Dysphagia, Quiz 4

• It is social
• Eating serves two purposes
•     -NUTRITION and HYDRATION
•           To stay healthy
•           To recover from illness or injury
•           To grow
•     -PLEASURE
•           Individual with dysphagia loses the ability to
•           participate in celebration of life or in social gatherings

Eating

• Because:
•     the individual has to THINK about what he/she is doing
•     need to determine if the individual is safe to eat alone

• Communication and swallowing probelems often co-occur - common structures
• It is within our scope of practice

Co-treat with Occupational Therapists

• the patient has clearly stated his/her preference about feeding or other life saving issues
• legal document and MUST be followed
• fist thing you see and everybody abides by

• refers to food, liquid, saliva etc penetrating the layrnx and entering the airway
•     -goes below the vocal folds
•     -food or liquid enters the lungs rather that the stomach
•      after the swallow

• beside clinical assessment
•     first run through and observing carefully

a rounded mass such as a large pill or soft mass of chewed food mixed with saliva

cerebro(head)vascular(bloodvessel) accident- a stroke which is an interruption of blood supply to some area of the brain

• Embolus
• Thrombosis
• Hemorrhagic Strokes
• Aneurysm

• a moving clot (piece of blood clot or a piece of atherosclerotic plaque) from another part of the body that lodges in the artery
• 

• occurs when an artery has gradually filled with plaque
•     -Atheroschlerotic plaque can lead to atherosclerosis
•       which is a hardening of the ateries
•     -80% of strokes
•     -both embolus and thrombosis result in the blockage
•      of an artery to the brain
•     -the blockage/closure leads to anoxia which is a
•       deprivation of oxygen to the area of the brain served by
•       that vessel
•    -infarct is tissue death
•    -Blockage that lasts over 3 min leads to death of
•       brain tissue death. swelling of brain tissue may lead
•       to additional damage
• 

involve bleeding in the brain

• a weakening in the artery that bulges and breaks leading to an interruption of blood flow to areas of the brain served by that vessel
• grows until it bursts
• not detectable until bursts
• killer headache
• 

swallowing

DO NOT RESUSCITATE

difficulty in swallowing or an inability to swallow

• MALNUTRITION or DEHYDRATION
• Individual may avoid eating and drinking

• Fiberoptic Endoscopic Evaluation of Swallowing
• tracking how individual swallows to see if safe to eat alone
• different consistencies tested water, nectar, etc

• a feeding tube that is placed directly into the stomach through an incision
• not safe for indv to swallow

• physician who deals with the gut digestive tract
• beginning and end

a needle placed in a vein used to deliver liquid nutrition or medication

chewing food in preparation for swallowing and digestion

• Modified barium swallow
• radiology suite tracks food and then checks to see where the food sticks

• nasogastric tube
• feeding tube that goes through the nose, through the pharynx and into the stomach
• comes out

noninstrumental clinical exam (BCA)

Neonatal intensive care unit

• NIL PER OS
• Nothing by mouth
• EVERYBODY SHOULD KNOW
• MUST be followed

bolus material enters the larynx BUT remains above the vocal folds

contraction of smooth muscles leading to movement of food through the digestive tract

• residue in btw the cheek and gum or under the tongue
• may have to sweep for indv

• a cough strong enough to expel material from the airway
• can't do it, not safe

• penetration of food or liquid into the larynx and passing below the vocal folds w/o a protective cough or choking occurring
• no indicator

Traumatic Brain Injury

the extenet to which an intervention can be shown to be beneficial under optimal or ideal conditions

the extent to which services are shown to be beneficial under typical conditions

• 1. Anticipatory stage/Oral prep phase
• 2. oral stage/phase - under voluntary control
• 3. pharyngeal stage/phase
• 4. esophageal stage/phase

• involves all of the senses - vision, hearing, touch, smell, taste
•     begins with cognitive level of awareness that food or drink
•       is avaliable to be consumed
•     the next coginitive process is to decided how to bring the
•       food or liquid to the mouth
•     once in the mouth if must be chewed
•       -how we chew
•       -how long we chew
•       -temp of the food
•       -size of the bite
•       -texture and consistency of the bite
• while chewing, we tighten our cheeks to prevent food from
•     lodging btw our gums and cheeks
•     we pull the soft palate down against the base of the
•       tongue to prevent food from falling past the tongue into
•       the open airway
•     we sue our tongue to move food around inside our mouth
•       and btw our teeth to chew
•     the lip or labial seal prevents food/liquid from falling out

• begins when we stop chewing and the tongue tip elevates to touch the alveolar ridge
•     the good is on top of the tongue, the tongue quickly seeps
•       back, pulling the food to the back of the mouth and
•       toward the pharynx
•     the soft palate moves up to make contact with the
•       posterior pharyngeal wall to prevent food from
•       accidentally entering the nasal passage (leading to nasal
•       regurgitation)
•     once food reaches focal pillars, it's all systems go
•     TAKES 1 SEC

• begins when the bolus makes contact w/ the anterior faucial
•     pillars which stimulate the tactile sensation that initiates the
•     swallow response
• four physiological responses occur during the pharyngeal
•     phase:
•           FIRST-the soft palate raises and makes contact with
•                pharyngeal wall to prevent material from entering
•                the nasal passages
•           SECOND-as bolus flows over the base of th tongue,
•                there is a "stripping action" caused by contraction
•                of the pharyngeal constrictor muscles-called
•                peristalisis
•           peristalsis moves the bolus downward
•           simultaneously, muscles elevate (raise) larynx
•          THIRD-the true and false vocal folds adduct tightly
•                providing two more levels of protection
•          FOURTH-the UES (Upper esophageal sphincter)
•               valve relaxes and is pulled open allowing the bolus
•               to enter the esophagus
• TAKES 1 SEC

as the bolus passes the UES (sphincter at the top of the esophagus) the sphincter closes and the peristaltic action of the esophageal muscles carries the bolus to the LES (at the bottom of the esophagus) which briefly opens to allow the bolus to enter the stomach

when the bolus hass passed, the sphincter closes to prevent gastric contents from re-entering the esophagus (a prob here leads to reflux)

TAKES 8-20 SEC

• GERD
• Stenosis-narrowing of pyloric sphincter (bottom of stomach)
• esophageal atresia-the esophagus ends in a lind pouch
• tracheoesophageal fistula-connection btw the esophagus and the tracheal wall
• respiratory disorders
• laryngeal web-failure of the vocal folds to completely separate in utero leaving an anterior web
• asthma
• vocal fold paralysis
• CNS/PNS damage
• Cardiac probs

• can occur at any age
• stroke
• TBI
• Dementia
• Neuromuscular diseases - MS, ALS, MG, Parkinson, MD
• Cancer and treatmens for cancer 
• surgery
• truama
• side effects of meds-dry mouth caused by 300 dif meds
• alcohol
• HIV and AIDS

• hospitals
• physician's offices
• convalescent care facilities
• hospice care
• rehabilitation facilities
• in the home

• SLP/SLPA
• OT
• PT
• Dentist
• dietician
• gastroenterologist
• neurologist
• otolaryngologist
• pulmonologist
• radiologist/radiology tech
• respiratory therapist
• RN.LVN
• Social worker, MFT
• Patient and family

• relevant eating, behavioral, medical info
• swallowing prior to the illness
• foods they like to eat-families sneak food-can be dangerous we need to educate the fam
• rituals of dining
• overal heath status-preexisting conditions
• prior illnesses, trauma, surgeries
• meds
• allergies
• dietary restrictions (kosher?)

• current medical status
• resp status
• esophageal diseases
• prior test results
• meds
• cognitive status
• social and empolyment history
• current delivery of nutrition

• always check advanced directive first
• may just be an interview regarding andy difficulty involved w/ eatingdrinking, taking pills
• experinence coughing or choking before, dureing or after swallowing
• listen for vocal hoarseness after swallowing - gurgly sounds at level of the vocal folds
• assess cognitive functioning and alertness (aware food is in front of them)
• assess resp, phon, reson, and artic systems-safe to swallow

• dysphagia tray
•     -items of varying consistency
•           liquids - regular thin, thickend (nectar), thinkend
•               (honey)
•           pudding
•           cookie/cracker

• Noninstrumental Exam
• Instrumental Assessment
•     -MBS
•     -FEES

• oral motor exercises to strengthen the muscles of the artics (increase muscle tone and strength for swallow)
• positioning
•     chin tuck
•     head rotation - turn head to the weaker side if there is
•         unilateral weakness. this directs food or liquid down the
•         stronger side by closing down the weaker side
•     head tilt-toward stronger side
• cueing step by step directions
• bolus modifications
•     smaller sips
•     smaller bites
• swallowing strategies
•     double or dry swallow>clearing any residual material
•     effortful/hard swallow>tell patient to squeeze hard in the
•         back of the throat during swallow
•     superglottic swallow>forced closure of the VF
•         take breath and hold
•         place small amount of food or liquid in mouth
•         swallow
•         cough to clear the throat while exhaling
•         swallow again
•     Mendelsohn maneuver (manual)
•         food/liquid in mouth
•         chew if needed
•         swallow while placing the thumb and first finder on
•             either side of the larynx. manually hold the larynx in
•             the elevated position for 3-5 sec durein gand after
•             the swallow
•         release the hold on the larynx and relax
•     thermal tactile stimulation-the pharyngeal phase begins
•         when the bolus contacts the anterior faucial pillars
•         triggering the swallow (shock)
•         The SLP strokes the anterior faucail pillar 5X with
•             frozen lemon glycerine swab or a chilled laryngeal
•             mirror before meals and sometimes intermittently
•             during meals to incr sensory awareness

• Same as adult just smaller organs
• Case history/review
• NICE
• Maybe instrumnetal exam
• treatment plan

• eating is social
• eating has emotional significance attached to it, we eat what we enjoy
• patients experience FEAR of choking
• depression
• grief
• embarrasssment-manners, use of utensils, being fed like baby, bib
• sense of loss or sense of self
• agiation-hand wriging, pacing, pulling or rubbing skin
• psychomotor retardation-slowed thinking and body movements
• speech with little or no inflection and low in volume
• fatigue

• spouse or partner feels anxiety, fear, depression, grief, embarrassment, hurt for loved one
• nervous, want to help, afraid of doing it right
• stresses-time energy patience tolerance

• the foods they eat and notavailable in the hospital - or they need to ask
• cultrual rituals of dining
• families sneak food and drink but may be wrong consistency or texture which can lead to aspiration
• families give them food/drink that is not on their diet
• must educate family on what is not safe for patient