Dysphagia

Question 1

List common conditions that are at risk for dysphagia issues.

Answer 1

• ›CVA
• ›Head Injury
• ›Brain Tumor
• ›Anoxia
• ›Guillain-Barre Syndrome
• ›MS
• ›ALS
• ›Parkinson’s Disease
• ›Myasthenia Gravis
• ›Poliomyelitis
• ›Quadriplegia

Question 2

What are the 5 phases of eating and swallowing?

Answer 2

• ›Anticipatory Phase:
  
  • Appetite
  • Sensory qualities of food
  • Utensils
  • Motivation
  • Cognition
• ›Oral Preparatory Phase
  
  • ›Looking at and reaching for food
  • Placing food in mouth and chewing
  • Rhythmic and rotary chew
  • ›Bolus formation facilitated by tongue movement
  • Time to form bolus depends on viscosity of food (softer food = shorter time)
  • Posterior portion of tongue seals velum and prevents food from going into the pharynx
  • Tongue divides food into portions to be swallowed
  • Larynx and pharynx at rest during this stage
  • Airway is opened
  • Mandible, Teeth, tongue, cheeks, lips
    
    • Difficulties: Decreased Lip Closure, ›Pocketing of food, ›Swallowing food before bolus is formed, ›Bolus is too large
• ›Oral Phase
  
  • ›Tongue moves bolus to back of the mouth toward pharynx
  • Tongue elevates to squeeze the bolus up against the hard palate
  • ›Tongue forms a central groove to funnel food posteriorly
  • ›Amount of food swallowed inversely related to viscosity of food
  • ›Voluntary phase
  • ›Takes about 1 sec to complete with thin liquids and slightly longer with thick liquids
  • ›Breath through nose.
  • ›Lips, Cheeks, Tongue
    
    • Difficulties: ›Increased time to chew food, ›Thinner foods move too quickly, Textured foods are difficult to manipulate and chew.
• ›Pharyngeal Phase:
  
  • Voluntary and involuntary
  • ›Swallow response
  • Soft palate (velum) elevates and contracts for closure of the nasopharynx
  • Tongue base elevates and moves bolus into the pharyn
  • ›Hyoid and larynx elevate and move anteriorly
  • Closure of larynx
  • ›Pharyngeal constriction
  • Bolus divides at the valleculae, moves down each side of pharynx through the pyriform sinuses
  • Bolus ends at the esophagus
    
    • Difficulties: Coughing, Decrease or absent swallow response, ›Pooling of bolus in valleculae, Pooling of bolus in pyriform sinus
• ›Esophageal Phase
  
  • Bolus enters the esophagus
  • Peristaltic contraction, 8-20 seconds
  • As food enters the esophagus, the epiglottis returns to the relaxed position, in which the airway is opened

Question 3

What are you assessing in the outer oral assessment?

What are you assessing in the inner oral assessment?

Answer 3

›First can they take any commands

›Cognitive-Perceptual, Physical Status- can they open jaw, get them in safe position

1. Outer Oral Status- (bedside swallow- trying to asses oral floroscopy. Assess mm of face) Tell them what your doing!!! Sensitivity to approaching face. Explain all actions to patient.› Count of 3​​​. Move within patient’s visual range and face.

• ​Sensation/ ​Symptoms for impaired sensation:
  
  • ›Drooling
  • Food on the mouth
  • ›Food falling out of the mouth
  • ›Client unaware
  • ›Light Touch- all over face, close eyes, how many times am I touching you
  • ››Touch Localization
  • ›Hot and Cold
• Musculature
  
  • Symmetry
  • Strength – MMT
  • Motor Control
  • Tone

2. Inner Oral Status›

• Explain each procedure to patient
• ›Keep within patient’s visual field
• ›Universal Precautions
• ›Latex Allergy
• ›Wet finger or tongue blade
• ›Count of 3
• Assessment
• ›Oral structures
  
  • Oral Structures – Dentition
    
    • 4 Quadrants
    • ›Right Upper
    • ›Right Lower
    • ›Left Upper
    • ›Left Lower
  • Oral Structures – Gum
    
    • ›Wet fifth finger
    • ›3x on gum of each quadrant
    • ›Bleeding, tender, or inflamed
    • ›Spongy or firm
    • Loose teeth and sensitive or missing teeth
  • Oral Structures – Cheek
    
    • ›Test each quadrant
    • ›Tone of buccal musculature
      
      • Firm with an elastic quality
      • Too easy to stretch
      • Tight without any stretch
    • ›Condition of the inside of the mouth
      
      • Bite marks on tongue, cheeks, lips
  • Oral Structure – Dentures
    
    • ›Need adequate fit
    • ›Make any repairs immediately ​
• ›Tongue musculature
  
  • Tongue Movement
  • ›Moving and shaping food
  • ›Propels food back in preparation for swallowing
  • ›Assess: strength, ROM, control, tone
  • ›Open mouth and assess with flashlight
    
    • ›Pink and moist
    • ›Very red
    • Heavily coated
• Tongue Musculature
  
  • Shape of tongue
  • ›Flattened
  • ›Bunched
  • ›Rounded
  • ›Normal: Slightly concave with a groove running down the middle
• Tongue Musculature
  
  • ›Grasping the tongue
  • ›Pull slowly forward (use gauze)
  • ›Walk wet finger from tongue front to back Hard ( Increased Tone)
    
    • Firm (Normal),
    • Mushy ( Low Tone)
    • ›Symmetry of tongue left to right ​
• Tongue Musculature
  
  • ROM and Tone:
  • ›Forward
  • Retraction = increased tone
  • Too far forward = low tone
  • ›Side-to-side
  • ›Up and down
• Tongue Musculature
  
  • Motor control:
  • ›Elevate, stick out, and move tongue laterally
  • ›Assess ease of movement, strength of movement, and coordination
• ›Palatal Function
• ›Swallowing

​

Question 4

What are the primitive oral reflexes and what are the normal adult reflexes?

Answer 4

Oral Reflexes

• Primitive:
• ›Rooting- move object to side
• ›Bite
• ›Suck-swallow

Oral Reflexes

Normal Adult

• ›Gag/ Palatal
• ›Cough

Question 5

What are the 6 questions that should be asked prior to ordering a bedside assessment tray and why is each question important?

Answer 5

6 questions that should be asked prior to ordering an assessment tray:

1. Is the client alert and able to transition from forming the bolus to an immediate swallow when presented with food?
2. With assistance, does the client display adequate trunk and head control?
3. Does the client display adequate tongue control to form a partially cohesive bolus to regulate the speed with which the bolus enters the pharynx?
4. Is the larynx mobile enough to elevate quickly and with sufficient force?
5. Can the client handle the saliva with minimal drooling?
6. Does the client have a productive cough, strong enough to expel any material that may enter the airway?

Question 6

What consistency of solids and liquids is on the assessment tray?

Answer 6

Solids- test in this order

• ›Puree- ie applesauce
• ›Mechanical Soft- graham crackers
• ›Regular- muffins

Liquids

• ›Honey-thick:
• ›Nectar Thick:
• ›Thin: water, coffee

Question 7

Describe some indicators of eating and swallowing dysfunction and aspiration.

Answer 7

Indicators of Eating and Swallowing Dysfunction

1. Difficulty with bringing food to mouth
2. The inability to shape food into a bolus
3. Coughing or throat clearing before, during, or after the swallow
4. Gurgling voice quality
5. Changes in breathing pattern
6. Delayed or absent swallow response
7. Poor cough
8. Reflux of food after meals

Acute Symptoms of Aspiration Immediately After Swallow

1. Any changes in the client’s color
2. Prolonged coughing
3. Gurgling voice and extreme breathiness or loss of voice

Signs of Aspiration

1. 1.Nasal Drip
2. 2.Increase in profuse drooling of a clear liquid
3. 3.Temperatures of 100 degrees F or greater

Question 8

When and why would a videofluoroscopy study be important to order?

Answer 8

›Videofluoroscopy Study (VSS)- with Speech

›

›Fiberoptic Endoscopy (FEES)

Question 9

What are the indicators for non-oral feedings?

Answer 9

• ›Aspirating more than 10% of food or liquid
• ›Combined oral and pharyngeal transit time is more than 10 seconds
• ›NG Tube
• ›G tube

Question 10

How should a client be positioned physically for safe eating and swallowing?

Answer 10

1. Seated on a firm surface, such as a chair
2. Feet flat on floor
3. Knees at 90 degrees flexion
4. Equal weight-bearing on both ischial tuberosities
5. Trunk flexed slightly forward (100-degree hip flexion) with the back straight
6. Both arms placed forward on table
7. Head erect, in midline, and the chin slightly tucked

Question 11

Identify various interventions at each stage of eating and swallowing.

Answer 11

Intervention –Oral Prep

• ›Trunk: see pg 707
• ›Head
• ›UE
• ›Face:
  
  • ›Decreased lip control: Side handgrip
  • ›Apraxia: Straw; Food on unimpaired side
  • ›Decreased Sensation: Pat mouth
• ›Tongue:
  
  • ›Pocketing: Stroke cheek
  • ›Retracted tongue: Double swallow

Intervention – Oral

• ›Slow oral transit:
  
  • ›Chin tuck
  • ›Flexion at hips; UE’s forward
  • ›Rest breaks
  • ›Finger under chin and move up and forward
• ›Tongue thrust:
  
  • ›Food toward back of tongue
  • ›Down and forward pressure with spoon
• ›Tongue retraction:
  
  • ›Food in center of tongue
  • ›Cold and hot food

Intervention - Pharyngeal

• ›Soft palate
  
  • ›Nasal regurgitation: Positioning; Slight chin tuck
  • ›Delayed swallow: Alternate cold and warm food with slight chin tuck
• ›Hyoid
  
  • ›Delayed swallow: Finger under chin and move up and forward
• ›Pharynx
  
  • ›Coughing: Alternate liquid with stage II or stage III solids
  • ›Coating on pharynx and/or gurgling voice: Dry swallow
  • ›Unilateral pharyngeal movement (low tone): Turn head toward affected side
• ›Larynx
  
  • ›Coughing, choking: Clear throat; effortful swallow
• ›Trachea
  
  • ›Continuous coughing: Cough; Suctioning; Heimlich maneuver

Intervention - Esophageal

• ›Regurgitation, Coughing, Choking: Report to medical staff.