Dysphagia Quiz 2

  1. 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
  2. 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
  3. 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
  4. 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
  5. Order of bedside swallow examination
    • 1. Chart Review
    • 2. Case History
    • 3. Patient Observation
    • 4. Oral-Mech Exam
    • 5. Swallow Examination if appropriate
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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)
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
Card Set
Dysphagia Quiz 2
Bedside Swallow/ Clinical Evaluation