Clinical Evaluation of Swallowing/Assessment Flashcards
What are the aims of dysphagia assessment?
- assesses ability to protect airway
- determine likelihood of safe oral intake
- best conditions to eat, best consistency
- determine cause of dsyphagia
- plan treatment for disorder
- advice for compensatory strategies
- nutritional management
- determine need for diagnostic studies
- establish baseline of clinical data
What is the difference between screening and diagnostic tools?
Screening:
- identify signs and symptoms of dysphagia
- quick, low risk, low cost
- identify high risk patients who need further assessment
Diagnostic Tools:
- deals with the ‘why’
- physiology and anatomy
Identify a) who does the Clinical Swallow Examination and b) what the four components of the CSE are
- SP ONLY
- case history and patient observations
- oromotor examination
- food/fluid trials
- recommendations
What materials would you have on hand for the CSE?
- pen and paper
- OCC health and safety equipment (gloves, gown, protective goggles)
- tongue depressor
- gauze/tissues
- swabs
- torch
- cup, spoon, straw
- modified foods and fluids
Explain what is involved in the case history and patient observations of the CSE
- interviews (with patient, significant other, nurse)
- medical chart (consider current health status)
What would be some key information to obtain about the patient in stage 1 of the CSE?
- history of disorder
- nature of disorder
- current issues of oral nutrition
- symptoms
- time since condition started
- current strategies
- diet and nutrition at current
- taste issues
- fears/concerns/worries
What are some important considerations to make during stage 1 of the CSE?
- diagnosis
- stability of medical state
- nature of conditions
- respiratory status
- medications
- history/presence of intubation
- history/presence of non-oral nutrition
- alertness
- cognition
- communication status
- oral condition/care
- positioning in bed
Explain the second stage of the CSE (oromotor examination)
View:
- hard and soft palate
- uvula
- posterior pharyngeal wall
- lateral sulcus
- facial arches
- tongue at rest (i.e. fasciculations, atrophy)
- oral mucosa
- oral care
- dryness/moisture
Dentition:
- amount of teeth
- condition of teeth
- dentures??
Cranial Nerve examination
What do you look for in the cranial nerve examination of the oromotor exam? Specify for all cranial nerves involved in swallowing `
Look at strength, speed, range of movement, symmetry
CNV - Jaw:
- masseter muscle
- bite together, feel strength
- open and close jaw against resistance
- extent of jaw opening
- impaired - sensory impairment anterior 2/3 of tongue?
CNVII - general:
- facial expression
CNVII - upper face:
- raise eyebrows, frown
CNVII - lower face
- lips; smile, pucker, rapid-alternating, seal, hold air in cheeks
CNIX and CNX - palatal movement
- velar elevation - depress back of tongue and ask for repeated phonation
- hypernasality? poor velar closure in phonation
CNIX and CNX - larynx
- vocal quality
- cough voluntary and reflexive
Explain step 3 of the CSE, including its purpose, what to observe, and when not do it
FLUIDS/FOOD TRIALS
Purpose is to determine:
- what consistencies of fluid and food they can safely manage
- the amount of food they can manage
- the manner of intake/assistance
Observe (fluids):
- effort to propel
- cohesion
- speed of flow
Observe (foods):
- mastication
- bite force
- cohesion of bolus
- dry/moist
Consider NOT doing:
- too ill
- not alert
- fluctuating medical state
- positioning
- oral cavity condition
Why begin with fluids in stage 3 of the CSE?
- Liquids are harder to control and testing fluids first lets you get a good idea of how well the patient can manage oral intake
- Testing fluids before foods means there is no pre-existing food residue in mouth/throat that could be aspirated
- Although aspiration risk remains, there is also a low choking risk for fluids
List some foods used at each level of the food trials
Liquidised:
typically not directly tested as consistency already tested in fluids trial (thin / slightly thick)
Pureed:
Tested with a PUREE eg., puree apple.
often not directly tested as consistency already tested in fluids trial (extremely thick) some may skip this step if the patient can manage extremely thick fluids or better, then it is often assumed they can manage this food consistency too.
Minced and moist:
Mashed banana, or use of packaged soft fruit eg “Peaches, Two fruits”
But be careful of the thin liquid/nectar they sit in - Remove this from the spoon!
Soft & Bite sized:
Use diced cake or diced banana.
If they can chew this OK, but are just a bit slow, then they will be OK on a soft diet.
If they take too long to chew or get fatigued chewing, then they are better off on Minced & Moist.
Easy to chew + Normal:
Use bread/biscuit:- if you have bread, make sure you also try them on the crust (hardest part to manage) and
if they manage it easily and quickly then they will be OK on a normal diet.
If you have a hard biscuit this will help you assess biting into hard foods and chewing with effort.
If they don’t have teeth, or don’t wear their dentures but can manage normal soft options at home – then “easy to chew” is the best option.
How do you know which consistency to trial first in the fluid/food trials?
- Start on the thinnest fluid/most normal food you think they are able to manage SAFELY based on your observations + oromotor exam
- Thick fluids can leave residue that is hard to clear + so better to progress from thinner to thicker
- You won’t need to test EVERY food / fluid……So starting with the most normal foods/fluid you think they can manage (based on your observations & oromotor etc)
- Progressing either to more modified (if they have difficulty), or more normal (if they manage it well)….. also means you will do less trials
BUT…its Patient dependent – CRITICAL you consider what they are likely able to manage based on observations/history
Constantly reassess with each trial – going up or down in fluid thickness / food modification - based on patients performance during trials
List; a) the amount in each trial, b) the manner of trials, and c) when to stop the trials
a) Begin assisted, try independent
Liquids - spoon to cup/straw
Solids - spoon to fork
b) - 3-4 of each consistency
- pause between each mouthful
- examine any fatigue effects
- do any strategies help?
- determine nature and extent of feeding assistance required
c) - aspiration signs
- patient unable to manage
What is considered ‘safe’ from the fluid/food trials?
- the consistency before the failed attempt is ‘safe’
- consider if failed attempts can be made safer with technique
- always try and incorporate techniques so that patient is eating most normal food safely
