Feeding/Swallowing

Question 1

Poor Feeding Can Lead to

Answer 1

-malnutrition
-dehydration
-weight loss
-emotional distress
-choking
-airway obstruction
-aspiration
-pneumonia
-death

Question 2

What is dysphasia

Answer 2

Difficulties with chewing and swallowing

Question 3

Dysphasia/malnutrition makes patients susceptible to

Answer 3

-Increased rate of hospitalization
-poor wound healing
-pressure injuries
-infections
-decreased muscle strength
-post op complications
-increase morbidity and mortality

Question 4

Emotional Distress and Dysphagia

Answer 4

-Is an issue in those with dysphasia who report anxiety and panic during meals
-They also report eating less meals due to these feelings and being very self conscious when eating with others due to coughing, choking, or drooling =increasing sense of isolation and decreased self esteem

Question 5

Aspiration

Answer 5

-When food and/or liquid goes down the trachea into the lungs
-linked to longer hospital stays, transfer to other facilities rather than back home, and mortality

Question 6

Aspiration Pneumonia

Answer 6

-Lung lobes affected depends on the patients position when aspiration occurred
-Most commonly it is the RLL
-Mortality rate for aspiration pneumonia is dependent on the volume and content aspirated but has been reported as high as 70%

Question 7

Swallowing involves

Answer 7

-Combination of voluntary and involuntary movements
-Involves 50 paired muscle movements and almost all levels of CNS and ANS
-Three stages, 1. Oral stage, 2. Pharyngeal stage, 3. Esophageal stage

Question 8

Muscle Tone and Swallowing

Answer 8

-Swallowing involves many muscles to efficiently work
-Need good muscle tone in the jaw, tongue, esophagus, sphincters as well as body trunk control
-If there are deficiencies on any of these areas, it can impact swallowing

Question 9

Swallowing and respiration’s

Answer 9

-During swallowing, resps stop as the respiratory passage (trachea) is blocked

Question 10

Three main stages of swallowing

Answer 10

1. Oral stage
2. Pharyngeal stage
3. Esophageal stage

Question 11

Oral phase

Answer 11

-Voluntary phase
-Purpose is to prepare the food/liquid for the swallow
-Food is placed in mouth and chewed to prepare bolus and liquid boluses are held very briefly between the tongue and roof of mouth
-Bolus is moved to back of mouth by tongue

Question 12

Potential Problems in Oral Phase

Answer 12

-Lips need to be coordinated and strong enough to keep food/fluids inside, if unable may see dribbling/spillage from mouth
-Tongue needs good control to move the food to the back of the mouth, if control is lacking food spillage to the back of throat and towards esophagus May occur
-Jaw needs good enough strength and control for chewing if not cannot mince food to form a good bolus
-Good dentition is required to mince food adequately or may be painful
-Mouth must be moist, xerostomia makes it difficult to soften food = dry bolus is difficult to swallow

Question 13

Interventions to assist with oral phase

Answer 13

-Provision of frequent and adequate mouth care
-Treat or correct underlying reason for xerostomia
-Provide manageable amount of food when assisting client to eat
-Use a teaspoon and ensure client is tolerating what is being provided
-Pace the meal as it is important to make sure mouth is empty before adding more food

Question 14

Pharyngeal phase

Answer 14

-Involuntary phase = takes 1-2 secs and purpose is to protect the airway
-Once bolus enters the upper throat above the larynx, soft palate rises to block off nasal passage
-Next hyoid bone moves to allow epiglottis to invert closing off the trachea
-Tongue base moves forward = leads to bolus moving downward to esophagus, all resp passages are blocked

Question 15

Potential problems in pharyngeal phase

Answer 15

-Aspiration is significant risk during this stage as the esophagus and trachea share a passage, if any step isn’t working aspiration may result
-Older adults tend to have a prolonged pharyngeal phase and a reduced cough reflex
-Strong cough reflex is important during this phase as it allows food/liquid which has entered the trachea to be expelled

Question 16

Esophageal Phase

Answer 16

-Involuntary phase with the purpose of transferring the bolus from pharynx to stomach
-During this phase bolus moves to the stomach through peristaltic waves of esophageal muscles

Question 17

Potential Problems in Esophageal Phase

Answer 17

-Retention of food and liquid in the esophagus after swallowing can result from a mechanical obstruction (tumour or stricture), a motility disorder (weakness or in coordination or esophageal spasm) or impaired opening of lower esophageal sphincter
-GERD is closely related problem although it is not a swallowing disorder. Individuals with gerd are at risk for reflux esophagitis as well as peptic strictures which can lead to an esophageal obstruction and result in dysphagia

Question 18

Reasons for difficulty chewing and swallowing

Answer 18

-Normal aging processes
-Medications
-Neurological changes
-Physical/structural diseases or injury

Question 19

Potential Complications/Consequences of difficult Chewing/Swallowing

Answer 19

-Malnutrition
-Dehydration
-Weight loss
-Emotional distress
-Choking
-Airway obstruction
-Inability to take medications
-Aspiration
-Pneumonia
-Death

Question 20

Dysphagia: Normal Aging

Answer 20

-Decreased saliva production making it harder to chew and swallow, also changes the way dentures fit
-Esophageal sphincter weakens and reflex may result
-Tongue mass and strength decrease making it harder to control food and clear the mouth
-Facial muscles atrophy which makes it harder to control the food in the mouth and may lead to pocketing of food in cheeks
-Cough reflex weakens sometimes resulting in “silent aspiration”

Question 21

Dysphagia: Medication

Answer 21

-Can cause drug induced Dysphagia
-Can result as a side effect of medication, a complication of therapeutic action, or drug induced esophageal injury
-Anticholinergics, antipsychotics, antidepressants, anti anxiety, anticonvulsants, neuromuscular blocking and muscle relaxers, immunosuppressants
-Many of these meds can cause effects such as dried mouth, sedation, confusion, and movement disorders which in turn can lead to Dysphagia

Question 22

Dysphagia: Neurological Condition

Answer 22

-Aquired: CVA, head/spinal cord trauma, infection such as polio, anorexia
-Congenital: Cerebral palsy, muscular dystrophy
-Degenerative: Parkinson’s, MS, ALS, Huntington’s, dementias
-Any condition that causes injury or damage to anatomical structures required for effective chewing and swallowing can cause Dysphagia including trauma and surgical intervention for disease management such as for cancer

Question 23

Clinical Manifestations of Dysphagia in the Swallowing Phases

Answer 23

-Drooling/leaking of food (oral)
-Prolonged chewing/delay/multiple swallows (oral)
-Coughing and/or choking during or after swallowing (pharyngeal)
-Gurgly or wet sounding voice (pharyngeal)
-Feeling if having food stuck in the chest (esophageal)
-Reflux (esophageal)
-Weight loss (any stage)
-Refusal of food or reluctance to eat (any stage)

Question 24

Who to refer to if these issues occur

Answer 24

-Document findings and communicate them to the team
-Dietician, OT, PT

Question 25

Assessment and Referral

Answer 25

-Important to assess everyone
-in LTC all new residents are to be screened using a meal observation form (MOS) within 72 hours of arrival
-Can be completed by any trained member of the HC team such as HCA, nurse however nurse must review
-Using MOS sheet certain responses indicate need for referral to OT or PT or RT

Question 26

Implementation of Safe Feeding Practice

Answer 26

-Anyone trained in feeding and completion of the MOS assessment can do so however it remains a nursing responsibility to assess, review and monitor

Question 27

Evaluation and Reassessment

Answer 27

-Ongoing evaluation of the effectiveness of the feeding plan for individuals is required
-May include daily/weekly weights, documentation on an intake/outtake sheet, caloric monitoring
-Also assess for any other complications or indications of feeding or swallowing difficulties such a pneumonia, assess lung sounds, dehydration, mucous membranes, UTI, skin assessment, ulcer development and delayed wound healing

Question 28

Assessments

Answer 28

-LOC and cognition
-Overall strength and coordination or facial muscles
-Oral cavity
-Voice/speech quality
-Cough reflex & swallow response
-Resp status
-Weight, labs, and diagnostics

Question 29

Assessment: LOC and cognition

Answer 29

-May change as meal progresses, client may be alert at the beginning however become fatigued and require intervention to continue feeding or May become too drowsy to safely feed
-Assess if client can understand process or sequence
-Can they remember, follow directions, pay attention to what you’re asking them to do
-Interventions such as limiting distractions such as TVs or feeding client in quiet spot may help

Question 30

Assessment: Overall Strength and Coordination

Answer 30

-Assess if client has core strength allowing them to sit up straight with strong neck muscles to keep head up
-Ensure their motor activity allows them to safely hold and coordinate movements required for eating
-Specifically assess facial muscles ensuring assessment of both sides of face
-Assess facial muscle strength, symmetry, coordination, sensation

Question 31

Assessment: Oral Cavity

Answer 31

-Assess muscle tone around mouth allows for strong lip closure
-Assess strength of tongue
-Assess oral cavity for alterations that would impact ability to eat and asses their dentition and dentures

Question 32

Assessment: Cough Reflex and Swallow Responses

Answer 32

-Cough reflex is protective mechanism which helps clear trachea if something has entered
-Note strength of cough and ability to clear their airway
-If someone does not cough it does not mean they are swallowing safely
-if cough is not present or poor, food and liquid may be trickling down trachea in lungs without any sign =silent aspiration
-assess for how swallow looks and how many swallows it takes to complete process
-gag reflex does not indicate good swallowing and decreased risk of aspiration NOT to be relied on

Question 33

Assessment: Resp Status

Answer 33

-assess for adventitious lung sounds and recurrent bouts of pneumonia

Question 34

Assessment: Weight, Labs, Diagnostics

Answer 34

-Assess clients weight if swallowing or eating impaired
-Know when client is weighed and notice trends
-Interpret serum albumin results as low levels can indicate malnutrition
-FEEs (fiberoptic endoscopic evaluation of swallowing)
-VFSE (video fluoroscopic swallowing exam)

Question 35

Feeding procedure #1) Care plan

Answer 35

-Check diet order
-Check for safe swallowing and feeding guidelines

Question 36

Feeding Procedure #2: Mealtime Position

Answer 36

-Eating or feeding in bed should be last resort
-It is beneficial to move for our whole body
-Head position is very important and SLP or sometimes a prescriber may recommend changes in head position depending on clients disease or status
-Head positions help redirect the flow of the bolus

Question 37

Head Positions: Head Tilt

Answer 37

-Tilt the top of head to the strong side
-Directs the food by gravity to the strong side of the mouth

Question 38

Head Position: Head Turn

Answer 38

-Turn the head to the weak side
-Closes off the weak side of the esophagus
-May help to prevent aspiration

Question 39

Head Position: Chin tuck

Answer 39

-Helps with swallowing
-May assist to prevent aspiration

Question 40

Feeding Procedure # 3: Diet Order

Answer 40

-Info in kardex or chart
-Therapeutic diets
-May be required to thicken fluids if ordered

Question 41

IDDSI

Answer 41

-International Dysphagia Diet Standardized Initiative
-Provides a common terminology to describe food textures and drink thickness
-Categorize food and drinks regarding textures and consistency
-No longer using “nectar, honey, pudding etc”
-Continuum of 8 levels where drinks are measured from levels 0-4 and foods 3-7
-overlap between food texture and drink thickness
-Thickened fluids must be order as part of diet order

Question 42

Free Water Protocol

Answer 42

-Frazier free water protocol was developed with the aim of providing patients with Dysphagia an option to consume thin water in between mealtimes
-Some studies have shown there is no increased incidence of aspiration pneumonia however the increase in fluid intake was not statistically significant either
-Conflicting evidence with this practice

Question 43

Med Pass and Supplements

Answer 43

-Med Pass Nutritional Supplement Program
-This program provides nutritionally high risk clients with a concentrated nutrition supplement
-One common supplement is Resource 2.0 however there are others
-Ordered in the same way medication is however RD or physician can
-Order is on the MAR and treated same as med
-Standard order is 60mL 4x a day
-Usually required to be refrigerated and are multi dose so will need to be dated and signed = important to note expiry times from opening
-Other nutritional supplements such as boost are not as concentrated and are part of diet order and usually come in clients tray

Question 44

Medications

Answer 44

-Administering meds for clients with Dysphagia can be difficult
-Assess options and discuss with prescriber and pharmacist
-Does the med come in a liquid form?
-Can the med be crushed or will crushing alter its action such as EC or gel caps ?