Transcript DYSI - Professional Practice Group

Welcome
© Jul 2008 by FH
Presenters:
Catherine, Lane, Seana, Sandy
Speech Pathology
© Jul 2008 by FH
Purpose of this training
Review Dysphagia and Aspiration definitions
Identify those people at risk for Dysphagia and/or
Aspiration
Understand the phases of the normal swallow
and identify what can go wrong
Role of Nursing in managing pt’s at risk for
Dysphagia and/or Aspiration
© Jul 2008 by FH
Definitions:
Dysphagia:
swallowing problems
within the mouth,
throat or both. It is a
symptom of other
medical conditions.
© Jul 2008 by FH
Definitions, continued
Aspiration: food or liquid
that goes through the
vocal cords into the
lungs.
Silent Aspiration: food
or liquid travels below the
level of vocal cords as
well but swallowing looks
normal upon exam
(~16%).
© Jul 2008 by FH
SLP Role:
Completion of nursing screening generated by
Admission Data Base
Bedside swallow assessment: Speech Pathologist
clinically assesses the three phases of the swallow,
including cranial nerve assessment and swallowing trials
using a variety of modified textures.
Modified Barium Swallow, (also known as a
Videofluoroscopic Assessment of Swallowing, or
Videofluoroscopy): Conducted in the Fluoro Dept with a
radiologist and speech pathologist. Different consistencies
of barium are presented to simulate actual meal
consistencies. The procedure is recorded on a videotape.
This is the only procedure to verify silent aspiration.
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Diagnoses, which INCREASE the risk for
dysphagIa and/or aspiration pna
Cerebral
Palsy
AIDS
General Medical
Decline
Parkinson’s
Spinal Cord Injury
(SCI)
PNA
TBI
Endotracheal
Disorders
Dementia
ALS
(Lou Gehrig’s)
ETOH WD
CVA
(Stroke)
Muscular
Dystrophy
COPD
Brain Tumors
Multiple
Sclerosis (MS)
Post- Polio
Developmental
Disorders
Head & Neck
Cancer
PNA of unspecified
origin
© Jul 2008 by FH
CVA
(Stroke)
as a risk factor
50% of stroke patients
experience aspiration 4
42-67% of stroke patients
present with Dysphagia within
the first 3 days 2,3
•
•
33% of patients with
Dysphagia develop PNA 4
33% of stroke patients’ deaths
are related to Aspiration PNA 5
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non-neurological risk factors
Non-modifiable
Modifiable
Weak or hoarse voice
Advanced Age
Poor Oral Care
Poor Dentition
severe & progressive
neurological deterioration
AMS
Tracheostomy
Over Sedation
Inability to sit @ 90
degrees
ETOH & Drug WD
Extended Intubation
hx of PNAs of unspecified
origin
Hx Psychotropics
© Jul 2008 by FH
phases of normal swallow
Phase 1
Swallowing begins in the oral or
transfer phase with chewing and
moistening of food with saliva. The
tongue presses against the hard
palate to transfer the chewed food
to the back of the throat; cranial
nerve V then stimulates the
swallowing reflex.
© Jul 2008 by FH
phases of normal swallow
Phase 2
In the pharyngeal or transport
phase, the soft palate closes against
the pharyngeal wall to prevent nasal
regurgitation. At the same time the
larynx rises and the vocal cords
close to keep food out of the lungs;
breathing stops momentarily as the
throat muscles constrict to move
food into the esophagus.
© Jul 2008 by FH
phases of normal swallow
Phase 3
Peristalsis and gravity work
together in the esophageal or
entrance phase to move food
through the esophageal sphincter
and into the stomach.
© Jul 2008 by FH
what can go wrong?
ORAL dysphagia
Phase 1 dysphagia typically results from a
neuromuscular disorder.
Poor lip closure
Poor tongue mobility
Poor oral opening (e.g. bite reflex)
[ Drooling, leaking, pocketing ]
•
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WHAT CAN GO WRONG?
PHARYNGEAL DYSPHAGIA
•
Phase 2 dysphagia may also result from neuromuscular
disease or obstructions.
Absent or delayed swallow
Reduced laryngeal elevation (e.g. 2° to
Tracheostomy)
Reduced laryngeal closure (e.g. hoarse or
breathy or wet or gurgly voice)
[ Signs of the above are coughing and/or
choking with P.O.’s ]
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WHAT CAN GO
WRONG?esophageal
DYSPHAGIA
•
Phase 3 dysphagia results from lower
esophageal narrowing by esophageal cancer,
esophagitis, GERD and esophageal-motility
disorders (e.g. diverticula)
•
[ e.g. One sign is sensation of food getting
stuck @ the breast bone area ]
© Jul 2008 by FH
observing Pts: before eating &
drinking
↓ LOC (e.g. pt is not alert, sleepy, etc)
Inability to cough on demand
Inability to manage own oral secretions (e.g.
drooling, coughing, choking)
Voice quality: wet/hoarse/gurgly
Generalized or partial weakness (e.g. inability
to feed self, inability to sit @ 90º)
* presence or lack of gag reflex is not indicative of swallowing difficulties
© Jul 2008 by FH
OBSERVING PTs: during &
after eating & drinking
Coughing/choking during or right after eating/drinking
Extra effort or time needed to chew or swallow
Food or liquid leaking from the mouth or getting stuck in
the mouth (pocketing)
A voice which sounds gurgling/wet/hoarse during or
after eating/drinking
Clearing their throat frequently during meals
Becoming SOB or shows a ↓ of > 2% in O2Sat during
P.O.s
© Jul 2008 by FH
OBSERVING PTs: during &
after eating & drinking (cont.)
Talking w/ food/liquid in their mouth
Refusing to eat certain consistencies (e.g. eats only
purees)
Ignoring one side of the meal tray (i.e. left or right
neglect)
Eating too rapidly (caused by TBI, dementia or other
cognitive issues)
Swallow looks ok but pt has low grade fever, ↑ RR,
coarse BS and/or ↓ O2Sat > 2% during or immediately
after eating/drinking.
Recurring PNA or chest congestion after eating
Weight loss, dehydration and generalized weakness
from
© Jul 2008 by FH
not being able to eat/drink enough
Evidence: Dysphagia,
Aspiration and PNA
~ Of the 700K Americans who experience a stroke annually, >
20% die within the 1st year 1
Dysphagia is clinically present in ~ 42% - 67% (294K-469K) of
patients within the first 3 days of stroke onset 2,3
~ 50% (147K-234K)of pt’s w/ dysphagia experience aspiration
4
~ 1/3 (98K-156K) of pt’s w/ dysphagia develop PNA requiring
treatment 4
~ 35% (49K) of post-stroke deaths are caused by PNA 5
There is a 3-fold increased risk of dying when diagnosed w/
PNA after an acute stroke 5
© Jul 2008 by FH
Evidence: dysphagia, Aspiration
and PNA (Cont.)
It is believed that post-stroke PNA is attributable to
the aspiration of oral secretions or other intake in the
presence of varying degrees of dysphagia 6
Aspiration PNA is a potentially
preventable complication of stroke
7
© Jul 2008 by FH
Evidence: dysphagia, Aspiration
and PNA (Cont.)
Timely management of pt’s w/ dysphagia will not only
↓ risk of aspiration but will also ↑ nourishment,
rehabilitation rates and ↓ length of hospital stay.
Multidisciplinary team approach is the most effective
way to manage dysphagia in acute stroke pt’s.
Nurses are well placed to detect and manage
swallowing difficulties in acutely post-stroke pt’s 24/7.
When nurses are trained to use a dysphagia
screening tool, aspiration risk is reduced by twothirds.
© Jul 2008 by FH
source: Lees l et al. Nurse-led dysphagia screening in acute stroke patients. Nursing Standard. 2006;21:6:35-42
Oral Hygiene
Why Is Oral Care Important?
Good oral hygiene significantly reduces the
risk of developing aspiration pneumonia for
both patients who are eating AND patients
who are not eating, (people with less saliva
have more bacteria in their mouths, which
can then be aspirated into their lungs)
© Jul 2008 by FH
Oral Hygiene, continued
Mouth care should be done:
•After every meal
•With a toothbrush and toothpaste
•With a suction catheter, if needed, (for
patient’s who have any difficulty
swallowing or managing their own
secretions)
© Jul 2008 by FH
Oral Hygiene, continued
Patients with nasogastric tubes, (NG tubes,)
require:
•The head of their bed should always be at
least at 30 degrees at all times, (unless the
feeding is turned off)
•A yankauer suction tube at their bedside
•Especially good mouth care
(Note: You may need to use a swab that
attaches to the suction catheter)
© Jul 2008 by FH
Oral Hygiene, continued
If you use a toothette for mouthcare with a
patient that is NPO:
•The toothette should only be damp, never
wet, (the extra liquid can be aspirated by the
patient)
•Remember the toothette is only part of oral
care, and a poor substitute for a toothbrush
(would you rather brush your own teeth with a
toothette or a toothbrush??)
© Jul 2008 by FH
Oral Hygiene, continued:
Dentures:
•Need to be washed after every meal
•Need to be stored in a hospital denture cup
with a patient name label
•Should be worn at all meals if medically
appropriate
•Should be listed on the belongings list and
immediately reported, if lost
© Jul 2008 by FH
Dysphagia Screening Tool
Elements of the Dysphagia Screening Tool:
•
RN Functional Screening: LOC, responsiveness,
postural control, voice quality & management of oral
secretions
Water Screening Test
Pulse Oximetry Monitoring
© Jul 2008 by FH
glossary
ALS (amyotropic lateral sclerosis): a fatal degenerative disease involving several motor neurons, manifested by progressive
weakness and wasting of muscles innervated by the affected neurons.
ASPIRATION: food or liquid that goes through the vocal cords into the lungs.
ASPIRATION PNA: pneumonia developing secondary to the presence in the airways of fluid, blood, saliva, or gastric contents.
CEREBRAL PALSY: a generic term for various types of nonprogressive motor dysfunction present at birth or beginning in early
childhood.
DIVERTICULUM: a pouch or sac opening from a tubular or saccular organ, such as the gut or the bladder.
DYSPHAGIA: swallowing problems within the mouth, throat or both.
EBP: evidence based practice.
GERD: gastroesophageal reflux disease.
LOC: level of consciousness.
PNA (pneumonia): inflammation of the lung parenchyma characterized by consolidation of the affected part, the alveolar air
spaces being filled with exudate, inflammatory cells, and fibrin.
SILENT ASPIRATION: food or liquid travels below the level of vocal cords as well but swallowing looks normal upon exam.
SOB: shortness of breath.
TBI: traumatic brain injury.
© Jul 2008 by FH
references
1.
Heart and Stroke Statistical Update. 2003. Ref Type: Report.
2.
Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001; 16:7-18.
3.
Kidd D, Lawson J, Nesbitt R, MacMahon J. The natural history and clinical consequences of aspiration in acute stroke. QJM.
1995;88:409-413.
4.
Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke. Evidence report/technology assessment 8. 2003. Ref.
Type: Report.
5.
Katzan Il, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of pneumonia on mortality among patients hospitalized for acute
stroke. Neurology. 2003;25:620-625.
6.
Hinchey JA, Shepard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke.
2005;36:1972-1976.
7.
Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Int Med.1988;109:582-589.
8.
Lees l et al. Nurse-led dysphagia screening in acute stroke patients. Nursing Standard. 2006;21:6:35-42.
9.
Mann G & Hankey G. Initial clinical and demographic predictors of swallowing impairment following acute stroke. Dysphagia
2000;16:208-215.
10.
Massey R & Jedlicka D. The Massey bedside swallowing screen. Journal of Neuroscience Nursing 2002;24(5): 2520260
11.
Perry L. Screening swallowing function of patients with acute stroke: Part one. Journal of Clinical Nursing 2002;10:463-473.
12.
Perry L. Screening swallowing function of patients with acute stroke: Part one. Journal of Clinical Nursing 2002;10:474-481.
13.
Hinchey JA, Shephard TJ, Furie K, Smith D, Wang D, Tonn S, For the Stroke Practice Improvement Investigators. Formal dysphagia
screening protocols prevent pneumonia. 2005;36:1972-1976.
14.
Kidd D, Lawson J, Nesbitt R, MacMahon J. Aspiration in acute stroke: a clinical study with videofluoroscopy. QJM. 1993;86:825-829.
15.
Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995;345:487-488.
© Jul 2008 by FH
references (cont.)
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21.
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22.
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subsequent to stroke. J Commun Disord. 2001;34:55-72.
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© Jul 2008 by FH