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Reasons to get swallow eval referrals
- CVA's: some facilities screen immediately following
- TBI
- Degenerative Disease
- Neuromuscular Disorders: ALS
- COP: risk factor for dyphagia- aspiration
- Intuerrupts inhilation
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Other referral reasons for a swallow evalutation
- Patient complaints:
- a) Globus: vague sensation that something is stuck/ need to swallow constantly
- -trouble with solid foods usually = esophageal NOT pharyngeal
- b) Odynophagia : painful swallow ("it hurts when I swallow)
- * more obvious aspiration symptoms
- c) coughing during meals
- d) weight loss: ask if deliberate!
- e) choking: sensation of being strangled
- f) food comming out of nose: velopharyngeal problems
- g) reflux: indicates espophageal problems
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What is the purpose of the bedside swallow (AKA Clinical Eval) ?
- 1. to determine treatment: Can I fix it? Is it aspiration?
- 2. Provide clinicinicas with information about:
- a) current medical dx, med history, history of swallowing disorder
- b) medical status: vent/trach
- c) pt's oral anatomy: missing parts(H&N cancer)
- d) respiratory function
- e) ability to follow directions
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What is the purpose of the bedside swallow (AKA Clinical Eval) ? (Cont.)
- f) Oral mech purposes:
- - labial control, palatal function, pharyngeal wall contraction, laryngeal control
- * atelectasis: when alveoli collapse/common 2 vent ptg's, lungs not airated
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Order of bedside swallow examination
- 1. Chart Review
- 2. Case History
- 3. Patient Observation
- 4. Oral-Mech Exam
- 5. Swallow Examination if appropriate
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Medical History: Sources of Info- for chart review:
- a) medical records
- b) nursing staff
- c) Family
- * allows you to consider: why is the ptn here before eval, use outside sources not just records
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The Medical Chart Includes:
- a) Medical History
- b) Information on med condititions that may have contributed to dysphagia
- c) list of meds: may be drug induced ( often esophageal/some oral and phayrngeal)
- d) results of previous dysphagia assessment/tx's
- e) lab results: can be helpful- notations on dehydration/malnourished
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Medical Hisotry: Historical Elements
- a) age/gender/ethnic background (some may have increased dysphagia)
- b) neurologic/psychiatric diseases: note!; may have extraneous movment in diadodykinesis rates
- c) Esophageal Disease
- e) Advanced Directive: living will: tube feeding/other life sustaining measures
- f) nutritional status: feeding tubes/malnutrition
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Patient/ Family Interview Components:
- a) Chief Complaint:
- - onset: sometimes an EVENT (such as a TBI/CVA)
- - how disorder has affected life
- b) Problem localization: show point, DON'T PLANT IDEAS
- c) specific foods: do some give you more trouble vs. others?
- d) regurgitation and reflux: more esophageal but we still want to note
- e) respiration
- f) dental complaints: dentures/ shape size of current
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Patient Observations: components
- a) Posture
- b) Alertness Level: person/place/time questions
- c) Presence of trache tube
- d) Presence of feeding tube: some professionals thinks they lead to aspiration
- e) Command following
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Oral Mech Exam Components: oral anatomy
- a) oral anatomy: Function
- - lip/ hard palate configuration
- - soft palate/uvular dimensions
- - lingual configuration
- - dental status
- - handeling of secretions
- * no gag reflex DOES NOT mean higher incidence of dysphagia/aspiration
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Oral Mech Cont. : Oral Motor Control Examination
- a) should examine rate/range/ and accuracy of movements of:
- lips/tongue/soft palate/ pharyngeal walls
* observe during speech, reflexive activity, and swallowing
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Laryngeal Function Examination
- a) sustain /a/
- b) observe presence/strength of voluntary cough: * some think you should have ptn cough at bedside
- c) slide up and down vocal scale
- d) s/z ratios
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Deciding to present trial swallows (with food)
- Logemann says NO if ptn is:
- a) acutely ill
- b) significant pulmonary complications (swallowing not top priority)
- c) weak voluntary cough
- d) is over 80- DR. S DOES NOT AGREE
- e) can't follow directions
- f) suspected of having pharyngeal dysphagia
- * then risk is high and benefit is low
* if ptn can follow directions/cough on command/has good pulmonary function: risk is low, benefit high
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If pt/ is being orally fed note:
- a) reaction to food (observe at meals or bedside: liquid/puree/solid)
- b) Oral movments while chewing/food manipulation: do they pocket? are they aware? can they move tongue?
- c) note ANY coughing/throught clearing/struggeling relative to swallowing and occurance during meal (before/during/ end- fatigue)
- d) drooling: changes in secretions
- e) duration of meal and oral intake: efficient/ how long? / how much?
- f) coordiation of breathing and swallowing
- * NPO: non per os for testing ( nothing by mouth)
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During trial swallows or during meals:
- a) assess hyolayrngeal excursion
- - 4 finger method: index behind mandible (initiation of tonge movement), middle at hyoid (hyoid bone movement), third at top thyriod cartilage/ fourth at bnottom of thyriod cartilage
- * 3rd and 4th can assess laryngeal elevation and triggering of pharyngeal swallow
- **Dr.S notes: hyo-laryngeal escurstion and initiation of pharyngeal swallow "pump of tongue"
- - judged to be adequate: not accurate at bedside
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During trial swallows or during meals: Continued
- a) after swallow ask pt. to say /a/ (vocal quality)
- b) can do: ask pt to turn head to each side and phonate: may squeeze pyriform sinuses into pharynx and cause voice to become gurgly
- c) can do: have pt. lift chin up: causes tongue base to push on valleculae and clear residual material from valleculae
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During trial swallows or during meals: Things to note
- a) presence of coughing: high incediene of silent aspiration (50-60%)
- b) note any changes in respiration: wet/increase in respiratory rate/ shortness of breath
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Signs/Symptoms of Aspiration at Bedside
- Coughing/choking
- Oxygen desaturation: look for pulse drop
- Wet vocal quality/ wet breath sounds post swallow
- sneezing immediately post swallow
- eyes watering after swallowing
- increased respiratory rate after eating
- hiccoughs after eating: stimulation of Vagus Nerve
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Example SOAP after bedside swallow
- S: X rays/ MRIs/ relative to exam
- O: Alert and awake/ results of oral mech, hyolaryngeal, pharyngeal/ overt sighns of aspiration
- * what you gave, how much
- A: signs and symptoms. present with ....
- P: diet rec what kind or other evals/ further assessment such as barium
** We DO NOT rec NPO or type of feeding tubes
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