Download Impaired Swallowing

Rehabilitation Nursing
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Aphasia
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Neurological condition
Normal language function absent or disordered
Inability to, in any combination:
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Form/speak words
Read written words
Listen to words read or spoken
Understand words read or spoken
Dysphasia
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Indicates the degree of language difficulty
Does not indicate total inability to communicate
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Agnosia
Total or partial loss of ability to recognize something or
someone familiar
 Perceptual difficulties
 Every sense may be working
 But fails to accurately interpret or recognize what they are
sensing
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Agraphia
Inability to write
 Writing is usually unintelligible words
 May be able to form the letters/words but they mean
nothing
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Alexia
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Inability to understand written words
AKA “word blindness”
Anomia
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Form of aphasia
Inability to name objects
Ability to recognize and
describe object
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Dysarthria
Difficult, poorly spoken speech
 Inability to use and control muscles for speech
 Usually disorder of CNS or peripheral nerve damage
 Important Note!!!!
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How does nurse tell difference?
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Basic Requirements
Levels of Language Production
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#1 Linguistic Competence
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#2 Cognitive Competence
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Appropriate order of sounds(syllables)
Appropriate application of word meaning
#3 Practical or Pragmatic Competence
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Appropriate use or application of words during
speech in plurality and tense
In all situations and social settings
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#1 Autonomic Speech
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Habitual response
#2 Imitation Speech
Copycat speech
 Must have ability to:
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 Hear /Understand the message
 Answer appropriately
 Reminder at this level!!!!
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#3 Symbolic Speech
Most advanced
 Speaks voluntarily
 Follows all language rules
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Specific Language Patterns
Communication Problems
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Normal Speech Center
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Located in the dominate cerebral hemisphere
 Left hemisphere for a right hand dominate
 Right hemisphere for left hand dominate
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Defect in use of language
Any combination of difficulty possible:
Speech
 Reading, Writing
 Understanding
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Can be receptive, expressive or both
AKA Fluent or Non-fluent aphasia
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RT ease or lack of ease in speaking the words
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Knows what to say
Inability to get the words out
Patient will:
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Work hard at trying to talk
Get frustrated while getting words out
May say something they did not mean to say
May have impaired writing or not make sense
Two types of non-fluent Aphasia:
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#1 Broca’s Aphasia
#2 Global Aphasia
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Discovered 1861
French Dr. Pierre Broca
Through autopsies on several patients
who could not talk
Discovered damage to their brains in same
consistent area which is named after him
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Usually from stroke
Occurs in left frontal hemisphere
Reminder of Normal Left frontal hemisphere
responsibilities:
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Imitation of autonomic gestures
Elaboration of thought(development or working out
details)
Ability to produce automatic and willed speech
Syntax
 Appropriate use of words in a sentence or phrase
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Auditory Understanding
Good
 Understands what is said
 If stroke extends…..
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Speech
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Deficits show up
Difficulty starting a conversation (willed speech)
Difficulty in using names
Difficulty with repletion (fluency)
Recognizes when making verbal mistakes
Speech telegraphic and inconsistent
Reminder!!
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Writing
 Writing reflects how they talk
Related impairments:
 Apraxia
 Inability to easily move tongue, mouth or throat
used in speech
 Note:
 Same muscles used in eating
 Can eat, just difficulty with speech
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Damage occurs in frontal area
Great extension of damage leaves little
perception response
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RT little sensory perception is getting to brain and
able to be interpreted
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Auditory understanding
 None
Speech
 Inappropriate word use
 May use automatic speech
 May appear fluent(repletion), but words meaningless
 Use of perseveration or echolalia
 If dysarthria, then speechless
Writing
 Impaired and unintelligible
Reading
 Same as writing
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Ability to easily talk
Problem is spoken words make no sense
Client does not understand:
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Spoken words
Written words
One type of Fluent Aphasia:
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Wernicke’s Aphasia
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Damaged area is left superior temporal area
Major problem is Semantics
Normal Left Temporal brain responsibilities:
Analysis of sensory impulses
 Understand detail
 Recognizes and understands sounds
 Understands language
 Correctly interprets visual information
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Auditory
Impaired
 Does not understand what is heard
 May hear talk, but lost on meaning of words
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Speech
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Speaks fluently
Gives impression they understand what is going on
Most cases, they haven’t got a clue
Speech smooth with normal rhythm, tone, phrase length,
grammar
Abnormal semantics- meaning of words
May use word substitutions
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Writing characteristics
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Reading
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Impaired writing
Impaired
May be impaired understanding of visual
perception
Important note when working with Wernicke’s
Aphasia clients:
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Key is use whole body commands
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Communicating to patient with
Aphasia
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Education level
Developmental level
Native spoken language
Previous speech problems
Any previous sensory perception
issues/corrections
PT assesses physical strength to carry out
commands
Auditory comprehension
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Impaired Verbal Communication
Impaired Social Interaction
Social Isolation
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#1 Find some way to communicate with
patient
#2 Protect/maintain patient’s self-esteem
#3 Listen to them/observe body
language/gestures for clues
#4 Assess for changes
#5 Encourage/Monitor for at least ONE
positive social interaction per day
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Encourage techniques of communication that
should:
Limit frustrations
 Reduce distractions
 Help correct misunderstandings
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Some helpful techniques:
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Treat patient as an adult
Encourage independence in their communication
Build self-esteem by encouraging decision making
Use appropriate eye contact
Keep distractions to a minimum
Consider their level of fatigue
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To help patient understand or comprehend:
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Speak normal tone
Keep communication clear/ brief
Support words with gestures/motions to describe
actions
Use commercial aids(picture boards)
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To help patient to express self and build self
confidence:
Maintain open body language
 Respond to all communication efforts by patient
 Do not finish the patient’s statement for them
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Patient’s without speech need to communicate:
Use picture boards
 Facial expressions
 Computers (Dynawrite)
 I phone App (My voice)
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Impaired Communication
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A problem in forming or articulating words of
speech
RT nerve difficulty
CNS nerve damage
 Peripheral Nerve damage
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Drooling
Chewing motion
Swallowing problems
Important Note:
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Can understand language/speech
Dysarthria seen in many neurological
disorders
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Flaccid
Spastic
Ataxic
Hypokinetic
Hyperkinetic
Mixed
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CN 5= Trigeminal Nerve
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CN 7= Facial Nerve
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Assess gag reflex
Assess ability to speak/cough
CN 12= Hypoglossal Nerve
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Assess symmetry and fatigue!!!
CN 9= Glossopharyngeal Nerve
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Ability to chew/move jaw
Assess tongue for symmetry, size, shape
Paresis causes tongue to protrude toward weak side
Speech/nurses:
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Assess ability of tongue to be coordinated and rhythmic
in movement
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Dysphagia
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Dysphagia
Difficulty with oral prep for swallowing
 Difficulty in moving the material from mouth to
stomach
 Difficulty with pain or discomfort with swallowing
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Bolus
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Deglutition
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Swallowing process by which anything passes from
mouth through pharynx, esophagus to stomach
Ataxic
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Soft mass of chewed food
Collection of saliva
Lack of coordination of muscle action of swallowing
Aspiration
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Inhalation of foreign substance into the lungs
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Required to normally function and work
together:
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Swallow muscles
Swallow nerves
Food must be placed in mouth for process to
begin
There are four stages in the normal process of
swallowing
Note: Difficulty can happen at any of these stages
or a combination of these stages
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Stage 1
Oral Preparatory
Stage 2
Oral(lingual)
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Stage 3
Pharyngeal Stage
Stage 4
Esophageal Stage
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Very fast process
Mouth to top of esophagus:
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Takes less than 2 seconds
Esophagus to stomach:
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Takes 8-20 seconds
Depends on length of esophagus
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Very safe process
Larynx closes as food passes by
Food is moved efficiently from mouth and pharynx:
 Works in sequence
 No food left behind
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If too big a bite at one time
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Swallow takes longer
Mouth and pharynx
 Muscles fail to work in sequence which is normal
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Muscles must work at same time
Often causes patient to hold breath to swallow
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Swallowing changes based on type of food
Some things do not change:
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Safety
Efficiency of swallow
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Any change in LOC
Poor head/neck control
Impaired cough/gag reflex
Using therapeutic devices to eat
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Place patient on Special Feeding Precautions
Customized instructions come from speech
therapy after:
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Assessment of swallow
 Bedside Swallow Evaluation on admission
 Gives safety guidelines immediately until further testing
done
 Barium Swallow Evaluation ASAP
 Assists in detailed discovery of degree of difficulty with
swallowing process and all involved stages
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Assess foods causing symptoms:
Thin liquids
 Milk/nectar
 Certain foods(rice)
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Assess patient’s eating habits(3 day history)
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Speech may come and sit alone with client observing:
 Length of time to eat
 Speed of eating
 Fatigue level
 Cough/gag reflex triggered anytime during meal
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Voice changes(nerve Innervation)
Sleep problems (pharynx)
Any esophageal problems
Cardiac symptoms(chest pain)
Respiratory Symptoms
Current medications
General medical history
Neurological history
Typical family diet
Work history
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Dysphagiagram or Barium Swallow
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Defines specific areas of weakness
Bedside Swallow Evaluation
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Done within 4 hours of admission
NPO until done
Makes recommendation to physiatrist who then gives
diet order
Uses various forms of water/ other food
May attempt use of straw
Observes patient’s response to different consistencies
Notifies OT for necessary adaptive tools
Notifies nursing of safety precautions for eating
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Silent Aspiration
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S&S
Tachycardia
Dyspnea
Cyanosis
HTN
Delayed cough
Possible elevated temperature
101° F with 30 minutes of aspiration
 Gurgled voice
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Aspiration
Shows all the above
 Except has immediate cough
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Considered a protective mechanism of airway
Interventions:
Have client flex at waist or neck
 May help clear airway
 If food lodged, then Heimlich Maneuver appropriate
 Prudent to have portable suction available
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Dysphagia
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Impaired Swallowing
Risk for Aspiration
Nutrition: Less than Body Requirements,
Imbalanced
Deficient Fluid Volume
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#1 Prevent Aspiration
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Staging diet helps improved control and safety over
food bolus
Often these patients are also supplemented through
PEG tube
Food likes/dislikes do not change with dysphagia
Caution: Normal Healthy food intake should take
minimum of 20 minutes, so do not hurry these
individuals with Dysphagia
Change and monitor liquid consistencies
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More texture found in food
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Mashed food with small pieces
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Thin liquids cause most aspiration problems
Liquid consistencies can be changed by adding
thickeners to change consistency
Thickened liquids take a longer time to
swallow. This increases patient’s ability to
control bolus
Warning: Do not mix consistencies! Can cause
patient to choke!
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Added to obtain a safe swallowing consistency
Used until throat muscles are stronger and able
to react faster
Products can be pre-thickened or may need to
add thickener
Thick-it product
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Ensure enough calories intake:
Repair
 Coping with stress of injury
 Coping with exercise activity in PT
 Maintain body weight
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Report any weight changes!
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Ordered by ST
Upright
Head midline
Arms supported on table
Chin tuck with neck flex
Food placed on unaffected side
Lip of cup on client’s lower lip for sipping
Client remains upright for 30-40 minutes after
meal
If in bed, HOB to at least semi-Fowlers position
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Well lighted
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Minimal distractions
TV off
Quiet environment
No talk with mouth full
Mouth care prior to meal
May require one-on-one during meals
Mandatory check tray for diet accuracy
Ensure all required adaptive equipment is used and
protected
Sit down with client
Encourage client to see and smell food
Identify the food placed in patient’s mouth
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Encourage rest prescription prior to mealtime
Coordinate medications to ensure comfort and
safety during mealtime
Check swallowing before giving next bite
ensuring mouth has completely emptied
If changed the diet which requires more
chewing watch closely for fatigue!!!!!!
Allow 30-40 minutes to assist these patient’s
with their meal. DO NOT RUSH!!!
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Patients initially are fed small amounts to
ensure ability to control
Alternate liquid and solid to help empty mouth
Avoid Straws!!!
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May not be able to safely swallow more than
one texture
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Avoid mixing foods
Use pulp free drink
Avoid bland food!
Use thickeners as needed
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Suction machine should be available in dining
room
Client chokes:
Lower chin
 Flex forward at waist
 Heimlich maneuver
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Use lightweight utensils:
Modified built-up handles
 Velcro straps
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Drinking cups
Plate guards
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Promote independence
Cue and coach to swallow before next bite or
swallow
Stroke digastric muscles to encourage swallow
Encourage ST exercises to strengthen involved
muscles
Points to Remember about Medications:
Medications may be given in custard, jelly or blended
fruit gelatin
 Avoid applesauce RT it falls apart during swallow
process
 Reminder to thicken all liquid medications to appropriate
consistency
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What did you learn?
How will you put this into your practice as a
nurse?
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