The Center for Life Enrichment Resource: MTTP Student Manual What is Dysphagia? Dysphagia is a condition of having difficulty swallowing Dysphagia is due to problems or damage in nerve or muscle control in the throat It is common after a stroke or in individuals with cerebral palsy Why does dysphagia occur? Dysphagia occurs when there is a problem with any part of the swallowing process Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing. As a result, food pieces that are too large for swallowing may enter the throat and block the passage of air How are people affected? People with dysphagia have difficulty swallowing and may also experience pain while swallowing Some people may be completely unable to swallow or may have trouble swallowing liquids, foods, or saliva Eating may become a challenge Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body The Process of Swallowing The process of swallowing involves the interaction of more than 20 muscles and several nerves The entire process is completed in several seconds The Normal Phases of Swallowing: Stage 1 1) Oral Phase- Food is placed in the mouth, chewed and turned into a bolus (lump of chewed food mixed with saliva) The bolus is moved toward the throat by the tongue The Normal Phases of Swallowing: Stage 2 2) Pharyngeal Phase- Food is moved by wave-like muscle action down the throat to the esophagus (tube to the stomach) During this process, the epiglottis closes to protect the trachea (breathing tube) Next the food enters the esophagus (tube to stomach) If the epiglottis doesn’t close properly, the bolus may enter the trachea and go into the lungs causing aspiration If there is abnormal muscle movement then the food bolus can become stuck causing a blockage/choking The Normal Phases of Swallowing: Stage 3 Esophageal Phase- Food is moved by wave-like muscle movement through a muscle ring into the stomach Normally, the food enters and stays in the stomach where the digestive process continues If the muscle ring does not function properly, stomach contents may go back up (reflux) into the esophagus 3) This is associated with heartburn or indigestion and is called Gastro-Esophageal Reflux Disease (GERD) What the individual might complain about/What to look for? There are identified “red flag indicators” that should be watched for during meals. Some of these include, but are not limited to: Pocketing food under the tongue, in cheeks or the roof of mouth Food remaining on the roof of the mouth or on tongue after swallowing Food spilling out of the mouth Diagnosis of stroke, cerebral palsy, GERD Taking fluids to drink to facilitate swallowing without chewing properly Putting food in the mouth before swallowing the previous bite More “Red Flag Indicators” Not chewing food adequately Tongue thrusting noted Coughing noted while chewing, when swallowing or after swallowing Regurgitating food or liquids from nose or mouth Eating quickly Eating very slowly Spitting food out of mouth Talking with food in mouth Stealing food Food stuffing PICA behavior (persistent and compulsive cravings to eat nonfood items) Excessive drooling Choking Throat clearing during meals or fluids “Wet” vocal sounds (gurgling) Multiple swallows of the same mouthful of food Gagging/retching Putting hands in mouth or forcing self to vomit Weight loss Complaining that food feels “stuck” Refusing to eat How is dysphagia diagnosed? Individuals with dysphagia or choking issues may self identify their signs/symptoms or family or staff may identify signs/symptoms A Choking Monitoring Tool has been developed by DDA and the following protocol should be followed in this order: 1. Staff notices a “red flag indicator” of choking as listed on the previous slides 2. Staff reports to the RN that a “red flag indicator” was observed 3. RN instructs the staff to complete the Choking Monitoring Tool 4. Staff completes the Tool as instructed by the RN and returns info to the RN or the RN completes the tool 5. RN evaluates the completed Tool and determines if further intervention is needed by the individual’s HCP The Choking Monitoring Tool Based on the information provided on the Choking Monitoring Tool, the HCP may recommend texture alterations in the diet or that the individual undergo a Swallowing Study where the mechanics of the swallowing process can be observed and aspiration determined If aspiration is an issue, then a G or J tube may be recommended In addition to the Choking Monitoring Tool, the RN may complete a “Choking Risk Screening Tool” What is the treatment? The HCP may order an alteration in diet consistency to address eating difficulties Puree- Blended Ground- Minced Chopped- Mechanical Soft Bite Size Regular Puree- Blended Description- smooth with no lumps, pudding like Consistency- smooth and thick enough to mound on a plate May need to add extra liquid when preparing Ground- Minced Description- foods are moist and soft textures Food processed to the size of rice or taco meat May add some liquid or condiment to help mix Chopped- Mechanical Soft Description- meats chopped ½ inch in size, other foods soft Meat cut into ½ inch pieces, fruits, and veggies chopped into fruit cocktail-size pieces Sandwich cut into 8 pieces or more- use soft breads and fillings Bite Size & Regular Bite Size Description- all foods cut or broken into 1 inch pieces Regular No preparation needed Liquids Liquids can be very difficult for an individual with a swallowing disorder to handle safely Liquids can be thickened to facilitate safe swallowing The HCP may order thickened liquids in the following manner: Nectar Consistency Honey Consistency Pudding Consistency Thin Consistency Nectar Consistency Description- able to go through straw, glides off spoon Examples- fruit nectars, shakes, eggnogs, smoothie Honey Consistency Description- will not go through a straw, flows slowly off a spoon Examples- honey, karo syrup, molasses Pudding Consistency Description- needs to be fed with a spoon Examples- pudding, yogurt Thin Consistency Description- no preparation needed Examples- water, tea, coffee, thin juices, soda Warning! Individuals who have been ordered thickened liquids should not be given foods that become liquid at room temperature. For example, gelatin, ice cream, sherbet, water ices, smoothies, shakes Follow directions on thickener packaging to achieve consistency as ordered Liquids given with medication must also be thickened as ordered The consistency of thickened liquids changes over time (continues to thicken) Your Responsibility Always be alert and observant while individuals are eating Choking Monitoring Tool should be completed when “red flag indicators” are noted Report any problems to the RN as soon as possible! Check out: Swallow: A Documentary - Dysphagia http://youtu.be/MrbEUDO6S5U Normal vs. Abnormal Swallowing http://tcle.org/employee-resources/ Part 2 Aspiration Pneumonia Aspiration of foreign material into the lungs may develop into pneumonia Aspiration occurs when the body’s normal defense against aspiration are breached For example, when the muscles used in normal swallowing do not function properly, material from the mouth can enter the trachea and lungs rather than the esophagus and stomach Individuals at Risk for Aspiration include, but are not limited to: Those with… Impairment of consciousness Seizure Disorder Impairment of esophageal function (including Hiatal Hernia, GERD) Impairment of swallowing mechanism (including cerebral palsy) Impairment of cough mechanism (including neuromuscular weakness, cerebral palsy) Oral/dental/sinus infections What the individual might complain about/What to look for? The individual may have experienced a one-time episode of aspiration or may experience on-going subtle aspiration These experiences may or may not be identified or witnessed The individual may present with shortness of breath, low blood oxygen levels, low blood pressure, fever, and chest x-ray changes How is it diagnosed? Aspiration pneumonia is usually diagnosed by clinical presentation and x-ray findings Failure of a swallowing study supports the diagnosis of aspiration pneumonia What is the treatment? The individual may be hospitalized for treatment of aspiration pneumonia Treatment may include suctioning and intubation (the insertion of a tube into the patient's airway) to protect the airway from further aspiration Supplemental oxygen may be needed Antibiotic therapy is required Your Responsibility If you identify “red flag indicators” for choking as described in the previous slides, the RN should be notified immediately Any symptoms of respiratory distress should be reported to the RN immediately Questions?