Lecture 3 powerpoints Flashcards
What do you do first with a potential dysphagia client?
do a quick screening.
What things do you do in a screening?
3 basic things.
- chart review
- take quick info on signs and symtoms
- do an observation of 3oz water test or a timed swallow test
what are some of the concerns of a screening?
It is not 100% accurate!
_false positives/False negatives further dx treatment is needed
what are the good things about screenings?
quick, its non invasive, low risk and low cost
symtoms of dysphagia?
4 Valleculae hesitation/pooling -base of tongue/epiglottic area -stuck high in throat pyriform pooling -stuck in the middle of the throat (just below larynx UES dysfunction\-pain in upper chest or inches below larynx or stuck in throat/high in chest Aspiration -couching/choking
How many px will have s/a? (silent aspiration?
50%
What do you want to find out during a bedside?
5 things:
1. Hx, Dx, Px's perception
-medical status
-nutitional status
(tube? restrictions?)
-respiratory status (trach or
vent)
2. Oral anatomy - oral mech
- control and function of
labial, lingual, palatal,
pharyngeal, laryngeneal)
3. congitive status (comprehension)
4. Sensory - taste temp texture
5. s/s of swallow attemptsItems for a bedside
9things: laryngeal mirror tongue blades cup spoon straw syringe (for delievery?) Towel/cloth gloves/gown eyewear/mask
What to look for in the chart review and what to ask for at the bedside
Resp. status and history Pnuemonia history (check for fever now) dysphagia history History of pneumonia Nutritional status Medications Physical exam Trial swallows
what to look for in Resp. status and hx
Trach, vent, intubated?? whats the rate at rest? Time saliva swallows and phase respiration Time cough Time breath hold (1 sec, 3 secs, 5 secs) Breathing pattern (nose or mouth)
what to look for in Dysphagia History
Onset? symptoms, Pt awareness, Localization?
What to look for in Nutritional status
Diet type/ duration/ tube? adequacy, complications
Medications complications could be?
some cause decreased alertness, zerostomia, delayed reaction time
After you take in information (interview/chart review) what do you do?
Physical exam (bedside swallow) Test: Oral cavity pharynx laryngeal function/signs respiratory function
During the physical exam, what are the first things you look for?
Anatomy and physiology
What are you looking for when you are examining the anatomy?
Posture and oral exam
what structures are you looking at, and what are you looking for when you are looking at the anatomy during an oral exam?
looking at the :
Lips, hard palate, soft palate, uvula, faucial arches, sulci, teeth and secretions
*you are looking for scarring and/or assymetry
When veiwing physiology, what are you testing for? what does the client do, and why?
You are testing for taste/texture/temp stimuli reactions, checking for Range of motion and functionality
Labial function… what would you do to see if it is working well?
- say /i/ (lip retraction)
- say /u/ (lip rounding)
ddk
-stops and lips around an object (test for lip closure/strenght)
Lingual function…. what would you do to see if its working well?
extension/retraction, corners of mouth, clear sulcus, tip to ridge, behind bottom teeth with open mouth. ddk, alveolar stops rub on palate velar stops for posteror tung
Soft palate
say /a/ -like apple (velum should stay down)
look for palatal reflex and gag reflex
physiologic exam you test for:
Tung function, lip fu\nction, soft palate function, apraxia, and abnormal oral reflexes
what are some abnormal oral reflexes?
Increased gag, tungue thrust and tontic bite
During the laryngeal function exam what do you do/look for in s/s
Look for:
- gurgly voice (penetration)
- hoarsness/breathiness (incomplete glottic closure)
- DDKs (neuro impairment)
- vocal scaling (less senesitivity, SLN fnx, ct m)
- cough strenght/throat cleer
- phonation time (/z/ to /s/ ratio) laryngeal control and resp. function
T or F: you always do a pft test?
PFT = pulminary function test
Falso!! only if warrented
List the PFTs
Spirometry
Manometry
Pneumotachometry
Spirometry
Measures Capacity in FVC and FEV1
manometry
Mreasures strenght In MIP and MEP
T/F you can always do trial swallows in a bedside?
Falso! if acutely ill, low pulmonary function, have a very weak cough, over 80 years old, less cognition, or suspect silent aspiration
What do you use in a beside swallow?
material that is easier for the px to swallow
where can you put your fingers during the bedside?
3 or 4 position on neck
What are you looking for during a bedside?
- reaction to tood
- oral movements (chew/manipulation/propulsion)
- coughing, throat clearing before/during/after
- Secretion levels
- Meal duration and amt
- Resp/swallow coordination
What can you find out from a bedside?
- Best posture for the safest swallow
- Best posture for food in mouth
- Best food consistency
- hypothesis to nature of swallowing disorder
- Recoomendation for a dx
What do you use during a Dx?
Imaging and non imaging tools
List some imaging tools
Videofluoroscopy (xray)
FEES/FEESST/Videoendoscopy
ultrasound/fMRI/PET
Scintigraphy
List some nonimaging tools
EMG
EGG
Acoustics
Manometery
EMG
Measures m. activity
EFF
Measures VF vibration at the TH level
Acousitcs
accelerometer (microphone) or stethoscope to listen
Monometry
Measures pressure
How many, and what are the goals of Videofloroscopy
6:
- Identify normal/abnormal A+p of swallow
- Evaluate airway protection pre/peri or post swalllow
- test efftive postures, maneuvers, bolus modifications and sensory enhancements for improveing swallowing saftey and effiecincy
- provide recommendations for best delivery of food
- choose best techniques
- education for collaborators/refferal souces/caregivers and px
Is MBSS always recommended?
NOO!
When is an MBSS not recommended?
- medically unstable (lethargic/unoriented/agitated/uncccoorapative/ cognitive deficits)
- if cleint doesnt want to change (DNR/chronic diz/end of life sits)
- Px cant be adequately positioned
- client is too large to fit into the imaging room
- allergy to barium (VERY RARE!!
What are some limitations to MBSS?
- barium is unnatural and may effectnatural swallow
- Time constraints do to radiation exposure
- not a true representation of a real meal
- hard to evaluate fatigue efect on swallow
- clients body may refuse the barium
- it is constapating
what are the pros and cons of FEES?
\+Examines A&P before and after swallow \+No radiation exposure \+Exellent view of VFS -No oral stage visible -White out
What does the Ultrasound measure?
\+tongue function \+Oral Transit time \+Hyoid motion - cant image pharynx -Oral stage only
what is an fMRI
Functional Magnetic Resonance Imaging (Neural Basis/Mechanisms
Neural mapping - cortical control
PET
Positron Emission TOmography Neural activity assoc. with motion - had radiation exposure
Scintigraphy
It is highly radioactive with gama rays
Ammount of aspiration residue
Mouth and pharynx not well visualized (cant id dysfunction can dx esophageal (GERD)
