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Dysphagia 3
Assessment
Question | Answer |
---|---|
3 Major Components of CSE | 1. medical history 2. physical examination of the swallowing mechanism (OME) 3. test swallows |
Purposes of CSE | - determines presence of dysphagia but does not disprove or prove aspiration - gives insight to anatomical and physiological factors - relative complication risks - alternate means of management - additional tests needed |
Relative Complication Risks of Dysphagia | - aspiration - dehydration - malnutrition - loss of enjoyment |
6 Reasons for CSE | 1. determine potential cause 2. develop a working hypothesis 3. tentative treatment plan 4. develop further questions 5. is the pt ready for treatment? 6. instrumental eval? |
Outcomes of CSE | - determine underlying neuromuscular function - onset, progression pattern, symptoms/signs - influencing factors - monitor progression - estimate prognosis - estimate long-term outcomes |
Limitations of CSE | - lack of methods for scoring - inconsistencies in observations - complete information not provided - aspiration/penetration cannot be viewed - only one moment in time |
Additional Factors to Monitor/Consider | - heart rate - pulse oximetry (oxygen is bound to hemoglobin) - respiration |
Signs and Symptoms of Hypoventilation | - fatigue - hallucinations - lethargy - disturbed sleep - depression - reduced appetite |
Signs | - objective - clinical measures/observations of behaviours during an exam |
Symptoms | - subjective - patient-reported change in bodily functions or sensations |
Pulmonary Defence Risk Factors for Pneumonia | - oral hygiene - loss of anatomical defences - blunted airway reflexes - impaired mucocillary clearance - weakened immune system |
Chart Review | 1. current hospital status 2. Hx and nature of the problem 3. medical conditions 4. medications 5. airway device hx? 6. hx and current nutrition status |
Interview Questions | - when did it start - how did it progress - what foods/liquids cause issues - do things get stuck - pain? - food allergies? - baseline diet - health history |
Observations during Ax | - LOA/mental status/behaviour - affect - nutritional state - motor speech - lang - independence - hydration - medical/health aids |
General Physical Findings | - respiration - speech/voice - mobility - upper extremity function - visual and auditory systems - muscle and bodily stability - coordination |
More Observations | - positioning - alertness - speech & lang - attention to the task - desire to eat - agitation |
Oral Phase Observations | - adequacy of chewing - oral clearance/residue - duration of the oral phase - endurance/fatigue - manner of feeding - behaviours during feeding - pocketing - premature spillage |
Pharyngeal Phase Observations** | - signs of airway compromise - vocal quality (before and after the swallow) - weakness (unilateral often) - decreased strength of pharyngeal constriction - residue - decreased hyolaryngeal elevation - delayed initiation d/t decreased sensation |
Signs of Airway Compromise | - post swallow expiration - airway congestion - coughing/throat clearing - change in breathing pattern - shortness of breath post swallow - increased resp rate - wheezing |
Vocal Quality (Before and After Swallow) | - wetness? - difficulty clearing secretions? - dry? - endurance or fatigue over time |
Esophageal Phase Observations ** | - effortful, repeated swallows - regurgitation - pt report globus sensation - reflux - increased transition time |
PO for CSE | - ice chips - water - nectar thick liquids or thickening agent - purees - mixed consistency (fruit cup) - dry solids (graham cracker/cookies) |
Objectives for MBSS | - evaluate anatomy and physiology - ID pattern of impaired physiology - ID consequences - evaluate the effect of compensatory strategies - confirm pt symptoms - make predictions |
MBSS MUST | - CSE fails to address the clinical questions presented by pt or symptoms - dysphagia characteristics are vague - respiration compromise - underlying medical problems - results required to set clinical course ** |
MBSS MAYBE | - direction of swallow rehab - high risk of aspiration due to pre-existing med dx - swallowing demonstrates an overt change - status fluctuates |
MBSS NO | - pt is in a fragile condition - pt won't fit into the machine - pt is not likely to cooperate - clinical judgement is such that the results will not alter clinical course* |
FEES MUST | - CSE fails to address the clinical questions presented by pt or symptoms - dysphagia characteristics are vague but esophageal issues are not detected - results are required to set clinical course - MBSS is not an option |
FEES NO | - blood range doesn't permit - nasal fractures/complex facial features - pt is agitated - pt has a CSF leak |
OME V Trigeminal | - touch different parts of face - open jaw and resist - move jaw side to side |
OME VII Facial | - raise eyebrows - close eyes tightly - puff out cheeks - purse out your lips - smile - put lips around a straw |
OME X Vagus | - voliltional cough - stick out your tongue and say "ahhhhh" and then ah-ah-ah - palpitate the swallow |
OME XII Hypoglossal | - stick tongue out - move tongue up and down - move tongue side-to-side - press tongue against the side of your cheek - sweep teeth with tongue |