Blank Dysphagia Fact Sheet

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					                                                                               NAME:
DYSPHAGIA FACT SHEET                                                         ADDRESS:


STATUS: (Risk factors):                                              DATE DEVELOPED                          REVISED:
                                                                     DYSPHAGIA LEVEL

TOPIC:                    PROPOSED STRATEGY/ACTIVITY:                                    TRIGGERS:
ORAL CARE AND      1.
MEDICATION                                                 Coughing with signs of struggle (watery eyes, drooling, facial redness)
ADMINISTRATION
                                                           Wet Vocal Quality

                                                           Vomiting

                                                           Sudden Change in Breathing
MEAL POSITION      1.
AND ADAPTIVE                                               Watery eyes
EQUIPMENT
GENERAL            1.                                      Total meal refusals (X 2)-nursing notified.
POSITIONING
AND                                                        Pocketing of food in mouth
WHEELCHAIR
POSITIONING                                                Weight loss/gain of 5lbs in a month
NUTRITIONAL        1.
CONCERNS
SPEECH ORAL        1.
MOTOR
CONCERNS
WHAT TO DO IF      1.
YOU NOTICE A
DYSPHAGIA
TRIGGER




SE Outreach – 8-19-05


                                                                                                               Dysphagia Plan: Page 1 of 1

				
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