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135 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Screening procedures provide the clinician with some _____ evidence that the patient has a swallowing disorder but do not provide information on the ______ of that order.
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indirect
physiology |
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Screening procedures tend to identify the _____ and _____ of dysphagia.
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signs
symptoms |
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Screenings should be _____, ____ ___, and ____ ____.
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quick
low risk low cost |
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What two characteristics are statistically examined during a screening?
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1. correctly id those who aspirate or have residue (true positives)
2. should not generate many false positives or false negatives. |
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Name the four abnormal behaviors that are indicators of the need for an in-depth physiologic study.
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rejection of food
food selectivity gagging open-mouth posture |
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Rejection of food
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rejection of oral intake, these indv should receive a MBS
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Food selectivity
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children limiting their oral intake to only selected foods;; should test reaction to various tast, temp, and texture combos.
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gagging
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indicates several diff abnormalities:
hypersenstivity tactile agnosia |
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Open-mouth posture
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need to assess the upper airway and dental structure
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At the end of the screening, the clinician should indicate whether the patient is: _ _ _ or whether the _ _ _ _ is _.
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a normal swallower
risk of dysphagia is high |
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Name the 12 things a bedside exam is designed to provide
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1. info on current dx and medical hx
2. pt's medical status 3. pt's oral anatomy 4. pt's respiartory function and its relationship to swallow 5. pt's labial control 6. pt's lingual control 7. pt's palatal function 8. pt's pharyngeal wall contraction 9. pt's laryngeal control 10. pt's general ability to follow directions and monitor and control her/his behavior 11. pt's reaction to oral sensory stim (tast, texture, temp) 12. pt's reactions and symptoms during attempts to swallow |
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The preparataory examination begins with:
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the collection of information from the pt's chart and includes complete examination of vocal tract control
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Chart review should be used to determine pt's: (3)
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respiratory status (ie pneumonia, trach tubes -current or hx)
hx of swallowing problems (such as duration, medical status, ability to follow directions, motivation) nutritional status |
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What are the two parts of a bedside/clinical examination
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preparatory examination
initial swallowing examination |
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Name the 5 things a chart review and hx should id
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1. current and past medical problems
2. current and immediate past medications (esp for xerostomia, reduced alertness, or delayed reaction time) 3. hx of swallowing disorder (time and nature of onset, symptoms, and pt's awareness of problems) 4. presence, type, duration, and method of placement of any airway device 5. presence, type, duration of placement, adquacy, and complications of oral and nonoral nutrition |
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Name five observations that should be made when entering a pt's room
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1. pt's posture in bed
2. pt's alertness and reaction to clinician's entrance 3. trach tube and it's status 4. pt's awareness and handling of secretions 5. pt's management of the tube |
page 140
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What is the physiologic hierarchy?
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1. respiration
2. swallowing 3. speech |
page 140
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xerostomia
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dry mouth
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page 140
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Aside from observing respiratory rate, name 4 things you should observe.
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1. time of saliva swallows relative to phases of the resp cycle
2. timing of any coughing relative to respiration - swallow coordination 3. duration of comfortable breath hold (1, 3, 5 sec) 4. pt's rest breathing pattern - oral or nasal? |
page 141
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Tracheostomy tubes are normally placed for: (3)
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1. upper airway obstruction at or above the level of the true vocal folds
2. potential upper airway obstruction 3. provision of respiratory care |
page 141
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Three parts of a tracheostomy
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outer cannula
inner cannula obturator |
page 141
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The _ cannula always stays in place
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outer
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page 141
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The - cannula remains in the tube except for cleaning
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inner
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page 141
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the _ is inserted only to provide a smooth, rounded tip during inital insertion
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obturator
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page 141
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Two procedures for weaning pt's off of trach tubes
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1. changing tube to a smaller size to encourage oral-nasal breathing + trach breathing
2. plugging the trach for periods of time |
page 142
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What are the two important variations to trach tubes?
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1. cuffed or uncuffed
2. fenestrated or unfenestrated |
page 142
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Cuffed trach tubes are placed when there is: (2)
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1. need for respiratory tx
2. potentional for the pt to aspirate |
page 144
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When the cuff is fully inflated:
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no material from above the larynx ac pass thru into the trachea and bronchi
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page 144
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The cuff must remain inflated if a pt is on mechanical ventilation that operates on postive pressure principles.
True or False? |
True
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page 144
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When is the cuff inflated?
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to deliver respiratory tx
to prevent aspiration pneumonia (for those who aspirate their saliva) |
page 144
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Why aren't cuffs left fully inflated for a long time?
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It causes tracheal irriation, ischemia and tracheal stenosis
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page 144
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What is the minimal leak technique?
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inflating cuff until no air can pass around it, then taking out 1 or 2 cc of air which prevents tracheal stenosis
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page 145
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An inflated trach cuff may inhibit:
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a patients relearning to swallow by restricting laryngeal elevation,
reducing laryngeal senstivity, or placing pressure on the esophagus viea the common posterior wall |
page 145
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Fenestrated trach tubes are used when:
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a pt is having difficulty producing voice w/a normal trach tube; fenestrated tubes are usually NOT cuffed
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page 146
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At the beginning of the beside/clinical or radiogrpahic study the clinician should examine the trach tube to: (4 things)
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1. determine the presence of a cuff and the status of the cuff
2. the size of the trach tube 3. the presence of fenestration also: 1. review length of time pt has had trach |
page 147
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If the trach has been in place longer than _ months, scarring my have formed and restrict laryngeal elevation
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six
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page 147
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A tube in place longer than six months results in: (3)
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reduced airflow
reduced stimulation to subglottic sensory receptors reduced vocal fold closure |
page 148
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Most swallows occur during the _ phase of the respiratory cycle
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exhalatory
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page 149
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Use of a _-_ _ on the trach tube may help in place of light digital occulsion
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one-way valve - also helps with speech production
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page 149
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_ and _ are reciprocal
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swallowing and respiration
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page 149
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The normal swallow usually occurs _ _ _ _ exhalation
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toward the beginning of
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page 150
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What test is used for tracheotomized pt's during the bedside?
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the blue dye test
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page 150
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Compare tracheostomy to intubation.
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intubation involves placing a tube through the mouth or nose, the pharynx and larynx, to the lower trachea; intubation usually done in emergency situations; intubation is considered a more stable airway
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page 150
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Do you do swallowing exercises with someone who is intubated?
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NO!
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page 150
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Based on a careful history, the clinician will have info on: (3)
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the localization of the disorder (in terms of stage)
the easiest and most difficult types of material for the pt to swallow the nature of the swallowing disorder |
page 150
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Oral anatomy examination looks at: (6)
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lip confinguration
hard palate config softe plate and uvula dimensions faucial arches lingual config adquacy of the sulci |
page 153
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oral-motor control exam should include: (3)
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1.eval of range, rate, and accuracy of the:
lips tongue soft palate pharyngeal walls 2.reflexive activity 3. swallowing |
page 153
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Pt's w/head injury or severe neurologic impairments have difficulty:
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opening their mouth, takes 3 to 5 minutes
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page 153
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Severely impaired neurologic pt's would benefit from:
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oromotor stimulation to help open the mouth more easily via massage
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page 153
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How do you determine if a bite reflex is present?
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using a 4x4 gauze roll to touch the teeth and alveolar ridge
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page 153
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If bite reflex is present, feed them with:
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a spoon that doesn't break or splinter
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page 153
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Do NOT give these to apraxic pt's during bedside:
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verbal directions regarding eating or swallowing
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page 154
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Name three abnormal oral reflexes
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hypersenstive gag
tongue thrust tonic bite |
page 154
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lingual function should be assessed both _ and _.
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anteriorly and posteriorly
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page 155
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For anterior tongue mov't, the pt should be asked to: (6)
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1. extend tong forward and back as far as possible
2. touch corner of mouth and do lateral movts 3. attmept to clear lateral sulcus 4. open mouth wide and elevate tongue to alveolar ridge 5. repate /ta/ 6. repeat a sentence with a lot of tip-alveolar stops |
page 155
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Pt w/difficulty in oral transit find _ easiest to swallow
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liquids
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page 152
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Pt w/delayed or absent trigger do best with a _ consistency
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thicker
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page 152
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Posterior tongue function is assessed by: (3)
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1. open mouth and lift the back ofgue as if saying /k/ and hold the back of the tongue elevated for several seconds
2. repeat the syllable /ka/ as rapidly as possible 3. repeat a sentence containing a number of back velar stop phonemes |
page 155
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Assessment of chewing is most safely done with _ rather than _
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gauze
food |
page 155
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Food _ is not recommended for bedside assessment
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chewing
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page 156
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How do you elicit a palatal reflex?
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Use a cold instrument w/ a laryngeal mirror against the juncture of the hard and soft palates or the inferior edge of the soft palate and uvula
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page 156
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What does a palatal reflex do?
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Stimulates soft palate movt but does not generate a total pharyngeal response of a gag reflex
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page 156
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What nerve carries the palatal reflex?
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afferent =glossopharyngeal (and possibly the vagus)
efferent = vagus (and possibly glossopharyngeal) trigeminal may be involved |
page 156
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Is there a relationship between presence or absence of a gag reflex and pt's ability to swallow?
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NO
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page 157
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What nerves carry the gag reflex?
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CN X and maybe CN IX
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page 157
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Compare and contrast the swallow vs gag reflex.
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Gag: triggerd by noxious stimulus (vomit or reflux), a motor response designed to squeeze material up and out of pharynx, triggered from surface tactile receptors
swallow: an organized set of motor actions to take food safely and efficently from mouth to stomach thus clearing noxious material from the pharynx; triggered from deep proprioceptive receptors |
page 157
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All food should be positioned at the point of _ sensitivity
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maximum
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page 158
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Examination of laryngeal function should begin with assessment of _ _.
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voice quality
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page 158
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gurgly voice
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associated w/aspiration; warrants referral for a radiographic examination
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page 158
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hoarseness
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suspected reduced laryngeal closure during swallow
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page 158
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asking the pt to slide up and down a vocal scale allows evaluation of
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function of cricothryoid muscle
and intrinsic muscles of the vocal cords test the superior laryngeal nerve (which innervates the cricothyroid muscle) |
page 158
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Name two techniques that could be used to increase a pt's airway protection prior to initiating any swallows
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supraglottic
super-supraglottic |
page 159
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What are the guidelines for the amount of aspiration a pt can tolerate before developing pneumonia?
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there are no guidelines; physican comes up with own
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page 159
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What info is collected from the bedside exam? (4)
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1 posture that may result in the best swallowing
2. best position for food in the mouth 3. the potentially best food consistency 4. some indication of the nature of the pt's swallowing disorder |
page 159
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When is risk high and benefit low? (6 instances)
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pts is acutely ill
significant pulmonary complications weak voluntary cough over 80 can't follow directions suspected of having a pharyngeal swallowing disorder |
page 160
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When is risk low and benefit high?
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pt can follow directions
pt can cough on demand has good pulmonary function |
page 160
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If pt is being fed orally, the clincian should observe feeding to note: (6)
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1. pt's reaction to food
2. oral movts in food manipulation and chewing 3. any coughing, throat clearing, or struggling behaviors or changes in breathing and their frequency relative to swallowing and when it occurs (before, during after) 4 changes in secretion levels throughout meal 5. duration of meal and total intake 6. coordination of breathing and swallowing |
page 160
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tilting the head down allows for (3 anatomical)
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wider vallecular space
narrowed airway entrance epiglottis farther back |
page 160
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With head downward, material is more likely to rest in the _ long enough for the _ _ to _
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valleculae
pharyngeal swallow trigger |
page 160
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Selection of food texture to use in the swallowing eval should depend on (3)
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1 info collected in hx
2 data on oral control 3 info on pharyngeal and laryngeal control |
page 162
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Pt's w/ poor oral control do best with _ liquid first
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thickened
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page 162
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Pt's w/ delayed pharyngeal swallow will do best with a _ consistency
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thicker
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page 163
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Pt's w/reduced tongue base or pharyngeal wall contraction do best w/_
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liquids
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page 163
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Pt's w/reduced closure of the laryngeal entrance do best with _ consistency
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thicker
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page 163
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What utensils should the clinician have for a swallowing eval (6)
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1. a size 0 or 00 laryngeal mirror
2. a tongue blade for wiping material onto the posterior tongue 3. a cup to give to give pt a small amt of material 4. a spoon for presenting liquids and paste 5. a straw to place liquid in the back of mouth 6. a syringe to squire 1 ml of liquid into the posterior oral cavity |
page 163
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Steps in working w/a trach pt and swallowing (3)
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1. deflate cuff
2. suction orally and trach 3. have pt occulde trach |
page 164
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Advantages to swallow tx w/trach tube in place
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clinician can see aspiration more directly
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page 164
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Problems related to trachs and swallow tx: (3)
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1. restriction of upward laryngeal movt to protect the airway b/c of scarring
2. compression of the esophagus by the tube 3. change in intratracheal pressure |
page 164
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The clinician can place her fingers on the pt's neck to assess: (2)
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oral transit time
phayrngeal delay time NO info on pharyngeal stage of swallow can be collected |
page 167
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The fluoroscopic procedure designed to examine the details of oral, pharyngeal and cervical esphageal physiology during swallowing is:
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the modified baruim swallow procedure
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page 169
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Name the three ways a MBS differs from a traditional upper gastrointestinal, or barium swallow
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purposes
type and amount of material used procedures used |
page 169
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Two purposes of MBS
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define abnomral anatomy and phsyiology
id and evaluate treatment strategies |
page 169
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The MBS assesses (2)
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whether pt is aspirating
why pt is aspirating |
page 169
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Compare and contrast the MBS to the traditional barium swallow
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trad bs: gives info on structural competence of the esophagus, particularly the lower two thirds of the esophagus, w/little attention paid to details of swallowing phsyiology in the oral cavity and pharynx.
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page 169
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Describe the MBS
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two swallows of 1, 3, 5, 10 ml
cup drinking of think liquid 1/3 tsp pudding 1/3 of a Lorna Doone cookie coated w/barium |
page 170
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Define oral transit time
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time for movt of bolus thru oral cavity from initiaation of posterior movt of bolus til head passes mandible/tongue base crossing
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page 174
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Define pharyngeal transit time
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time of pharyngeal phase
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page 174
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pharyngeal delay time is
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time from end of oral transit time til trigger
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page 174
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The P-A view is helpful in looking at (2)
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symmetries in function
viewing residues in valleculae and pyriform sinuses |
page 177
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Can pharyngeal physiology be determined at bedside?
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No
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page 179
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introduction of treatement strategies (4 in order)
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postural techniques
tech to incr oral sensation swallowing maneuvers diet changes |
page 180
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Swallow maneuvers cause:
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fatigue
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page 180
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Name the five postural techniques
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head back
head down head roated (to damaged side) head tilted (to better side) lying down |
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Postural techniques do two things:
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1. redirect food flow
2. change pharyngeal dimensions |
page 181
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Reduced posterior propulsion of bolus by tongue:
name posture to use and why |
head back;
uses gravity to clear oral cavity |
page 181
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Delayed trigger:
name posture to use and why |
head down;
widens valleculae; narrows airway entrance |
page 181
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reduced tongue base posterior movt:
name posture to use and why |
head down;
pushes tongue base back to wall |
page 181
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unilateral wall dysfunction:
name posture to use and why |
head down or head rotated to damaged side;
head down to push back epiglottis and narrow laryngeal entrance head rotated to increas vocal fold closure and narrow laryngeal entrance |
page 181
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reduced laryngeal closure
name posture to use and why |
head down;
places epiglottis in more protetive position; narrows airway entrance |
page 181
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reduced pharyngeal contraction:
name posture to use and why |
lying down on one side;
changes gravitation effect on phayrngeal residue |
page 181
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unilateral pharyngeal paresis:
name posture to use and why |
head rotated to damaged side;
twists phayrnx, eliminates damaged side of pahrynx from bolus path |
page 181
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cricopharyngeal dysfunction:
name posture to use and why |
head rotated;
pulls cricoid cartilage away from posterior pharyngeal wall, reducing resting pressure in UES |
page 181
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When are oral sensory techniques used?
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w/apraxics
delayed onset of oral swallow delayed trigger of pharyngeal sw |
page 182
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Sensory techniques include: (6)
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1. inc downward pressure of sppon on tongue
2. presentation of sour bolus 3. presenation of cold bolus 4. presentation of a bolus requiring chewing 5. presenation of a laryger volume bolus 6. thermal-tactile stimulation |
page 182
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Measures of the effectiveness of sensory procedures to increase oral sensory input include: (3)
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1. duration of time from command to swallow uintil initiation of the oral stage of swallow
2. oral transit time 3. pharyngeal delay time |
page 182
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Oral onset time and oral transit times can be measured from:
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ultrasonography
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page 182
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Name the four swallowing maneuvers:
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1. supraglottic swallow
2. super-supraglottic swallow 3. effortful swallow 4. Mendelsohn |
page 183
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Supraglottic swallow
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designed to close the airway at the level of the true vocal folds before and during the swallow
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page 183
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Super-supraglottic swallow
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designed to close the airway entrance before and during the swallow
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page 183
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Effortful swallow
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designed to increase tongue base posterior motion during the pharyngeal swallow, thus improving bolus clearance from the valleculae
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page 183
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Mendelsohn maneuver
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designed to increase the extent and duration of laryngeal elevation and thus increases the duration and width of the UES
also improves overall coordination of swallow |
page 183
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Order of interventions introduced (four)
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1. postural
2. tech to improve oral sensation 3. swallow maneuvers 4. food consistency/diet changes |
pages 181-183
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reduced range of tongue motion:
easiest consistencies and those to avoid |
easiest: thick liquid
avoid: thick foods |
page 184
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reduced tongue coordination:
easiest consistencies and those to avoid |
easiest: thick liquid
avoid: thick foods |
page 184
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reduced tongue strength:
easiest consistencies and those to avoid |
easiest: liquid
avoid: thick, heavy foods |
page 184
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delayed pharyngeal swallow:
easiest consistencies and those to avoid |
easiest: thick liquids and thicker foods
avoid: thin liquids |
page 184
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reduced airway closure:
easiest consistencies and those to avoid |
easiest: pudding and thick food
avoid: thin liquids |
page 184
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reduced laryngeal movt contributing to criocopharyngeal dysfunction:
easiest consistencies and those to avoid |
easiest: liquid
avoid: thicker, higher viscosity food |
page 184
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reduced pharyngeal wall contraction:
easiest consistencies and those to avoid |
easiest: liquid
avoid: thick, higher viscosity food |
page 184
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reduced tongue base posterior movt:
easiest consistencies and those to avoid |
easiest: liquid
avoid: higher viscosity food |
page 184
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The report begins with:
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a description of the pt's symptoms or complaints
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page 185
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The second part of the report:
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measures of oral transit time for each material swallowed, followed by a description of any neuromuscular or anatomic problems observed in the oral phase
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page 185
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The third part of the report:
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pharyngeal transit times and any anatomic or neuromuscular problems; amount of aspiration; etiology of aspiration
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page 185
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Last part of the report (4):
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1. management of nutritional intake and any swallow management strategies to be used at meals
2. results of the interventions and tx used in the study 3. procedures for swallowing tx 4. reevaluation |
page 185
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If the report does not contain the anatomic or _ reason for aspiration or residue AND the _ attempted to reduce or eliminate these symptons and their effects the study is _.
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physiologic
interventions incomplete |
page 185
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