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Dysphagia > Bedside Evaluation > Flashcards

Flashcards in Bedside Evaluation Deck (26):
1

Bedside Evaluation History (6)

- Respiratory Status (ventilator, trach, pnemonia?)

- History of Swallowing Problem (How long, what type, describe it, what type of food causes choking, and how often)

- Nutritional Status (How do they get their nutrition, Do they have trouble with liquids, soft foods, or meat (we don't need to know their food preferences)

- Neurological Examination Results (any disorders that can cause swallowing issues)

- Otolaryngologic Examination Results (any VF paralysis)

- Dysphagia Symptoms

--- What type of medications is the pt. on, do they reduce salivia, do they have dry mouth?

--- Has the pt. had any other swallowing evals? (what is the outcome, did it help, what compensatory treatments did they learn?

--- ask about symptoms

2

Observation of Patient (7)

1 Patient Posture (Do they have good tone, weakness, head falling forward)

2 Patient level of alertness (pt. must be alert and cooperative)
--- Must be able to follow directions
--- If the pt. can not produce a voice you cannot do a bedside exam, need to do a MBS, because you must be able to voice to see if a pt. is aspirating
--- You can feel the swallow, even if they cannot voice, but you still have to do MBS
--- Pt. w/ dementia, they may be alert, but not cooperative so you need to do a MBS

3 Patient management of their own secretions (Individuals who are drooling, frothing, and unable to handle secretions are very severe and should have a MBS)

4 Presence of congestion (May be a sign of pneumonia, refer for a modified if you cannot clear the congestion. Have the pt. try to clear the congestion and then say /a/, it could be due to excess mucus on the VF. If voice was clear after clearing throat you can do a bedside. If gurgly/wet voice continues, do MBS)

5 Presence of Tracheostomy tube & status (How long has the pt. had the trach?, we don't do swallow studies on pts. who have been extubated unless it has been 24 hours, larynx needs to recover

6 Ability to follow directions

7 Correspondence of observation with information from chart & nursing staff ( ask the nurses about choking and talk to the family)

*** If pt. can't do water (may have weak musculature) Thin liquids, water, is the most difficult to swallow (but water is safest to aspirate)

*** If pudding causes a problem (thicker consistencies maybe a pharyngeal issue, pharyngeal parastylsis issues, think about innervation what's causing it?)

3

Patient Report (6)

- Patients description of Problem ( a lot of pts. have trouble describing swallowing problems)

- Onset of the problem

- Course of the problem (has it gotten worse or better)

- Management of various food consistencies (better with liquids, solids, soft foods, hardest consitency is water because it moves the fastest)

- Localization of disorders

- Presence of coughing (signifies aspiration, could be silent)

4

Oral Motor & Anatomy Exam

- Anatomical Assessment

- Functional Assessment of articulators

- Areas to look at:

--- Labial Functions

--- Lingual Functions

--- Soft Palate Functions

--- Oral Reflexes

--- Laryngeal Functions (diaodichokinetic rate /i/ /i/ /i/, or have pt. cough voluntarily)

5

Labial Functions

- Lip spreading/rounding

- Rapid alterations /i/, /u/

- closure (tight closure, how long can they do it)

6

Lingual Functions

- Lingual Functions

1. Tongue tip /ta/

--- Tongue Extension

--- Rapid alternations (lateralize quickly)

--- Tongue activation

--- Diadochokinetic rate

2. Posterior of the tongue /ka/ (therapy technique)

--- Lift back of tongue & hold

--- Diadochokinetic rate

--- Sentence repetition

7

Soft Palate Reflexes

- Sustain /a/

- Rapid repetition /a/

*** Listen for hypernasality

8

Oral Reflexes (3)

1. Palatal Reflex (elevation of the palate)

*** Say /a/ and watch bilateral movement

- Junction of hard & soft palate

- Junction of soft palate & uvula

2. Gag Reflex

- Base of tongue or posterior pharyngeal wall

3. Swallow Reflex (tongue triggers swallow)

- Base of anterior faucial pillar

9

Laryngeal Functions 1

1. Voice Quality

2. Diadochokinetic Rate

1. Hoarse or breathy

- Poor laryngeal closure, laryngeal function examination

2. Does it sound breathy when they do /puh, tuh, kuh/?

- Ask to patient to cough (voluntarily) is it strong or weak (can VF go together)

10

Laryngeal Functions 2

1. Pitch

2. Sustain /s/ & /z/

3. Length of Phonation

1. Slide voice up and down scale

--- Evaluates external superior laryngeal nerve which triggers the swallow reflex

--- Inability to change pitch

----- Cricothyroid

* If pitch is monotone, we know that the cricothyroid muscle is impaired

* Assess pitch if you think that the pt. has a pharyngeal phase issue (Same CN innercation for the cricothyroid as base of pharynx)

2. How long?

3. Measures respiratory capacity

11

Time swallow & up and downward excursion of larynx

- Index finger at the base of the tongue

- Middle finger on hyoid bone

- Place 3rd finger on top thyroid cartilage

- Place 4th finger on bottom thyroid cartilage

- To assess initiation time (time bolus moves through oral cavity to initiation of swallow)

- Normal Swallow time is between 1 & 2 seconds

12

Behavioral Assessment

1. Memory (Dementia patient could have trouble with swallowing because they can't remember how to do it)

2. Self-Discipline

3. Ability to Follow Directions

13

Food Assessment Materials 1 (6)

- Size 00 laryngeal mirror

- Metal spoon

- Straw

- Tongue blade

- Suction machine (trachs and vents)

- Blue food coloring (used with trachs and vents, allergies can be an issue, not used everywhere)

14

Food Assessment Materials 2 (food) (8)

- Glass of H2O

- Nectar thick liquids

- Honey thick liquids

- Applesauce (thin puree)

- Pudding (thick puree)

- Fruit cocktail or banana (mechanical soft)

- Ground meat

- Bread

*** You can thicken liquids if the pt. is at risk of aspirating (safer to aspirate water with thick it)

15

Bedside Swallow Test

What are you looking for? (3)

- Using the tray of food, the SLP will determine:

--- use of the lips, cheeks tongue to take in food and swallow it,

--- watch for signs of aspiration,

--- make recommendations about how the patient should eat (types of food and liquid, position, kinds of utensils

* For each consistency you are making an assessment + taking notes

* Start with the pts. original diet ( if pt. is on nectar thick liquids, start there.

* Lots of aspiration, stop and switch to MBS

16

Clinical Signs of Aspiration (5)

- Coughing and choking

- Wet sounding voice- have pt. clear throat and get a baseline. Then have pt. swallow and try to produce /a/ again.

- Throat clearing

- Swallowing multiple times for a small bite

- Limited movement of the larynx in the neck

*** With every consistency listen to the voice afterwards (you need to have voice)
--- Have the patient sustain /a/

17

Procedures Sometimes Used During Bedside Swallowing Screenings

1. Cervical Auscultation

2. 3 ounce water swallow test

3. Blue dye test

18

Cervical Auscultation

- Means listening to a patient’s breath sounds

- Procedure:

--flat diaphragm of the stethoscope is placed laterally on the neck

--clinician listens with stethoscope to breath sounds

19

Sound of Normal Swallow Sequence

- Breath sounds are heard

- Breathing stops (usually in the middle of an exhalation

- A sound described as a clunk or a swish is heard

- Breath sounds are heard again

20

Can you hear aspiration?

- Aspiration is suspected if a flushing sound of material is heard prior to the initiation of the swallow

- With wet breath sounds,

- Coughing, or

- A distorted voice after the swallow

21

3 ounce Water Swallow Test

- Patient given 3 ounces of water in a cup and asked to drink without interruption

- Abnormal response:
--- coughing during or for one minute after completion of the swallow, or a wet gurgly voice quality after the swallow.

--- Use this test for recommendation of a MBS

22

Blue Dye Test 1

- This test is a screening test for aspiration that may be used at beside with the tracheostomized patient

- The patient can be given measured amounts of blue-dyed foods and the tracheostomy suctioned immediately after the swallow for the presence of the blue-dyed foods, indicating aspiration the test does not reveal

--- The anatomic or physiologic causes of aspiration

- The result is clearly positive however, if the blue dye is evident through the coughing or suctioning from the tracheostomy tube the clinician should recommend a radiographic study.

23

Blue dye test 2

- Blue tinged secretions that are later suctioned from the tracheostomy

--- Do not necessarily mean that the patient is aspirating

- It is normal for the blue dye to mix with secretions and gradually coat the trachea

- Unless a variety of food consistencies are presented the patient may not aspirate on the food consistency tested but may aspirate on other food consistencies

24

Procedures for Blue Dye Test

- The nurse should suction

- Consider the optimum food & posture positions

- Begin with easiest consistency

- Use small amounts of materials

- Provide detailed instructions to the patient

- Proceed slowly

25

Signs & Symptoms of Dysphagia (6)




1. Pocketing food in the sulci or collection of food on the hard palate

2. Delayed or absent elevation of the hyoid bone & thyroid cartilage

3. Coughing & choking (silent aspirators can not be identified at bedside)

4. Gurgly voice quality

5. Excessive secretions (may be a result of aspiration)

6. Expectoration or regurgitation (could be esophageal obstruction)

26

MBS

-Different consistencies are dipped in barium some consistencies as bedside swallow tray (looks at esophagus up)

- Barium just involves a big cup of barium, looks at esophagus down. It shows how food enters the stomach through the esophagus.