Dysphagia Dysphagia (the medical term for difficulty (the medical term for difficulty

swallowing)swallowing)

Refer to SLPRefer to SLP

When your patient is requiring cues to When your patient is requiring cues to swallow.swallow.

When food/liquid is falling out of patient’s When food/liquid is falling out of patient’s mouthmouth

When food is stuck in their cheeksWhen food is stuck in their cheeks When patients are coughing or choking When patients are coughing or choking

when eatingwhen eating When their voice is wet/gurgly consistentlyWhen their voice is wet/gurgly consistently When the patient reports “things are getting When the patient reports “things are getting

stuck”stuck”

Obtaining a ReferralObtaining a Referral

1. Consult with the SLP1. Consult with the SLP 2. Request swallow evaluation 2. Request swallow evaluation

through through

nursing or physiciannursing or physician

Cues for safe intakeCues for safe intake

Swallowing strategies or “cues” may Swallowing strategies or “cues” may include:include: Small bites/single sipsSmall bites/single sips Chin tuckChin tuck Tongue or finger sweepTongue or finger sweep Alternate liquids with solidsAlternate liquids with solids Clear throat (if gurgly) and swallow againClear throat (if gurgly) and swallow again Swallow with effort Swallow with effort Double swallowDouble swallow

RHFW Swallowing ProtocolRHFW Swallowing Protocol

Have you ever wondered if your Have you ever wondered if your patient is on a special diet due to patient is on a special diet due to dysphagia ?dysphagia ?

If so, the following information will be If so, the following information will be very beneficial to you.very beneficial to you.

How to check patient’s diet How to check patient’s diet

1. Physician’s orders1. Physician’s orders

2. Nursing blue book2. Nursing blue book

3. Orange arm band on patient to have 3. Orange arm band on patient to have

current dietcurrent diet

4. Rehab Dining Program book for special4. Rehab Dining Program book for special

diets (located in top drawer in diningdiets (located in top drawer in dining

room)room)

How to check patient’s diet How to check patient’s diet – cont’d.– cont’d.

4. Orange sheet placed above patient’s 4. Orange sheet placed above patient’s

bed lists diet and strategiesbed lists diet and strategies

5. If still unsure, consult with SLP5. If still unsure, consult with SLP

RHFW Diet ModificationsRHFW Diet Modifications

Mechanical soft – No tossed salad, bread is Mechanical soft – No tossed salad, bread is being sent out instead of toast at breakfastbeing sent out instead of toast at breakfast

Mechanical soft with chopped meat – as Mechanical soft with chopped meat – as listed above, except the meat is cut into listed above, except the meat is cut into small piecessmall pieces

Mechanical soft with ground meat – as listed Mechanical soft with ground meat – as listed above, except the meat comes groundabove, except the meat comes ground

Diet Modifications Cont’dDiet Modifications Cont’d

Mixed Mechanical Soft and Pureed dietMixed Mechanical Soft and Pureed diet

This is when 1 or 2 items are soft solid This is when 1 or 2 items are soft solid

i.e. macaroni and cheese. i.e. macaroni and cheese.

*the rest of the patient’s foods are puree *the rest of the patient’s foods are puree

consistency, i.e. applesauce, mashed consistency, i.e. applesauce, mashed

potatoespotatoes

RHFW Diet ModificationsRHFW Diet Modifications- cont’d.- cont’d.

Pureed diet – all foods are pureedPureed diet – all foods are pureed

Appropriate snacks we offer are Appropriate snacks we offer are applesauce, yogurt, ice cream, applesauce, yogurt, ice cream, pudding, baby food (available from pudding, baby food (available from kitchen)kitchen)

Liquid ModificationsLiquid Modifications Nectar Thick Liquids – the consistency of Nectar Thick Liquids – the consistency of

syrup or fruit nectar.syrup or fruit nectar.

To thicken to nectar consistency, use a To thicken to nectar consistency, use a 120ml juice or ½ of a styrofoam cup of 120ml juice or ½ of a styrofoam cup of liquid, add 1 nectar thickener packet and liquid, add 1 nectar thickener packet and stir 15 sec., let sit 3 minutes, assess stir 15 sec., let sit 3 minutes, assess consistency prior to giving to patient. Is consistency prior to giving to patient. Is it too thick or not thick enough? Do you it too thick or not thick enough? Do you know what to do if it doesn’t look right?know what to do if it doesn’t look right?

Liquid Modifications – Liquid Modifications – cont’d.cont’d.

Honey Thick Liquids – thicken to the Honey Thick Liquids – thicken to the consistency of honey. consistency of honey.

Thicken 120 ml juice or ½ of a small Thicken 120 ml juice or ½ of a small styrofoam cup of liquid by putting in styrofoam cup of liquid by putting in 1 honey thickener packet, stir for 15 1 honey thickener packet, stir for 15 seconds and then sit for 3 minutes. seconds and then sit for 3 minutes. Assess the consistency.Assess the consistency.

Where to find thickenerWhere to find thickener

1. With the condiments in the dining room1. With the condiments in the dining room

2. Ring the bell and ask the dietary staff2. Ring the bell and ask the dietary staff

3. Nurses station, in the nourishment room.3. Nurses station, in the nourishment room.

What kind of thickener do What kind of thickener do we use?we use?

RHFW currently uses Thick & EasyRHFW currently uses Thick & Easy Comes in individual packetsComes in individual packets Starch based productStarch based product We also have pre-thickened apple and We also have pre-thickened apple and

orange juice as well as thickened milk. orange juice as well as thickened milk.

Where would a patient buy Where would a patient buy thickener?thickener?

Thickener can be purchased at Thickener can be purchased at places such as Wal-Mart or other places such as Wal-Mart or other pharmacies. Often you may have to pharmacies. Often you may have to ask at the counter for it. ask at the counter for it.

Thickeners can be purchased in Thickeners can be purchased in packets, in canisters or in pre-packets, in canisters or in pre-thickened liquid form.thickened liquid form.

Do we have any pre-thickened Do we have any pre-thickened liquids?liquids?

Yes,Yes, we have nectar and honey we have nectar and honey thickened boxes of milk, apple and thickened boxes of milk, apple and orange juice. Ensure and V-8 are orange juice. Ensure and V-8 are naturally nectar thick.naturally nectar thick.

Location: Cafeteria and in the Location: Cafeteria and in the nourishment room.nourishment room.

Rehab Dining ProgramRehab Dining Program

Purpose: To provide a Purpose: To provide a comprehensive, multidisciplinary, comprehensive, multidisciplinary, organized system to identify, assess, organized system to identify, assess, treat and supervise/assist patients treat and supervise/assist patients with swallowing and/or feeding with swallowing and/or feeding difficulties.difficulties.

Dining Program ObjectivesDining Program Objectives

1.1. To identify patient with need for assist/supervision To identify patient with need for assist/supervision at meal to increase independence and safety with at meal to increase independence and safety with eating/swallowing.eating/swallowing.

2.2. These patients eat together at RESERVED tablesThese patients eat together at RESERVED tables3.3. Written recommendations for swallow precautions, Written recommendations for swallow precautions,

self-feeding techniques and adaptive equipment self-feeding techniques and adaptive equipment for consistent follow through.for consistent follow through.

4.4. Advance diet and reduce assist/supervision as Advance diet and reduce assist/supervision as appropriate to reflect progressappropriate to reflect progress

5.5. Educate patient and caregiver regarding Educate patient and caregiver regarding swallowing/feeding needs throughout their stay.swallowing/feeding needs throughout their stay.

Appropriate Dining Program Appropriate Dining Program ReferralsReferrals

1.1. Oral and pharyngeal dysphagiaOral and pharyngeal dysphagia

2.2. Visual deficits including neglect Visual deficits including neglect and/or inattentionand/or inattention

3.3. Inadequate intake due to cognitive Inadequate intake due to cognitive deficitsdeficits

4.4. Hemiparesis, quadriparesisHemiparesis, quadriparesis

Rehab Dining ProcedureRehab Dining Procedure

1.1. Patients will be identified as possible candidates Patients will be identified as possible candidates during assessment and as they progress, i.e.: during assessment and as they progress, i.e.: from NPO to PO statusfrom NPO to PO status

2.2. Speech and/or Occupational Therapy will assess Speech and/or Occupational Therapy will assess and recommend dining program as appropriate. and recommend dining program as appropriate. Nursing may refer for consideration also. Nursing may refer for consideration also.

3.3. Speech and/or OT will complete a Rehab Dining Speech and/or OT will complete a Rehab Dining Precautions/Program Sheet (Orange). This will Precautions/Program Sheet (Orange). This will be placed above the patient’s bed and in be placed above the patient’s bed and in binder. This binder is located in top drawer of binder. This binder is located in top drawer of cabinet in the dining room.cabinet in the dining room.

Rehab Dining Procedure Rehab Dining Procedure - cont’d.- cont’d.

4. Patients will sit at designated tables during 4. Patients will sit at designated tables during mealtime. Visitors may sit close by as appropriate.mealtime. Visitors may sit close by as appropriate.

5. Assigned therapy/nursing staff will supervise the 5. Assigned therapy/nursing staff will supervise the patients given their individualized programs. Other patients given their individualized programs. Other staff will also assist with tray set-up.staff will also assist with tray set-up.

6. Status/progress will be documented in the therapy 6. Status/progress will be documented in the therapy notes and nursing notes. Change in status should be notes and nursing notes. Change in status should be communicated directly with the primary therapist for communicated directly with the primary therapist for the responsible patient.the responsible patient.

7. A change in diet or strategies will be updated on the 7. A change in diet or strategies will be updated on the orange sheet in binder and above patient’s bed. orange sheet in binder and above patient’s bed.

Team Conference Form Team Conference Form and and

SwallowingSwallowing

Goal: to be consistently Goal: to be consistently completed by OT or SLP completed by OT or SLP (when on the case).(when on the case).

SLP’s are currently scoring the swallowing SLP’s are currently scoring the swallowing section using Max, Mod, Min etc. depending section using Max, Mod, Min etc. depending on the level of cuing. on the level of cuing.

Also, list the diet (Min A mech. soft & grd Also, list the diet (Min A mech. soft & grd meat) meat)

Use FIM scoring as follows Use FIM scoring as follows

Independent (7) – Regular diet and thin Independent (7) – Regular diet and thin liquids, no cues.liquids, no cues.

Independent with strategies (6) with all Independent with strategies (6) with all consistencies.consistencies.

Supervision (5) = Pt. swallows more than Supervision (5) = Pt. swallows more than 90% of the time without cues.90% of the time without cues.

FIM Scoring

Min A (4) = Pt. swallows 75 - 90% of Min A (4) = Pt. swallows 75 - 90% of the time without cues.the time without cues.

Mod A (3) = Pt. swallows 50 – 74% of Mod A (3) = Pt. swallows 50 – 74% of the time without cues.the time without cues.

Max A (2) = Pt. swallows 25 – 49% of Max A (2) = Pt. swallows 25 – 49% of the time without cues.the time without cues.

Dependent (1)– Pt. is NPO or swallows Dependent (1)– Pt. is NPO or swallows without cues less than 25% of the time.without cues less than 25% of the time.

FIM Scoring – Cont’d.

Questions? Questions?

Contact Speech Contact Speech Therapy at Therapy at

X 6135 or x 6136X 6135 or x 6136

Print the test, complete, copy for yourPrint the test, complete, copy for yourrecords and give the original to yourrecords and give the original to yourmanager. manager.

For Therapy Services, Evan should For Therapy Services, Evan should receivereceive

a copy in his box.a copy in his box.

Thank you!Thank you!