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FOUNDATIONS OF DYSPHAGIA

DEFINITIONS
Aspiration - When material enters lungs. Silent Aspiration - Aspiration occurring with no signs/symptoms (aka triggers) Dysphagia - Difficulty feeding or swallowing Dysphagia Triggers - Symptoms or signs that may signal the occurrence of aspiration Coughing – forceful exhalation of air Choking – airway is blocked GERD/Reflux – stomach contents come back up into esophagus or mouth

Consequences of Aspiration may include Pneumonia or lung damage and Death.

The risk for Aspiration is not limited to meal times. It can occur ANY TIME, day or night. This includes food, drink, medication, saliva, and vomit

The risk for Aspiration is not limited to meal times. It can occur ANY TIME, day or night. This includes food, drink, medication, saliva, and vomit

For Dysphagia
            Coughing with signs of struggle during or after meals Sudden change in breathing such as wheezing Wet/gurgley voice quality Excessive drooling Holds food in mouth for more than 20 seconds Sudden change of color around the lips and face Fever Refusal of foods for more than 2 meals Watering eyes Gagging Facial grimacing TRIGGERS can be INDIVIDUALIZED such as, one person always “holds breath and turns red in the face” or another person may “vocalize a low wet-sounding moan”

Revised 06-01-2005 Jamie Bailey SLP, CCC Becky Smitha, OTR, ATP

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FOUNDATIONS OF DYSPHAGIA
IF YOU NOTICE ANY TRIGGERS ASSOCIATED WITH DYSPHAGIA AT ANY TIME

1. Ensure safety of client, support and reassure. This is a health and safety issue! If person is
coughing, encourage to cough and clear airway. If choking, follow emergency procedures.

2. Check all instructions for diet texture, fluid texture, positioning, eating instructions, adaptive
equipment, pace of eating, bite or drink size or dysphagia interventions. Self-correct if any of the instructions were not followed correctly.

3. If client has stopped exhibiting the trigger and is alright, resume meal. 4. If client does not demonstrate any further problems, document episode as a selfcorrected trigger. 5. If client demonstrates the trigger AGAIN, stop meal and call for an evaluation. Document who was called and the time the call was made. 6. Wait for further instructions from Nurse. 7. It is recommended that all data regarding the observance of triggers be recorded on the FLOW SHEET and also in notation format.

To decrease the risk of Aspiration:  Always have client in the identified, most upright position during Oral Care, Med-Pass, Mealtime, Dressing, Personal care, and Bathing or Showering.  Always refer to the Dining Plan, Dysphagia Fact Sheet, Positioning Program and Schedule (or the informational documents that your organization uses that contain this information). Correct Diet Texture and Positioning throughout the day can help to decrease the risk of ASPIRATION.

IT IS RECOMMENDED THAT MEAL (DINING) PLANS, DYSPHAGIA FACT SHEETS AND DAILY TRACKING OF
TRIGGERS ON THE FLOW SHEET BE LOCATED IN DATA BOOKS WHERE ALL RESPONSIBLE STAFF CAN REFER TO THEM AT ALL TIMES

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FOUNDATIONS OF DYSPHAGIA

1. A “TRIGGER” CAN OCCUR AT ANY TIME, 24/7. 2. A “SELF-CORRECTED TRIGGER” MEANS THAT IT OCCURRED ONE 3.
TIME AND THE INTERVENTION YOU PROVIDED WAS SUCCESSFUL IN PREVENTING IT FROM HAPPENING AGAIN. DOCUMENT IT. A “NON-CORRECTED TRIGGER” MEANS THAT IT HAPPENED AT LEAST A SECOND TIME. THIS REQUIRES A CALL TO A NURSE AND MUST BE

DOCUMENTED.

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FOUNDATIONS OF DYSPHAGIA

Abnormal Oral Patterns in Adults Tongue Thrust - Tongue is thick and bunched. Tongue movement is an extension of the tongue between the teeth or gums.

How to FEED Press bowl of spoon down firmly in the middle of the person’s tongue, holding it there for a few seconds to give him/her time to close mouth. 2. Remove the spoon so it comes straight out of person’s mouth. 3. May present food into the side of mouth to avoid stimulating tongue thrust.
1.

Bite Reflex - Jaw closes with upward movement. Bite reflex may increase if object in mouth is pulled on. How to FEED 1. If person bites on spoon, do not pull spoon out of mouth. Maintain a hold on the spoon, and count to ten. If person still does not release, tuck their chin and their jaw should release. 2. If person has a metal spoon, report bite reflex to Nurse and / or (person that should have this information reported to) so that the meal plan can be changed to include use of a coated spoon

Revised 06-01-2005 Jamie Bailey SLP, CCC Becky Smitha, OTR, ATP

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FOUNDATIONS OF DYSPHAGIA

You can do a number of things to help ensure the safety of clients who experience swallowing disorders.
 The client should be fed in a quiet environment with minimal distractions. TURN OFF radio or television. Avoid conversations with other caregivers.  The client should be encouraged not to carry on a conversation during the meal.  The client should be encouraged to focus on swallowing and try to remember any strategies learned for safe swallowing.  The client should be positioned according to the instructions of the Dining Plan and may need to be repositioned during the meal.  The client may tolerate foods of one texture (e.g., puree) better than foods of mixed textures (e.g., vegetable soup). If there is a question, talk to the SLP, Registered Dietitian or member of the dysphagia team.  The client may be unable to take liquids in any form or amount at any time. ALERT others if a client has a special feeding plan.  The client must have good control of tongue function, good airway protection, and a rapid swallow to use a straw. Straws decrease the level of sensation an individual has of the liquid prior to swallowing and permits too large an amount of liquid to enter the throat, causing possible ASPIRATION.  The client should have Well-Fitted dentures. If not, the client may eat better without dentures, or denture adhesive may be used to improve chewing and feeding.  The client should be fed SMALL amount of food – no more than a teaspoon at a time.  After each meal, the caregiver should provide complete oral care to ensure that no food remains in the mouth.  The client should be kept in an upright position for at least 30-60 minutes after eating.  Provide sips of fluids THROUGHOUT meal; do not hold all fluids until the end of the meal unless it is medically indicated.
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FOUNDATIONS OF DYSPHAGIA

Bites that are TOO BIG and sips that are TOO MUCH.
What is too big - Any bite or sip that can not be safely handled in 1 swallow

        

Follow the dining plan Watch the neck for signs of a swallow Use the correct utensils Do not overload the eating utensil. Follow the dining plan Know how to identify the person’s swallow WATCH for the swallow DO NOT guess WATCH for distress signals that tell you the person needs another swallow Follow dining plan instructions regarding the number of swallows NEEDED for EACH bite or sip Follow the dining plan for instructions on supporting or cueing the person for midline with a chin tuck

Giving bites and sips TOO FAST!
What is TOO FAST! – Too Fast is when the person does not have time to swallow and breathe between bites



Poor HEAD ALIGNMENT
What is Poor HEAD ALIGNMENT – Poor head alignment is when the head is not in midline with a chin tuck, not only when giving food/fluid but during the swallow.

A safe practice is maintaining the head in midline with a chin tuck from presentation until after the swallow



Placement of the FOOD/FLUID
What is POOR placement? – when the FOOD/FLUID is placed where the person CANNOT safely swallow or handle it.

 

Place food/fluid on the center of the tongue or an alternate place in the mouth as noted on the dining plan Follow the dining plan Use the correct utensil as specified on the dining plan

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FOUNDATIONS OF DYSPHAGIA

1. Remember that the person is REQUIRED
to swallow during tooth brushing.

POSITIONING

2. Make sure the person is properly aligned
and supported and that the head is maintained in midline with a chin tuck.

TOOLS

1. Suctioning toothbrush may be helpful 2. Refer to assessment before using 3. Collis-Curve tooth brush  
Toothpaste is NOT needed to clean the teeth. If the person is having difficulty swallowing, or an inability to spit the toothpaste or mouthwash out, then toothpaste and mouthwash should be avoided. Brush one quadrant of teeth, give a short break to get a breath and swallow, then brush another quadrant. A toothette could be used to swab the mouth with diluted mouthwash or diluted toothpaste. MAKE SURE THE EXCESS WATER, MOUTHWASH OR TOOTHPASTE IS SQUEEZED OUT.

THINGS TO CONSIDER
   

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FOUNDATIONS OF DYSPHAGIA

1. Remember that the person is REQUIRED

POSITIONING

to swallow during medication administration.

2. Make sure the person is properly aligned
and supported and that the head is maintained in midline with a chin tuck.

3. There is a direct relationship between the
dining program and safe medication administration. If a person needs thickened liquids for safe dining, they also need it during medication administration.

TOOLS

Pill crusher

 The size pill a person can swallow is the
same as their diet texture.

 The consistency of the medication may
need to be altered so the person can safely swallow it.

 Runny liquids may need to be altered, and

THINGS TO CONSIDER


dry medications may need to be added to a moist food so the person can safely swallow it. Administration of the medication should be the same as the dining plan, using the same placement techniques, size of presentations, number of swallows, positioning and adaptive equipment.

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FOUNDATIONS OF DYSPHAGIA

MYTH

MYTH BUSTERS OR

FACT?

1. It is normal for some people to cough throughout their meal. 2. It is a good sign for someone to cough up a lot of phlegm first thing in the morning or after a drink of juice (for example) because they are getting that junk out of their lungs. 3. Milk and milk products should be avoided by people who have swallowing problems because it makes them produce more mucous. 4. Even though a person is getting only pureed food, it is okay for them to give chocolate pieces or other foods that “melt in their mouth”. 5. If a person is coughing during meals, that means they are okay because they are keeping all that stuff out of their lungs. 6. If a person is not coughing during meals, that means they are okay and are not aspirating. 7. A straw is always helpful in providing liquids to an individual, especially if they show signs of oral spillage. 8. If a person has dysphagia and is supposed to sit upright when eating but is able to say that s/he wants to lay back in the recliner to eat, that is their right to seat there. 9. I like to eat in my recliner so it should be okay for a person with dysphagia to eat in their recliner. 10. If nothing bad has happened up until now, it isn’t going to happen. If you aren’t concerned, maybe even a little bit nervous about someone’s safety at meals, you SHOULDN’T be assisting them.

THINK: Are you willing to bet someone’s life on a myth? KNOW THE FACTS ABOUT DYSPHAGIA

Revised 06-01-2005 Jamie Bailey SLP, CCC Becky Smitha, OTR, ATP

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