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Chapter 11 - Disorders of Swallowing
Terms in this set (67)
Swallowing disorder increase the risk of ____________
What is gastroesophageal reflux (GER)?
movement of food or acid from the stomach back into the esophagus
What is aspiration?
inhalation, especially the inhalation of fluid or food into the lungs; in phonology, a puff of air that is released in the production of various allophones
What are the lifespan issues of swallowing disorders?
*problems occur in children and adults
*newborns may be unable to suck/ingest nutriment
*may refuse food, develop unhealthy habits
*related to diverse conditions
*feeding difficulties in kids can stress the parent/child relationship
*among older people, it can lead to isolation, depression, frustration, and diminished quality of life.
What are the outcomes of swallowing disorders?
*malnutrition and ill health
What is a bolus?
A chewed lump of food ready for swallowing. Or, the substance to be ingested when eating or drinking.
What are the four phases of swallowing?
*oral preparation phase
The swallowing process: what is the oral preparation phase?
*the tongue cups to hold fluid in a liquid bolus against the front portion of the hard palate
*the tongue and cheek move the food to the teeth to form a solid bolus
*the prepared bolus is held in the mouth by the soft palate, which moves forward and down to touch the back of the tongue and close the passage to the pharynx
The swallowing process: what is the oral phase?
*once the bolus is formed, the oral stage begins
*the bolus is moved from the front to the back of the mouth
*the pharyngeal swallow reflex is triggered when the bolus reaches the anterior faucial arch
*oral transit usually takes 1-1.5 seconds
The swallowing process: what is the pharyngeal phase?
*the velum contacts the rear pharyngeal wall
*base of the tongue and the pharyngeal wall move toward one another to create pressure needed to project the bolus into the pharynx
*pharynx squeezes bolus down
*hyoid bone rises, bringing layrnx up and forward
*vocal folds close and epiglottis covers airway
*complete when the pharyngoesophageal segment opens and the food/liquid enters esophagus
*usually takes less than 1 second
The swallowing process: what is the esophageal phase?
*muscles of the esophagus move the bolus in peristaltic contractions into the stomach
*usually takes about 8-20 seconds
What are some disorders that can occur in the oral preparation/oral phase?
*if the lips do not seal properly, drooling can occur
*chewing can be impaired due to poor muscle tone or paralysis involving the mouth or because of missing teeth
*insufficient saliva impedes adequate bolus formation
*muscles of the tongue might not function well
What are some disorders that can occur in the pharyngeal phase?
*if the swallow is not triggered or is delayed, material may be aspirated
*an open velopharyngeal port can lead to substances going into and out of the nose
*poor tongue mobility may result in insufficient pressure in the pharynx
What are some disorders that can occur in the esophageal phase?
*if peristalsis is slow or absent, the complete bolus might not be transported to the stomach
*residue on the esophageal walls can result in infection and nutritional problems
Infants and children with swallowing disorders may experience what?
*inadequate growth, ill heath, fatigue, difficulty learning, poor parent-child relationships
Children with _____or _____deficits or ___disease are vulnerable to feeding and swallowing disorders
CNS, PNS, neuromuscular
True or false, dysphagia may occur at any phase and may range from mild to severe
What are some causes of pediatric dysphagia?
*intellectual disability and developmental delay
*structural and physiological abnormalities
What are the characteristics of pediatric dysphagia related to cerebral palsy?
*most common cause of neurogenic pediatric dysphagia
*excessive muscle tone, abnormal posture and movements, possible hyperactive gag
*GER (gastroesophageal reflux) is common; ingestion may be painful
*uncoordinated swallowing can lead to aspiration
*may require gastrostomy tube feedings
What is spina bifida?
congenital malformation of the spinal column typically involving associated neural damage, resulting in limited sensation and motor control difficulties
What are the characteristics of pediatric dysphagia related to spina bifida?
*may experience feeding difficulties in all phases
*sensory impairments and dyspraxia can disrupt sucking and food intake
*cranial nerve damage can affect pharyngeal and esophageal stages
What are the characteristics of pediatric dysphagia related to intellectual disability and developmental delay?
*delayed motor coordination in children with ID/DD may interfere with eating and the oral phase of swallowing
*children may be limited in their ability to express food desires and preferences
What are the characteristics of pediatric dysphagia related to autism?
*children with autism may have significant feeding problems
*behaviors that can interfere with feeding include social withdrawal, impaired communication, stereotypic behaviors, and sensory hypersensitivity
*the types of food that are consumed may be restricted, possibly leading to poor nutrition
What are the characteristics of pediatric dysphagia related to HIV/AIDS?
*feeding and swallowing disorders are prevalent in children with HIV/AIDS
*they have difficulty with oral secretions and exhibit odynophagia (painful swallowing)
*HIV positive children often exhibit developmental delays, language deficits, and poor attention skills
Children born with cleft palate or lip are impaired in the ______ phase
Congenital abnormalities of the jaw, as in _________, or of the face, as in _____________, negatively affect oral intake or food.
Pierre Robin Syndrome; Treacher Collins Syndrome
________________ prevents normal esophageal swallowing and results in choking
What is pyloric stenosis?
The pyloric sphincter narrows and prevents food from entering the small intestine
Up to _____% of individuals over age 55 experience swallowing difficulties
What are the characteristics of adult dysphagia related to a stroke?
*dysphagia is a serious problem for 25% to 75% of individuals who suffer stroke
*facial paresis is the primary factor after stroke
*all phases of ingestion are likely to be slowed and impaired
*swallowing and breathing are poorly coordinated, increasing risk for aspiration pneumonia
*pneumonia is the cause for about a third of deaths following stroke
What are the characteristics of adult dysphagia related to cancer of the mouth, throat, or larynx?
*swallowing problems are likely after treatments for cancer
*dysphagia severity related to tumor size/location and the surgical procedure
*radiation may result in diminished salivation, swelling, mouth sores, and reduced swallowing reflex
*chemotherapy can cause nausea, vomiting, and loss of appetite
What are the characteristics of adult dysphagia related to HIV/AIDS?
*susceptible to numerous opportunistic infections
*esophageal ulcers and esophagitis
What are the characteristics of adult dysphagia related to multiple sclerosis?
*CNS disorder characterized by relapse and remission
*delayed swallowing reflex and reduced pharyngeal peristalsis are the primary symptoms
What are the characteristics of adult dysphagia related to ALS?
*poor tongue movement is sometimes an early sign
*reduced tongue mobility may result in spillage into the airway before the pharyngeal swallow has been triggered
*the larynx might not elevate and close adequately
*pharyngeal peristalsis is frequently reduced, causing material to remain in the pharynx
*all of these may result in aspiration
What are the characteristics of adult dysphagia related to Parkinson's Disease?
*about 30% of individuals with PD exhibit dysphagia
*oral transport may be impaired by a front-back rolling pattern of the tongue
*pharyngeal swallow may be delayed and laryngeal closure may be impaired
*aspiration can occur when the patient inhales pharyngeal residue
*esophageal motor abnormalities impede swallowing even early on
What are the characteristics of adult dysphagia related to spinal cord injury?
*higher incidence of esophageal dysphagia
*they may experience heartburn, and slow/abnormal esophageal peristalsis
*surgery to the anterior cervical spine may result in dysphagia
*oral preparatory and transport stages are impaired in some post-surgical patients; others experience pharyngeal weakness or upper esophageal sphincter malfunction
What are the characteristics of adult dysphagia related to medications and nonfood substances?
*medication can cause drowsiness/confusion, interfering with anticipation and oral phases
*dry mouth is a side effect of more than 300 medications
*high dose of steroids may impede pharyngeal swallowing
*antipsychotics may cause tardive dyskinesia: involuntary, repetitive facial, tongue, or lip movements
*smoking and excessive caffeine and alcohol can interfere with normal swallowing
What are the characteristics of adult dysphagia related to dementia?
*the cognitive deficits of dementia may impede attention and orientation to food
*impaired oral preparatory movements may result in poor bolus formation and drooling
*transport of the bolus may be prolonged
*delayed pharyngeal swallow and reduced laryngeal elevation can result in aspiration
What are the characteristics of adult dysphagia related to depression and social isolation?
*as people enter old age, they may be lonely or unmotivated to cook for themselves
*mealtime difficulties in one home for the aged were documented in 87% of residents
*depression is associated with diminished interest in food, restlessness, and fatigue
*the throat may feel tight
*some may feel too tired to eat and are exhausted after they eat, leading to malnutrition
What is silent aspiration?
Lack of cough when food or liquid enters the airway
How is the swallowing screening done for newborns?
*primary indication of dysphagia in infants is failure to thrive
*full term infants not accepting breast or bottle are signaling feeding problems
*observed during mealtimes to evaluate breathing and physical coordination, oral-motor functioning, and techniques that enable quantification of nutritive and non-nutritive sucking
How is the swallowing screening done for the elderly?
*there are checklists for screening for dysphagia in older adults
*3-ounce water test identifies 80-98% of patients who are aspirating (but maybe not silent aspiration)
*stroke patients who exhibit a delay in moving food from the front to the rear of the mouth and have incomplete oral clearance signal the likelihood of dysphagic complications
*inappropriate weight may be an indication of poor nutrition due to dysphagia
What are three areas that might result in a referral regarding dysphagia?
*difficulties have been observed related to feeding and ingestion of food or liquid
*the client appears to be at risk for aspirating
*the client appears not to be receiving adequate nourishment
What info should be obtained during the case history?
Obtain information about the location of the swallowing problem, the kinds of food that are easiest and hardest to swallow, and the nature and severity of the disorder
In a clinical assessment, the SLP observes feedings as it occurs normally, paying attention to what?
*is the caregiver patient and attentive?
*does feeding take place in a reasonably quiet environment free from distractions?
*what position is the individual in when eating or drinking?
*how does the client express feeding preference?
In a clinical assessment, what should be determined regarding cognitive and communicative functioning?
determine alertness/wakefulness, ability to follow directions, and general functioning
In a clinical assessment, what should be determined regarding head and body posture?
*note position of the head and whether the client can position the head given instruction
*note general body posture and tone
In a clinical assessment, what should be determined regarding the oral mechanism?
*abnormalities of the lips, teeth, tongue, palate, and velum should be noted
*look for facial symmetry and note weaknesses (drooping)
*motor difficulties such as tremor, flaccidity, excessive muscle tone, and poor coordination are noted
*assess motor difficulties and oral reflexes, as well as sensation
*note drooling, gum and tooth infections, or upper airway obstruction
In a clinical assessment, what are the signs of laryngeal disfunction ?
*indirect signs include hoarse, gurgly, or breathy voice quality before/during/after swallow
*inability to rabidly repeat /ha/ with a clear voiced vowel sound
*inability to produce vocal tones up and down scales
*an s/z ratio greater than 1/3
*inability to produce a strong cough
*in difficulties are noted, refer to otolaryngologist
What are the components of a bedside swallowing examination?
*can be completed if client is alert and does not have a history of aspiration
*the client's reaction to the appearance of food and drink is evaluated
*oral mechanism function is observed throughout the swallow
*pharyngeal phase swallowing efficiency can be judged in part by noting specific behaviors during food or drink intake
*a small amount (1 tsp) of think or thick liquid may be placed in the mouth, and the client is encouraged to swallow
*inability to cough may suggest difficulty closing the larynx to protect the airway
*nasal regurgitation reflects inadequate VP closure
*observe the movement of the hyoid bone and thyroid cartilage
*record the number of times the client swallows for each amount of food or drink
*if vocal quality changes after swallowing, this may indicate pooling of liquid
*note difficult and safe food consistencies
*determine preferential placement in the mouth for food or liquid
How should a tracheostomy tube be managed?
*some clients have a tracheostomy tube for breathing
*a swallowing evaluation may still be conducted with physician approval
*the cuff is deflated and secretions from the mouth and above the cuff are suctioned
*the patient covers the tube before each swallow to normalize tracheal pressure
What is a modified barium swallow study? (AKA videofluroscopy)
An X-ray procedure used for suspected dysphagia and/or aspiration
How is the modified barium swallow study? (AKA videofluroscopy) done?
*barium is coated onto or mixed into food or liquid
*SLP determines size, texture, and consistency of the food/liquid and head/body position
*radiologist or X-ray tech observes movement of barium
*video recorded for later analysis
*useful in determining whether the client should be fed orally or nonorally, what food textures are safest, and what types of therapy are appropriate
What is fiberoptic endoscopic evaluation of swallowing?
*for adults too ill for MBSS
*flexible laryngoscope through nose into pharynx
*coughs, holds breath, and swallows dyed food
*may reveal premature spillage, airway closure
*provides information about desirable posture, preferred food types, aspiration
What is scintigraphy?
*measure amount of aspiration
*radioactive tracer mixed with food
*radioactive markers placed externally
*SLP positions, suggests swallow procedures, interprets results
*provides insight regarding esophageal function and may help determine whether oral feedings are safe
What is ultrasound/ultrasonography?
*imaging technique using inaudible sound waves
In dysphagia intervention, what should be the goals of the feeding environment ?
*relaxed and unhurried
*develop self-feeding skills if possible
What should the body and head positioning be when eating?
*upright, 90 degree hip angle, symmetrical
*reduce extraneous movement
*chin tuck, head back, head tilt, and head rotation are all different movements for different types of problems
What kinds of foods are not recommended for kids under 5 with neuromotor difficulties?
foods that are hard to chew, small or slick when wet, or are thick and sticky
What are the four food texture levels?
Level 1 - dysphagia - pureed
Level 2 - dysphagia - mechanical soft
Level 3 - dysphagia - advanced
Level 4 - regular
What are the levels of liquids?
thin, nectar-like, honey-like, and spoon-thick
How can food be modified to help those with dysphagia?
*don't use straws - these allow too much fluid into the mouth
*spoons with shallow bowls limit food amounts
*avoid placing food in the mouth until the previous bolus has been swallowed
*patients are encouraged to swallow twice per bite or sip
*foods of varying temperatures may increase the sensory awareness of food
What are some alternate methods of swallowing for those with dysphagia?
*effortful and double swallowing
What are the different medical treatments that can help with dysphagia?
*neurological patients benefit from being medicated before eating
*atropine can control drooling
*Nifedipine may be useful in managing dysphagia after stroke
*Botox can improve swallowing in cricopharyngeal muscle spasticity/hypertonicity
*some medications cause or contribute to swallowing disorders
What kind of clients will require nonoral feeding methods?
clients who require more than 10 seconds to swallow a bolus or who aspirate more than 10% will likely require at least some nonoral feeding
What are some nonoral feeding methods?
*nasogastric tube: feeding tube is placed through the nose and into the stomach
*pharyngostomy: feeding tube is inserted into the stoma (a small opening)
*esophagostomy: feeding tube is placed in the esophagus through a hole in the chest
*percutaneous endoscopic gastrotomy: feeding tube is placed in the stomach through a hole in the abdomen
What are the objectives of trying to improve dysphagia?
*improve food and drink intake
*success is beneficial at least 80% of the time
Which empowerment strategy would the nurse discuss with the family of a chronically ill child?
The nurse is caring for a pediatric client with a history of seizure activity. The child is being treated with gabapentin. The nurse knows that gabapentin should not be given within 2 hrs of which class of medication?
What are some causes of gas?
What age is play audiometry used for?
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