NURS 3614 FundamentalsDysphagia

Loree DuBose, RN, MSN

Difficulty with swallowing or chewing food or liquids

Difficulty with language

Dysphagia DysphasiaSwallowing disorders, or dysphagia, is a general term used to describe the inability to move food from the mouth to the stomach. This condition should be differentiated from any other disorder that prevents transfer of food to the mouth or food beyond the stomach. Feeding disorder, which is the inability to get food to the mouth, and gastric outlet obstruction, the inability of food to pass from the stomach into the small intestine, should be differentiated from swallowing disorders. An average of 10 million Americans are evaluated for swallowing disorders annually. Many causes have been identified for dysphagia. Dysphasia is spelled the same way but the g is replaced with a s. This is how you can recall that dysphasia is difficulty with speech or language.

Potter & Perry Textbook have one page (1010) of information for dysphagia. This is not enough for the responsibility that you will have in clinical so I have added multiple slides to assist you with patient/resident care during clinicals & future nursing practice.Many of the residents and patients that we will take care of in Long Term Care (LTC) or Long Term Acute Care (LTAC) have a medical diagnosis of Dysphagia. One of the objectives for clinical is assist with feeding and feeding patients/residents that cannot feed themselves. It is important for you to understand this topic to avoid an issue of aspiration during feeding of a patient.

Normal Swallowing A&P review

First, food must be chewed thoroughly. Then it is moved to the back of the mouth by tightening the cheek muscles and pressing the tongue against the roof of the mouth. From this point on the process becomes automatic -- it is a reflex that people do not actively control. In "rapid- fire" succession, the soft palate closes the nasal airway to prevent food from backing into it, the airway into the lungs is closed, and the esophagus (food pipe) relaxes allowing food and liquid to enter it. The muscular esophagus then contracts in a wave-like action, sweeping the food along into the stomach. A blockage or a malfunction anywhere in this part of the body or in the nervous system controlling swallowing can result in dysphagia. There are two types.

Swallowing cont.Pictures are (left) Pharangeal and (right) esophageal phase of swallowing

Key Terms

ObstructionPocketing of foodGlobus sensationBolusRegurgitation Aspiration pneumoniaStrictureGERDMyopathyPureedViscocitySupraglottic swallowMendelsohn ManeuverSilent aspirationMastication

Dysphagia Assessment includes

Difficulty in initiating swallowingA feeling of obstruction as if food has become stuck in the throatVoice changeDifficulty with chewing or weakness of muscles of masticationPocketing of food in the mouthGlobus sensation or pain in the hypopharynx

The nurse gathers data by observation, interview and interventions associated with feeding or food intake. Some of this data is reported by the patient and other data is readily observed by the nurse. Ex: Pocketing of food in the mouth. The nurse includes assessment of the mucous membranes for each of his/her patients and can see, using a pen-light, this assessment data. Every patient MUST have mouth assessment. Apply what is learned in Health Assessment class to this topic.

More Symptoms

Coughing after eatingDroolingImpairment gag reflex and ability to clear bolus, cough, and breathingNasal regurgitationInappropriate breathing or speaking while swallowingWeight lossRecurrent pneumonia

Fluid & Caloric Replacement

IV fluidsParenteral alimentationNG tube/short termGastrostomy tube placed by percutaneous endoscopic means (PEG tube)Jejunostomy for known reflux & aspiration (performed under general anesthesia)

If a patient is unable to swallow without the risk of aspiration then their nutrition must be provided using an alternate method or the cells and tissues will die from starvation.Parenteral alimentation and IV fluid replacement can be prescribed by the physician or clinician to meet caloric and fluid requirements. The necessary caloric/fluid needs must be calculated to meet the patient's daily needs. This method is expensive and carries a risk of infection because it is an invasive method for nourishment.Esophagostomy is a procedure needed in patients in whom other placements may not be possible and to help in the control of pharyngeal secretions. You will learn more about this in future med-surg courses.

You learned about Nasogastric (NG) tubes in skills lab. These are convenient for the short term use, but their use is limited by complications including regurgitation, irritation, bleeding, and discomfort. Medications such as H2-blocker or proton-pump inhibitors should be given as prophylaxis to prevent some of the above complications that occur with NG tubes.You also learned about feeding tubes in skill lab. Recall that a Gastrostomy tube can be placed by percutaneous endoscopic means (PEG), allowing for continuous or bolus feedings. Risks are the same as mentioned above, and reflux prevention is performed by feeding the patient in a vertical position, using H2-blockers to decrease gastric pH, Chlorpromazine or Maxolon to facilitate gastric emptying, and proton-pump inhibitor to decrease gastroesophageal reflux. (GERD)Jejunostomy may be indicated in patients with known reflux and aspiration. This procedure is performed under general anesthesia and could involve continuous or bolus feeds.

Team Approach for Diagnostics & Management of DysphagiaPhysiciansNursesRegistered dietitianPsychologistSpeech pathologistOccupational therapistA Common Priority Goal: Prevention of aspiration pneumonia (prevent food & liquids from entering into the lungs )

Often a team approach to the treatment of dysphagia is needed. Several types of health care providers -- physicians, registered dietitian, psychologist, speech pathologist, occupational therapist they all work together to develop the best program that will be specific to each patients needs.

Refer to Box 44-7 for Multiple Causes of DysphagiaP&P page 1010

EndoscopyScope for: polyps, biopsies and obtain imagesNormal images

The endoscope has revolutionized the field of gastroenterology. Through it, the physician can directly examine almost any part of the intestinal tract. Biopsies can be obtained, polyps removed and clear images obtained. This gallery of endoscopy images provides views of the GI tract from top to bottom. The gallery is separated into the various organs within the abdomen - esophagus, stomach, colon, etc. Within each section, there are normal images and then the various diseases and problems can be seen by the physician/clinician.

Esophagus This picture is an image of the middle of the esophagus. It has a wide open tubular appearance and pink coloration. Seconds after this picture was taken, a contraction occurred. These normal sweeping wavelike contractions are what move food and liquid from the mouth to the stomach. (Refer to A&P slide review)

The Larynx This is what your voice box looks like from above. You notice the vocal cords on each side. These move back and forth as air is forced out over the cords. Amazingly, these simple fibrous bands of tissue allow us to talk, whisper, shout and sing the entire range of melodious and rich bass tones. This is a normal appearance of the larynx. When patient have surgery to remove cancer of the larynx, they may loose the ability to speak. Special equipment can be used and taught to the patient for artificial vocal cords.

Lower Esophageal Sphincter These are images of the end of the esophagus. There is a specialized muscle here which acts like a valve and which is called the lower esophageal sphincter (LES). It remains closed most of the time, only opening to allow swallowed food and liquid to be swept through into the stomach. When you belch, the air pressure in the stomach overcomes the pressure of the valve and the air you have swallowed bursts up the esophagus past this valve. The LES in Image 1 is closed while that in Image 2 is open.

Esophageal DysphagiaFood/liquids stop in the esophagusConsistent stomach acid reflux causes inflammationNarrowing (stricture) of the esophagusChest discomfort due to liquids sticking in the middle and lower chestSolid foods cause more problems than liquids

Treatment: dilate/widen the space

Do you recall from an earlier slide that there are 2 types of dysphagia? Esophageal dysphagia occurs when food/liquid stops in the esophagus. This happens most often because of consistent stomach acid refluxing (backing up) into the esophagus. Over time, the reflux causes inflammation and a narrowing (stricture) of the esophagus. Food and eventually liquids feel like they are sticking in the middle and lower chest. There may be chest discomfort or even real pain. Fortunately, physicians can usually dilate (widen) this narrowing, and there is now treatment available to keep it from returning. Cancer, hiatus hernia, and certain muscle disorders of the esophagus are less frequent causes of esophageal dysphagia. Solid food is usually more of a problem than liquids

Esophageal Strictures

Examples of Esophageal Strictures A stricture is a narrowing in a tube. It is like a dam across a stream which obstructs the flow. Strictures most often are benign and caused by acid refluxing into the lower esophagus. As this inflamed tissue breaks, scar formation occurs and causes contraction, much as a burn injury does to the skin. In time, the narrowing can become quite severe and obstruct the flow of food into the stomach. Image 1 is that of a very tight fixed stricture which measures only about 1/4 inch across. In Image 2 the stricture is not as tight, perhaps 1/2 inch. However, in this picture you see the inflammation and ulceration of the esophagus which leads to the stricture. Fortunately, most strictures can be effectively relieved.

Dilation of Strictures

Treatment The physician can use a variety of methods to gently but forcefully open, or dilate, a stricture. Dilatation is often performed in conjunction with an upper endoscopy exam. one of the following dilatation methods may be used: Bougie -- A series of increasingly larger, soft rubber or plastic dilators are moved across the stricture, gently opening it. Guided wire -- A thin wire, placed across the stricture, is used to guide increasingly wider dilators over it. Balloons -- Different types of sausage-shaped balloons can be placed across the stricture. The balloon is sharply inflated to open the narrowed area.The physician chooses the type of dilatation that is most appropriate for each patient.

Medications can cause Dysphagia

CNS depressantsAntipsychoticsCorticosteroidsLipid-lowering agentsColchicineAminoglycosidesAnticholinergic drugs

Some Medications produce effects due to a decrease in cognition or development of drug-induced myopathies. These medications are listed above.

Oropharyngeal dysphagia

Difficulty moving food to the back of the mouth to start the swallowing processSymptoms: drooling, choking, coughing during or after meals, pocketing food between teeth & cheeks, gurgly voice quality, inability to suck from a straw, nasal regurgitation, chronic respiratory infection or weight lossLiquids are more of a problemResults from nerve or brain disorders

Recall there are 2 types of dysphagia.Oropharyngeal dysphagia involves difficulty moving food to the back of the mouth and starting the swallowing process. This type of dysphagia can result from various nerve or brain disorders such as stroke, cerebral palsy, multiple sclerosis, Parkinson's and Alzheimer's diseases, cancer of the neck or throat, a blow to the brain or neck, or even dental disorders. Depending on the cause, symptoms may include drooling, choking, coughing during or after meals, pocketing of food between the teeth and cheeks, gurgly voice quality, inability to suck from a straw, nasal regurgitation (food backing into the nasal passage), chronic respiratory infection, or weight loss. Liquids are usually more of a problem in oropharyngeal dysphagia.

Mastication: Chewing food

Thickened liquids increase oropharyngeal control.

A diet of chopped or pureed foods decreases difficulties with mastication.

Definition: Chewing food/breaking down food using teeth

National Dysphagia Diet (2002)

To provide uniformity in/of diets provided to clients with dysphagia

Dysphagia puree Dysphagia mechanically alteredDysphagia advancedRegular

An important part of the treatment is helping the patient get adequate nutrition, while protecting against complications such as pneumonia from food or liquid getting into the lungs. Obviously, this requires a specialized diet. There are four different diet levels from pured to regular diet. The diets vary in texture and consistency, and are chosen depending on which would be most effective for a specific patient.

Dysphagia Puree

Pureed foodSmooth, mashed potato-like consistencyMeat pureed to a smooth pasty consistencyCaution with foods that do not blend wellExample: zucchini seeds

Foods in this group are pured to a smooth, mashed potato-like consistency. If necessary, the pured foods can keep their shape with the addition of a thickening agent. Meat is pured to a smooth pasty consistency. Hot broth or hot gravy may be added to the pured meat, approximately 1 oz of liquid per 3 oz serving of meat. CAUTION: If any food does not pure into a smooth consistency, it may make eating or swallowing more difficult. For example, zucchini seeds sometimes do not blend well.

I have inserted a hyperlink that advertises food preparations for people with certain diet modifications. This has become a profitable business as the population of people live longer and non-professional care providers (this includes spouses, adult children and etc.) may need pre-made products with dietary modifications to assist with feedings/nutrition intake.http://www.pure-afoods.com/

Dysphagia mechanically altered

Minced foodsChopped into very small pieces 1/8 inch similar to sesame seeds

Level 2 Minced Foods in this group should be minced/chopped into very small pieces (1/8 inch). The flecks of food are similar in size to sesame seeds

Dysphagia Advanced

Ground or chopped foodsDiced into - inch pieces (similar to the size of rice and up to the size of macaroni or bread cubes)

Ground Foods in this group should be ground/diced into 1/4-inch pieces. These pieces of food are similar in size to rice. Chopped Foods in this group should be chopped into 1/2-inch pieces. These pieces of food are similar in size to uncooked elbow macaroni or croutons (small bread cubes).

Regular

Modified regular foodsSoftMoistRegularly textured foods

Modified Regular Foods in this group are soft, moist, regularly textured foods

Beverages & Liquids 4 Levels

Thin=low viscosityNectarlike = medium viscosityHoneylike =viscosity of honeySpoon-thick =viscosity of pudding

Commercial Thickening Agents

Thick n EasyThick ItThick SetThixx

Commercial Thickening Agents are used to add to the liquid to obtain the desired viscosity. These can be expensive for patients on fixed incomes.

Medium Viscosity

Eggnog Fruit nectars (apricot, peach, pear) Honey Thick creamed soups Soft set pudding with added Milk Tomato juice Buttermilk Ice cream (no nuts or fruit chunks) Milkshakes

The Registered Dietician and/or Physician writes an order for a specific modification for all liquids and/or foods consumed by a patient with dysphagia. As a patients condition improves and it is determined that the risk for aspiration is less then the order is commonly written to advance a diet to another level. This includes beverages.

Spoon Thick Liquids:

Cooked hot cereal Pudding Custard Gravy Yogurt (no nuts or fruit chunks) Cottage cheese mixed in Blender with milk or fruit Thick malt and milkshakes

How to Thin Liquids

Add hot milk-based liquids (hot milk or cream) to pured soups, pured vegetables, or cooked cereal. Add other hot liquids (broth, gravy, sauces) to mashed potatoes, pured or ground meats, and pured or chopped vegetables. Butter or melted margarine may also be used. Add cold milk-based liquids to cream, yogurt, cold soups, pured fruits, or puddings and custards.

If too much thickener is added to a liquid the viscosity allows the spoon to stand up in the beverage without support. To reverse the viscosity see above slide. Care-givers must be taught these adaptations when preparing food and beverages for patients with dysphagia.

How to Thicken Liquids and Foods

Add:Baby ricePotato/banana flakesPlain unflavored gelatinStrained meat or baby foodMashed white or sweet potatoes to pureed vegetables

The following thickeners can be used as substitutes for commercial thickeners and can save the patient money.Examples include:Add baby rice to hot milk-based liquids. Add potato flakes, mashed potatoes, or flaked baby cereal to other hot liquids (soups, sauces, gravies). Add plain unflavored gelatin, pured fruits, banana flakes, or a commercial thickener to cold liquids. Add potato flakes, mashed potatoes, thick sauces or gravies, canned pured or strained meat (baby food), or a commercial thickener to pured soups. Add flaked baby cereal, flavored gelatin, cooked cream of rice or wheat cereal, or a commercial thickener to pured fruits. Add mashed white or sweet potatoes, potato flakes, sauces, or commercial thickener to pured vegetables.

How to Reduce the risk of aspiration:

Chin TuckHead RotationHead TiltSupraglottic swallowValsalva ManeuverMendelsohn Maneuver

Chin tuck: The patient holds the chin down, increasing the epiglottic angles, and pushes anterior laryngeal wall backward, thereby decreasing the airway diameter.

Head rotation: The ipsilateral pharynx is closed, forcing the food bolus to the contralateral pharynx while cricopharyngeal pressure is decreased.

Head tilt: This technique guides the bolus to the ipsilateral pharynx using the effect of gravity.

Supraglottic swallow: This technique involves simultaneous swallowing and breath-holding, closing the vocal cords and protecting the airway. The patient thereafter can cough to expel any residue in the laryngeal vestibule. The Valsalva maneuver may be used to maximize vocal cord closing.

Mendelsohn maneuver: This maneuver is a form of supraglottic swallow in which the patient mimics the upward movement of the larynx by voluntarily holding the larynx at its maximum height to increase the duration of the cricopharyngeal opening.

Adequate Fluids

Necessary for body functions48-64 oz dailyThin liquids difficult to swallow but there should be progression within 4 weeksThickener added

Liquids Fluids are essential to maintain body functions. Usually 6 to 8 cups of liquid (48-64 oz) are needed daily. For some dysphagia patients, this may present problems because thin liquid can be more difficult to swallow. In this case, fluid can be thickened to make it easier to swallow. However, close monitoring by the dysphagia team is required for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within 4 weeks. These patients are high risk for dehydration and the complications that occur with dehydration including dysrhythmias.

Calories Are Needed..

Eating is difficult & causes fatigueClient wants to stop eating without adequate calorie intakeFortify the foods with calories & especially protein

Supplemental Calories The greater problem for some patients is eating enough calories. The whole process of eating simply becomes too difficult and too tiring. However, calorie and protein intake can be increased by fortifying the foods the patient does eat. Fortify milk by adding 1 cup of dry powdered milk to one quart of liquid milk. Use this protein fortified milk when making hot cooked creamed soups, sauces, milkshakes, and puddings. Also add margarine, sugar, honey, jelly, or pured baby food to increase calories. Add strained baby fruit to juices, milkshakes, and cooked cereals. Add 1 jar of strained baby meat to soup, such as strained chicken noodle soup. Also add strained baby meats to sauces and gravies, and mix with strained vegetables. Add juice to prepared fruit, cereal, or milkshakes.

Assistance with FeedingUpright position/near 90 degrees/30 min. before eating (rest) and again afterwardsSmall bites only to 1 teaspoonEat slowly..one food at a timeAvoid talking while eatingPlace food into strong side of the mouthCheck for pocketing inside cheeksBend forward, chin-down, when swallowingDo Not Wash Food Down Relaxed atmosphere..no distractions

Nursing Interventions: The following are some general guidelines for safe swallowing. Remember that dysphagia patients have individual requirements, so all of these guidelines may not apply to every patient. Use your judgement & critical thinking. This is application learning.NOT just for a test or EXAM. Learn this for accountability when providing patient care at the bedside!Maintain an upright position (as near 90 degrees as possible) whenever eating or drinking. Take small bites -- only 1/2 to 1 teaspoon at a time. Eat slowly. It may also help to eat only one food at a time. Avoid talking while eating. When one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check the inside of the cheek for any food that may have been pocketed. Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway. Do not mix solid foods and liquids in the same mouthful and do not "wash foods down" with liquids, unless you have been instructed to do so by the therapist or dietician. (no absolutes in medicine)Eat in a relaxed atmosphere, with no distractions. Following each meal, sit in an upright position (90 degree angle) for 30 to 45 minutes.

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