Ch 7 Physical Evaluation

Front 1

Three main Components in physical evaluation

Back 1

Medical History
Physical inspection of the swallow musculature
Observation of swallowing competence with test swallows

Front 2

Logeman’s 5 reasons

Back 2

Define potential cause (medical history)
Establish a working hypothesis that defines disorder
Establish a tentative treatment plan
Develop a potential list of questions that may need further study
Establish the patients readiness to cooperate with any further testing

Front 3

Medical History

Back 3

Prior or current medical records
Conversations with the medical staff
Conversations with patient and family
Patient with intact medical status describing dysphagia symptoms
Stroke?
Endotracheal Tube?
Advanced Directive

Front 4

Congenital Disease

Back 4

Relating to childhood
Relating to neurological disease

Front 5

Neurologic Disease

Back 5

Most common cause of dysphagia
Medical complications from the disease
Side effects from medication (Seizure drugs may effect overall motor performance)

Front 6

Surgical Procedures

Back 6

Endotracheal tube through vocal folds
Aerodigestive or respiratory tract
Fundoplication of LES
Myotomy of UES
Head and neck surgery
Radiation/chemo
Possible X nerve damage from cardiopulmonary surgery, thyroid surgery, upper airway, cervical spine

Front 7

Diabetes

Back 7

systemic metabolic disorder
May affect swallowing, esophageal peristalsis

Front 8

Disturbance in the body’s chemical balance may act

Back 8

2ed on CNS and produce dysphagia
Toxins secondary to medication intolerance
infections

Front 9

list Metabolism disturbances

Back 9

Dehydration
undernutrition
Compromise physical and mental performance

Front 10

Respiratory Impairment common traits with swallowing

Back 10

Respiratory disorders can easily compromise swallowing
COPD
Asthma
Hx of aspiration pneumonia?

Front 11

Esophageal Disease

Back 11

Esophageal motility?
Stenosis of esophageal body?
Enlarged heart compressing esophagus?
GERD/Dialation?

Front 12

Advanced Directive

Back 12

Whether to tube feed if feeding problem is severe

Front 13

Two or more of following features are

Back 13

more predictive of dysphagia than a single marker(Dysphonia, wet sounding voice, dysarthria, secretion management, volitional cough, laryngeal elevation)

Front 14

things to look for in patients for dysphagia

Back 14

Observations of medical interventions that may affect swallowing-Tracheostomy?
Observation of mental status
Observation of Cranial Nerves
Observation of patient, swallowing and feeding during test swallow

Front 15

During trials most important elements include

Back 15

Failure to swallow thin liquids
Wet voice after swallow
Failure to swallow thick liquids
A cough after swallow
A lack of ability to self feed

Front 16

Nasogastric Tube (NG)

Back 16

Inserted through nose to stomach
Available in different sizes, small (Dobhoff) for regular feedings, large for medications
May slow sequence of pharyngeal swallow

Front 17

Gastrostomy (PEG)

Back 17

tube placed in stomach

Front 18

Jejunostomy

Back 18

tube placed in small intestine

Front 19

Intervenous feeding Catheters

Back 19

arm, Hickman in subclavian artery

Front 20

Tracheostomy tubes

Back 20

Need access to lungs to maintain pulmonary toilet
Placed when patient is in respiratory distress
Blocked upper airway post trauma /surgery
May interfere with VF closure and restrict laryngeal elevation
Large 8mm and small 6mm, smaller easier for patient to talk
Inflatable cuff cuts off potential saliva flow to lungs
Fenestrated

Front 21

Fenestrated

Back 21

portal for airflow to VF

Front 22

Respiratory Pattern best if patient is

Back 22

partially weaned from ventilator support before attempting oral feeding
Vital and tidal respiratory capacities should be measured

Front 23

Oxygen saturation levels (SpO2) measures

Back 23

O2 to arterial blood levels

Front 24

below 90% SpO2 may

Back 24

risk for swallowing impairment

Front 25

Declining respiratory capacities in ALS patients are predictive of

Back 25

airway protection disorders

Front 26

what to look for in Mental Status

Back 26

Observation of alerting indication of whether patient will be safe oral ingester
Cooperation of patient
Agitation, confusion, disorientation
Difficult to arouse
Medication effects
Ability to learn

Front 27

Cranial Nerve Examination
Sensory and motor assessment of

Back 27

V, VII, IX, X, XI, XII
Asymmetry, weakness, abnormal movements at rest, abnormal movements during volitional efforts

Front 28

Facial Muscles (VII)

Back 28

At rest and during movement, lip pursing, smiling, closure with effort
Test lower and upper facial muscles to test UMN/LMN involvement

Front 29

Muscles of Mastication (V)

Back 29

Move jaw up/down and laterally
Restrictions may indicate trismus, restriction in the ability to open jaw
Strength of muscles of mastication can be appreciated by palpation as patient bites down

Front 30

Tongue Musculature (XII)

Back 30

Protrude, lateralize, /taka/ rapidly, tongue tip to roof of mouth, protrusion against blade
Inspect for atrophy/fasciculations LMN
Check sensation in reconstructed area
Check for thrush (oral candidacies)

Front 31

Oral Cavity in physical evaluation

Back 31

Look for lesions
Fungal infection (candidiasis) may cause odynophagia, painful swallowing
Xerostomia, dryness may indicate a lack of saliva, moisture, tongue may be reddened with thick secretions
Inspect dentition

Front 32

Fungal infection (candidiasis) may cause

Back 32

odynophagia, painful swallowing

Front 33

Xerostomia, dryness may indicate a lack of

Back 33

saliva, moisture, tongue may be reddened with thick secretions

Front 34

Oropharynx in physical evaluation

Back 34

Velum during rest and phonation (X)
Assess gag and if velum elevated or not, cough elicited? (IX, X)
Presence of gag do not indicate normal swallow
Absence of gag is isolated abnormal finding and may not have significance

Front 35

Pharynx in physical evaluation

Back 35

Activity of pharynx best visualized with endoscopy
May visualize superior pharyngeal constrictor during gag, falcetto voice

Front 36

Larynx IN physical evaluation

Back 36

Listen to phonation/voice quality
Dry swallow under palpation will help to assess laryngeal elevation, should be 2-4 cm

Front 37

test swallow prerequisistes

Back 37

Alert, no significant neuro impairment, swallows secretions with out respiratory compromise

Front 38

Grossly assess swallow response for test swallows

Back 38

Thin to thickened liquids, puddings, items requiring mastication
Volumes at 5-10-ml moving to 20-ml if successful
Make observations of chewing and bolus preparation
Check respiratory rate pre and post swallow, an increase in rate or respiratory congestion can signal airway compromise
Cervical auscultation checks sound of bolus content entering the pharynx and sound of bolus as it leaves pharynx and enters esophagus, followed by respiration

Front 39

Environment for test swallows

Back 39

Bedside feeding data should be gathered for 3 meals, because eating circumstances may change
Avoid distractions such as radio, television, talking, check eyeglasses and dentures

Front 40

Feeding Questions

Back 40

Can patient open containers?
Find food on tray?
Use utensils properly, transport food to mouth?
Feeding rate appropriate?
Bite size appropriate?
Difference in taking liquid by straw and by cup?
Need for special feeding utensils, provided?
Need for dentures, in place, properly fitted?

Front 41

______ posture is best for swallowing

Back 41

upright

Front 42

posture

Back 42

Upright posture is best for swallowing
Can patient maintain upright throughout a meal
If special posture is recommended, observe if this posture is used
With PEG head of bed should be elevated to avoid reflux

Front 43

Eating

Back 43

Diet level should be noted
Soft, puree, mechanical soft, regular
Level appropriate to patient?
Consistency of fluids appropriate or is there a need for thickener?
Which is more difficult, liquids or semisolids?
Does adequate mastication take place?
Does item sit in mouth without attempt to swallow?
Are there choking episodes before, during, or after swallow?
Note amount eaten, time taken to eat a meal
Note changes in respiratory status
Bedside monitors (SpO2)
Audible respiratory distress
Wheezing/difficulty clearing secretions
Feeding assistant may be needed

Front 44

Observation of behavior at beginning and ending of a meal for

Back 44

fatigue, behavioral change, Fatigue may decompensate safe swallow in some patients

Front 45

Cervical auscultation can assist in

Back 45

assessment as can manual manipulation of larynx

Front 46

The Bedside Assessment of Swallowing Safety

Back 46

Computer- based test to regularize clinical evaluation
Examiner assigns scores to various physical parameters physical
Data summarized in a report
Assists clinician in setting treatment goals
Assists in determining whether further lab tests are needed

Front 47

Mann Assessment of swallow ability

Back 47

Has psychometric integrity
Reliability and validity data on 128 first time post stroke patients
Examiner makes judgments of dysphagia and aspiration severity using clinical diagnostic criteria (ordinal risk rating) or adding individual subtest scores and comparing them with subtest sample