Medical record review Pt Interview Cathy Lazarus Screening Purpose of screening Provides indirect evidence that the pt has a swallowing disorder Determine if the pt is A normal swallower Exhibits symptoms of oral stage dysfunction ID: 1047091
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1. Clinical AssessmentScreeningMedical record reviewPt. InterviewCathy Lazarus
2. Screening
3. Purpose of screeningProvides indirect evidence that the pt has a swallowing disorderDetermine if the pt isA normal swallower Exhibits symptoms of oral stage dysfunctionAt risk for aspiration is high & further Dx assessment is needed
4. Principles of screeningAsk other therapistsFacility specificRequest screens routinelyScreen only if problem noted15 minutes or less EasyInexpensiveHands-off in some facilitiesAnswers the ? Is the pt dysphagic?Does not answer the ? What is the nature of the swallowing disorder?
5. Screening formQuestions 1-4Chart reviewQuestions 5-10Brief observation of pt
6. Infants, children, DD adults, dementia indicators for full evalRejects foodInadequate intakeFood selectivityTaste, temperature, textureGaggingForward gag triggerNo gag triggerOpen mouth posture during eatingExamine nasal and oral structures
7. Bedside or clinical examinationPreparatory examination&Initial swallowing evaluation
8. Preparatory examinationMedical historyConversation with medical staffSkilled nursing facility (SNF)HospitalConversation with ptConversation with familyPt chart review
9. Pt chart reviewCurrent/past medical problemsCurrent/past medications Xerostomia Reduced alertnessDelayed reaction timeHx of swallowing disorderTime of onsetNature of onsetFood catching in pharynx
10. Pt chart reviewHx of swallowing disorderTime of onsetNature of onsetFood catching in pharynxDifficult and easy foodPts perception or awareness of the problem
11. Pt chart reviewAirway device placementEndotrach tube (intubation) during surgeryMechanical ventilationTracheostomy (tracheotomy)http://library.umsmed.edu/pe-db/images/pe-intub.jpghttp://www.tracheostomy.com/equipment/images/t-tube.jpghttp://en.wikipedia.org/wiki/Tracheal_intubation
12. Pt chart reviewOral nutritionDiet consistenciesNon oral nutritionType of tubeNG tubeNasal gastricPEG tubePercutaneous endoscopic gastrostomy (PEG) Through skin into stomachJejunostomyThrough skin into small intestineDuration of placementComplicationshttp://www.btinternet.com/~cliff_forsyth/peg05.jpg
13. Additional chart review itemsComments in nursing notes onAbility to follow directionsMotivationCognition levelBehavioral concerns
14. Pt chart review (Groher 2003)
15. Initial swallowing exam
16. ObservationsRespiratory statusRate at restRespiratory distressPostpone evalSaliva swallowed duringInhalationExhalationTiming of coughRespiration-cough coordinationhttp://www.natural-care.com/room.jpg
17. ObservationsHow long can pt hold breath1, 3, 5 sec.Nasal or mouth breather?http://media.scout.com/Media/Image/19/196120.jpg
18. Trach tubesPresence of trach tubeCuffed or uncuffedRecommended reading on trach tubeshttp://catalog.nucleusinc.com/enlargeexhibit.php?ID=852www.tracheostomy.com http://www.petergerrard.homestead.com/files/procedure.jpg
19. Trach tubesPassy-Muir speaking valve (above)Fenestrate tube (right)http://www.passy-muir.com/patients/photos/halloween04.aspx
20. Trach tubesTrach in >6 mosScar tissueReduced laryngeal elevationCuff should be deflated for swallow exam if possible
21. VentilatorsSwallowing reciprocal (opposite) of respirationPt must be able to complete pharyngeal swallow during vent’s exhalation timeBlue dye test Controversial
22. Questions for ptWhen did swallow problem begin?Has it gotten worse slowly or rapidly?Are some foods/liquids more difficult?What happens when you try to swallow?Does food stick anywhere? High? Low?Pts reliable with oral and pharyngeal disordersPts NOT reliable with esophageal disordersDo you cough or choke? When?50% are silent aspirators