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30 Cards in this Set
- Front
- Back
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Evaluation
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I. Chart Review
II. Patient interview & observation III. Bedside evaluation (subjective) IV. Instrumental assessment- MBS/FEES (objective) |
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Chart Review
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MD Order
Medical history- admitting diagnosis, previous treatment for dysphagia, medications- sedative, how given Dietary Notes- diebetic, salt restriction Respiratory Status- Rhonchi, RALES, Wheeze Multidisciplinary team notes |
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Signs and symptoms of dysphagia
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Temperature spikes (aspiration pneumonia)
Drooling/increased secretions Weight loss Coughing/choking Pocketing in sulci Pneumonia Changes in diet Patient complaint Dehydration |
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Patient Interview
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Ask for a description of the problem
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Bedside evaluation
Materials |
Gloves, spoons, cups, straws
Ice chips Water Nectar consistency Honey Pureed Solids |
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Bedside Eval
Oral Mech Exam |
Examine for oral cavity structural abnormalities
Dentition (dentures) Strength, ROM & Coordination Jaw function (open/close) Labial function (pucker, smile, /puh/) Lingual function (protrude, retract, elevate, /tuh/ /kuh/) Velar function /a/ Gag reflex (CN 9 & 10) Voluntary swallow (laryngeal elevation) |
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Laryngeal Examination
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Do they have a tracheostomy tube?
Vocal Quality Coughing Throat clearing Pitch range |
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Cognition/Communication
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One- two step directions
Ability to express needs Short term memory |
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Summary of Evaluation Steps
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1. Preassessment (chart, interview, OPM)
2. Respiratory Check (lung sounds pre- and post feeding 3. Position patient 4. Ice chip by spoon *STOP if signs/symptoms of aspiration and or pt medically unstable *Order MBS if indicated |
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Bedside Swallow Evaluation Continued
If stable, continue with trials |
5. Start with spoon, have pt self feed if possible, during trials place hand under ching using the Logemann technique
Assess/Feel for: Tongue mvmt Delay in laryngeal elevation Relative strength and height of laryngeal mvmt Multiple swallows |
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Subjectively assessing laryngeal elevation
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Logemann's Technique:
Index finger under chin, behind mandible Middle finger at hyoid bone Third finger at the top of the thyroid cartilage 4th Finger at bottom of thyroid cartilage Compare time elapsed between initiation of tongue mvmt and initiation of Hyoid and Laryngeal mvmt provides an estimate of OTT & Pharyngeal delay. Also laryngeal strength and height |
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Typical presentation order
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Ice chips
Nectar (spoon, cup, straw) Pudding Solids Liquid (spoon, cup, straw) Present each consistency 3 times |
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Bedside swallow eval cont
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Evaluate Vocal Quality /ah/
Check for oral cavity residue Note delayed coughing/throat clearing Use compensatory strategies if indicated |
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Bedside swallow eval cont
After trials |
Pt remain upright 30 min
Nurse/Respiratory therapist to note changes (temp spikes, wheezing) Report and recommendations (diet, compensatory strategies, exercises, follow up tx) Coordinate with dietician (3 day cal count, oral supplements), other referrals (GI, Neurologist, ENT) Speak to MD for orders (instrumental exam, diet-NPO/PO) |
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When the bedside isn't enough
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FEES
MBS Scintingraphy CT Scan MRI Manometry |
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FEES
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Flexible Endoscopic Eval of Swallowing
Passes trans nasally into the pharynx where the tip of the scope hangs just above the VF in the upper laryngeal vestibule Advantages: comes on a cart so a pt on a ventilator can easily use it, can bring it where ever you want cost less (no radiologist) Disadvantage: White out at moment of swallow residue visable |
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Scintigraphy
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Nuclear Medicine
Radionuclide is mixed into the ingested material and the patient is placed in a supine position under a gamma camera for imaging |
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Computed Tomography - CT
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Cross-sectional imaging technique that uses computer synthesis of x-rays
Not typically used as primary diagnostic tools for oropharyngeal/esophageal problems |
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MRI
Magnetic Resonance Imaging |
Technique that uses a large magnetic field without radiation to create three dimensional images with computer synthesis
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Manometry
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Measurement of pressures with some structure (esophageal sphincter compliance)
Can be used in combination with videofluoroscopy (MBS). This is called videomanometry |
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MBS Contraindications
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Decreased alertness
All oral phase problems Refusal to eat Other medical diagnosis (apraxia, dementia, oral defensiveness, hypersensitive gag) |
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Diet Recommendations
NPO |
Short/Long-term alternate feeding sourceCalorie count (consult dietician regarding all nutritional issues)
Pleasure feeds (can handle small amounts but unable to maintain nutrition) Therapeutic feedings with SLP |
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NPO Considerations
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Inadequate nutrition/hydration via p.o. - pleasure feeds for QOL
Aspiration on all consistencies Maximum cues/strategies needed upon MBS- therapeutic feedings Potential improvement with p.o. intake |
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Alternative Feeding Methods
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A. Nasoenteric
1. NGT Nasogastric Tube 2. Nasoduodenal Tube (Dobhoff) B. Tube Enterostomies 1. Gastrostomy Tube (G-Tube) 2.PEG Tube 3.Jejunostomy (J-Tube) C. Parental 1. Total Parenteral Nutrition (TPN) |
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NGT
Nasogastric tube |
Tube passes through
Nares Nasopharynx Esophagus Stomach Advantages: easily replaced/removed Disadvantages: only for a few weeks or pt can get infections |
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Nasoduodenal Tube (Dobhoff)
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Similar to NGT
Tip goes through stomach into the duodenum or jejunum Adv: Smaller diameter Disadv: short term, done under x-ray |
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G-Tube
Gastrostomy tube |
Surgical procedure where tube is placed in the stomach
Adv: more comfortable than NGT Dis: infection, 3-6 mo |
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PEG Tube
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Same as G-tube but placed under local anesthesia or conscious sedation
Adv: more comfortable than NGT Dis: infection, 3-6 mo |
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J-Tube
Jejunostomy tube |
Surgical procedure where tube is inserted directly into the small intestine
Adv: for pts with severe reflux |
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TPN
Total Parenteral Nutrition |
Intravenous route
Catheter extending through the subclavian vein to the superior vena cava For pts whos gastric system can't handle a tube Disadv: very expensive |
