(the medical term for difficulty swallowing) Dysphagia (the medical term for difficulty swallowing)

Refer to SLP When your patient is requiring cues to swallow. When food/liquid is falling out of patient’s mouth When food is stuck in their cheeks When patients are coughing or choking when eating When their voice is wet/gurgly consistently When the patient reports “things are getting stuck”

Obtaining a Referral 1. Consult with the SLP 2. Request swallow evaluation through nursing or physician

Cues for safe intake Swallowing strategies or “cues” may include: Small bites/single sips Chin tuck Tongue or finger sweep Alternate liquids with solids Clear throat (if gurgly) and swallow again Swallow with effort Double swallow

RHFW Swallowing Protocol Have you ever wondered if your patient is on a special diet due to dysphagia ? If so, the following information will be very beneficial to you.

How to check patient’s diet 1. Physician’s orders 2. Nursing blue book 3. Orange arm band on patient to have current diet 4. Rehab Dining Program book for special diets (located in top drawer in dining room)

How to check patient’s diet – cont’d. 4. Orange sheet placed above patient’s bed lists diet and strategies 5. If still unsure, consult with SLP

RHFW Diet Modifications Mechanical soft – No tossed salad, bread is being sent out instead of toast at breakfast Mechanical soft with chopped meat – as listed above, except the meat is cut into small pieces Mechanical soft with ground meat – as listed above, except the meat comes ground

Diet Modifications Cont’d Mixed Mechanical Soft and Pureed diet This is when 1 or 2 items are soft solid i.e. macaroni and cheese. *the rest of the patient’s foods are puree consistency, i.e. applesauce, mashed potatoes

RHFW Diet Modifications - cont’d. Pureed diet – all foods are pureed Appropriate snacks we offer are applesauce, yogurt, ice cream, pudding, baby food (available from kitchen)

Liquid Modifications Nectar Thick Liquids – the consistency of syrup or fruit nectar. To thicken to nectar consistency, use a 120ml juice or ½ of a styrofoam cup of liquid, add 1 nectar thickener packet and stir 15 sec., let sit 3 minutes, assess consistency prior to giving to patient. Is it too thick or not thick enough? Do you know what to do if it doesn’t look right?

Liquid Modifications – cont’d. Honey Thick Liquids – thicken to the consistency of honey. Thicken 120 ml juice or ½ of a small styrofoam cup of liquid by putting in 1 honey thickener packet, stir for 15 seconds and then sit for 3 minutes. Assess the consistency.

Where to find thickener 1. With the condiments in the dining room 2. Ring the bell and ask the dietary staff 3. Nurses station, in the nourishment room.

What kind of thickener do we use? RHFW currently uses Thick & Easy Comes in individual packets Starch based product We also have pre-thickened apple and orange juice as well as thickened milk.

Where would a patient buy thickener? Thickener can be purchased at places such as Wal-Mart or other pharmacies. Often you may have to ask at the counter for it. Thickeners can be purchased in packets, in canisters or in pre-thickened liquid form.

Do we have any pre-thickened liquids? Yes, we have nectar and honey thickened boxes of milk, apple and orange juice. Ensure and V-8 are naturally nectar thick. Location: Cafeteria and in the nourishment room.

Rehab Dining Program Purpose: To provide a comprehensive, multidisciplinary, organized system to identify, assess, treat and supervise/assist patients with swallowing and/or feeding difficulties.

Dining Program Objectives To identify patient with need for assist/supervision at meal to increase independence and safety with eating/swallowing. These patients eat together at RESERVED tables Written recommendations for swallow precautions, self-feeding techniques and adaptive equipment for consistent follow through. Advance diet and reduce assist/supervision as appropriate to reflect progress Educate patient and caregiver regarding swallowing/feeding needs throughout their stay.

Appropriate Dining Program Referrals Oral and pharyngeal dysphagia Visual deficits including neglect and/or inattention Inadequate intake due to cognitive deficits Hemiparesis, quadriparesis

Rehab Dining Procedure Patients will be identified as possible candidates during assessment and as they progress, i.e.: from NPO to PO status Speech and/or Occupational Therapy will assess and recommend dining program as appropriate. Nursing may refer for consideration also. Speech and/or OT will complete a Rehab Dining Precautions/Program Sheet (Orange). This will be placed above the patient’s bed and in binder. This binder is located in top drawer of cabinet in the dining room.

Rehab Dining Procedure - cont’d. 4. Patients will sit at designated tables during mealtime. Visitors may sit close by as appropriate. 5. Assigned therapy/nursing staff will supervise the patients given their individualized programs. Other staff will also assist with tray set-up. 6. Status/progress will be documented in the therapy notes and nursing notes. Change in status should be communicated directly with the primary therapist for the responsible patient. 7. A change in diet or strategies will be updated on the orange sheet in binder and above patient’s bed.

Team Conference Form and Swallowing Goal: to be consistently completed by OT or SLP (when on the case).

SLP’s are currently scoring the swallowing section using Max, Mod, Min etc. depending on the level of cuing. Also, list the diet (Min A mech. soft & grd meat) Use FIM scoring as follows

FIM Scoring Independent (7) – Regular diet and thin liquids, no cues. Independent with strategies (6) with all consistencies. Supervision (5) = Pt. swallows more than 90% of the time without cues.

FIM Scoring – Cont’d. Min A (4) = Pt. swallows 75 - 90% of the time without cues. Mod A (3) = Pt. swallows 50 – 74% of the time without cues. Max A (2) = Pt. swallows 25 – 49% of the time without cues. Dependent (1)– Pt. is NPO or swallows without cues less than 25% of the time.

Contact Speech Therapy at Questions? Contact Speech Therapy at X 6135 or x 6136

Print the test, complete, copy for your records and give the original to your manager. For Therapy Services, Evan should receive a copy in his box. Thank you!