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ST. MARY’S MEDICAL CENTER
POLICY AND PROCEDURE MANUAL
Title:
Section:
Approved By:
Care of the Patient with
Dysphagia
Type:
Nursing
Prepared By:
# of Pages:
Jenny Edwards, RN
1 of 4
Policy:
To describe the care of the patient with dysphagia and to reduce the risk of aspiration.
Definitions:
Impaired ability to swallow is a major concern due to the risk of aspiration pneumonia,
difficulty with nutrition and difficulty with the administration of medications. These
issues may cause complications and increase the length of hospital stay. Severe cases of
aspiration pneumonia may be fatal. Aspiration may also be caused by vomiting,
regurgitation, or improper tube placement. Dysphagia may be more severe if brain stem
injury is present.
Signs of potential aspiration include:
 Coughing or choking while eating or drinking
 “Wet” or “gurgly” sounding vocal quality during meals
 Increased congestion after oral intake
 Slowness when eating
 Taking multiple swallows of a single mouthful of food or delay in swallowing
response (holding food in mouth)
 Fatigue or shortness of breath while eating
 Weight loss because of slow eating
 Repetitive bouts of pneumonia
 Drooling, inability to swallow own secretions
 Complaint that foods “get stuck” in throat
 Tearing of the eyes with swallowing (may indicate silent aspiration)
 “Pocketing” food
 Facial weakness or drooping (may accompany swallowing difficulties)
 Weak cough
Objective:
The most common cause of aspiration is impaired swallowing which may be tested by the
dysphagia screen (see form SMMC 17-334). Nursing Dysphagia Screen is indicated upon
admission of all patients who are at high risk for aspiration and have not yet been
screened by Speech Therapy. Patients who may be at high risk for aspiration include:
 All dementia patients
 Stroke
 COPD
 CHF
 Any intubated patient at time of extubation
 Any medical condition related to vocal cords
ST. MARY’S MEDICAL CENTER
POLICY AND PROCEDURE MANUAL
Title:
Care of the Patient with
Dysphagia
Section:
Approved By:




Type:
Nursing
Prepared By:
# of Pages:
Jenny Edwards, RN
2 of 4
Neuromuscular disorders (ALS, Guillian Barré, Myasthenia Gravis)
Aspiration pneumonia suspected or diagnosed
Esophageal disorders
Voiced complaints of difficulty swallowing
Procedure:
I. Overview
 Patient identified as high risk for aspiration will remain NPO until dysphagia
screen is completed.
 Swallow screen will be completed on admission by competency validated
nurse.
 A second swallow evaluation may be required with a status change.
 If screen reveals evidence of dysphagia, maintain NPO and notify physician
for Speech Therapy consult and/or video swallow study.
II. Content
A. Managing Secretions
1. Preferred position is Semi-Fowlers (head of bed at 30 degrees or
greater, unless contraindicated).
2. If management of secretions is a significant problem, have suction setup available at bedside.
3. Perform aggressive oral care and respiratory assessment every four (4)
hours and as needed, to include suctioning of the posterior pharynx.
4. Assess stability and patency of airway.
B. Nutrition
1. Follow feeding/swallowing strategies as recommended by speech
therapy.
2. Based on recommendations of speech therapist, collaborate with
nutritional services to provide appropriate texture and consistency of
food.
3. Conduct ongoing assessment of adequacy of fluid and caloric intake.
4. For meals, position patient upright (90 degrees). Patient should remain
positioned at 90 degrees for 30 minutes after meals.
5. Permit adequate time and verbal prompts for chewing and swallowing.
ST. MARY’S MEDICAL CENTER
POLICY AND PROCEDURE MANUAL
Title:
Care of the Patient with
Dysphagia
Section:
Approved By:
Type:
Nursing
Prepared By:
# of Pages:
Jenny Edwards, RN
3 of 4
6. Check patient’s mouth for pocketing of food or incomplete
swallowing.
7. If feeding tube is present and patient is receiving continuous feedings,
check tube position every four (4) hours and as needed. If patient is
receiving intermittent feedings, check tube position before each
feeding. Note that NG and ND tube feedings are generally not
recommended if gag reflex is absent.
8. If the patient is receiving NG feedings in addition to oral feedings, it
may be helpful to stop tube feedings for 1 to 2 hours prior to oral
feeding to help stimulate the appetite.
9. Consult with occupational therapy if assistive devices are needed to
facilitate feedings.
10. After thorough training, encourage family members/SO to assist with
feeding. Often, a patient will eat more if fed by a family member than
by staff
11. Thicken liquids to appropriate consistency, if needed.
C. Medications
1. If dysphagia is marked, consider alternative routes for PO medications.
2. If oral route for medications is utilized, check patient’s mouth for
pocketing after medication administration.
3. If patient is on thickened liquids, use this consistency when
administering medications.
III. Teaching
A. Teach patient and/or family:
1. to visually check own mouth for pocketing of food
2. appropriate food selections for texture and consistency
3. optimal position for eating
4. suctioning, if needed
5. signs and symptoms of pneumonia (congestion, fever, decreased LOC)
6. to thicken liquids as needed
Documentation:
 Complete dysphagia screen form (SMMC: 17-334) on admission and with any
change in patient status.
 Patient Education form – dysphagia teaching
ST. MARY’S MEDICAL CENTER
POLICY AND PROCEDURE MANUAL
Title:
Care of the Patient with
Dysphagia
Section:
Approved By:
Formed:
Reviewed:
Revised:
Type:
Nursing
Prepared By:
# of Pages:
Jenny Edwards, RN
4 of 4
7/25/07
Policy and Procedure Signoff Pathway
Department/Committee/Personnel
As Appropriate
Vested Department
Vested Department
Vested Department
Forms Committee - Director of HIM
Nurse Practice – Assoc. Director of Nursing
Nurse Managers – Director of Nursing
Policy /Procedure Committee – Director of P&P Committee
Medical Executive Committee – VP of Medical Affairs
Implementation/Education/Rollout Accountability
Approval
Signature
Date