Chapter 5 Flashcards
Why study Clinical Assessment: to define to establish a ? to establish a tentative? to find potential ? to establish ?
potential cause (medical Hx)
working hypothesis that defines the disorder
treatment plan
questions that need further investigation/assessment
pt’s readiness
Enables SLP to: integrate information from: the review of standardized observations from collaboration with ?
interview/case history medical/clinical records protocols physical examination physicians and other caregivers
observe and assess function during ?
speech and swallowing tasks
- face
- jaw
- lips
- oral mucosa
- tongue
- teeth
- hard palate
- soft palate
Purpose of the clinical assessment:
identify the? and ? based on ?
this may include identifying factors that may affect swallowing function such as: - - - - - - - -
presence and observe the characteristic of dysphagia /clinical s/s.
bolus size bolus consistency bolus temperature bolus taste (sensory responses) -fatigue during a meal -posture -positioning -environmental conditions
Identify clinical signs and symptoms of ? in order to ?
determine need for an ?
esophageal dysphagia, gastroesophageal reflux, or laryngeal deficits/ make appropriate referrals to another specialty
instrumental eval. following clinical examination
determine if the patient is an appropriate candidate for ? based on clinical examination findings such as - - - - -
make clinical ? - - - -other ?
treatment or management
- medical stability
- cognitive status
- nutritional status
- psycho-social environmental factors
- behavioral factors
recommendations:
- positioning
- food and liquid consistency modifications
- feeding route alterations
- other clinical strategies designed to enhance the efficiency and safety of swallowing
Medical HX: may be gathered from: - - -
should always be reveiwed with a certain level of ?
prior medical records
current medical records
conversations with: medical staff, SOs, family/caregivers, Pt directly
speculation/considerations
Obtaining Medical Hx:
considerations:
Hx of ?
Hx of ?
Hx of ? -especially significant if ? - - -
congenital disease
-CP, syndromes, etc.
neurologic disease:
CVA, head trauma/TBI, progressive neurologic diseases (MS, ALS, PD, Mg, etc)
Sx:
- received general anesthesia (ET intubation)
- fundoplication, myotomy (GI)
- H&N CA - resection, biopsy. Chemotherapy ? radiation?
- cardio pulmonary, thyroid, cervical spine, thoracic
Considerations continued: ... and ... disorders ? -disturbances in the body's? - -
systemic and metabolic disorders
- chemical balance that result from toxins (medications/intolerance)
- infections (sepsis, UTI, etc.)
- dehydration/malnutrition (undernutrition), weight loss
respiratory impairment
-COPD, ASTHMA, ETC.
ESOPHAGEAL DISEASE:
gerd, ACHALASIA, bARRETT’S ETC
Considerations continued:
advance ?
a pt may or may not have executed ?
if the pt has chosen not to be ? the need for further testing or treatment may be ?
directives
-an advance directive stating his/her preference if dysphagia is severe
tube fed under any circumstance/ contraincated
CSE also known as
bedside swallow eval
A part of the exam can be completed with ?
observations are particularly important for pts who are ?
some assumptions can be made about the ? based on?
basic observation of the pt’s medical status
bedfast and undergoing medical or surgical tx
swallowing performance based on observational data
Feeding method: non oral
enteral feeding
NG tube (nasogastric)
G-tube (gastronomy)
J-tube (jejunostomy)
IV (intravenous)
TPA (total parenteral nutrition)
Both NG and PEG tubes may be either
continuous
bolus
Tracheostomy tubes:
inserted through ? to allow access to the lungs for ?
-vary in
may interfere with ?
tracheotomy site/ mechanical ventilation and or pulmonary toilet
lumen (size)
vocal fold closure
Respiratory patterns:
mechanically ventilated:
varying levels of ?
-most SLP’s collaborate with ?
Respiratory compromise:
increased ?
decreased ?
vent assistance in order to maintain adequate respiration
-medical staff for vent weaning prior to PO trials/assessment
ROR makes it difficult for the adequate swallow apnea duration
SpO2 levels (<90%) may indicate higher risk of swallowing impairment
Mental Status: can the pt. participate in the ? -follow? -stay? -extreme ? -etiology of? -....
exam
simple verbal directives
alert/awake for duration of time that would be equivalent to a meal
agitation
AMS (expected to be temporary or more permanent)
cognitive considerations for POC
CN Examination: should focus on the ? usually focused on the ? any abnormalities including: - - - -
head and neck musculature for swallowing to assess CN function
motor aspects of innervation
- asymmetry
- weakness
- abnormal movements at rest
- abnormal movements during volitional efforts
Facial Muscles/ muscles of mastication
observations may be made at ?
-eg ?
assessment of ?
- strength for ?
- palpitation of?
- assess for
- assess
rest and during tasks such as lip pursing and smiling for CN VII
-pt keeping lips pursed as SLP attempts to separate
muscles of mastication
- opening and closing mandible
- masseter muscles while biting down
- trismus (restriction of jaw opening)
- lateral movements
Tongue Musculature: assessed for integrity by: - -rapid -movement of -protrusion -inspection for -inspection for -general
tongue protrusion and lateral movements
- tongue movements (tongue tip elevation, ta)
- tongue to roof of mouth
- against resistance (tongue blade)
- atrophy, fasiculation (both from LMN movement)
- structural changes (resection, etc.)
- assessment of sensation
Oral Cavity: inspect and assess; - - indicative of ? often causes
unusually
-
lesions
candidiasis (thrush)
-fungal infection 2* immune system decompensation
-odynophagia
saliva flow
- xerostomia
- unusually thick secretions
dental status:
- caries, missing teeth, broken teeth
- ill-fitting dentures/partials
Oropharynx: inspect and assess: - should be observed ? place tongue blade on ? if present the velum should? Test
the presence of gaga reflex is NOT an indication of? many normals do not
the absence of gag reflex therefore in isolation of an otherwise normal inspection may not be ?
velum
at rest and phonation
posterior tongue and test gag reflex/ bilaterally/ CN IX and X
normal swallow response / have gag reflex
important consideration of dysphagia
Pharynx:
there are no ?
in some pts activity of the pharyngeal constrictor can be observed after ?
tests of pharyngeal function that can be easily appreciated during CSE
an active gag reflex or during production of falsetto voice
Larynx: assess both ? -ask pt to ? - - -
-
intrinsic and extrinsic musculature of swallow
- phonate and listen to vocal quality (conversation)
- hoarseness
- breathiness
- wet, gurgling quality
dry swallow
- palpation of the larynx at the level of the thyroid notch and feel for laryngeal elevation during the swallow
- normal elevation ranges from 2 - 4 cm
PO trials: if appropriate, continue with trials of? - - - - - - - start with ? and then ?
prepared foods and liquids of varying consistencies and viscosities: thins nectars honeys puddings puree mechanical soft solids (regular)
smaller bolus (5-10cc) / increase as appropriate to 20-25cc size
PO trials: observation and interaction are key during the ? on each consistency assess for: -... - -slow excessive -delayed or reduced - -... vocal quality -poor
PO trials of the exam
- pocketing in lateral or anterior sulcus
- labial spillage (anterior spillage)
- slow oral transit time
- excessive tongue movement
- delayed or reduced laryngeal elevation
- coughing/throat clearing which appears directly related to PO
- wet/gurgly vocal quality
- poor secretion management
Other observations: during all PO, the following considerations must be noted - - - - - ability to ? is strong indicator of safety
positioning
environment (effects on cognitively impaired pts)
appearance/position of tray (if observing during meal time)
pacing
level of assistance required
self-feeding ability
self feed
