L7 Clinical Assessment Flashcards
List the Goals of Assessment in Swallowing?
- Answer patient/team questions about swallowing
- inform patient/ team of new swallowing concerns
- Thorough assessment
- Form clinical impressions
- Determine severity and areas affected
- Make recommendations
- Get consent to implement recommendations
- educate patient on results and recommendations
- Refer to other specialists
- Put discharge supports in place
A thorough assessment consists of:
- case history
- general observations
- OPE
- oral trials (swallow function)
- Optional: QOL or swallowing questionnaires
When assessing SLPs should form clinical impressions about:
- risk of aspiration
- prognosis
- risk vs benefit considerations in relation to patient goals
SLP swallowing recommendations could consist of:
- texture/ consistency changes
- environmental changes
- postural changes
- feeding
- utensils
- positionioning
- therapy exercises
T or F: When reading a chart you don’t need to worry about who wrote the information.
False- the social worker noting the surgeon cut through the vagus nerve is different than the surgeon noting it
What are 8 things to consider when formulating a clinical impression and giving recommendations?
- medical history
- socio-cultural history
- cognitive/ language/ speech status
- physical status
- Oral motor/ sensory exam
- Test Swallows
- Nutritional Exam
- Feeding Exam
Swallowing assessment by an SLP includes both ______ and ______ evaluations
clinical
instrumental
List the 6 elements of the Clinical Evaluation Process:
1) Subjective Complaints
2) Medical History
3) Social-Cultural Status
4) Clinical Observations
5) Oral Peripheral Exam
6) Swallowing Trials
In terms of subjective complaints; list 6 things you would ask about:
- Site or timing of impairment
- Onset, Frequency and Progression
- Aggravating factors and compensatory mechanisms
- Screening for impaired nutrition and hydration
- Associated symptoms
- Other symptoms and signs of complications
subjective complaints:
The site/timing of impairment could be during the ______, _______ or ______ phase
oral, pharyngeal or esophageal
subjective complaints:
List possible associated symptoms:
- feeling of obstruction (globus sensation)
- odynophagia
- nasal regurgitation
- halitosis
- choking, coughing, speech or voice change
- heartburn, nocturnal coughing or chest pain
- Dysgeusia
subjective complaints:
The influence of food textures, temperature and fatigue on swallowing would be examples of ________
aggravating factors and compensatory mechanisms
that we should ask about
subjective complaints:
Ancillary symptoms and evidence of complications could include:
- changes in appetite or eating enjoyment
- respiratory problesm
- sleep disturbances
- dry mouth or saliva changes
List the 16 things that should be considered when taking a medical history? (e.g nutritional history . . .)
- nutritional
- gastrointestinal
- respiratory
- laryngological
- neurological
- cardiovascular
- renal
- musculoskeletal and connective tissue disorders
- metabolic disorders
- psychiatric
- general weakness & de-conditioning
- medications
- surgeries or radiation
- current treatments
- family history
- previous swallowing exams
Why do we consider nutrition?
nutrient, hydration deficiency and weight loss may
contribute to reduced muscle function, respiratory
function, &/or reduced cognition.
Body Mass Index (BMI) kg/m2 [Norm = 18.5 – 24.9]
Albumin and Pre-albumin levels [can be artificially
lowered CHF, renal dysfunction … b/c increases in
plasma volumes]
B12, RBC, Hematocrit 9HCT) and Hemoglobin
(Hgb)
Anemia (iron deficiency) can cause cognitive decline
Why consider Gastrointestinal health?
reflux, obstruction, motility disorder may contribute
to heartburn, chest pain, food sticking, nausea,
vomiting.
GI reflux is failure of Lower Esophageal Sphincter. I is common in ____% of persons over 60 yr., and can cause sleep disturbances.
67%
History of _______, _______, _______, and
________ may affect swallow.
(aspiration) pneumonia, COPD (chronic obstructive pulmonary disease), tracheotomy, and asthma
WBC is _________ if elevated it could indicate ______
number of leukocytes in blood
infection
T or F: The relative change in peripheral oxygen saturation is more important than the absolute change
true
The baseline respiratory rate is _____/ min
20 breaths (above that is tachypnea)
Why consider laryngological health?
structural disease / injury, laryngeal nerve injuries
may affect airway protection abilities
Why consider neurological health?
disease / injury may contribute to impaired
cognition, movement, postures, coordination
Why consider cardiovascular health?
consequent neurological deficits and /or meds may
affect level of alertness, cognition, movement
- they may cause pulmonary congestion with impaired respiratory function.
Why consider renal health?
may cause electrolyte imbalance & contribute to
reduced appetite, level of alertness and cognition
Why consider musculoskeletal and connective tissue disorders?
may affect movement of structures and muscles
Why consider Metabolic disorders (eg. diabetes)?
reflected in electrolyte imbalance may affect nutrition/hydration, mental status, muscle function]
Why consider psychiatric health?
may affect behavioural controls, drug therapies (i.e.
neuroleptics) may induce movement disorder
Why consider general weakness and deconditioning (eg. after illness)?
may affect range and strength of movements, may reduce cough effectiveness.
How and why do we consider medication?
- Consider the dosage and timing.
- Is there anything the patient usually takes but has stopped for some reason (eg. swallowing problems).
- Any new medications, could potential side effects affect swallowing
Why consider surgeries and radiation?
- Read the surgical notes, especially check whether
any suspected nerve damage occurred or what tissue
was removed- what type of repair was done. - Find out what radiation fields were included and
dosage per location.
Why consider current treatment?
- Check with team and patient as to current treatments.
- If you think it may impact swallowing, collect more information about the details of the treatment, and what the prognosis for patient is for recovering from this issue is. This information will help you as you look
It is especially important to consider family history in dysphagia ______
NYD (not yet diagnosed)
When reviewing previous swallowing exams consider____ and _____. If more information is needed _______
when it was and what was recommended
contact the clinician
It is important to note what other ________ have seen during their care of the patient.
interprofessionals (nurse, RT, OT, PT etc.)
What is important to consider pertaining to social and cultural status during an assessment? Who can you ask for more information?
1) Family and Caregivers (food preparation, can patient feed himself)
2) Food preferences and allergies
3) Location of residence (home vs retirement vs nursing home)
Ask the Social Worker
List 5 goals of the Clinical examination:
- to answer questions the patient/ team has
- determine further questions
- continue gathering evidence about swallowing to draw conclusions
- assess ability to protect airway
- establish baseline data to chart change
List the first steps of a clinical examination:
- Introduce yourself and give purpose of visit
- Explain procedure, take consent
T or F: A good clinical examination starts with an environmental scan and assessment of the patient overall status
True
List 9 clinical observations during the clinical exam:
- feeding status (oral / textures, NPO, IV, etc)
- Tracheostomy (type, point in weaning process)
- Nutrition/ hydration status
- Mental status (ability to follow instructions)
- Alertness and orientation
- Receptive and expressive language
- Visual perceptual-motor function, hearing
- Physical status (postural stability, respiration)
- Environment
What is the goal of the oral peripheral exam:
Determine range, speed, accuracy of movements and sensation of areas associated with swallowing
List the 9 things assessed during an OPE:
1) Voice and Speech
2) Muscles of facial expression
3) Muscles of Mastication
4) Pathological Reflexes
5) Oral Mucosa
6) Dentition
7) Pharyngeal Palate
8) Tongue
9) Sensation
Do an OPE:
Good Job!
T or F: You typically start a swallowing trial with water
–> puree –> soft –> hard
True
Before feeding a patient ensure that the patient is:
- as upright as possible
- alert and able to focus on the task
- respiration status is not a concern
- not NPO
- allowed to take the item you want to give (allergies)
Who should feed the patient during a swallowing trial?
- if patient can feed themselves assess this
- try hand over hand feeding if needed
- as a last resort do full feeding
Exercise extreme caution during the feeding trial if:
- no laryngeal elevation
- severe dysphonia/ dysarthria
- very weak cough
- drowsy
- severely impaired mental status
- severe pulmonary/ respiratory disorder
During the swallowing trial you look at what three phases?
- oral phase
- pharyngeal phase
- laryngeal phase
Swallowing trial:
What do you look for during the oral phase?
- Tongue ROM
- Lip Closure
- Bolus Control
- Rotary Chewing
Swallowing trial:
What do you look for during the pharyngeal phase?
- laryngeal ROM and rate
- nasal regurgitation
Swallowing trial:
What do you look for during the laryngeal phase?
- Wet phonation/ voice AFTER ingestion of bolus
- coughing or choking
The SLP Clinical assessment findings look at:
- Clinical impressions
- Treatment recommendations
- Follow up plan
Clinical impressions consist of:
- type of dysphagia
- severity of dysphagia
- characteristics of each phase
- safety and efficiency
- factors contributing to presentation
- prognostic indicators
Treatment recommendations consist of:
- oral textures
- compensatory
- exercises
T or F: On FOIS level 7 is the worst
False - level 1
Describe the 7 levels of FOIS:
1 - NPO
2- tube dependent with minimal attempts of food or liquids
3- tube dependent with consistent oral intake of food or liquids
4- total oral diet of a single consistency
5- total oral diet with multiple consistencies but requiring special preparation or compensations
6- total oral diet with multiple consistencies without specials preparation with specific food limitations
7 - oral diet, no restrictions
