Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Swallowing Team Speech Safety Department of Learning with Special thanks to Speech Therapy & Rehabilitation Staff at Broward Health Coral Springs for contributing to this learning module. Note: 1 Contact Hour and 1 Stroke Hour Q00501 Information Purpose • To provide information on the basics of dysphagia and aspiration precautions and intervention to promote safety among patients at Broward Health. Contact Hours • This course material is approved for 1 contact hour for: Clinical Social Work, Marriage & Family Therapy & Mental Health Counseling, Nursing, CNA’s, Occupational Therapy, Respiratory Care, Dietetics and Nutrition Outline • Introduction to Dysphagia • Anatomy • Phases of the Swallow • Signs and Symptoms of Dysphagia • Aspiration Precautions • Aspiration Pneumonia • Swallowing Techniques • Dysphagia Diets • Tests and Recommendations • Summary Methodology • This module contains didactic information and a post-test and an evaluation tool Objectives • List the 3 parts of the esophagus • Identify the 4 categories of dysphagia • List types of dysphagia diets • Identify 4 causes of aspiration • Identify 3 swallowing techniques Contact Person • If you have questions, concerns or issues regarding this module, please contact the Regional Clinical Education Department at your facility. Disclaimer • This Self-learning Module is not intended to give the reader details on the specific policies and procedures (P&P) used at Broward Health facilities. • Please refer to your facilities P & P on the Broward Health intranet located in the document library. Introduction to Dysphagia Dysphagia What is Dysphagia? How Does it Happen? • From the Greek word: • The mouth, tongue, and epiglottis play a vital role in the swallowing process. • Dys: Loss of • Phagia: Ability to eat (to swallow) • Dysphagia refers to any disorder in the swallowing process that does not allow food or fluid to pass safely from the mouth to the stomach. • There are various causes that can lead to different types of dysphagia. • If the oral or pharyngeal areas become weak or uncoordinated, there is a risk that food or drink that is swallowed may end up in the lungs rather than the stomach. • This can have serious health consequences. Dysphagia • Oral dysphagia means it takes more time and effort to move food or liquid from your mouth to your stomach. • Pharyngeal dysphagia means there is an impairment in the movement of the epiglottis, larynx, hyoid or posterior pharyngeal wall. • Dysphagia may also be associated with pain (Odynophagia). • In some cases, swallowing may be impossible. • But persistent dysphagia may indicate a serious medical condition requiring treatment. • Occasional difficulty swallowing, which may occur when you eat too fast or don't chew your food well enough, usually isn't cause for concern. • Dysphagia can occur at any age, but it's more common in older adults. • The causes of swallowing problems vary, and treatment depends on the cause. Worldwide Prevalence • Dysphagia is generally a sign of underlying diseases that can be associated with varied diagnoses. • Neurological disorders, cancer and age-related physiologic changes are the major primary diagnosis associated with swallowing difficulties. Prevalence Worldwide 35 - 50% Stroke Patients 5.6-8 mio patients 80% Alzheimer Patients +/- 19.2 mio patients 50% Parkinson Patients 3.2 mio patients 33-40% Multiple Sclerosis Patients 0.8-1 mio patients 44 -51% Cancer: Head & Neck +/- 0.25 mio patients 40-50% Elderly Population Hospital (12-49%) • mio = minimally invasive oesophagestomy Nursing Home (32-51%) Community (15%) Terminology Mastication • The process of chewing by which the teeth and tongue work together to break down food to form a bolus. Bolus • The collected and shaped body of food which has been chewed and chemically processed by enzymes prior to being swallowed Pocketing • Food sticks between the cheek and the teeth/gums after the swallow Residue • Some food or liquid remains in the mouth or the throat after the swallow Terminology (Continued) Penetration • The Process in which food or liquids enters the larynx but does not become inhaled into the lungs. These foreign substances are ejected from the laryngeal area Aspiration • The inhalation of food, liquid, or other foreign matter into the lungs Silent Aspiration • Patient does not cough when aspiration occurs Peristalsis • The wave like motion which conducts the bolus through the oral, pharyngeal, and esophageal structures Swallowing Trivia • The swallow mechanism is innervated by 7 pairs of nerves and 26 muscle groups • We swallow more than 600 times each day • We swallow about once every minute while asleep • Of the 2 palates, which is able to move, hard or soft? • The hard palate contains bone and cannot move. The soft palate, which contains the uvula, has no bone and consists of muscle fibers. The levator of the soft palate elevates to seal off the nasal cavity from the oral cavity, and is innervated by the pharyngeal plexus of the vagus (X) nerve. The tensor muscle contracts to make the soft palate stiff, and is innervated by the mandibular branch of the trigeminal nerve (V3). • Is swallowing Voluntary or Involuntary? • While swallowing is very difficult to stop when started, thus appearing to be an autonomic action, it is actually voluntary. All the muscles involved are striated voluntary muscle. Initiation of the swallow is voluntary as you can swallow when there is not food in your mouth. However, the peristalsis movement of the esophagus is involuntary as it is initiated when the bolus reaches the UES at the end of the pharyngeal phase. Anatomy Introduction Understanding the Anatomy • The mouth and throat are made up of a many different parts. The esophagus is a muscular tube that carries food and liquids from the throat into the stomach. • It is located behind the breathing tube (trachea, or windpipe). • The esophagus is divided into three parts, going from the top to the bottom: the cervical/proximal esophagus, thoracic/medial esophagus and abdominal/distal esophagus. Anatomy of the Mouth Anatomy of the Esophagus 3 Parts to the Esophagus • Cervical/Proximal esophagus: This part of the esophagus begins at the upper esophageal sphincter (UES). It lies approximately at the level of the 6th cervical vertebra (C6) and extends to the 5th thoracic vertebra (T5). • Thoracic/Medial esophagus: This part of the esophagus extends from the 5th thoracic vertebra (T5) to the 10th thoracic vertebra (T10). • Abdominal/Distal esophagus: This part of the esophagus extends from the esophagus/gastric (GE) junction, which is about the level of the xiphoid process. Phases of the Swallow Normal Swallowing Lateral view of bolus propulsion during swallowing: Phases of a Normal Swallow • Swallowing is complex, and a number of conditions can interfere with this process. • Sometimes the cause of dysphagia can't be identified. However, dysphagia generally falls into one of the following phases: Oral Preparatory Food is broken down by chewing and mashing with tongue and exposure to enzymes in saliva which creates a bolus. Oral Bolus is propelled posteriorly by tongue to reach anterior faucial pillars, which triggers the swallow reflex Pharyngeal Vocal folds close, epiglottis inverts to cover air way, and bolus travels over base of tongue to vallecule and then the pyriform sinuses. Esophageal Food travels down esophagus through the means of peristalsis and enters stomach Difficulties that Can Occur During the Swallow Oropharyngeal • Difficulties with the passage of the food bolus from oral cavity to cervical esophagus. Possible causes of Oropharyngeal Dysphagia include: Neurological Disorders • Certain conditions can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus when you start to swallow. Certain disorders, such as multiple sclerosis, muscular dystrophy and Parkinson Disease. Neurological Damage • You may choke, gag or cough when you try to swallow or have the sensation of food or fluids going down your trachea (windpipe) or up your nose. Sudden neurological damage, such as from a stroke, traumatic brain injury (TBI), Amyotropic Lateral Sclerosis (ALS) or spinal cord injury. Pharyngeal Diverticula A small pouch that forms and collects food particles in the throat, often in cervical/proximal esophagus, leads to difficulty swallowing, bad breath and repeated throat clearing or coughing. Cancer Certain cancers and some cancer treatments, such as radiation. • This may lead to pneumonia. Difficulties that Can Occur During the Swallow Esophageal Dysphagia • Esophageal dysphagia refers to the sensation of food sticking or getting stuck in the base of your throat or in your chest after you've started to swallow. • Some of the causes of esophageal dysphagia include: Achalasia • When the lower esophygeal muscle (sphincter) doesn’t relax properly to let food enter the stomach, it may cause food to back up into the throat. • Muscles in the wall of the esophagus may be weak, which worsens over time. Diffuse Spasm • This condition produces multiple high-pressure, poorly coordinated contractions of the esophagus, usually after swallowing. • Affects the involuntary muscles in the walls of the lower esophagus. Esophageal Stricture • A narrowed esophagus (stricture) can trap large pieces of food. Esophageal Tumor • Difficulty swallowing tends to get progressively worse when esophageal tumors are present. Esophageal Ring • A thin area of narrowing in the lower esophagus can intermittently cause difficulty swallowing solid foods. • Tumors or scar tissue, often caused by gastroesophageal reflux disease (GERD), can cause narrowing. Difficulties that Can Occur During the Swallow Esophageal Dysphagia (cont.) • Some of the causes of esophageal dysphagia include: Eosinophilic Esophagitis • This condition, which may be related to a food allergy, is caused by an overpopulation of cells; eosinophils in the esophagus Foreign Bodies • Food or other objects can partially or completely block your throat or esophagus. • Older adults with dentures and patients who have difficulty chewing their food may be more likely to have a piece of food lodged in the throat or esophagus Gastroesophageal Reflex Disease (GERD) • Damage to esophageal tissues from stomach acid backing up into the esophagus can lead to spasm or scarring and narrowing of the lower esophagus Radiation Therapy • This cancer treatment can lead to inflammation and scarring of the esophagus. Scleroderma • Development of scar-like tissue, causing stiffening and hardening of tissues, can weaken the lower esophageal sphincter, allowing acid to back up into the esophagus and cause frequent heartburn. Signs and Symptoms of Dysphagia Signs and Symptoms of Dysphagia Signs and symptoms associated with dysphagia may include: • Hoarse vocal quality • Difficulty swallow Signs • Bringing food back up (regurgitation) • Coughing or gagging when swallowing • Drooling Symptoms • Food or stomach acid back up into your throat • Frequent heartburn • Pain while swallowing (odynophagia) • The sensation of food getting stuck in your throat or chest or behind your breastbone (sternum) • Cutting food into smaller pieces or avoiding certain foods because of trouble swallowing • Unexpectedly losing weight Risk Factors The following are Risk Factors for Dysphagia: • Aging • Due to natural aging oral, pharyngeal and esophageal musculature become weakened. • Elderly patients are at greater risk of certain conditions, such as stroke or Parkinson's disease. Older adults are at higher risk of swallowing difficulties. • Certain health conditions • Patients at any age with certain neurological or nervous system disorders are more likely to experience difficulty swallowing. Complications Difficulty Swallowing can Lead to: • Malnutrition, weight loss and dehydration • Dysphagia can lead to inadequate nourishment and hydration. • Respiratory problems • Food or liquid entering your airway when you try to swallow can cause respiratory problems, such as aspiration pneumonia or upper respiratory infections. • 25-30% of patients with dysphagia are “silent aspirators” • Patients who silently aspirate are at greater risk for aspiration pneumonia • In the elderly with dysphagia those who have silent aspiration have a higher mortality rate Dysphagia Consequences Many patients with dysphagia go unrecognized or undiagnosed until a major event such as aspiration pneumonia occurs. Dysphagia Consequences The Vicious Cycle Aspiration Pneumonia Aspiration Pneumonia Aspiration pneumonia can occur when: • Inhalation food, drink or vomit into your lungs. • Poor oral hygiene resulting in bacteria in the saliva • A patient has a weakened immune system in combination with other risk factors • Something disturbs your normal swallow function, such as a brain injury, stroke, swallowing problem • Excessive use of alcohol or drugs. Aspiration Pneumonia Causes • Aging • Anesthesia • Coma • Dental problems • Esophageal disorders • Ingesting large amounts of alcohol • Reduced levels of alertness • Sedatives • Swallowing problems Only air should enter the lungs. Inhaling food, liquids, etc. may accidentally get into the airway and then further into the lungs. It can cause an irritation and swelling in the lungs and bacteria may grow . Who is at Risk? • The highest risk of this condition is seen in elderly individuals with a history of any of the following: • Stroke • Neurologic diagnoses • Seizures • Dental problems/poor oral hygiene • Lung disease • Patients requiring feeding assistance. Aspiration Pneumonia Symptoms Diagnosed by: • Symptoms of this condition are similar to other types of pneumonia. They include: • Bad breath • Blue discoloration of the skin • Chest pain • Cough, possibly with green sputum, blood, pus or a foul odor • Difficulty swallowing • Excessive sweating • Fatigue • Shortness of breath • Wheezing • Prompt treatment can make a significant difference in recovery. • Swallowing evaluation/Modified Barium Swallow • Arterial blood gas • Blood culture • Bronchoscopy • Chest x-ray • Complete blood count (CBC) • CT scan of chest • Sputum culture Aspiration Pneumonia Treated • Treatment depends on the severity of the pneumonia If treatment is acquired quickly, this condition rarely causes complications. • The overall prognosis depends on: • Generally, the first line of treatment is antibiotics • How much of your lungs have been affected • Choosing the right antibiotic can be difficult. The bacteria that causes this condition may be hard to identify • The type of bacteria causing the infection • Note: patients with trouble swallowing may need alternate means of nutrition • The severity of the pneumonia Without correct treatment or late treatment, pneumonia can cause long-term problems. • Lung abscess and inflammatory problems may occur. • Some patients will develop acute respiratory failure, which could be fatal. Tests and Diagnosis Tests & Diagnosis Tests and Diagnosis: Barium Swallow (X-ray of the esophagus with contrast material) • A barium solution coats the esophagus, allowing a better view on x-ray, e.g. shape and muscular activity Video Swallow/Modified Barium Swallow • Swallow barium-coated foods of different consistencies. • This provides an image as the food travels through the mouth and esophagus. Endoscopy • A thin, flexible lighted instrument (endoscope) is passed down your throat to view the esophagus. Esophageal Muscle Test (Manometry) • A small tube is inserted into the esophagus and connected to a pressure recorder to measure the muscle contractions of the esophagus when swallowing. Fiber-optic endoscopic evaluation of swallowing (FEES) • Examination of the pharyngeal and esophageal areas with a special camera (endoscope) and lighted tube when swallowing. Imaging Scans • These may include CT scan which combines a series of x-ray views and computer processing to create cross-sectional images of the body's bones and soft tissues; • MRI scan which uses a magnetic field and radio waves to create detailed images or organs and tissues • Positron Emission Tomography (PET) san which uses a radioactive drug (tracer) to show how the tissue and organs are functioning. Tests & Treatments Tests & Treatments • Treatment for dysphagia depends on the type or cause of the swallowing disorder Oropharyngeal Dysphagia • May be referred to a speech-language pathologist • Therapy may include: • Exercises - certain exercises may help coordinate swallowing muscles to re-stimulate the nerves that trigger the swallowing reflex. • Learning Swallowing Techniques - Learn how to place food in your mouth or to position your body and head to help you swallow Esophageal Dysphagia • Treatment approaches for esophageal dysphagia may include: • Esophageal Dilation - for a tight esophageal sphincter (achalasia) or an esophageal stricture an endoscope with a special balloon attached to gently stretch and expand the width of the esophagus or pass a flexible tube to stretch the esophagus (dilatation) • Surgery - For an esophageal tumor, achalasia or pharyngeal diverticula surgery may be necessary to clear the esophageal path. • Medications - Difficulty swallowing associated with Gastroesophageal Reflux Disease (GERD) can be treated with prescription oral medications to reduce stomach acid. These medications may need to be taken for an extended period of time. Severe Dysphagia • If difficulty swallowing prevents you from eating and drinking adequately the following may be recommended: • Feeding Tube - In severe cases a feeding tube inserted directly into the stomach will bypass the part of your swallowing mechanism that isn’t working normally. Tracheostomy What is a Tracheostomy? • A tracheostomy is a procedure to create an opening through the neck into the trachea. • This allows direct access to the windpipe and the patient now breaths directly with the tracheostomy tube rather than through their nose or mouth. • When a new tracheostomy is placed, a SLP will often be ordered to evaluate the patient’s ability to safely swallow. • Patients with existing tracheostomies, where the patient has been eating and shows no signs or symptoms of aspiration, generally do not need to be seen by a SLP. Aspiration Precautions Aspiration Precautions General Guidelines to Prevent Dysphagia General Guidelines to Prevent Aspiration • Although swallowing difficulties can't be prevented, you can reduce your risk of dysphagia by eating slowly and chewing your food well. • Feed small amounts of food. • Early detection and effective treatment of GERD can lower your risk of developing dysphagia. • Provide oral care before and after meals. • Seat patient fully upright • Do not force feed. • Never put food or fluids in the mouth of a patient who is not fully alert. • Crush pills and put them in soft food such as pudding or applesauce. • Some pills should not be crushed, check with pharmacist or physician before crushing any pills. Prevention (cont.) As a caregiver to someone who may aspirate, the following are some general guidelines: Caring for someone who can eat and drink orally: • Seat the patient in an upright position when eating or drinking, such as Sitting up in a chair • If the patient is unable to sit in a chair, position the patient in bed so they are upright • Keep the patient sitting upright for 30 - 45 minutes after eating to reduce the risk of aspirating residue and/or reflux management • Remind the patient to eat slowly and chew well • Do Not distract the patient • This is especially important for patients with cognitive problems. • Check the patient’s mouth for leftover/pocketed food after eating • Do Not serve food or drink for at least 2 hours before bedtime Caring for someone who has a feeding tube; or cannot eat or drink through their mouth: • Keep the patient in an upright position as much as possible • Do Not lay the patient flat if they are getting continuous feedings • Turn the feeding tube off if you need to lay the patient flat for any reason • Check feeding tube residuals as directed by healthcare provider. • If a large amount of tube feeding is aspirated, the healthcare provider should be notified as soon as possible. Sitting Upright Remember what 90 degrees looks like! Oral Care: What, When & How What? When? How? • Antiseptic oral rinse, e.g. Scope • Most importantly before breakfast • Upright or nearly upright position • Mouth Moistener • Before and after every meal • Pen Light • Before water if patient is on Free Water Protocol • Visually inspect with pen light (remove dentures) • Suction toothbrushes & sponges • Toothbrushes • Toothettes • Toothpaste • Every 2 - 4 hours for NPO patients (including intubated/ventilated patients) • Soft toothbrush and fluoride toothpaste • Clean all surfaces (teeth, gums, palate & tongue) • Rinse with antiseptic mouthwash (Scope) • Mouth moistener, if needed • Suction toothbrushes are available for patients who are NPO Oral Care: Do’s Special Considerations: • Oral care is more important than ever! • Dentures • Brush with non-abrasive gel paste. At night soak for 15 minutes in denture cleaning product. Rinse and store overnight in water. • Edentulous/Intubated/Ventilated patients • If the patient has adequate oral control and ability to spit… • Proceed as usual with head positioned over sink to avoid swallowing • If a patient with inadequate oral control… • Hang head over sink • Toothette with alcohol free antibacterial oral rinse. Brush tongue with toothbrush • Suction toothbrush as necessary • Use suction toothbrush/sponge and antibacterial oral rinse (Scope) • Rinse with dry toothette or gauze • Small amount of toothpaste • Optimize bacterial prevention with mouthwash. Oral Care: Don’ts Oral Care “Don’ts” • Don’t use toothettes to clean teeth, they don’t remove plaque • Don’t use toothettes with water only, does not remove bacteria • Don’t assume the mouth is clean without looking Swallowing Techniques Swallowing Techniques Swallowing may seem like a simple task, since it is typically automatic, however, it is actually complex, involving varied nerves and muscles. Swallowing Techniques • The appropriate swallow techniques will be determined by the Speech Language Pathologist (SLP) following the results of the Swallow Evaluation. • The following section describes some of the most common swallow techniques that you may see at the patient’s bedside. Common Swallow Techniques • Multiple Swallows • The patient is instructed to swallow 2 times before taking the next bite or sip • This technique helps clear any food or liquid residue which may remain in the throat • Alternate Liquids and Solids • Cue the patient to take a bite • When it has been completely swallowed, next have them take a sip, and repeat • This technique clears food residues that may be left in the oral cavity or throat. Swallowing Techniques Common Swallow Techniques (cont.) • Effortful Swallow • The patient is instructed to swallow “hard” as if swallowing a pill or something dry • This technique is helpful for patients who have weakened pharyngeal musculature • Swallow-Cough-Swallow • The patient is cued to swallow the bite then cough voluntarily then swallow again. • This technique helps to prevent food or liquids from going into the trachea “wrong pipe” • Chin Tuck • The patient is instructed to tuck the chin close to chest before the swallow and keeps chin down until finished swallowing • This technique reduces chance of aspiration for some patients; however, Chin Tuck does not help all patients Seek Immediate Care In assessing aspiration precautions in people outside the hospital setting, seek immediate medical care if any of the following occur. If the patient has: • Trouble breathing or starts to breathe rapidly • Breathing very slow or stops breathing • Significant coughing after eating or drinking • Coughs up thick, yellow or tan sputum • Fever or persistent symptoms for more than 72 hours • Fever and their symptoms suddenly get worse Dysphagia Diets Dysphagia Diet Diet Indication Description Level I Severe dysphagia • Thick liquids (Most Restricted) • Patients just beginning to eat by mouth • Decreased fiber • Unable to safely: Level II • Swallow chewable foods • Safely drink thin liquids Moderate dysphagia • • Can tolerate minimal easily chewed foods Cannot swallow thin liquids safely • No coarse textures, nuts, raw fruits or vegetables • Medications must be crushed and mixed with pureed foods • Thickened liquids with thickener as needed • Nectar or honey thick liquids • Decreased fiber. No bread products or rice • No coarse textures, nuts, raw fruits or vegetables • Medications may need to be crushed in puree foods or in liquid form Dysphagia Diet Diet Level III Rule of Thumb: Should be soft enough to mash with a fork. Level IV (Least Restricted) Indication • Difficulty chewing, manipulating or swallowing foods Description • Mechanically soft • Pasta or Soup • No tough skins • Patients beginning to chew • No nuts, or dry, crispy, raw or stringy foods • Meats need to be minced or cut into small pieces • patients chewing soft textures, swallow liquids safely • Liquids as tolerated, thicken liquids may still be necessary • Medications may need to be crushed in pureed foods or in liquid form • Soft textures that do not require grinding, chopping • No nuts, no raw, crisp or deep fried foods • Medications and liquids as tolerated Diet Restriction Options No Mixed Consistency = Thin Liquid + Solid • Any food that has both a thin liquid part and a solid part (can be an exclusion on any type/level diet), examples: • Vegetable soup • Broth = thin liquid; Vegetables = solid • Cold cereal • Milk = thin liquid; Cereal = solid Note: It is more difficult to manage thin liquids and solids at the same time. Liquid Consistencies Thickest to Thinnest • Honey Thick Liquids • Similar consistency to honey or thick syrup • Nectar Thick Liquids • Similar consistency to buttermilk or tomato juice • Thin Liquids • Regular liquids • No modifications needed Thickened Liquids • Hydration is critical to overall good health of patients with dysphagia • Proper consistency and adequate consumption are key factors in promoting safe hydration for your patients Liquid Consistencies Pre-thickened Liquids • Includes: • Fruit Juice • Dairy item • Advantages Powered Thickeners • Available to thicken other liquids Thin Liquids • In addition to beverages, other items are considered to be a “Thin Liquid” because they become liquid at body temperature: • No mixing required • Ice chips • They are exactly the correct thickness and do not continue to thicken as they sit • Ice cream & Sherbet • Jello What’s Wrong with this Picture? • On this tray there is a nectar thick drink, as well as, a soup which contains a thin liquid. • Normally, these won’t occur on the same tray. • But, it’s always important to double-check for diet restrictions/modifications before feeding any patient. Always Check the Diet Order • Always compare the items on the tray with information on the Swallowing Precautions Sign. • Look specifically for both liquid and diet texture • Look for service instructions such as: • No Straws • Liquids by Spoon Only • Feeding assistance • 1:1 Feeding vs 1:1 Cueing (Prompting the Patient) • If the tray and orders/precaution sign don’t match, do not feed the patient until tray corrected, notify the RN/Speech therapist Conclusion • Dysphagia is a serious condition that requires clinical screening and treatment. • Treatment involves speech therapy treatment and/or diet and liquid modifications. • Swallowing techniques • Team Communication is essential • The National Dysphagia Diet provides specific dietary guidelines to reduce risk of complications from dysphagia Recommendations Lifestyle Modifications Lifestyle Modifications If you have trouble swallowing, be sure to see a doctor and follow their advice. Also, some things you can try to help ease your symptoms include: • Changing your eating habits. Try eating smaller, morefrequent meals. Be sure to cut your food into smaller pieces and eat more slowly. • Trying foods with different textures to see if some cause you more trouble. Thin liquids, such as coffee and juice, are a problem for some people, and sticky foods, such as peanut butter or caramel, can make swallowing difficult. Avoid foods that cause you trouble. • Avoiding alcohol, tobacco and caffeine. These can make heartburn worse. Recommendations for Feeding Patients Recommendations for feeding/assisting patients to eat: • Carefully observe the patient to make sure they have swallowed before taking the next bite or drink. Note: • An empty mouth does not mean the patient has swallowed. • It only means the food/drink is no longer in the mouth • The larynx (Adam’s apple ) should rise and fall during a swallow, which you may be able to feel or see. Recommendations for Feeding Patients STOP feeding the patient and inform the RN if: • You aren’t sure if the patient is swallowing • The patient can’t stay awake • The patient shows signs and symptoms of aspiration When helping patients to eat or drink, be aware of the following: • Rate - Go Slow!!!! • Amount - Small bites and sips • Swallows - Watch/Feel for the Larynx (Adam’s apple) to go up & down Recommendations for Feeding Patients cont. Recommendations for feeding/assisting patients to eat: If the patient needs supervision and/or assistance with oral intake: • Know whether or not the patient wears full or partial dentures and if they are in place • Never leave food or drink within their reach or sight • Always have dentures/partials soaking in water or cleaning solution in a labeled denture cup • If left dry, dentures can change shape and become unusable Note: • When not in use, remove partial dentures, since they can be a choking risk! Summary • If you have any concerns regarding the swallowing safety of any patients always discuss with the RN and SLP. • If a swallow evaluation is needed, an order needs to be obtained from a physician. • A SLP will evaluate the patient and provide recommendations and treatment options. • By understanding and following the SLP recommendations regarding diet, swallow techniques and precautions you are: • Helping your patients remain: • Comfortable • Free of aspiration / pneumonia • Hydrated • Nourished Bibliography/References/Websites American Speech-Language-Hearing Association http://www.asha.org/ St. Johns Healthcare, Dysphagia Diets & How to Keep Patients Safe from Aspiration, 2012 Getting a Handle on Aspiration Pneumonia, 2013 www.healthline.com The Mayo Clinic www.Mayoclinic.com The website is owned by the Mayo Foundation for Medical Education and Research. The Mayo clinic mission is to empower people to manage their health. The website offers useful and up-to-date information and tools on a wide variety of health topics. Website includes information on difficulty swallowing. MedLine Plus www.nlm.nih.gov/medlineplus A service of the United States National Library of Medicine and the National Institutes of Health, MedlinePlus brings together authoritative information from the National Institutes of Health (NIH), and other government agencies and health-related organizations. Information about Swallowing difficulty is on the web site. The Ohio State University Medical Center Patient Education Materials http://medicalcenter.osu.edu/patientcare/patient_education The patient education web site has information about dysphagia . Dysphagia and Aspiration Precautions Self-assessment - January, 2015 1. The esophagus is located behind which structure: a. Trachea b. Right bronchi c. Left Bronchi d. Aorta 2. Which of the following are components of the 3 parts of the esophagus: a. Cervical/proximal b. Thoracic/medial c. Abdominal/distal d. All of the above 3. Which of the following statements are correct relating to the anatomy of the esophagus: a. In front of the cervical esophagus is the trachea b. Beside the cervical are the structures in the carotid sheath c. The thyroid gland curves around from the front of the neck and can sit beside the cervical esophagus d. All of the above 4. In this phase of a normal swallow Food is broken down by chewing and mashing with tongue and exposure to enzymes in saliva which creates a bolus. a. Oral Preparatory b. Oral c. Pharyngeal d. Esophageal 5. Food reamins between the cheek and the teeth/gums after the swallowing process is called: a. Silent Aspiration b. Pocketing c. Residue d. Palates 6. Which of the following facts related to swallowing are correct: a. The swallowing mechanism is innervated by 7 pairs of nerves and 28 muscle groups b. The average person swallows more than 600 times each day and once every minute while sleeping c. While swallowing is very difficult o stop when started, thus appearing to be an autonomic action, it is actually voluntary d. All of the above 7. Dysphagia refers to any disorder in the swallowing process that does not allow food or liquid to pass safely from which of the following: a. Mouth to cervical esophagus b. Mouth to thoracic esophagus c. Mouth to abdominal esophagus d. Mouth to stomach 8. According to worldwide prevalence, the major primary diagnosis associated with swallowing difficulties include which of the following: a. Neurological disorders b. Cancer c. Age-related physiologic changes d. All of the above 9. Which of the following statements related to dysphagia are correct: a. May be associated with pain and in some cases swallowing may be impossible b. Occasional dysphagia usually isn’t cause for concern; but persistent dysphagia may indicate a serious medical condition requiring treatment c. Dysphagia can occur at any age; but usually in older adults; Treatment depends on the cause of swallowing difficulty d. All of the above Self-assessment_Dysphagia & Aspiration Precautions_012115 10. Oropharyngeal dysphagia can be caused by many disorders including which of the following: a. Neurological disorders, e.g. Parkinson’s, Muscular Sclerosis, Muscular Dystrophy b. Neurological Damage, e.g. Stroke, Brain or Spinal Cord Injury c. Esophageal Diverticula, e.g. Pouches that form and collect food in the esophagus; Cancer d. All of the above 11. Which of the following are causes of esophageal dysphagia: a. Diffuse spasms; GERD; Foreign body b. Esophageal stricture; Esophageal ring c. Esophageal tumor; Radiation therapy d. All of the above 12. Which of the following are considered signs and symptoms of dysphagia: a. Being hoarse; unable to swallow b. Chronic coughing or gagging when swallowing; drooling c. Frequent heartburn; Unexpected loss of weight d. All of the above 13. Dysphagia may lead to which of the following complications: a. Malnutrition b. Dehydration c. Weight loss d. All of the above 14. Which of the following tests may be used to determine the diagnosis and degree of dysphagia: a. Barium Swallow (X-ray with contrast material); Modified Barium Swallow Study b. Endoscopy; Esophageal Muscle Test c. Fiber-optic Endoscopic Evaluation of Swallowing (FEES); Imaging Scans d. All of the above 15. Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration pneumonia occurs. a. True b. False 16. The “Rule of Thumb” in the Level III - Dysphagia Diet is which of the following: a. Food should be soft enough to mash with a fork b. Medications can be given normally, e.g. crushing, dissolving c. May eat nuts, or dry, crispy, raw or stringy foods d. Liquids are restricted 17. Which of the following diet restriction options are correct: a. No straws b. It is difficult to manage thin liquids and solid food at the same time, e.g. vegetable soup c. No mix consistency can be an exclusion on any diet d. All of the above 18. When caring for a patient with “Swallowing Precautions” you should: a. Always check the diet order b. Look for service instructions such as: No straws, feeding assistance and/or Liquids by spoon only c. 1:1 feeding versus 1:1 cueing d. All the above 19. Which of the following are potential causes of aspiration: a. A decreased level of consciousness, e.g., stroke, traumatic brain injury, neurological disease, seizures b. Aging; Dental problems c. Drinking large amounts of alcohol; Taking medications that cause drowsiness d. All of the above Self-assessment_Dysphagia & Aspiration Precautions_012115 20. Which of the following symptoms can occur with aspiration: a. A change in voice and skin color (cyanotic) b. Coughing c. Difficulty breathing; Fever d. All of the above 21. Which of the following are general guidelines to prevent aspiration: a. Feed small amounts; Do not force feed b. Use as little water as possible; Crush pills if pharmacy approved c. Never put food or liquids in the mouth of a person who is not fully alert d. All of the above 22. When caring for someone who can sit upright, which of the following are general guidelines for aspiration prevention: a. Sit upright in bed or in a chair, up to 45 minutes after eating b. Do not distract the person; remind them to eat slowly and chew well c. Do not serve food for at least 2 hour before bedtime d. All of the above 23. Which of the following are correct statements relating to oral care in the patient with dysphagia: a. Most important before breakfast; before and after every meal b. Before water, if patient is on a Free Water Protocol c. Every 2-4 hours for NPO patients, including intubated/ventilated patients d. All of the above 24. Which of the following are correct statements regarding recommendations for feeding patients a. Know whether or not the patient wears a full or partial set of dentures b. If dentures are left dry they can change shape and be unusable; When not in use dentures should be removed as they are a choking risk c. Never leave food or drink within the reach or sight of the patient. d. All of the above 25. By understanding and following the Speech-Language Pathologist recommendations regarding diet, swallow techniques and precautions, you are helping your patient with which of the following: a. To be comfortable b. Free of aspiration / pneumonia c. Hydrated and Nourished d. All of the above Self-assessment_Dysphagia & Aspiration Precautions_012115 Dysphagia and Aspiration Precautions Self-assessment - January, 2015 1. The esophagus is located behind which structure: a. Trachea b. Right bronchi c. Left Bronchi d. Aorta 2. Which of the following are components of the 3 parts of the esophagus: a. Cervical/proximal b. Thoracic/medial c. Abdominal/distal d. All of the above 3. Which of the following statements are correct relating to the anatomy of the esophagus: a. In front of the cervical esophagus is the trachea b. Beside the cervical are the structures in the carotid sheath c. The thyroid gland curves around from the front of the neck and can sit beside the cervical esophagus d. All of the above 4. In this phase of a normal swallow Food is broken down by chewing and mashing with tongue and exposure to enzymes in saliva which creates a bolus. a. Oral Preparatory b. Oral c. Pharyngeal d. Esophageal 5. Food reamins between the cheek and the teeth/gums after the swallowing process is called: a. Silent Aspiration b. Pocketing c. Residue d. Palates 6. Which of the following facts related to swallowing are correct: a. The swallowing mechanism is innervated by 7 pairs of nerves and 28 muscle groups b. The average person swallows more than 600 times each day and once every minute while sleeping c. While swallowing is very difficult o stop when started, thus appearing to be an autonomic action, it is actually voluntary d. All of the above 7. Dysphagia refers to any disorder in the swallowing process that does not allow food or liquid to pass safely from which of the following: a. Mouth to cervical esophagus b. Mouth to thoracic esophagus c. Mouth to abdominal esophagus d. Mouth to stomach 8. According to worldwide prevalence, the major primary diagnosis associated with swallowing difficulties include which of the following: a. Neurological disorders b. Cancer c. Age-related physiologic changes d. All of the above 9. Which of the following statements related to dysphagia are correct: a. May be associated with pain and in some cases swallowing may be impossible b. Occasional dysphagia usually isn’t cause for concern; but persistent dysphagia may indicate a serious medical condition requiring treatment c. Dysphagia can occur at any age; but usually in older adults; Treatment depends on the cause of swallowing difficulty d. All of the above Self-assessment_Dysphagia & Aspiration Precautions_012115 10. Oropharyngeal dysphagia can be caused by many disorders including which of the following: a. Neurological disorders, e.g. Parkinson’s, Muscular Sclerosis, Muscular Dystrophy b. Neurological Damage, e.g. Stroke, Brain or Spinal Cord Injury c. Esophageal Diverticula, e.g. Pouches that form and collect food in the esophagus; Cancer d. All of the above 11. Which of the following are causes of esophageal dysphagia: a. Diffuse spasms; GERD; Foreign body b. Esophageal stricture; Esophageal ring c. Esophageal tumor; Radiation therapy d. All of the above 12. Which of the following are considered signs and symptoms of dysphagia: a. Being hoarse; unable to swallow b. Chronic coughing or gagging when swallowing; drooling c. Frequent heartburn; Unexpected loss of weight d. All of the above 13. Dysphagia may lead to which of the following complications: a. Malnutrition b. Dehydration c. Weight loss d. All of the above 14. Which of the following tests may be used to determine the diagnosis and degree of dysphagia: a. Barium Swallow (X-ray with contrast material); Modified Barium Swallow Study b. Endoscopy; Esophageal Muscle Test c. Fiber-optic Endoscopic Evaluation of Swallowing (FEES); Imaging Scans d. All of the above 15. Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration pneumonia occurs. a. True b. False 16. The “Rule of Thumb” in the Level III - Dysphagia Diet is which of the following: a. Food should be soft enough to mash with a fork b. Medications can be given normally, e.g. crushing, dissolving c. May eat nuts, or dry, crispy, raw or stringy foods d. Liquids are restricted 17. Which of the following diet restriction options are correct: a. No straws b. It is difficult to manage thin liquids and solid food at the same time, e.g. vegetable soup c. No mix consistency can be an exclusion on any diet d. All of the above 18. When caring for a patient with “Swallowing Precautions” you should: a. Always check the diet order b. Look for service instructions such as: No straws, feeding assistance and/or Liquids by spoon only c. 1:1 feeding versus 1:1 cueing d. All the above 19. Which of the following are potential causes of aspiration: a. A decreased level of consciousness, e.g., stroke, traumatic brain injury, neurological disease, seizures b. Aging; Dental problems c. Drinking large amounts of alcohol; Taking medications that cause drowsiness d. All of the above Self-assessment_Dysphagia & Aspiration Precautions_012115 20. Which of the following symptoms can occur with aspiration: a. A change in voice and skin color (cyanotic) b. Coughing c. Difficulty breathing; Fever d. All of the above 21. Which of the following are general guidelines to prevent aspiration: a. Feed small amounts; Do not force feed b. Use as little water as possible; Crush pills if pharmacy approved c. Never put food or liquids in the mouth of a person who is not fully alert d. All of the above 22. When caring for someone who can sit upright, which of the following are general guidelines for aspiration prevention: a. Sit upright in bed or in a chair, up to 45 minutes after eating b. Do not distract the person; remind them to eat slowly and chew well c. Do not serve food for at least 2 hour before bedtime d. All of the above 23. Which of the following are correct statements relating to oral care in the patient with dysphagia: a. Most important before breakfast; before and after every meal b. Before water, if patient is on a Free Water Protocol c. Every 2-4 hours for NPO patients, including intubated/ventilated patients d. All of the above 24. Which of the following are correct statements regarding recommendations for feeding patients a. Know whether or not the patient wears a full or partial set of dentures b. If dentures are left dry they can change shape and be unusable; When not in use dentures should be removed as they are a choking risk c. Never leave food or drink within the reach or sight of the patient. d. All of the above 25. By understanding and following the Speech-Language Pathologist recommendations regarding diet, swallow techniques and precautions, you are helping your patient with which of the following: a. To be comfortable b. Free of aspiration / pneumonia c. Hydrated and Nourished d. All of the above Self-assessment_Dysphagia & Aspiration Precautions_012115 Broward Health Medical Center Broward Health Coral Springs Broward Health Imperial Point Broward Health North Broward Health Weston Broward Health Physician Group Broward Health Community Health Services Awards this Certificate of Compeletion This certifies that [StudentNameAtTimeOfCompletion] [LicenseNumber] Has successfully completed thefollowing course: Dysphagia and Aspiration Precautions CE Broker Num ber: 20-XXXXXXX For 1.0 contact hour on [CompletionDate] Florida State Board CE Broker Provider Number 50-1443 Jean Seaver, RN, MSN Do Not send this certificate to your designated Florida State Board Retain for your personal records for 4-years