Department of Health Library Services ePublications

(1)

Department of Health Library Services ePublications - Historical Collection

Please Note: Aboriginal and Torres Strait Islander people should be aware that this publication may contain images, voices or names of deceased persons in photographs, film, audio recordings or printed material.

Purpose

To apply preservation treatments, including digitisation, to a high value and vulnerable Historical collection of items held in the Darwin and Alice Springs libraries so that the items may be accessed without causing further damage to the original items and provide accessibility for stakeholders.

Reference and Research Disclaimer

Please note: this document is part of the Historical Collection and the information contained within may be out of date.

This copy is a reproduction of an original record. Please note that the quality of the original record may be poor and cannot be enhanced with the scanning process.

Northern Territory Department of Health Library Services Historical Collection

(2)

b)o~IO

^-.,^'TC

HISTORICAL COLLECTION

. .

-

PROTOCOL FOR MANAGEMENT

OF EATING/SWALLOWING

DYSFUNCTION IN ADULTS

::J€

DEPARTMENT OF HEALTH AND COMMUNITY SERVICES

,,...

'

DL HIST 616.8526 CRO 1989

,.__

.

(3)

TERRITORY .. JLLl.nLJUA

PO BOX 40596 CASUARINA NT0811

(4)

i

(5)

CONTENTS

FORWORD

1. Introduction 2. Aims of Protocol

3. Referral of Patients with Swallowing Dysfunction 4. Swallowing Assessment 5. Management Programme for

Dysphagic Patients 6. Conclusion

APPENDIX

1. Contact Numbers for Referral 2. Form HR132-2/88

3. Test Meal

4. Form HR175-5/89

5. Sample Menu of Food Choices

REFERENCES

i 1 2 3

5 8

16

18 19 21

2 25

7

(6)

1. INTRODUCTION

Royal Darwin Hospital services a number of and disorders of oral func the term used to desc a difficulty in can occur for a number of reasons such as

oral surgery, neurological/degenerative sease, lead

a)

b)

c)

e)

cerebral

regime.

assessment of team

Minimi length of maintaining adequate

of of

return to as near as poss

fe for

this

z status, and

care

oral

(7)

f

- assessment

(8)

3

3. REFERRAL OF PATIENTS WITH SWALLOWING

3.1 for referrals.

and features sugge

mouth.

Severe

II

Food

, cons

s

nerve) .

s

mouth after or

or absent

or absent gag re

more f

Tracheostomy.

tric tube

Flue s of consc

reflexes.

loss.

s.

(9)

4

These signs and clinical features may be apparent in present with the following disorders:

Neurological CVA

Head Injury Neoplasms

Demyelinating diseases Inflammation

Cerebral Palsy

Oropharyngeal/Oesophageal Neoplasms

Inflammation Trauma

Oral Surgery

(10)

5

3.2 Re

3.2.1 A written Consultation st Form (HR44-4/88)

.2.3

. 1

The

should be completed for the Speech st Dietitian and attached to Consults clipboard at Nurses' s

on an after hour bas I is ated it is

commence naso-gas oral assessment can be c

nasogas tube should for assessment and When

prognosis for assessment

These factors are

2) •

(11)

1 INDICATOR

consciousness

imal)

- NO ORAL INTAKE

conscious not appropriate refuses

inabil

1 imi ted by

chest suction more frequent than 40 min

respirator

head/ neck structural defects

reflexes

anarthria apraxia CN:

PROGRESS

bed

quadriplegia dentures not

being chest more than

t racheos tomy nasogas tr ic feeding

reflexes

palatal gag

each presenting

to the r or left

+ FURTHER ASSESSMENT

reluctant co-operates

herniplegia

- - ~ - - - -

poor teeth poor dentures drooling

-- ---

oral

IV/ gastro feeds

dyspraxia CN

own teeth good dentures

breathing:

diaphragm

---

nasal selective breath

normal

The Speech st will consult with and

Nurs staff in obta tis information

(12)

(13)

8

5. MANAGEMENT PROGRAMME FOR DYSPHAGIC PATIENTS

A programme of diet regimes has been devised for the

dysphagic patient, with the intended function of providing appropriate nutritional support whilst swallowing

disability is treated. In some instances, enteral feeding may be the primary source of nutrients, until such time

that oral intake is considered.

5.1 Specific Principles of the Management

5.1.1. A series of graded diets are introduced and

adjusted for patients identified as per described protocol.

5.1.2. Meals are presented in order of increasing difficulty with regard to consistency, amount and

texture, in order to encourage improvement in the patient's ability to swallow.

5.1.3. Quantitative assessment of amounts taken is essential.

5.1.5

This enables:

a) calculation of nutrient intake by the Dietitian.

b) adjustment to enteral feeding schedule (if applicable).

c) assessment of patient tolerance and progress.

d) acceptability/suitability of foods provided.

Fluid intake is monitored.

A variety of food flavours, textures, consistencies and temperatures are introduced to each patient, as an appealing taste will help to facilitate an improved swallow by increasing the role of sensation the swallowing process.

(14)

9

5 2

process.

(15)

STAGE:

1.

2 •

PATIENT STATUS

* May demonstrate fluctuating consciousness.

* Unable to initiate a swallow

* Drooling may be present.

* Cough reflex may be absent.

* Gag reflex may be absent.

* A weak, poorly co-ordinated, inconsistent dry swallow can be elicited.

* Swallow is very delayed.

NUTRITI

* Nasogastric feeds provide all required nutrients.

* Small quantities of pureed foods are introduced

at each meal but do not contribute significantly to nutrient intake.

* Attempts are made to made to initiate a dry swallow.

* Speech Pathologist is responsible for

trialling of foods to the patient in the presence of Nursing staff.

* Patient's likes and dislikes are

documented.

* Nursing staff document quantity and type of food.

(Refer Appendix 4)

* Introduction of therapeutic oral techniques.

* Appropriate positioning.

0

(16)

5. cont.

STAGE:

3 • 3A

3B

PATIENT STATUS

* Overall condition of patient improved.

. Swallow more consistent and range of movement increased but speed remains reduced.

Increasing and improved co-ordination of swallow.

TION

Nasogastric feeds

significantly contribute to nutrient intake,

however, increasing amounts of pureed foods are consumed.

Pureed diet now

significant contributes to nutrient intake and nasogastric feeds are

usted accordingly.

* O al intake is now

significant in terms of nutritional adequacy.

Nursing staff supervise oral feeds in co unction with Speech Pathologist.

* Speech Pathologist commences education of patient in

his/her abili to cope with long term management of

swallowing sfunction.

* Dietitian supervises nutrient intake.

* Speech Pathologist and

Dietitian agree on cessation of nasogastric feeds.

(17)

5. 3 cont.. Programme STAGE:

4.

5.

PATIENT STATUS NUTRITION

* Swallow is approaching a more* Nasogastric feeds have normal pattern. ceased. Puree diet

* Speed has improved but still continues and soft is less than normal. foods are introduced.

* Patient's swallow now closely approximates normal

or is normal.

* A slight slowness may still exist but does not cause difficulties.

* All structures move in a co-ordinated manner.

* Thickened fluids are encouraged between meals.

* Vitamin supplementation may be indicated.

* Foods selected from

soft and/or full ward diet (FWD).

* Vitamin supplements may still be indicated.

MANAGEMENT

* Patient may be self feeding.

* Speed of swallow and amount of food will need to be monitored by Nursing staff.

* Dietitian supervises

I

nutrient intake.

* Dietitian and Speech

j Pathologist monitor oral feeds.

* Continuing education and support of patient by Speech Pathologist.

* Dietitian provides

information and education for ongoing nutritional support.

N

(18)

5 ..

1 3

At 1, foods are initially quantities (1-2 teaspoons), and

to total

An accurate record of Nurs staff are reques 24 hours

(19)

Table 3:

STAGE 1

Nasogastric

feeding Yes

Thickened No

fluids

Breakfast

Dinner

·ea

2*

Yes

Vitabrits/

Puree porridge.

Puree fruit.

Thickened cream soup.

Puree veges.

Soft dessert.

Puree veges.

Soft dessert.

VERY SMALL quantities to be offered.

1 4

3

Yes gradually decreasing

Yes

Vi tabri ts/

Puree porridge.

Puree fruit.

Puree protein.

Puree veges.

Soft dessert.

Puree protein.

Puree veges.

Soft dessert.

4

No

Yes

Introducing Regular fluids.

Vi tabri ts/

Porridge.

Cornflakes/

Rice Bubbless Soft fruit.

Cream soup.

Puree and/

or soft protein.

Soft veges.

Soft dessert.

Cream soup.

Puree and/

or soft protein.

Soft veges.

Soft dessert.

5

No

Soft and /or full diet selected from hospital menu.

II

(20)

The Dietitian and Speech Pathologist, in consultation Medical and Nursing staff, decide when the nasogastric

tube will be removed.

Nasogastric feeding is not ceased until adequate oral intake has been well established, and patient progress suggests that this can be appropriately

The Dietitian Diet Kitchen staff work to ensure appropriate food flavour and presentation. Food taste, colour and texture are reviewed in order to minimize monotony of diet in the early stages. This close monitoring of patient progress ensures an

is maintained at all levels of management, to ensure optimal progress and recovery.

5.5 Management Considerations

Each patient's progress will be dependent on a number of factors. It is likely that many patients commence Stage 1 and move through to 5 success

The following points need to be considered in the management of each patient:

i. patient's health and

ii. time frame in which patients progress from stage;

i i i . overlap of stages and variability level;

iv. psychological/motivational aspects;

v. social/cultural aspects;

vii. environmental considerations;

viii. food presentation, patient tolerance and

(21)

1 6

CONCLUSION

This protocol has outlined a set of standards to be in the identification, assessment and management of dysphagic patients at Royal Darwin Hospital.

In doing so this ensures a standardized, minimum level of quality care to patients with dysphagia.

The protocol thus enables the development of quality assurance procedures for dysphagia management and therefore contributes to the overall improvement of patient care that Royal Darwin Hospital continues to strive towards.

This protocol will be reviewed and updated as

Review: March 1991.

(22)

1 7

(23)

1 8

NUMBERS FOR REFERRAL Current extensions:

Speech Pathology 8578 or page Dietitian 8727 or page

8061 ^II

8071 ^II

APPENDIX 1

(24)

Positioning (assessment) (optimal)

physical observations

strength

Vocal Quality

Summary:

Swallow:

Speech Patholoaist

1 9

CONTACT - CRITERIA FOR FURTI-ER SWAllOWIN'.i

Public/Private H.R.N.

Ward

PROGNOSTIC oral intake, monitor progress semi/un

conscious not appropriate refuses

inability

limited by •••

chest suction more frequently than 40 min

respirator

anarthria apraxia CN:

aphonia no oral ref laxes

defects ref !exes

dull indifferent to surrounds disoriented

imitates reluctant gives up bed bed

quadriplegia dentures not

worn chest suction more frequently than 2 hourly

tracheostomy

primitive reflexes elicited

moderate dysarthria dyspraxia CN:

dysphonia palatal gag pharyngeal gag

reluctant co-operates

hemiplegia poor teeth poor dentures drooling

oral gast ro

mild dysarthria dyspraxia CN:

intermittent dysphonia spontaneous swallows

chai chair

normal

reflexive cough

DATE: I ./19 .. ~ -

(25)

DYSFUNCTION,

The patient is not suitable at this time for oral intake of food, liquid or medication because of danger of aspiration.

Rationale: See Swallowing Assessment Therefore, recommend nil by mouth

Patient will be reviewed daily/~~ times/week

Patient is suitable candidate for further intervention (see below}

- - - + - - - ·

EDUCATION PATIENT: stages of swallow and implications of impairment

OF SWALLOWING ASSESSrvENT

test textures: 1 • - - - results:

2. - - - - 3. - - - ~ 4. ~ - - - -

Videradiography:

PLANNING OF STIMULATION/EATING REGIME:

Stage/Regime: _ _ _ _ _ _ _ _ _ · - - - ~

STAGE 5:

PATIENT CHOOSES SUITABLE FOODS FOR SELF FROM MENU

- - - 1 - - - l

NORMAL FULL DIET

DISCHARGE S U M M A R Y : - - - - - - - -

- - - -

(26)

21

APPENDIX 3

TEST MEAL

Test meal to be presented in small amounts by Speech Pathologist.

Stage:

2 Jelly, Yoghurt, Tomato sauce.

3 Ice cream, Puree Baked Beans, Apricot Nectar, Cream and Vegemite.

4 Baked Beans, mashed Potato.

5 Bread, Cake, Water.

(27)

(28)

c::r

^u,c^{where a} ^ID ^riate

crtiaoiTua:si

Cl, .••

- - ... - , , '*-·::,-111...,

.

_" _·-

...

--· .... -· ^·-,; --,1111_.,, I _...,,._

-

·-

Vc,iu.,..,, .,,,,..,l:I"'

...

R f i l l I £ ' 1 t .r·r;OCltm

- fresh/tinned

. ,

' '

Fruit - fresh/tinned (ag sandwich, custard etc)

PJIA:1t/l=ii::h/r.hit"k:Anfnthor

, '

' ^'

- - ·- ---r --~-

'¥ - - - -

.

..

^'

..

^.., \"'"'""''-"I

,.

•HVlfl'<l<C41l:;IQ.IIIIV

, ..

\"""""" '"''"'I - fresh/tinned

-

\"'"""'''"""! ^..

Fruit - fresh/tinned

-

Meat/Fish/Chicken/

. _'

- -

·-

---t'~'-4,- . ., -- ^-.a.::

'

.

_-

..

(describe)

-

^..^, ~ - 1

H1'-'

Dessert (describe) Fruit - fresh/tinned Other

Biscuit (describe) Fruit - fresh/tinned Other

"' .

"

Principal Name Name(s)

0.0.B. Sex

Specialist

H~Al:'."IIQS: AMOUNT

OFFERED slice/s

pkt/s bowl/pkt/

dsp/tsp

..

J - . , r r

tsp

.

^f .. ^f

' ^,.

,.:'!..- -- ... --.

- - . - - - , L.:>jJ

scoop/dsp/tsp slice/s

.

.. ^., ..

l"""'''"""l"''"'I"

,--· --,· ·-r ..

..

f -, ·-r

bowVdsp/tsp scoops/dsp/tsp slice/s pkt/s bowVdsp/tsp pcs/dsp/tsp

.

..

r--· - - r ·-r-

AMOUNT t'HUI c11'<i EATEN

(29)

(30)

25

APPENDIX SAMPLE MENU OF FOOD CHOICES

(TAKEN FROM HOSPITAL MENU - SUNDAY WEEK 3)

2* 3 4

BREAKFAST Vitabrits/ Vitabrits/

Puree Puree

porridge. porridge.

Puree Puree

preserved preserved

fruit. fruit. fruit.

DINNER Thickened Thickened Cream soup.

cream soup. cream soup.

Puree chicken.

Gravy.

Puree potato. Puree potato.

Puree Puree cauliflower/

cauliflower/ White sauce. sauce White sauce.

Icecream. Icecream. Icecream

TEA Thickened Thickened Cream

cream soup. cream soup.

Puree beef/gravy.

Puree potato. Puree potato.

Puree pumpkin. Puree pumpkin.

Puree Puree fruit salad/

salad/ custard.

custard.

* Only VERY SMALL amounts.

(31)

(32)

REFERENCES 1.

2.

3.

4.

Anderson J.

Costa L. &

McArthur J.

Critchley M.

sher M.

27

Protocol for Enteral Nutrition Royal Darwin Hospital (N.T.

October 1986.

·nysphagia & Feeding for Lidcombe Hospital.

(N.S.W. Department of Health) 1985.

Butterworths Medical Dictionary 1978

Dysphagia Rehabilitation Prince Henrys Hospital Sydney

1983.

(33)