Transcript Care of the Patient with Dysphagia

Care of the Patient
with Dysphagia
St. Mary’s Medical Center
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Policy
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describe the care of the patient
with dysphagia and to reduce the
risk of aspiration.
Definitions
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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:
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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:
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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
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include:
All dementia patients
Stroke
COPD
CHF
Any intubated patient at time of extubation
Any medical condition related to vocal cords
Neuromuscular disorders (ALS, Guillian Barré,
Myasthenia Gravis)
Aspiration pneumonia - suspected or diagnosed
Esophageal disorders
Voiced complaints of difficulty swallowing
Overview
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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.
Managing Secretions
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Preferred position is Semi-Fowlers
(head of bed at 30 degrees or greater,
unless contraindicated).
If management of secretions is a
significant problem, have suction setup available at bedside.
Perform aggressive oral care and
respiratory assessment every four (4)
hours and as needed, to include
suctioning of the posterior pharynx.
Assess stability and patency of airway.
Nutrition
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Follow feeding/swallowing strategies as
recommended by speech therapy.
Based on recommendations of speech
therapist, collaborate with nutritional services
to provide appropriate texture and
consistency of food.
Conduct ongoing assessment of adequacy of
fluid and caloric intake.
For meals, position patient upright (90
degrees). Patient should remain positioned
at 90 degrees for 30 minutes after meals.
Permit adequate time and verbal prompts for
chewing and swallowing.
Nutrition - Continued
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Check patient’s mouth for pocketing of food or
incomplete swallowing.
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.
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.
Nutrition - Continued
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Consult with occupational therapy if assistive
devices are needed to facilitate feedings.
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
Thicken liquids to appropriate consistency, if
needed.
Medications
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If dysphagia is marked, consider alternative
routes for PO medications.
If oral route for medications is utilized,
check patient’s mouth for pocketing after
medication administration.
If patient is on thickened liquids, use this
consistency when administering
medications.
Teach patient and/or family:
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to visually check own mouth for pocketing of
food
appropriate food selections for texture and
consistency
optimal position for eating
suctioning, if needed
signs and symptoms of pneumonia
(congestion, fever, decreased LOC)
to thicken liquids as needed
Documentation:
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Complete dysphagia screen form (SMMC:
17-334) on admission and with any change
in patient status.
Patient Education form – dysphagia
teaching