Clinical Decision Making Flashcards
What is the first step in interviewing?
Collecting information:
- current swallowing/oral intake issue?
- description of problem
- do any strategies help?
- current medication?
- how is this different to the past?
- what is the impact on the individual?
What is the second step in interviewing?
Decision making:
- formulating hypotheses and make decision re. plan
- severity
- possible cause
- need for information and
assessments?
What would you expect a) to observe and b) the functionality of a classification of NO dysphagia?
(Considering age appropriateness), you would see:
- full labial seal
- forms a cohesive bolus
- masticates food successfully and with ease
- efficient lingual search for loose food particles
- prompt swallow reflex initiation (1 sec)
- adequate/full laryngeal excursion on palpation
Functionality:
- managing regular diet and fluids
What would you expect a) to observe and b) the functionality of a classification of mild dysphagia?
May see:
- occasional difficulty forming seal
- occasional issues with bolus formation
- able to break down all textures but some effort required
- mild lingual weakness
- pharyngeal delay of ~1-3 seconds following propulsion from oral cavity
- slightly reduced or delayed laryngeal excursion
Functionality:
- may need 1 level fluid or 1 level diet modification, or managing thin fluids with a strategy
What would you expect a) to observe and b) the functionality of a classification of moderate dysphagia?
May see:
- reduced ability to form lip seal -> consistent anterior spill
- coughing on some consistencies
- some issues with bolus formation, some oral residue
- masticates solids with difficulty (hard and chewy textures problematic)
- some difficulty with lingual search
- pharyngeal swallow delay of ~3-6 secs
- incomplete or delayed laryngeal excursion
- at risk for airway compromise
Functionality:
- will often need some degree of fluid and food modification
What would you expect a) to observe and b) the functionality of a classification of severe dysphagia?
May see:
- impaired labial closure, inability to remove food/fluid from spoon, consistent anterior leakage
- unable to masticate solids
- poor bolus formation, consistent oral residue
- prominent oral pooling and inability to clear, premature spill to pharynx because of poor lingual control)
- pharyngeal swallow delay 6-10 secs
- laryngeal excursion delayed or incomplete
- significant risk of airway compromise
Functionality:
- managing quite modified fluids and foods
What would you expect a) to observe and b) the functionality of a classification of profound dysphagia?
May see:
- no labial seal, inability to maintain food orally
- little to no attempt at mastication
- prominent oral pooling
- inability to form a bolus
- absent swallow or >10 sec to generate pharyngeal swallow
- laryngeal excursion marginal to non-existent
- extreme risk for airway compromise
Functionality:
- unable to eat orally or only having small oral trials (1-2 teaspoons) with SP
Explain the continuum of complete oral intake, to nil by mouth
Complete oral intake
->
Oral + non-oral: combine partial intake with supplementation
->
Nil by mouth
What are the top variables most frequently considered by clinicians when recommending oral/non-oral intake?
- amount of aspiration (i.e. frequency)
- secretion management
- patient diagnosis; severity of condition; prognosis
- history of pneumonia; respiratory status; cough
- alertness; ability to complete compensatory postures
- patient wishes
What are the two main forms of non-oral supplementation to ensure patients are receiving appropriate nutrition?
Enteral feeding (via normal gastric system)
- nasogastric/orogastric
- Percutaneous Endoscopic Gastronomy (PEG)
Parenteral nutrition (not via normal gastric system, uses blood system)
- Total Parenteral Nutrition (TPM)
- IV line (fluids only - hydration)
Explain what nasogastric feeding is, including some advantages and disadvantages
Tube feeding via nose to stomach; provided continuously or in ‘bolus’ feeds
Advantages:
- allows temporary delivery of non-oral nutrition during swallow recovery/health recovery (temporary, 6-8 weeks)
- no surgery required
- easy to insert
Disadvantages:
- physical presence in the nose, pharynx and oesophagus
- potential for reflux - can lead to aspiration
- patient can take out easily
- uncomfortable for patient
What are nasojejunal/orojejunal tubes?
- tubes via oral or nasal and into jejunum - bypassing stomach
What is jejunostomy?
- where the tube is placed below the stomach into the jejunum
- placed to reduce the risk of reflux
What is gastronomy? Include disadvantages
- general surgical procedure performed under general anaesthetic
- most typically inserted percutaneously
- generally considered a long term solution to severe swallowing disorder as it removes the risk of nasal and pharyngeal irritation
- continuous or bolus feeds
Disadvantages:
- stoma site can leak, become sore or infected
- not necessarily permanent - i.e. reversible if swallow improves
- issues of reflux can be problematic for some patients
What is Total Parenteral Nutrition?
= non-enteric
Parenteral nutrition - by way of solution infused directly into the blood stream
- for nutrition depleted patients who can’t take nutritional needs via enteral means (typically GI tract is non-functional)
- infused into a central/main vein
- very expensive
- typically only used for critically ill
