The Diet Rx & Dysphagia Flashcards
dysphagia
Swallowing impairment that occurs as a result of anatomical of physiologic abnormality. Difficulty swallowing food efficiently & safely.
Oral dysphagia
Trouble chewing, keeping food in the mouth or swallowing it out of the mouth. Includes weak tongue, or lip muscles, difficulty propelling food into the throat, difficulty initiating swallow.
pharyngeal dysphagia
Impaired ability to swallow food into the esophagus without leaving any in the throat or letting it get into the airway (aspiration). Delayed reflex, swallow does not clear bolus, aspiration may occur.
esophageal dysphagia
Difficulty swallowing food through the esophagus to the stomach. GERD, stenosis, blockage, strictures.
Causes of dysphagia
CVA, neuromuscular disease, extubation, cancer of head and neck, aging, heart problems, breathing issues, weakened state
presbyphagia
Age related dysphagia
Symptoms of dysphagia
Pocketing, tongue thrusting, facial weakness, slow oral transit, coughing, choking, delayed elevation of larynx, drooling, hoarseness, slurred speech, regurgitation, wt. loss, excessive eating time, aspiration pneumonia
Changes associated w/ aging that can cause dysphagia
Loss of dentition. Reduction of saliva. Reduction of strength of pharyngeal & esophageal peristalsis. Decreased bite force
Normal swallowing requires
Full movement, strength, and coordination of facial muscles, lips, tongue, and throat
Four phases of swallowing
Oral preparation. Oral transit. Pharyngeal transit. Esophageal transit.
Oral preparation
Chewing and preparation of bolus. Food is mixed w/ saliva to form bolus.
Abnormalities of oral prep
Reduced lip or cheek tension. Reduced oral sensation. Reduced tongue movement. Mucositis. Xerostomia. Total glossectomy. Loss of dentition
Oral transit
Bolus propelled to back of throat by tongue. Swallowing reflex is triggered.
Problems with oral transit
Delayed or absent swallow reflex. Reduced coordination during prep for swallow.
Pharyngeal transit phase
Involuntary swallowing reflex, bolus is carried through pharynx to top of esophagus. Larynx closes, soft palate lifts & closes off entrance to nose.
Problems w/ pharyngeal transit
Reduced laryngeal closure. Slowed movement of bolus through pharynx. Decreased laryngeal elevation. Dysfunctional cricopharyngeal flap
Esophageal transit
Esophageal peristalsis carries bolus through esophagus through LES into stomach
Problems w/ esophageal transit
Weakened circopharyngeus. Reduced peristalsis. Esophageal obstruction.
How is dysphagia diagnosed?
Initial bedside swallow evaluation. Fiberoptic endoscopic evaluation of swallow (FEES). Indirect or fiberoptic laryngoscopy. Videofluoroscopic examination.
Who is on the dysphagia team?
Physician. RD. Speech-language pathologist. Nurse. OT. Radiologist.
Dietitian’s role in dysphagia
Choose foods & beverages for nourishment and rehabilitation. Assure nutrition & hydration. Translate physical findings into menus that are acceptable both physically & emotionally.
Level 7 dysphagia
Normal in all situation: normal meal plan, no extra time needed. NDD 4
Level 6 dysphagia
Within functional limits/Modified independence: normal meal plan, functional swallow. May need extra time. No aspiration across consistencies. Spontaneously clears. NDD 4
Level 5 dysphagia
Full PO: modified meal plan &/or independence: Mild dysphagia, distant supervision; may need one meal plan consistency restricted: Clears spontaneously. Aspiration of thin liquids. NDD 4
Level 4 dysphagia
Full PO: Mild-moderate dysphagia, intermittent supervision/cueing; one to two meal plan consistencies restricted: Clears on cue. NDD 3&4
Level 3 dysphagia
Full PO: Moderate dysphagia, total assist, supervision, or strategies; two or more meal plan consistencies restricted: Clears with cue. NDD 2&3
Level 2 dysphagia
Non-oral nutrition needed: Moderately severe dysphagia, maximum assistance, or maximum use of strategies w/ partial PO only: No cough. NDD 1&2
Level 1 dysphagia
Non-oral nutrition needed: Severe dysphagia, NPO, unable to tolerate any PO safely: unable to clear, unable to swallow. NDD 1
What factors may affect thickened liquid viscosity?
Temperature. Continuous hydration of the thickening agent in the pre-thickened liquid. Issues w/ instant thickener continuing to thicken. No consistency across product lines w/in manufactures or between competitors.
What taste will trigger reflex swallowing?
Sour.
The viscosity of thickened liquids is measured in?
centipoise (cP). Thin liquid: 1-50 cP. Nectar-thick liquid: 51-350 cP. Honey-thick liquid: 351-1750 cP. Pudding-thick liquid: >1750 cP
Dysphagia Outcome and Severity Scale (DOSS)
Is the rating scale developed to help determine where to begin in prescribing a nutrition prescription within the NDD textures
What are the primary things to monitor for in dysphagia?
BMI. Blood work may be needed for some patient to access nutriture. Hydration status. Acceptance and nutritional adequacy of the meal plan.
Indications for the clear liquid diet
GI illness, including N/V, diarrhea, abdominal distention. In prep for GI surgery, procedure. To reintroduce foods after NPO when poor tolerance, aspiration, leak are anticipated.
Guidelines for preoperative fasting
Fast from clear liquids for 2 hrs. before procedures requiring general anesthesia. Fast from food for 6 hours before procedures requiring general anesthesia.
Guidelines for patients with diabetes
ADA states that clear liquid diets are inappropriate for diabetic patients. If on a clear diet, diabetics should receive 200g CHO spread throughout the day. Transition to solids should occur as quickly as possible.
Full liquid diet
Includes all foods on the clears + milk and small amounts of fiber. Thin cereals, gruel, strained soups, milkshakes, custard, pudding, juice with pulp.
Indications for Full liquid diet
Short-term use as transition to soft diets following GI surgery.
Contradictions of full liquid diet
Long-term use. Lactose intolerance. For patients who can tolerate solid foods, or can’t tolerate thin liquids.
What does the current literature say about the full liquid diet?
No data supporting its use. Earlier discharge makes use of elaborate post-op diet regimens impractical. Use dysphagia instead as required.
The diet prescription
Designates type, amount, frequency of feeding based on pt’s needs, care goals. May specify kcal goal, may limit of increase various components of the diet.
Modifications that can be made
∆ in consistency. ↑/↓ energy, type of food/nutrient consumed. Eliminate specific foods/components. Adjust ratio of Fat, PRO, CHO. ∆ in #, frequency of meals. ∆ in delivery route of foods.
Is the full liquid diet nutritionally sufficient?
No, may contain adequate energy, fat, and protein. May be inadequate in vitamins, mineral, bioactive substances.
Rational for Level 1 dysphagia diet
Designed for people with moderate to severe dysphagia, with poor oral phase abilities & reduced ability to protect their airway. Close or complete supervision needed, alternate feeding methods may be indicated.
Rational for the Level 2 dysphagia diet
Is a transition from pureed textures to more solid textures. Chewing is necessary. Mild to moderate oral/pharyngeal dysphagia. Assess for tolerance of mixed textures.
Rational for Level 3 dysphagia diet
Transition to regular diet. Chewing is required. Mild oral/pharyngeal dysphagia. Mixed textures must be tolerated.
Common home food thickeners
Powdered milk, potatoes. Instant cereal. Cottage cheese, heavy cream. Bread crumbs. Strained bananas.
