Care of the Patient with Dysphagia

1. Care of the Patient with Dysphagia St. Mary’s Medical Center

2. PLEASE NOTE: YOU MUST VIEW THE ACCOMPANYING VIDEO ON CLOSED CIRCUIT TELEVISIONPRIOR TO COMPLETING THIS MODULE

3. Policy • To describe the care of the patient with dysphagia and to reduce the risk of aspiration.

4. 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.

5. 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

6. 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.

7. 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 • Neuromuscular disorders (ALS, Guillian Barré, Myasthenia Gravis) • Aspiration pneumonia - suspected or diagnosed • Esophageal disorders • Voiced complaints of difficulty swallowing

8. 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 astatus change. • If screen reveals evidence of dysphagia, maintain NPO and notify physician for Speech Therapy consult and/or video swallow study.

9. Managing Secretions • 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 set-up 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.

10. Nutrition • 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.

11. Nutrition - Continued • 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.

12. Nutrition - Continued • 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.

13. Medications • 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.

14. Teach patient and/or family: • 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

15. Documentation: • Complete dysphagia screen form (SMMC: 17-334) on admission and with any change in patient status. • Patient Education form – dysphagia teaching