News You Can Use: Detecting Dysphagia

Detecting dysphagia
May 2017 Vol. 12 No. 5

Author: Carel Mountain, DNP, RN, CNE; Kimberlee Golles, MS, CCC-SLP

It’s 8:00 am and time for your 83-year-old patient, Virginia Johnson*, to take her oral medication. She was admitted with a left femoral fracture following a fall. After the initial surgery, she developed a urinary tract infection, and this morning she is disoriented and confused. As Mrs. Johnson takes the first pill, you notice she takes a long time to swallow and then coughs immediately after. You recognize that Mrs. Johnson may have dysphagia and that she’s at risk for developing aspiration pneumonia.

As the population ages, hospital clinicians see more patients with dysphagia resulting from stroke, dementia, and Parkinson’s disease. (See Causes of dysphagia.) Patients with dysphagia are at high risk for developing aspiration pneumonia as a result of food, liquid, or oral bacteria going into the lungs. Other complications include dehydration, malnutrition, and airway obstruction. Through consistent patient interaction and using a simple assessment technique, nurses can recognize dysphagia early and make referrals to help prevent complications, decrease hospital stay, and contribute to the health and safety of patients.


Bedside assessment

Use the PASS acronym to determine your patient’s risk for dysphagia (See Don’t PASS up the opportunity.) Start by asking if it’s probable that the patient will have difficulty swallowing. For example, intubated patients and those with feeding tubes are at risk for dysphagia. Next, ask for an account or history of previous swallowing problems, which may indicate future problems and the need for additional or immediate intervention.

The third step is to screen your patient for observable symptoms such as drooling, coughing, or change of voice or speech. Your observation doesn’t need to be formal; simply watch the patient while he or she is eating or taking medications. However, to ensure accuracy, make the following preparations:

Ensure that the patient is seated as upright as he or she can tolerate without significant discomfort or pain.
Make sure the patient is fully awake and alert.
Note patient behaviors when eating or taking medication. For example, does the patient appear impulsive or anxious?

Any of the following signs or symptoms may indicate the need for an immediate referral to a speech-language pathologist (SLP) for dysphagia assessment:

coughing or throat clearing before, during, or after swallowing
wet, gurgling voice before, during, or after swallowing
shortness of breath after swallowing
drooling or loss of liquid from the mouth
holding food or liquid in mouth for extended time without swallowing
complaining of food or liquid feeling stuck.

Patients with risk indicators should also be referred for assessment by an SLP. Making a referral may not require input from a provider, but check your organization’s policy.
Interdisciplinary referral

Collaboration between speech pathology and nursing can help reduce complications related to poor swallowing. The SLP, after careful assessment, can adjust the patient’s diet related to the degree of swallowing difficulty. In addition, the SLP may prescribe the following exercises:

neck muscle exercises
tongue and oral exercises
coughing exercises
pursed lip breathing
effortful swallowing.

Nursing considerations

Poor oral function can lead to an increase in gram-negative anaerobic bacteria and masticated food residue in the mouth, both of which increase the patient’s risk of developing upper respiratory infections and aspiration pneumonia. And in patients with decreased mobility, compromised respiratory status, or reduced cognition, poor oral hygiene may increase the risk of bacterial infections secondary to aspiration of secretions, food, or liquid into the lungs.

To prevent these complications secondary to dysphagia, ensure good oral hygiene. Provide consistent oral care, at least three times a day, including cleaning the tongue, palate, and teeth with a brush or swab. You or the SLP also can train patients, nursing assistants, and family members to provide oral care. It’s best to choose a consistent time, such as lunch, for reminding and encouraging the patient to perform swallowing exercises prescribed by the SLP

To ensure consistency of care, document all nursing interventions, including aspiration precautions, education, and patient understanding.
Stop complications before they start

Your early and accurate detection of dysphagia helps reduce patient complications. Using the PASS bedside swallowing assessment is an easy way to identify at-risk patients, make appropriate referrals, and stop the complications of dysphagia before they start.

After recognizing Mrs. Johnson’s difficulty swallowing, you notify her physician and make a referral to the SLP, reporting your PASS observations. After completing the swallowing evaluation, the SLP informs you that Mrs. Johnson appears safe for nectar thickened liquids and requests that her pills be administered crushed in puree. By working as a team, you and the SLP adjusted Mrs. Johnson’s plan of care, thus avoiding potential complications and ensuring Mrs. Johnson an uneventful recovery.

Carel Mountain is director of nursing at Sacramento City College in Sacramento, California. Kimberlee Golles is a speech-language pathologist at Kaiser Permanente Medical Center in Walnut Creek, California.

*Name is fictitious.
Selected references

Campbell G, Carter T, Kring D. Nursing bedside dysphagia screen: is it valid? J Neurosci Nurs. 2016;48(2):75-9.

Canham M. Looking into oropharyngeal dysphagia in older adults. Nursing. 2016;46(6):36-42.

Hines S, Kynoch K, Munday J. Nursing interventions for identifying and managing acute dysphagia are effective for improving patient outcomes: a systematic review. J Neurosci Nurs. 2016;48(4):215-23.

Park Y, Oh S, Chang H, Bang, H. Effects of the evidence-based nursing care algorithm of dysphagia for nursing home residents. J Gerontol Nurs. 2015;41(11):30-9.

Seedat J, Penn C. Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting. S Afr J Comm Disorders. 2016;63(1).

Poetry by Nurse Monique A. Shaw

Molestation, a sad plight

It's not enough to keep me up at night.

Projects, shelters, even evictions

Is that enough to make me lose my conviction?

The witness of a horrible stabbing,

Domestic abuse and a kidnapping.

She’s your mom! Yes, I know!

But the paperwork said she let me go!

All this before the age of ten

At what age will this tragedy end?

Brighter days must soon be near

Off to San Diego where the skies are clear.

Is it here that this will all end

Is my triumph about to begin?

No, not now I’ll have to wait

Let’s pile some more upon my plate.

ADDICTION! Why mom? Why did you choose

Drugs will surely make you lose.

Our home, our friends, our money, our things

You smoked them, you snorted and shot them up.

Walking the Downtown streets late at night

Nowhere to go, we spot a light.

Is that a sign? A vacancy?

Yale Hotel on F Street, our new home to be.

It is here where friends become family

And, of course, more tragedy.

NO! STOP IT! IT ISN'T SO! MY MOM DOES NOT HAVE HIV!

STOP TALKING! I'M NOT LISTENING! STOP LYING TO ME!

Off we move and leave our friends

The family that stays with me through thick and thin.

Now, In-Home Nurses and medication

I’m only in Junior High School, I need a vacation.

The drugs, they’re just too strong

She can’t let go and continues to succumb.

Now three little letters turn into four

AIDS came tapping at my mother’s door.

DEATH! Two times in a one year span

First dad now mom, it’s too much man!

Junior High, High School and College is the future for me

Constantly holding a 3.0 to a 3.33.

Life has many twists and turns and crooked paths

As we often learn.

Love provides an interruption

But abandoning college was never my solution.

Marriage at age twenty and a new place to call home

Military life in Illinois is where I'll roam.

Also Virginia and Mississippi

The love is now gone, there’s nothing here for me.

Back to San Diego from where I came.

Time to pack up and start again.

Now a single mother, I must go back to school

Go back to the path which I always knew was cool.

A Medical Assistant I’ll quickly become

To make decent money to try and move on.

Child, work and school that’s my daily routine

Working hard to fulfill my lifelong dream.

Along comes the news I’ve patiently waited for

Two long years or maybe more.

Monique, you’ve made it, your name has come up

Are you ready for Nursing School? Of course, there’s a but.

But I’m pregnant with another child, over ten years later.

Its OK, we’ll see you next year but not any greater.

The year came and went quick as a flash

Nursing School is here, time to attend class.

The toughest two years I really must say

But I remember my past and what I endured many days.

I persevered and progressed and completed the program

And walked across the stage with my kids looking on.

And knew that although life sometimes seemed bleak

That this was the TRIUMPH I always did seek.

So you may ask, “Do you think this scholarship can help you live your dream?”

Yes in many ways, one can only imagine

Higher education is the goal and is my passion.

From RN to BSN this is now my desire

This scholarship will help me live my dreams and aspire.

Monique A. Shaw, R.N.

 Monique is a registered nurse in the Southern California area. She is currently working on her BSN while balancing the busy life of work and mom.

Are you using the ANA tools and resources?

ANA offers tools and guidance to help you be your best

As an RN, you invest much of your time and energy into making sure patients follow their treatment plans and do everything they can to improve their health and wellness. But are you taking the same steps to boost your own physical, mental and spiritual health and well-being? The American Nurses Association (ANA) recommends that you do — for the benefit of both you and your patients.
Now, there’s a way to evaluate your own health and wellness, and compare how you’re doing to other RNs as well as the overall population. Also, you can assess the health and safety of your work environment, including risks such as ergonomic injuries, sharps injuries, and bullying and workplace violence, and measure it against that of your nursing colleagues across the country.
In November, ANA launched the HealthyNurse^TM Health Risk Appraisal and Web Wellness Portal in collaboration with Pfizer Inc — online tools for all RNs and RN students to assess their health and wellness. The survey provides valuable data on your individual health risks as well as how you compare against ideal benchmarks.  The website component of the appraisal allows survey-takers to find resources on topics for which  they want more education or want to focus on improvement.
ANA encourages all RNs and nursing students to take the free online Health Risk Appraisal to build a comprehensive database of nurses’ health and their work environments. The survey takes about 20 minutes to complete. You can find the survey at www.anahra.org.
What is a HealthyNurse?
The HealthyNurse Health Risk Appraisal and Web Wellness Portal is a component of ANA’s HealthyNurse  program.  In October, ANA’s Board of Directors adopted a new  HealthyNurse definition and related constructs to guide the program and associated initiatives.
ANA defines a HealthyNurse as one who actively focuses on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal and professional well-being. A healthy nurse lives life to the fullest capacity, across the wellness to illness continuum, as they become stronger role models, advocates, and educators, personally, for their families, their communities and work environments, and ultimately for their patients.  The constructs further advise nurses that, adherence to each of these constructs enhances the healthy nurse’s full capacity to care. Nurses whose practice is characterized by the HealthyNurse  constructs can function to their highest potential, personally and professionally.
Five constructs of the HealthyNurse
•  Calling to Care — Caring is the interpersonal, compassionate offering of self by which the healthy nurse builds relationships with patients and their families, while helping them meet their physical, emotional, and spiritual goals, for all ages, in all health care settings, across the care continuum.
•  Priority to Self-Care — Self-care and supportive environments enable the healthy nurse to increase the ability to effectively manage the physical and emotional stressors of the work and home environments.
•  Opportunity to Role Model — The healthy nurse confidently recognizes and identifies personal health challenges in themselves and their patients, thereby enabling them and their patients to overcome the challenge in a collaborative, non-accusatory manner.
•  Responsibility to Educate — Using non-judgmental approaches, considering adult learning patterns and readiness to change, the healthy nurse empowers themselves and others by sharing health, safety, and wellness knowledge, skills, resources and attitudes.
•  Authority to Advocate — The healthy nurse is empowered to advocate on numerous levels, including personally, interpersonally, within the work environment and the community, and at the local, state, and national levels in policy development and advocacy.
Visit http://anahealthynurse.org for valuable resources and to participate in ANA’s HealthyNurse^TM Health Risk Appraisal.

— Adam Sachs is a public relations writer at ANA.