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Posts tagged ‘clinical swallow evaluation’

Jun 11

Assessing the Swallow: 101

Assessing the Swallow:  101

Assessment of the swallow can be one of the most valuable pieces of information in your treatment plan for a patient with dysphagia.  There are so many factors that need to be considered when you receive an order for a patient with dysphagia.

Clarification of the order

It is vital to get a clarification of your order.  Talk to the nurse for that patient if available or speak to the ordering physician to find out why a swallowing evaluation was ordered in the first place.  There are times that an evaluation is ordered because the person can’t swallow their potassium pill (I’m not sure if there are any people that can actually swallow that enormous pill!)

Chart Review

A thorough chart review should be performed prior to walking in to see that patient.   Personally, I like to review the chart prior to speaking to the nurse, doctor, patient or family member so that I know as much as possible about that patient.

There are several parts of the chart that can provide critical information for assessment of your patient.  The important areas of the chart to review include lab results, chest xray results, medications and patient history/diagnoses.

Lab Results

Lab results can give you an look at your patient’s current medical status.  These are typically drawn daily in the acute care hospital setting and may be taken periodically or as needed in a Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTACH) or Home Health setting.  There are several labs that can give you a good overall picture of your patient.

Nutrition:  Body Mass Index (BMI) and Albumin/Prealbumin are numbers that give us good information of the overall nutrition/hydration status of our patients.

White Blood Count (WBC):  The number of WBC can tell us if the patient has an infection (number is high) or if the patient is at risk for infection (number is low).  It is important to note the Neutrophil number as these are the cells that are in the oral cavity and help to eliminate bacteria from the oral cavity.  When Neutrophils are high or low the patient may have an increased risk of developing a pneumonia.

Red Blood Count (RBC):  This number tells us how effective the body is in circulating oxygen through the body.  Important to note is that if Hemoglobin is below 8 or if Hematocrit is below 25%, therapy should be deferred as the patient is not medically stable to participate in therapy at that time.

Sodium, Potassium and Chloride give us a good look at nerve conduction and assist in muscle function.   Sodium, Potassium and Chloride are electrolytes.  These electrolytes also play a role in acid/base balance within the body.

Swallowstudy.com has a great review of lab values which you can find here.

Chest Xrays:

While chest xray results can be very valuable, interpretation can be tricky.  Typically the radiologist will indicate if there are infiltrates and which lung lobe the infiltrates are found.  Infiltrates do not always indicate aspiration of food or drink.  To be accurate in determination of what has been aspirated, a culture would have to be completed.   It is important to note as well that aspiration can be from refluxed or vomited material which would need medical management.  It is also important to note that aspiration of food/liquids can occur in either lobe, left or right.

Medication:

Medication can alter many aspects of a patient’s functioning.  Medication can dry out mucosal membranes (antihistimines, allergy medications, antidepressants, anticholinergics, analgesics, diuretics), affect motor function (Parkinson’s medication, antidepressants, antiepileptics, anticholinergics) or medications such as Haldol can worsen the swallow.  It is important to note changes in function as they correlate with new medications or changes in medication.  Also remember that having the ability to look up medications can be vital as some diagnoses may not be listed for patients and medications can lead you to uncovering diagnoses not listed otherwise in the medical chart.

Patient History:

Patient history can absolutely be the meat of your chart review.   This is where you are looking at patient diagnoses, particularly any diagnosis that can lead to a dysphagia.  It is important to note if the patient has a history or diagnosis of dysphagia, recurrent pneumonia, degenerative diseases such as Parkinson’s or ALS, history of TBI or stroke or even diabetes that has not been managed well.

In the history will often also be a discussion on why the patient was admitted to the hospital or to the facility and may even touch on swallowing, whether the patient has had difficulty for some time or if there is new difficulty with swallowing.  If the history makes no indication of swallowing difficulty and the patient has an infiltrate in either lung, aspiration may not be related to swallowing difficulty.

After a thorough chart review, you are probably ready to see the patient.  It is very important, when possible, to interview the patient to see how they view the problem, whether or not there is a history of dysphagia that is not listed in the chart and the complaint that prompted an SLP evaluation.

Using Vital Signs

Vital signs such as oxygen saturation, heart rate, respiratory rate can all give you valuable information on your patients.  These can all give you an idea of current medical status and if the patient is able to have endurance for a meal or even for your evaluation.   Oxygen saturation and temperature have often been used to determine if a patient is aspirating, however there is no evidence that links a spike in temperature or a drop in oxygen saturation with an aspiration event.

During the Evaluation

During your Clinical Swallowing Evaluation (CSE), it is critical that you assess cranial nerve function.  Not sure how to do that?  We have you covered AND you can catch up on last minute CEU’s at the same time!  Northern Speech Services has a phenomenal cranial nerve course for assessment and treatment of the swallow (yes, I am a little biased!  Yes, I do receive a small amount of money for this course if you choose to purchase it, but no fear, I will not retire from your purchase!)  You can also use screens such as Peak Flow and the 3 ounce swallow in addition to food or meal trials to determine if further, instrumental assessment is required.

You Can’t Do it All During the CSE

It is critical to remember that you will not be able to complete a full, reliable evaluation at bedside.  You cannot reliably assess pharyngeal function, airway protection or the effectiveness of modification, compensation or maneuvers without visualizing all of these areas with instrumental assessment.  The Clinical Swallowing Evaluation can lead you to determine whether an instrumental assessment is required or if there is no need.

Instrumental Assessment

If you feel that the patient needs a modified diet, requires use of compensation, maneuvers or that you need to develop an effective treatment plan for your patient, instrumental assessment would be indicated.  You may only have Modified Barium Swallow Studies (MBSS) or you may only have Flexible Endoscopic Evaluation of Swallowing (FEES) available.  Both can be very effective in determining pathophysiology of the pharyngeal swallow, to determine how the bolus flows throughout the oropharyngeal cavity and into the esophagus, effectiveness of airway protection, diet modification as well as the accuracy and effectiveness of maneuvers and compensations.

If you are looking for guidance through the Clinical Bedside Evaluation (CSE) there is an app for that!  Look for Dysphagia2Go available through the App Store for your iPad.

There is also an app from Tactus Therapy called Dysphagia Therapy that can assist you with cranial nerves, the clinical exam and choosing therapeutic techniques.  You can buy that right here.

You may have also heard about this pocketguide that I helped to write.   It’s called The Adult Dysphagia PocketGuide Neuroanatomy to Clinical Practice.   This is a great guide to help you through the evaluation and treatment planning process.   If you don’t win a copy this year (2019) from my give-away, you can purchase a copy of the Pocketguide here.  Again, small amount of money for me, no fear of retirement from both the book and the apps!

Also, look for articles on Dysphagia Ramblings related to assessment including:

We Can’t Treat What We Don’t Know

Standardizing Dysphagia Assessment and Treatment

“Aspiration Risk”

Oral Care

The Interview

  • Leder, S..B., Suiter, D.M., & Warner, H.L. (2009). Answering orientation qustions and following single-step verbal commands: effect on aspiration status.  Dysphagia, 24(3), 290-295.
  • Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307.
  • 57  Martin-Harris B, Brodsky MB,  Michel Y,  Castell DO Schleicher D, et al.  MBS Measurement Tool for Swallow Impairment—MBSImp: Establishing a Standard.  Dysphagia, 2008, Volume 23, Number 4, Pages 392-405.
  • Suiter DM, Leder SB.  3 Ounces is All You Need.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia).  2009; 18(4):  111-116.
  • Logemann, J.A. (1998).  Evaluation and treatment of swallowing disorders (2nd ed).  Austin, TX: Pro-Ed.27 Wijting Y., Freed M. (2009).  Training Manual for the use of Neuromuscular Electrical Stimulation in the treatment of Dysphagia.
  • Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.

 

 

 

Jun 6

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The Interview

Dysphagia Ramblings The Interview

The Clinical Swallowing Evaluation

One of the most crucial components, at least for me, of the Clinical Swallow Evaluation (CSE), is the interview.

I haven’t found a lot of published research regarding the interview portion of the CSE, so if you’ve found any, please let me know in the comments!

There is a nice example of some interview questions in The Source for Dysphagia by Nancy Swigert.

Chart Review

I probably spend the better half of my evaluation time digging in the chart for information and then interviewing anyone I can find that can answer to questions about the patient.

The chart review gives me an idea of the patient.  You are looking for diagnoses, medications, lab values, history, etc.  (Not to fear, there will be a post on chart reviews!)

The Interview

As I said before, the interview is where I can get an abundance of information!  I typically will try to find the nurse or even the doctor after reading the chart to get more information.  What is the patient doing?  How are they eating their meals, taking their pills?  How alert is the patient?  What is the plan for the patient?

Now, unless you want the person to get all defensive on you, don’t just run into the room and start firing questions at the patient!  You don’t want them to feel ambushed.   Introduce yourself and tell them why you are there.   Maybe ask a couple of questions not swallowing related.   You can comment on who is in the room.  “Oh, you have a lot of visitors today.”  That will usually prompt some introductions as well.

I try to keep it as light as possible.   Don’t go in with the “I think you’re aspirating and you will probably get pneumonia and die” line up and ready to fire.   You have no idea what is going on with this person and they probably had no clue that a Speech Language Pathologist worked with swallowing.

We all know the famous line.   You:  “Hi, I’m Susie/Stan and I’m the Speech Language Pathologist.”  Patient/family:  “There is nothing wrong with my/their speech.   Just listen to me/them talk.”

Make that person comfortable.  Sometimes, they know that we work with swallowing.   Maybe they have had some experience or someone they love has had some experience with dysphagia and they don’t want that thick crap to drink.   Let them know you’re not the thickened liquid police and you just need to see what’s going on so that you know if you can help them with any problem they may be having related to swallowing.

What do I ask?

In a perfect world, the family is present in the room for an evaluation.   Don’t look at the family as judging you and what you’re doing.   Chances are, they have no idea what to expect from you.

If the patient is able to answer questions and the family is available, I interview them all at the same time.   I really have tried to develop a list of interview questions, but have found the interview much more effective if it is patient-driven.

I do ask about the current or most recent hospitalization.   What happened that you had to come to the hospital?  What is your current problem?  Are you having trouble with swallowing your food?   How about those pills?  How do you do when you are at home?  Do you have any trouble swallowing pills at home?

I also like to find out if there are any foods that are avoided or if there is a specific method they use to take pills.   Bonus if the nurse comes in to pass meds so that you can actually observe the patient taking their pills!!

Pills

Speaking of pills, I almost always have patients say, well, I do ok with my pills except for one.   It’s huge.  When I ask if it’s the potassium pill, the answer is almost always yes.   I would say nearly every patient I evaluate that takes a potassium pill has trouble with it.

I always ask the patient/family about neurologic diagnoses or even previous surgeries or cancer treatment.   The thing is, the chart can be great as well as the history and physical section of the chart, BUT there can be information missing or inaccurate.

Take for example, the patient I had several years ago that was in the hospital for weakness.  The chart had nothing in it about previous tonsil cancer with 37 sessions of radiation or the fact that the person had a large portion of their stomach removed due to cancer.

I really want my patient to feel like they were interrogated by the FBI.   Now, don’t shine a bright light in their face or slam the table trying to intimidate them, but you need to get down to the heart of the problem, or the lack of a problem with swallowing.

If the person is having trouble with any consistency, how long has this been happening?  Have they ever had an instrumental assessment?  Have they ever had therapy for swallowing?  If so, when, where and for how long?  It’s also nice if they or the family can remember what they did for therapy.

Has the person already had their meal today?  If so, how did they do?   Was there a consistency more difficult than the others?  What happens with that consistency, does it get stuck?  Does it make them cough?  Have them define difficulty as much as possible.

Is it Dysphagia or is it GERD?

Many times, the patient complains that the food gets stuck “right here”.  If I were a betting person, I would bet nearly every time they point to the same spot on their throat.  Which is often associated with GERD.

How do you know which is which?

Well, you don’t without instrumental assessment, but you can do something to find out the probability of GERD or reflux.   Do you use the Reflux Symptom Index?  This is a great way to have the patient answer questions related to GERD.   You can download a free copy right here.

Now what??

Remember to let the interview guide you.   You may have a million more questions based on a particular answer or comment by a patient.    The more comfortable you make the patient, the more they will likely share with you.

If they complain of difficulty with some foods, what foods are they.   Sometimes that patient may be taking pills that cause xerostomia (dry mouth) or they may have had radiation treatment causing xerostomia making it more difficult to swallow foods such as meat, bread or rice.   Maybe they need to include water with their meal.   Sometimes dipping the food in an oil, such as olive oil or adding gravy will help to eliminate the difficulty chewing or swallowing.

The interview process should answer so many questions for you and lead you into the actual hands-on part of the evaluation, maybe giving the patient some trial consistencies, recommending an instrumental assessment, the cranial nerve assessment, etc.

What do YOU ask?

Do you have a list of go-to questions or a questionnaire that you find helpful?  Post it in the comments below!  You can also go to the Internet Resources page and find some downloadable outcome measures to use in your evaluation during the interview.