Exam #2 Flashcards
- List the goals, objectives, and action plans of dysphagia intervention.
- To avoid morbidity associated with dysphagia
- Ensure that swallowing is safe (protective function)
- Ensure that patient has adequate hydration and nutrition (supportive function)
Goals are met through objectives
Targeting specific aspects of swallow physiology
E.g., hyolaryngeal excursion, UES opening duration
Objectives are accomplished through action plans
Specific techniques, frequency of practice of techniques, etc
E.g., Mendelsohn maneuver (HLE); Shaker exercise (UES opening)
- Describe the pertinent management considerations.
- Nature of swallowing deficit (feeding difficulty/swallowing difficulty) (voluntary vs involuntary)
- Patient characteristics
- Specific diagnosis/prognosis, severity, psychosocial factors- Influences motivation
- Ability to follow instructions
- Medications
- Support from caregivers, etc.
- Can we maintain oral intake?
If time to swallow bolus is > 10 sec, oral intake not recommended
If amount aspirated > 10% per trial, oral intake not recommended
Will change over time: re-assessment to advance diet, or recommend further restrictions - When to intervene? How to intervene?
Situation dependent
Prognosis, motivation, EBP
***If treatment is appropriate:
What options are available?
Why would they work with this patient?
What are anticipated risks/benefits?
What are anticipated functional outcomes?
Patient empowerment
Increases compliance; ensures patient’s needs are met
- List the 3 main management approaches for dysphagia.
A. Compensation
Meant to be short-term adjustments to facilitate safe oral intake.
B. Therapeutic/Rehabilitation
to improve swallowing physiology with lasting effects; change in physiology expected to remain once therapy stops
C. Preventative
Minimize negative outcomes (nutrition/hydration deficits, infections, etc.)
To minimize or prevent dysphagia in high-risk populations
- Contrast enteral and parenteral nutritional support.
Enteral- nutrition is passed through the intestine (if GI tract is functional)
Nasogastric/Nasointestinal Tube
Gastrostomy Tube
Jejunostomy Tube
Parenteral- (not by mouth, not by intestine GI tract not funcitonal
TPN = total parenteral nutrition
PPN = peripheral parenteral nutrition
- Describe the indications for and types of parenteral support.
Indications:
nonfunctional gastrointestinal tract, and
feeding required for > 1 week
Types:
Total Parenteral Nutrition (TPN)
Peripheral Parenteral Nutrition (PPN)
feeding required for 7 – 10 days
- Describe the suggestions for transitioning from nonoral to oral feeding.
- Identify a safe oral bolus
- Provide intermittent tube feeds
- Ingest oral feedings before tube feeding- ensuring that patient is actively engaged and enjoying the food
- Reestablish a normal meal routine- may get family and friends to come in to enjoy the meal with them
- Provide a specific diet in the initial stages- what should a meal constitue (meat/vegetable/specific diet)
- Document the type, amount, and time to eat of all materials taken by mouth
- Document any problems with the oral diet and any complications
- Involve patient/family in preferences for advancing oral diet- if they want to continue to advance an oral diet (age, overall health, they may have had a traumatic experience)
- Monitor swallow performance, nutrition and hydration, and respiratory complications
- List the prosthetic management options.
adaptive feeding devices
palatal prostheses
synthetic saliva
jaw sling- increases jaw support (keeps a place for the tongue)
- Describe the benefit and specific aims of various postural adjustments.
redirect bolus flow and change pharyngeal dimensions
1. head back/extension- assists with oral transport to move things backwards
Don’t want to do that if there is inadequate airway closure
2. head down/chin down- facilitates airway protection during the actual swallow
Anterior structures shift posteriorly
3. head rotated to the side
Closes off the weaker side (hemiparesis of a VF)
4. head tilted to the side
Promotes oral transport by engaging side of the larynx
Should evaluate changes in residue, aspiration, transit time
- Describe at least 3 oral sensory awareness strategies.
provision of a preliminary stimulus prior to oral phase of swallow
increasing downward pressure against tongue
sour bolus
cold bolus
larger volume of bolus (>3ml)
bolus requiring chewing
thermal-tactile stimulation
- Describe the pros and cons of various textures and texture modifications.
Thin liquid:
Pro:
Easiest to have on hand and to consume.
Con:
Aspiration risk and difficult to control
Thicken liquid
Pro: slows down swallow and gives system more time to initiate, more control
Con: less appealing texture
Pudding/Puree
Pro:smooth consisitency, easy to prepare
Con: texture sensitivity
Chopped/Minced
Pro: more texture/flavor-more natural
Con: if not prepared correctly – can lead to aspiration
Cookie/Cracker
Pro: familiarity/appealing
Con: aspiration and dryness
Modification
Pro: create a safe swallow as possible, reduce risk of aspiration
Con: relying on texture modifications may mask the root causes of dysphagia instead of addressing them through more detailed clinical assessments and rehabilitative interventions
- Define the advantages of modifying bolus presentation.
Volume
average bolus size = 15-26mL (gender differences)
delay in triggering pharyngeal swallow – may benefit from a larger bolus (sensory input)
May have a lot of residue leftover as a result
weak pharyngeal swallow – may benefit from smaller boluses at a slower rate (more control/less residue)
will be individual-dependent
Temperature
cold (enhanced awareness), extremes of hot/cold (typically ingested in small amounts).
Meal time/frequency- if clients fatigue throughout a meal, you may want to make it earlier in the day. Can also do more frequent meals that are smaller/faster
Distractions
Alternating food/liquid wash
Taste/Smell/Aesthetics
- Define the pros and cons of dry/saliva swallows and liquid wash approaches to dysphagia management.
Multiple (Dry/Saliva) Swallows
designed to clear residue from mouth and pharynx
pros:
prevents aspiration after swallow
use with oral and pharyngeal weakness
cons: Increases feeding time (bad for ppl who fatigue easily)
Liquid Wash
pros: clears residue from mouth and pharynx
prevents aspiration after swallow
same indications as Dry Swallow
cons: use thin liquids to remove residue (if patient is able to manage thin liquids)
- List the 3 broad therapeutic approaches for dysphagia management.
A. Compensation
Meant to be short-term adjustments to facilitate safe oral intake.
B. Therapeutic/Rehabilitation
to improve swallowing physiology with lasting effects; change in physiology expected to remain once therapy stops
C. Preventative
Minimize negative outcomes (nutrition/hydration deficits, infections, etc.)
To minimize or prevent dysphagia in high-risk populations
Describe at least 3 voluntary maneuvers.
Supraglottic swallow (SGS)
Super Supraglottic swallow (S-SGS)
Effortful swallow
Mendelsohn maneuver- - to improve hyolaryngeal movement elevation and excursion and, consequently, opening of the upper esophageal sphincter during swallowing
Sit or stand comfortably. Start to swallow normally. When your larynx (voice box) is at its highest point, squeeze your throat muscles to hold it in that position for 3 counts, and then relax. You can use your fingers to feel your larynx move
Evidence is mixed for many maneuvers
Not all have been evaluated relative to altering health outcomes
Trying to make these processes more voluntary
Describe a sensory facilitation technique as a compensatory and therapeutic management approach.
Thermal-tactile Stimulation
Air-pulse Stimulation
designed to facilitate initiation of a dry swallow
Based on premise that a “swallow” is likely the best motor activity for improving swallowing
Typical resting swallowing rate = 1 sw/min
Patients with neurogenic dysphagia demonstrate decreased sw/min (Theurer et al., Arch Phys Med Rehab)
- Identify any unique treatment considerations of the dementia types.
Visual and olfactory aspects
Hallmark feature= weight loss 40%, predictor of mortality
Weight gain= protective effect
Reduction of mass in the gums can be the first sign of weight loss
Personality/behavioral/language changes as result of frontal lobe impact
Disinhibition (rude behavior, comments on appearance ex.)
- List key assessment components/questions that may be relevant for a
dementia admission into acute care.
Swallow assessment, cognitive assessment?
Some potential questions: Why has hospital admission occurred?
Is this an acute problem?
What has been his/her level of functioning over past few days, weeks, months?
What do caregivers perceive as the problem with eating and drinking?
Can the person consent to assessment and intervention?
Is the person dying?
What food and drink textures are available at home?
Are there any patterns to their skills and difficulties?
Does the caregiver manage these issues?
How does behaviour impact on the problem?
Is the patient able to describe their difficulties?
Could swallowing difficulty be due to effects of medication?
Does the patient have an advanced decision/previously held view re: wishes for advanced stage care? (Smith et al., 2009)
