One month after a cerebrovascular accident, Mrs. D, 48 years old, continued to refuse to leave her room to eat and sent her meals back to the kitchen untouched. To help her with this lifethreatening problem, nurses must be aware of basic information about dysphagia and effective feeding techniques. This article will review the swallowing mechanism, signs and symptoms of dysphagia, and will offer techniques to help facilitate effective patient swallowing.
PHASES OF SWALLOWING
There are three phases of swallowing: oral, pharyngeal, and esophageal phases. In the oral phase, food is chewed, mixed with saliva, and formed into a bolus. The bolus is then worked into the back of the mouth by the inward push of food and the action of the tongue. This phase is primarily under voluntary control.
The pharyngeal phase is the beginning of the involuntary portion of swallowing. Here, the tongue raises and arches upward and the soft palate closes off the nose. The larynx elevates and is brought forward, meeting ander the base of the tongue. The epiglottis then folds down over the larynx ;o assist and direct the food down toward the esophagus. The pharyngeal walls move forward, the vocal cords close, and breathing ceases momentarily as the bolus moves downward.
The third phase occurs as the bolus enters the esophagus. The bolus is addanced downward by the peristalic movements of the esophageal muscles. Despite the complex process, swallowing is effortless in normal, healthy individuals. Patients who have had a stroke, head trauma, some cancers, neuromuscular disease of the brainstem, or damage to certain cranial nerves are likely to suffer from dysphagia.1
The nervous system provides the sensation to and activates these muscles. Damage to the 5th, 7th, 9th, 10th, or 12th cranial nerves will impair the person's ability to swallow. The Table reviews the name, function, and outcome of damage to the aforementioned cranial nerves on the chewing and swallowing process. FOT some people, eating becomes difficult, fatiguing, and even frightening. The situation becomes more complicated when the individual is unable to swallow, move food or liquid to the mouth, or place or hold food or liquid in the mouth. Swallowing, ordinarily a simple, effortless function, is now a highrisk activity.
SYMPTOMS OF DYSPHAGIA
Eating has many social implications; it is normally enjoyed in the company of others while sipping a drink or chatting. These tasks become impossible for many people who have experienced stroke, head trauma, or neurological damage. Eating can now be a degrading, embarrassing, or even life-threatening experience. These people have to face liquid running down their chins, spilling on their clothing, or coming out of their noses. Many care providers have watched patients struggle to chew, yet still be unable to swallow their food. Instead of swallowing it, the food either pockets in their cheek, spills out of their affected oral side, or causes them to choke violently or silently aspirate. What can be done?
Identifying the patients at risk, recognizing the symptoms of abnormal swallowing, and learning nursing techniques are of vital importance. Symptoms demonstrated by the patient vary depending on the area of the brain and the nerves or muscles affected by disease or injury.
Some symptoms of abnormal swallowing are difficulty initiating the swallow (seen by the up and down movements of the neck muscles as the patient tries to force an exaggerated swallow); packing of food into the cheeks easily observed due to lost muscle control); drooling; cough or throat clearing, especially after a swallow, or an absent or weak cough; and fluid leaking from the nose after swallowing.2
Aphysiatrist, a board-certified physician with additional education in physical rehabilitation medicine, may order a dysphagia assessment. If a registered nurse admits all patients, a careful assessment should be conducted that focuses on neurological areas as well as targeting the above list of symptoms.
In addition, all patients should be carefully assessed during meals until they are judged as being at low risk for choking. All new patients may be required to attend supervised group feeding for at least three meals. If problems are identified, a formal dysphagia evaluation order is obtained from the physiatrist or the primary physician.
The ear, nose, and throat consultant, under the direction of a physician, can conduct specific diagnostic studies to evaluate dysphagia. It is the physician who will recommend alternate feeding and positioning techniques, but there are some general techniques the nurse can readily employ. (Figures 1 through 4.)
Always be prepared for choking. All employees should be certified in cardiopulmonary resuscitation and the assessment and management of a choking patient. A suction machine with tubing and yanker should be available, as well as a portable oxygen tank.
The patient should be awake, alert, and possess a reflexive and effective cough. The patient's gag reflex can be assessed by tickling die throat with a wet cotton swab. The nurse should also ask the patient to produce an audible cough and finally a voluntary swallow. Carefully observation of muscle movement and actions should be noted.
Positioning is of prime importance. The patient should sit up straight, lean slightly forward, shoulders should be straight, and the head flexed with a forward pitch. This will allow the chin to fall forward, facilitating the closure of the trachea and helping to open the esophagus.
As a general feeding technique, food should be placed onto the unaffected side of the tongue. The nurse should press down gently on the tongue and rock the spoon back and forth. This will help deposit the food on the tongue. Remember to avoid touching the teeth or advancing the spoon too deeply into the mouth.
Remember, eating is a social activity; it should be pleasant and leisurely. Food should be prepared attractively and smell good. Be sure that the patient has used the bathroom before eating and his mouth and hands are clean. If possible, the patient should be out of bed in either a wheelchair or chair.
Provide an environment conducive to eating. Limit distractions and environmental noise to enable the nurse to provide verbal and visual cues to the patient. The nurse should tell the patient exactly what she is doing and how he can help, step by step: "Open your mouth, feel the spoon on your tongue, feel the food, taste it, chew, lift your tongue up to roof your of mouth, hold your lips closed, put your chin down, swallow, swallow again, relax."
The following methods help promote s wallowing.
* Take your time. Do not ask the patient to speak until a few seconds after swallowing to decrease the risk of aspiration.
* It may be necessary to physically hold the patient's lips together or teach the patient how to perform this technique.
* If food packing is a problem, encourage the patient to use his fingers to clear food out of the cheek.
* Figure 1. Guide the patient in placing the proper amount of food on the fork. Cue the patient to place the fork on the unaffected side of the tongue and use a rocking motion to help deposit the food.
* Figure 2. Remind the patient to swallow twice. This ensures the complete clearance of the pharyngeal tract. The use of gestures helps reinforce spoken instructions.
* Figure 3. Show the patient how to clear pocketed food from the affected side of the mouth.
* Figure 4. Thickening agents can be added to beverages to facilitate safe swallowing. Straws should not be used as they require more steps before the swallowing actually occurs.
* Do not wash food down with liquids because they are difficult to swallow. Many patients with dysphagia will be on specific diet restrictions, such as soft solids only. As the patient increases strength or skill with an adaptive technique, he may be advanced up the scale to full and clear liquids. Often, thickening agents will be added to liquids to facilitate swallowing ease. Be sure family and staff understand the dietary restrictions.
* Remember that many patients need to swallow twice to completely clear the pharyngeal track.
* Remember that proper positioning is of utmost importance. Continue to have the patient sit up for at least 15 minutes after eating. Be sure to provide effective mouth care after meals and remove any residual food from the mouth.
* Effective feeding techniques should be taught to not only the patient but also the family and staff. Never assume that staff know the art of assistive feeding techniques.
FUNCTION AND OUTCOME OF DAMAGE TO CRANIAL NERVES ON CHEWING AND SWALLOWING PROCESSES3
- 1 . Logemann J. Assessment of Swallowing Physiology. Gaylord, Mich: Northern Speech Service, Ine; 1984.
- 2. Bonalanza T. Dysphagia Management: A Guide to Recovery. San Mateo, Calif: Mills Memorial Hospital; 1982.
- 3. Hufler DR. Helping your dysphagia patient eat. WV. 1987; Sept:36-38.
FUNCTION AND OUTCOME OF DAMAGE TO CRANIAL NERVES ON CHEWING AND SWALLOWING PROCESSES3