Feeding Unit Flashcards
the process of “setting up, arranging, and bringing food or fluid from the plate or cup to the mouth, sometimes referred to as ‘self-feeding’
feeding
the “ability to keep and manipulate food/fluid in the mouth and swallow it; eating and swallowing are often used interchangeably
eating
a complicated process in which food, liquid, medication, and saliva pass through the mouth, pharynx and the esophagus into the stomach.”
swallowing
considered the normal consumption of solids and liquids
deglutition
In the first year of life a baby should ___ his or her weight
triple
considered a measurable outcome of feeding or eating
growth
Feeding, eating and drinking are important for
social interaction and human function
old man’s best friend
aspiration pneumonia
method of receiving food via the gastric system or naso-gastric system
enteral feeding
dysfunction in any stage or process of eating. It includes any difficulty in the passage of food, liquid, or medicine, during any stage of swallowing that impairs the clients ability to swallow independently or safely.
dysphagia
eating and feeding are natomically and physiologically complex activities that require effective, coordinated function of ____, _____, and ____
motor, sensory, and cognition
contexts important to evaluate in feeding/eating
culture attitudes & values social opportunities effect of medical condition environmental factors
extension-retraction of the tongue, up and down jaw excursions, and loose approximation of the lips
suckling
negative pressure in the oral cavity, rhythmic up and down jaw movements, tongue tip elevation, firm approximation of the lips and minimal jaw excursion
sucking
head turning in response to tactical stimulation
rooting
rhythmic bite and release pattern
phasic bite reflex
1 suck/second
nutritive suck
2 sucks/second
non-nutritive suck
other issues from birth-6 months
weak or uncoordinated sucking
flattening & spreading of the tongue combines with up and down jaw movements
munching
spreading & rolling movements of the tongue, tongue lateralization and rotary movements
chewing
movement of the tongue to the sides of the mouth to propel food between the teeth for chewing
tongue lateralization
smooth interaction & integration of vertical, lateral, diagonal & eventually circular movements of jaw used in chewing
rotary jaw movements
easy, gradual closure of the teeth on the food, with an easy release of the food for chewing
controlled, sustained bite
If child has
Head control
More mature suck, ready for ___
Spoon feeding
Strained or pureed foods
If child handles food through
sucking action but can
not move food to sides of
mouth, ready for ___
Thickened pureed or soft
mashed foods
If child begins up and down
chewing movement, ready for ___
Ground table foods
If child has Increased tongue and lip
Control; sits alone without
support, ready for ___
cup drinking
Foods to suggest when a child is ready for spoon feeding and strained or pureed foods
Infant cereal, 1st and 2nd stage baby foods, pureed table foods
Foods to suggest when a child is ready for thickened pureed or soft mashed foods
Mashed potatoes, well cooked mashed vegetables, soft diced fruits, applesauce
foods to suggest when child is ready for Ground table foods
Ground fruits and vegetables, non-stringy meat mixed with gravy
when do feeding skills develop
In utero
when does sucking begin
Utero: last month of pregnancy
what is the earliest feeding pattern
suckling
what happens during sucking
lips form tight seal on nipple, less jaw excursion. Up and down movement pattern.
when will babies typically achieve a 1:1 ratio for sucks to breaths
2 days of age
How much can infants suck per feeding at 3 months
7-8 oz
When can children eat strained foods
6 months
When can cup drinking begin
4-6 months
When can soft solids be introduced
7 months
Explain what happens during munching
up and down jaw movements with uncontrolled force
What are interfering factors to feeding
prematurity abnormal tone sensory feedback delayed cognitive development behavior respiratory illness GI problems chronic illness anatomic abnormalities
elevates mandible. Most efficient muscle to chew
masseter
Most efficient muscle to crush objects
temporalis
flap of skin that covers the larynx to prevent food from entering larynx
epiglottis
stage of swallowing where food is chewed and prepared for swallowing
oral preparatory phase
stage of swallowing where the tongue pushes the food or liquid to the back of the mouth
oral transit phase
stage of swallowing where the swallow is triggered and the food or liquid is moved into the pharynx (the canal that connects the mouth to the esophagus
pharyngeal phase
stage of swallowing where food or liquid enters the esophagus and is carried into the stomach
esophageal phase
4 stages of swallowing
oral preparatory, oral transit, pharyngeal, and esophaeal
airway is open during what stages of swallowing
oral prep, oral, and esophageal
what texture should you give a client who has delayed swallowed
viscous or thickened
prerequisite/developmental issues
- Behavioral observations
- Oral motor behaviors
- Feeding guidelines
- Progression of food textures
- Typical growth expectations
- Monitoring growth
In 1st year, weight doubles by __ months
6
In 1st year, weight triples by __ months
12
In 2nd year, weight gain by - pounds
4-6
In 2nd year, length gain by - inches
4-5
In 3rd year, weight gain is - pounds
3.5-5.5
In 3rd year, length gain is - inches
2-2.5
what is the schedule of loss due to factors like malnourishment
weight, length, and head circumference
role of OT in dysphagia screening and evaluation
Ot is trained to
select
administer
interpret dysphagia screening & assessment tools
provides early ID of clients who are at risk for a particular problem. Checks to see if there is further need for evaluation. Easy to use, quick, safe, inexpensive.
screening
provides a wide variety of information on how the client performs through an entire meal in the most natural setting
assessment
protocol for assessment
O Chart review & interview (feeding history) O Cognitive component O Visual perceptual component O Physical component O Test tray of different foods/textures
if a meal takes > __ minutes or < __ minutes, it is concerning
30, 10
example screening
O Under/over weight O no weight gain in one month O meal > 30 minutes or meal< 10 minutes O signs of discomfort O gagging, coughing, or choking O difficult to position O fed semi-reclined O exclusive breast or formula fed O not on table food at 16 months O not using utensil by 2 1/2 years O food refusal O anatomic abnormalities O garage feedings-tube
Fluoroscopic recording and videotaping of the anatomy and physiology of the oral cavity, pharynx, and upper esophagus using boluses to assess swallowing function
modified barium swallow
use of stethoscope or microphone to assess swallowing function by listening to the swallow sounds and concurrent breathing sounds
cervical ascultation
Process of passing a flexible fiberoptic endoscope through the nose and positioning it to observe structures and function of the swallowing mechanism to include nasopharynx, oropharynx, and hypopharynx.
fiberoptic endoscopic evaluation of swallowing (FEES)
Active swallowing by the patient allows for a measure of ____ _____ along the esophagus in manometry
muscle contraction
A procedure which measures the strength, timing, and sequencing of pressure events in the esophagus by a catheter with pressure transducers.
manometry
procedure for measuring the reflux
(regurgitation or backwash) of acid from the
stomach into the esophagus that occurs in
gastroesphageal reflux disease.
esophageal pH monitoring
probe monitors the ________in the esophagus and transmits the information to a recorder that is worn by the patient
acidity
if you thought a child had silent aspiration or might be at risk for aspiration, which test would you choose
modified barium swallow
if a client was complaining of a lot of pain while eating, which test would you choose
esophageal pH monitoring
if you were suspecting food wasn’t going down because of a blockage, which test would you choose
fiberoptic endoscopic evaluation of swallowing (FEES)
in the pre-oral phase, what are somethings you want to screen for
Trunk control and positioning Oral hygiene Arousal Attention Orientation Organization/problem solving Behavior Visual acuity & perception Olfaction & gustatory sense Habits Affect Stress & anxiety Motor planning UE control
what are difficulties associated with dysphagia during the oral preparatory phase
Poor lip closure
Difficulty holding a bolus together due to tongue movement or coordination
Difficulty creating a bolus
Food falling into sulci due to lip tone or strength
Difficulty holding food against palate
what are difficulties associated with dysphagia during the oral (transit) phase
Delayed initiation of oral phase due to apraxia
Deficient anterior tongue movement
Poor bolus mobilization
Difficulty contacting the hard palate with tongue
Deficient posterior tongue movement
“Piecemeal deglutition”
what are difficulties associated with dysphagia during the pharyngeal phase
Delayed “triggering” of the pharyngeal swallow
Reduced tongue base movements
Insufficient closure of the soft palate
Unilateral or bilateral pharyngeal weakness
Reduced laryngeal elevation
Laryngeal penetration or aspiration
what are difficulties associated with dysphagia during the esophageal phase
Incompetence of UES Incompetence of LES Abnormalities in flow of food Anatomy Stricturing (narrowing of esophagus)
can lead to swallowing difficulty with possible nocturnal aspiration of residue in the diverticulum.
Zenker diverticulum
Type of dysphagia where there is disruption of UMN causes alteration in sensation, tone, and coordination
Swallowing may be weak or poorly coordinated
Pseudobulbar
Type of dysphagia that results from lower motor cranial nerve involvement
Weakness
Sensory deficits
paralytic
Type of dysphagia where there is loss of motor or sensory innervation
Due to anatomical structure abnormality
mechanical
what you would see with dysphagia from CVA
Unilateral cortical Poor coordination & reduced tone Food loss Boluses difficult to control Food pocketing Reduced oral sensation Delay in swallow response Pharyngeal weakness
what you would see with dysphagia from TBI
Deficits depend on location and size of lesion
Similar to strokes
Behavioral and cognitive challenges
Postural challenges due to tone
difficulties of feeding with MS
progressive oral and pharyngeal weakness,
difficulties of feeding with PD
oral and pharyngeal muscle weakness
Develop delayed swallow response and reduction in airway protection, which makes them at risk for aspiration.
Weak cough
Weakness or spasticity in limbs
difficulties of feeding with AD
Forgetting when to eat
Develop dyspraxia (forget what the purpose of things are)
Sensory aversion
difficulties of feeding with ALS
Spasticity Decreased endurance (reduce amount of food you give them)
difficulties of feeding with MG
Oral and pharyngeal muscle weakness
Fatigue
feeding problems may occur due to what 3 things
Motoric problems
Sensory processing problems
Behavioral problems
what might contribute to motoric feeding problems
decreased ROM
irregular tone
praxis problems (motor planning)
what might contribute to sensory feeding problems
oral tactile aversion
gustatory aversion
low registration to sensory information of food
motoric feeding interventions are targeted to assist the client with:
Successfully bring food or drink to the mouth without spilling
To independently feed him or herself age appropriate or developmentally appropriate meals
Maintain correct and safe posture for feeding and drinking
posture feeding interventions (motoric)
Appropriate posture for feeding based on client’s needs
Seating system
Positions to reduce tone or provide enough support for low tone
Upright position may be best if there are pharyngeal problems requiring chin-tuck modified swallowing
Therapist posture/position
advantages/disadvantages of front positioning of therapist
advantages: can look at symmetry, they can see you, better body mechanics
disadvantages: if they have a lot of tone, it’s hard to control them
advantages/disadvantages of side positioning of therapist
advantages: can use more parts of your body to support them
disadvantages: can’t see the other side of body
advantages/disadvantages of behind positioning of therapist
advantages: Hand over hand scooping
Providing jaw support
Helping facilitate the lips and other muscles
disadvantages: can’t see face
gathering food on utensils interventions (motoric)
Adaptive Equipment
Practice scooping and transporting of non-food items or food items to self or other container
bringing food or drink to mouth interventions (motoric)
Resting elbows on tray or table for greater stability
Provide tactile cueing at mouth
Provide physical assistance if spillage is an issue, even after AE is used
apraxia interventions (motoric)
Consistent environment
Minimal conversation
Milieu in which client’s responses are expected
Hand-over-hand guiding techniques
Alternating food textures and tastes may stimulate sequencing
Facilitating arousal to oral areas interventions (oral preparatory)
Towel swipes
Facial massage
Vibration
Beckman oral motor exercises
Facilitating increased ROM interventions (oral preparatory)
ROM to oral structures
Tongue lateralization
Beckman Exercises
strengthening interventions (oral preparatory)
Bite blocks Gauze chewing (putting food in gauze wrap and have them practice chewing)
how to facilitate a bite reflex
avoid tugging or pulling on the spoon, use a coated spoon, turn spoon slightly, provide downward pressure on chin to release the bite, you can also provide pressure on the condyle region of the TMJ while applying downward pressure on the mandible to try and release the bite.
how to facilitate tongue thrust
The client may need to eat thicker foods to reduce tongue thrust. Provide downward pressure on tongue when presenting the bite to prevent tongue thrusting, encourage backward and forward motion of the spoon to help the tongue retract. Facilitate mouth closure after the bite to reduce tongue thrust. For clients who can follow HEPs, you can practice the tongue-thrust, slurp, swallow method which is demonstrated during the first minute of the you-tube clip. This technique facilitates tongue retraction.
how to facilitate chewing
Pre-requisites of chewing include- 1) can swallow without coughing, 2) cognitive development above 6-8 mos, and 3) demonstrates adequate jaw support. Client must also have tongue lateralization and up and down munching movements of the jaw prior to chewing. You can facilitate chewing by placing long narrow food in between the molars (licorice) and facilitate jaw control- soft foods that can easily be broken down or food can be easily broken down by saliva. If the food is not easily broken down then place the food in cheese cloth or gauze.
how to facilitate tongue lateralization
can be performed by taking a nuk brush or a tongue depressor and touching it to the sides of the mouth, teeth, roof of mouth or lips by the therapist and having the client follow with his or her tongue.
working on oral management is best accomplished when the client is :
Alert
Can maintain adequate trunk and head positioning with assistance
Need to be gaining tongue control
Can manage secretions with minimal drooling
Has a reflexive cough
exercise and facilitation technique interventions (pharyngeal phase)
biofeedback
thermal stimulations
how to stimulate a swallow
Temperature (cold bolus) Sour bolus Carbonated bolus Textured bolus Dry swallows
types of modified swallows
Chin tuck
Head turn/rotated
Effortful swallow
Supraglottic swallow
This technique involves simultaneous swallowing and breath-holding, closing the vocal cords and protecting the airway. The patient thereafter can cough to expel any residue in the laryngeal vestibule. The Valsalva maneuver may be used to maximize vocal cord closing
Supraglottic swallow
Dysphagia Management for Patients with Progressive Neurological Disorders
Rest before eating Position chair so that it is accessible Lightweight utensils Hotplate Cups with spouts Straw drinking Built-up handles Ample time to eat High caloric mini meals Remain upright after the meal Oral hygiene following all meals and snacks
Interventions for Unilateral CVA: R or L
Avoid thin liquids and sticky boluses
Have client hold lips closed on paretic side
Provide cheek and lip support to maintain straw or spoon.
Increase flavor of bolus
Provide bolus of 10-20 mL to improve swallow
Practice chewing with gauze on the hemiparetic side to build musculature
Have client sweep tongue across cheek and perform cheek massage to clear pocketing on hemiparetic side
Thermal tactile stimulation
Head rotation to affected side
Chin tuck
Interventions for L CVA only
Use tips for feeding a client with apraxia
Hand of hand guiding
Cheek stimulation
Use gestures and non-verbal cues more than verbal cues
Interventions for R CVA only
Provide assistance to grade bolus size
Gentle external stimulation to cheek to facilitate lip seal
Rubbing cheek on paretic side to clear food
Pinch straw or provide HoH A for control cup drinking to limit bolus consumption
Chin tuck or rotation techniques
Coughing after swallows
Interventions for brainstem CVA
Sensory stimulation techniques Thermal tactile stimulation Strengthening exercises for the larynx Chin tuck Mendelsohn Maneuver
Interventions for multiple CVAs
More compensatory vs. rehabilitative interventions
Diet manipulation- avoiding thin liquids or loose foods (thickened purees)
Potentially alternative nutrition methods than oral nutrition
Interventions for brain injury
Stabilization of the body using proper positioning
Inhibition techniques to manage hyper or hypo-tonicity prior to feeding
Interventions focused on triggering a swallowing reflex and tong control (biggest areas of deficit in this population)
Oral preparatory interventions to help client control the bolus
Desensitization programs to decrease pathological reflexes
Have client sweep tongue on both sides and massage both cheeks or on affected side if unilateral weakness to clear pocketing
Thermal tactile stimulation
Extra time at meals given
Diet texture manipulation to reduce aspiration risk (avoid thin liquids)
Swallowing retraining
Interventions for brain tumors
ROM and resistive exercises to oral muscles innervated by cranial nerves to maintain strength required for oral manipulation of food
Retraining sensation to oral motor structures
Similar strategies to CVA for swallowing
Thermal tactile stimulation
Effortful swallow, supraglottic swallow or super-superglottic swallow
Interventions for MS
Modified swallowing techniques taught early on in disease process
ROM and strengthening to improve weakness of facial and oral muscles- DO NOT over exert client
Seating and positioning especially for head positioning
Adaptive equipment for eating
Provide modified easy-to-use meal programs to assist with frontal lobe memory loss for client and caregiver
Thickened liquids
Chin tuck
Interventions for PD
Coincide mealtime when medications are most effective
Stretching of upper body, shoulders and neck to reduce rigidity before meals
Positioning to reduce tremors
Adaptive equipment (especially weighted equipment- can reduce spilling caused by tremors)
Supervision during feeding to facilitate appropriate grading of the bolus
AROM for oral structures prior to feeding
Voice treatment to strengthen phonation helps with oral and pharyngeal phases of swallowing
common dysphagia problem where foreign substances enter lungs on inhalation
aspiration
common dysphagia problem where there is inflammation of the lungs caused by foreign substances
pneumonia
food or secretions when inhaled “aspirated” may cause
aspiration pneumonia
greater than average fluid loss from the body or fluid intake below the recommended amount can lead to ____
dehydration
causes of greater than average fluid loss
increased urination, diarrhea, vomiting, excessive drooling, perspiration
causes of fluid intake below the recommended amount
problems in sucking, drinking, or swallowing
inability to communicate thirst
incorrect mixture of tube feedings or formulas
loss of appetite from medications
how can we help with excessive drooling
verbal cues, positioning
symptoms of dehydration
loss of body weight
reduced output of urine or no urination
excessive thirst, loss of appetite, dryness of mouth, and mucous membranes
sunken eyes
increased respiration, and heart rate
lethargy, drowsiness, irritability, flushed skin, etc.
conditions associated with dehydration
Oral motor feeding difficulties, especially with drooling
Short-bowel syndrome or ileostomy
Conditions with prescribed diuretics such as cardiac conditions or BPD
Seizures: seizure medication can cause constipation
Inability to signal thirst
Infrequent passage of feces or the passage of extremely hard, dry fecal matter
constipation
An ____ _____ and a ____ ______ are the most important signs to monitor for the presence of constipation.
irregular pattern and hard stool
Constipation can cause
discomfort, pain, swelling of abdomen, and irritability
causes of constipation
decreased physical activity
dehydration
abnormal muscle tone leading to impaired function of the intestinal tract
lack of routine toileting habits or the inability to attain an upright, supported position for toileting
Child who is extended has difficulty producing a bm due to not being able to obtain enough flexion
abnormal anatomy or neurological function of the intestinal tract
type of non-oral feeding given to a client on life support
parenteral nutrition
all nutrients provided intravenously by not using the gastrointestinal tract. The IV solution contains pre-digested nutrients that are absorbed directly at the cellular level
parenteral nutrition
non-oral feeding that is preferred. Uses the GI tract.
enteral nutrition
why is enteral nutrition the more preferred route
less risks involved maintain use of intestines cost effective formula is easy to prepare, and the procedure may be more accepted by the consumer
Tube placement where it is passed through the mouth into the stomach. Usually inserted at mealtime and removed following feeding.
oral gastric
Tube placement where it is passed through the nose into the stomach. Generally used on a short-term basis.
nasogastric (NG tube)
Tube placement where it is passed directly into the stomach through the abdominal wall. Used for moderate-term or long-term basis.
gastrostomy (G tube)
Pros and cons of NG tube
+ nonsurgical
+ bolus or continuous
+ allows for prefeeding and feeding while in place
- desensitizes swallowing response
- increase aspiration risk, pharyngeal -secretions, & nasal reflux
Pros and cons of G tube
- surgical
+ bolus or continuous
+ allows for prefeeding & feeding program
+ less risk of reflux & aspiration
+ does not irritate the swallowing mechanism - stoma can be inflamed
- families perceptions
dysphagia diet 1
Thin liquids (e.g., fruit juice, coffee, tea)
dysphagia diet 2
Nectar-thick liquids (eg, cream soup, tomato juice)
dysphagia diet 3
Honey-thick liquids (ie, liquids are thickened to a honey consistency
dysphagia diet 4
Pudding-thick liquids/foods (eg, mashed bananas, cooked cereals, purees)
dysphagia diet 5
Mechanical soft foods (eg, meat loaf, baked beans, casseroles)
dysphagia diet 6
Chewy foods (eg, pizza, cheese, bagels)
dysphagia diet 7
Foods that fall apart (eg, bread, rice, muffins)
dysphagia diet 8
Mixed textures (eg, chicken noodle soup)
S&S of dysphagia
Difficulty initiating swallowing
A feeling of obstruction as if food has become stuck in the throat
Voice change
Difficulty with chewing or weakness of muscles of mastication
Pocketing of food in the mouth
Coughing after eating
Drooling
Impaired gag reflex and ability to clear bolus, cough, and /or breath
Nasal regurgitation
Weight loss
Recurrent pneumonia
