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Copy of Dysphagia inservice for HAS

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by

Natasha Fitzpatrick

on 12 June 2014

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Transcript of Copy of Dysphagia inservice for HAS

Patient's medical History
Orofacial / Cranial Nerve Examination
Cough reflex testing if indicated
Swallow Trial using different foods/fluids

Management Plan:
Further assessment if needed -videoswallow
Compensatory Strategies
Rehabilitation Exercises
Modified Diets


Role of the Speech Language Therapist - SLT

Stroke
Parkinson’s disease
Motor Neurone disease
Multiple sclerosis
Dementia
Myasthenia Gravis
Head & Neck cancer
Huntington's
Conditions that can lead to damage causing dysphagia:

First phase
Food is chewed and mixed with saliva

Second phase
Food is pushed to the back of the mouth

Third phase
Food is pushed downwards

Fourth phase
Food is moved into the stomach

What is a normal swallow?

Take a sip of water &
swallow without closing your lips

Try this!

Chew marshmallow with your tongue pressed hard against your bottom teeth & flat on the floor of your mouth.

Do not move your tongue!

Try this!

Marshmallow?

To give information about dysphagia and how it is managed

To provide information about SLT role in dysphagia management

To tell you how you can help! 

Overall aim of presentation

by
Natasha Fitzpatrick

Speech & Language Therapist




Health care assistant
In-service


Follow SLT recommendations
Supervise meals
Discourage talking
Patient to remain upright after eating for 30 mins
Avoid straws and beakers
Encourage self-feeding
If concerned discuss with nursing staff

Minimise distractions
Ensure
dentures
are fitting well
Feed from front
Ensure thorough mouthcares are provided

( If a patient aspirates saliva with bacteria
in it, this is far more dangerous than clean saliva)
Other ways you can help:

A condition in which the action of swallowing is either
difficult to perform
painful
or where swallowed material
doesn’t reach the stomach
how it should.



What is dyspha
g
ia?



Dyspha
g
ia- swallowing impairment

Dyspha
s
ia- communication deficit


First, a little vocabulary…

No food
No drink
No ice chips
No oral medications

Mouthcares+++




NBM = nil by mouth

Food or drink that has been changed so that the patient can manage it more easily/safely.

Liquids:
Thin (normal) fluids
Mildly thick fluids
Moderately thick fluids

Food:
Smooth puree
Minced and moist
Soft
Normal



What is a modified diet?

Long meal times
Patient’s report
Oral residues
Effortful chewing
Poor chest status
Weight loss
Unable to be sat upright


Relevant diagnosis
Reduced LOC
Altered cognition
Drooling
Slurred speech
Facial weakness
Voice changes
Frequent coughing

Warning Signs-

Coughing or choking with foods
Pocketing of food
Wet or gurgly voice
Drooling
Throat clearing
Extended time to finish meal


Symptoms of dysphagia

What you can do ?

What you can do ?

Report swallowing problems (e.g. pocketing food, coughing and choking, drooling…) to SLT

Ensure recommendations regarding feeding are followed
...What might these be?


What else you can do...
Level 150 –
Mildly Thick

Unmodified –
Regular Fluids

Jelly and Ice cream?
Ice chips?
Ice blocks?

Can someone who is on Mildly thick fluids have…


Cohesive and pours slowly
Possible to drink directly from a cup although fluid flows very slowly
Spooning this fluid into the mouth may be the best way of taking this fluid

Moderately Thick Fluids
Previously “Grade 2 Fluids”


Pour quickly from a cup but slower than regular, unmodified fluids
May leave a coating film of residue in the cup after being poured
Able to drink this fluid thickness from a cup

Mildly Thick Fluids
Previously “Grade I Fluids”

Fluids are thicker than normal fluids similar to naturally thick fluids such as fruit nectars, but not as thick as a thick shake.



Mildly Thick Fluids
“Grade I Fluids”

Level 400 –
Moderately
Thick

Level 150 –
Mildly Thick

Unmodified –
Regular Fluids

Moderately Thick Fluids
Previously “Grade 2 Fluids”

Fluids are similar to the thickness of room
temperature honey or a thick shake and flow slowly.


Characteristics
Characteristics
Look for signs of difficulty
Ensure patients receive correct diet
Follow SLT recommendations
Report any concerns to a nurse who can then refer to SLT

What can you do?
Smooth Pureed Diet


Smooth and lump free but may have a grainy quality
Moist and cohesive; holds its shape on a spoon
Can be moulded, layered or piped

Minced- moist Diet

Small lumps can be broken down with the tongue
Soft and moist and easily forms into a ball
Easily mashed with a fork
May be presented as a thick puree
with obvious lumps in it
Lumps are soft and rounded
(no hard or sharp lumps)

Soft Diet


Can be chewed but not necessarily bitten
Minimal cutting required –
Easily broken up with a fork
Should be moist

served with a sauce /gravy
to increase moisture content

Food can be bitten and chewed.
There are various textures of regular foods
Some are hard and crunchy while others are naturally soft
These are everyday foods!

Food Inclusions and Exclusions:
By definition
all
foods and textures can be included

Regular Diet
“Normal Diet”
Characteristics
Characteristics
Characteristics
Characteristics

(Sauces and gravies should be served at the required thickness level if pt is on thickened fluids)
To re-cap..
N
O
R
M
A
L
Thickened fluids are
always
safer to swallow than thin fluids.

Quantity of fluid does
not
matter- Sips v's Gulps.

Straws make it easier
for a patient to take fluids.

supplements can be thickened

Swallowing Myths
Questions??
NO!!!
What was difficult?
Why?
What did you have to do?

What was difficult?
Why?
What did you have to do?
Why is dysphagia a problem?
If a person has problems managing food/liquid, this may not go down correctly and it may go into their lungs - this can cause an

aspiration pneumonia

Which is
very dangerous

Silent
aspiration..
(A patient may have an NGT tube in place for nutrition/ medication)
Sit upright at 90°
Small sips / Mouthfuls
Allow time ++
Reduce distractions

Try and encourage self-feeding if possible
Patient to stay sitting up for 30mins after E & D
Ensure mouth is clean after means
Communication
Not
a one-way street! Understanding
and
expressing.


Pre-swallow phase
Getting ready to swallow, stimulating senses

Total communication
 speaking
 writing
 gesture
 drawing
 facial expression
 modelling
 use of a communication board
 pointing
 Use a combination of all of the above


Give time for the patient to respond!

Can they identify objects?

Objects
in the environment, body parts etc
• Can they understand
1-stage
commands?

Does this person actually understand what I am saying to them or is it just that their pragmatic skills are still intact?
Is their yes / no response accurate? If so, can you use these to clarify answers?

(e.g. nodding head, looking interested, turn taking, etc)

Acknowledge when you have not understood a message
If the patient is becoming frustrated acknowledge their difficulty and suggest you come back to it at another time

Encourage the use of
total communication
to supplement a spoken message

If they know the
first sound
/ letter of the word

Can they
draw it, point to it
in a picture or
gesture it
?

Can they think of a
related word
Give a
lead in phrase
e.g. “you drink from a….” (cup)

Give them the
first sound
to cue the word e.g. “you drink from a c….” (cup)

 Ensure the patient has the
necessary aids
(glasses, hearing aids etc)

Speak slowly
and pause frequently
 Use
short sentences
and instructions
 Emphasise
key
words
 Allow the first step of an instruction to be completed before giving further instruction
 Use
simple but appropriate
language

Repeat
the message if the patient appears confused or uncertain

Questions??
Full transcript