /a/ again.
  • Throat clearing
  • Swallowing multiple times for a small bite
  • Limited movement of the larynx in the neck
  • ** With every consistency listen to the voice afterwards (you need to have voice)
  • – Have the patient sustain /a/
17
Q

Procedures Sometimes Used During Bedside Swallowing Screenings

A
  1. Cervical Auscultation
  2. 3 ounce water swallow test
  3. Blue dye test
18
Q

Cervical Auscultation

A
  • Means listening to a patient’s breath sounds
  • Procedure:

–flat diaphragm of the stethoscope is placed laterally on the neck

–clinician listens with stethoscope to breath sounds

19
Q

Sound of Normal Swallow Sequence

A
  • Breath sounds are heard
  • Breathing stops (usually in the middle of an exhalation
  • A sound described as a clunk or a swish is heard
  • Breath sounds are heard again
20
Q

Can you hear aspiration?

A
  • Aspiration is suspected if a flushing sound of material is heard prior to the initiation of the swallow
  • With wet breath sounds,
  • Coughing, or
  • A distorted voice after the swallow
21
Q

3 ounce Water Swallow Test

A
  • Patient given 3 ounces of water in a cup and asked to drink without interruption
  • Abnormal response:
    • – coughing during or for one minute after completion of the swallow, or a wet gurgly voice quality after the swallow.
    — Use this test for recommendation of a MBS
22
Q

Blue Dye Test 1

A
  • This test is a screening test for aspiration that may be used at beside with the tracheostomized patient
  • The patient can be given measured amounts of blue-dyed foods and the tracheostomy suctioned immediately after the swallow for the presence of the blue-dyed foods, indicating aspiration the test does not reveal

— The anatomic or physiologic causes of aspiration

  • The result is clearly positive however, if the blue dye is evident through the coughing or suctioning from the tracheostomy tube the clinician should recommend a radiographic study.
23
Q

Blue dye test 2

A
  • Blue tinged secretions that are later suctioned from the tracheostomy

— Do not necessarily mean that the patient is aspirating

  • It is normal for the blue dye to mix with secretions and gradually coat the trachea
  • Unless a variety of food consistencies are presented the patient may not aspirate on the food consistency tested but may aspirate on other food consistencies
24
Q

Procedures for Blue Dye Test

A
  • The nurse should suction
  • Consider the optimum food & posture positions
  • Begin with easiest consistency
  • Use small amounts of materials
  • Provide detailed instructions to the patient
  • Proceed slowly
25
Q

Signs & Symptoms of Dysphagia (6)

A
  1. Pocketing food in the sulci or collection of food on the hard palate
  2. Delayed or absent elevation of the hyoid bone & thyroid cartilage
  3. Coughing & choking (silent aspirators can not be identified at bedside)
  4. Gurgly voice quality
  5. Excessive secretions (may be a result of aspiration)
  6. Expectoration or regurgitation (could be esophageal obstruction)
26
Q

MBS

A
  • Different consistencies are dipped in barium some consistencies as bedside swallow tray (looks at esophagus up)
  • Barium just involves a big cup of barium, looks at esophagus down. It shows how food enters the stomach through the esophagus.

Dysphagia (8 decks)

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