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dysphagia — Transcript

by ann best · 5,705 words · 1,007 segments · language en · Watch on YouTube

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0:08okay
0:09well welcome to the next lecture
0:13um now we're going to be talking about
0:16dysphagia
0:17and swallowing um
0:21first of all we're going to talk about
0:23the different stages of
0:24normal swallowing um you'll you'll see a
0:28lot of different patients from
0:29swallowing issues
0:31whether it's
0:34from cva's to any of the
0:38neurological disorders that we
0:41talked about earlier it could be because
0:45of any other surgeries they've had
0:48so although when you typically think of
0:51the swallowing you'll think of speech
0:53therapy
0:55occupational therapy is getting highly
0:57involved in swallowing and disaster as
1:00well
1:01and not only directly in with the
1:03treatment
1:04but we work very very closely with the
1:07speech therapist as well
1:08because we need to make sure that if
1:11they're
1:12have the speech therapist is doing any
1:14strategies to work on swallowing
1:16that when we're with the patient working
1:18on self-feeding
1:20that we're following up with those
1:21strategies as well
1:24so um the first part of this is just
1:26talking about the normal swallowing the
1:29different stages of swallowing
1:33the first um couple of
1:37stages there's a pre-oral and oral
1:40preparatory and an
1:41oral all of these stages are
1:44voluntary meaning that the patient will
1:47voluntarily
1:48do that so pre-oral
1:52is just the um the oral
1:56motor muscles working correctly and then
1:59oral preparatory
2:01is getting the food into the mouth
2:03closing around the lips
2:04closing around the food and then the
2:08oral
2:09is getting from the food from the front
2:12of the mouth
2:13to the back
2:16and then when you get to the pharyngeal
2:19this is involuntary
2:21so once the food and you'll hear a lot
2:24of times it will be called a bolus
2:26the bolus is anything it's either the
2:29food or the liquid that's formed into
2:31the mouth that you're going to swallow
2:33so you'll hear a lot of it called a
2:35bolus
2:37the pharyngeal is once it's to the back
2:40of the throat
2:41that's when it's going down into that
2:44starting to go into the esophagus
2:48so then this first section
2:51is pretty much what um ot and speech
2:53will deal with
2:55the esophageal is once it's into the
2:58esophagus
2:59it moving down into the stomach
3:03so what i want you to do is there's this
3:06youtube link that i would like you to go
3:09and watch it's just a minute and a half
3:11it's
3:11two minutes um it gives a really good
3:13explanation
3:14of some pictures so you can see
3:18how the bolus will be moved from the
3:23front of the lips all the way down into
3:24the esophagus
3:32okay so now that you've watched what a
3:35normal swallow looks like
3:37we're going to kind of look at what
3:40happens when that swallowing
3:42is impaired and what can cause those
3:44impairments
3:46so you can have many of the diseases
3:48that could be causing you know central
3:50nervous system
3:50peripheral nervous system motor
3:54motor issues musculature within the
3:58face and lift ropes any trauma to the
4:01affected area could be
4:02causing issues for swallowing
4:06well what happens when somebody gets the
4:08dysfunction
4:10and the despite it typically so you
4:13understand where the dishonesty is in
4:15the actual swallow part
4:17so it's just getting it from once it's
4:19in the back of the throat
4:21down into that it's swallowed correctly
4:25what's it gonna lead to well it's to
4:27lead to dehydration
4:28and malnutrition first if somebody's not
4:32swallowing correctly they're
4:35they're probably not even going to be
4:37eating a lot or
4:38drinking a lot because they're scared of
4:40what's going to happen
4:43aspiration and pulmonary issues are huge
4:47because as you saw in the normal swallow
4:51that epicolitis needs to close in order
4:54for the liquid to not go
4:56into the trachea what happens with that
4:59aspiration
5:00is that's what happens the liquid goes
5:03into there for some reason mechanical
5:06reason
5:06everything's not sliding down to the
5:08esophagus correctly
5:10and there's some sort of delay in the
5:13food going down correctly so when we say
5:15somebody clocked because it went down
5:16the wrong pipe
5:17it really did go down the wrong pipe it
5:19ended up going down into the trachea
5:22instead of the esophagus and what
5:25happens once it hits the trachea
5:28it's kind of like that tickles and
5:30that's what's causing the cough
5:32because it's your lungs telling your
5:33body wait a minute there's this foreign
5:35thing coming in here that's not supposed
5:37to
5:38be here so the cough is your
5:41body's way of coughing it back up
5:44so it can go down the right way again
5:47well sometimes things still leak in
5:50through there
5:51and it can cause a pneumonia and
5:55respiratory distress and then those
5:57things could lead to death
5:59so it is very very very important
6:02that we are very aware of what the
6:05aspiration
6:06and pulmonary risks are and do whatever
6:09we can to try and prevent
6:11those things
6:18along with the actual um
6:22nostalgia we also have more on the
6:24respiratory stuff
6:26doing secretion management you have to
6:29make sure that the airway is
6:31free of any of the secretions usually
6:34you will see
6:35this type of thing done by the
6:36respiratory therapist
6:38this is their specialty
6:41but we need to be aware of what happens
6:44so we understand
6:45okay if they had a tracheostomy
6:49what does that mean how is that going to
6:51affect their ability to eat and defeat
6:53themselves
6:54so we need to know what is that going to
6:58lead you why are we going to need to
6:59address those things
7:03once they've had the tracheotomy removed
7:06that still leaves a possible hole in
7:08their neck think how that's going to
7:09affect
7:11all that musculature that's in that area
7:13but they're going to be having a
7:15difficulty swallowing
7:18it's going to reduce their taste and
7:20their smell
7:23it's just the mechanism behind
7:26all of your taste buds and remember in
7:29order to taste correctly you
7:31smell things that all works together all
7:33of that is really
7:34inhibited once you involve
7:37an issue with like a tracheotomy
7:46and then an open one so this one would
7:49be
7:49you know if it's once they have closed
7:51it it's still all kind of healing you've
7:53done major trauma to the area but even
7:55if it's an
7:55open one it's still definitely going to
7:57reduce your swallowing response
7:59i think there's now this hole in this
8:01area
8:02that's to help them breathe so those
8:05muscles are not
8:06working correctly
8:10and then if your patient is on a
8:11ventilator
8:13that ventilator is assisting them to
8:15breathe
8:16so if that's doing all of the work
8:20their swallow is going to be delayed
8:23what research is showing is that
8:25they haven't been and they say this one
8:27for a week or more
8:29so if they've not been alert enough to
8:32be able to do
8:33swallowing on their own they've been on
8:35a ventilator so that's doing all of the
8:37breathing the inhalation and
8:39exhalation for them they don't have to
8:42work hard to make everything work
8:45so even if they're alert on a ventilator
8:49they're not doing a lot of the
8:51swallowing responses that are
8:52needed so those muscles are just like
8:55other muscles
8:56if they're not working they're going to
8:58get weak
8:59and then not work properly so it's very
9:03important to know
9:04okay my patient was on a ventilator for
9:06at least a week
9:07they're probably going to have some
9:09swallowing difficulties
9:11i need to make sure i'm following
9:13whatever their protocol is
9:15i said we ourselves might not be dealing
9:18with any of the care with these things
9:19but you need to
9:20know what to look for you know did they
9:24have one of these things previously
9:26that would make them prone to some
9:28swallowing difficulties
9:36this slide is just someone what um some
9:39different diagnosis kind of what you
9:41might see
9:42where you might see the deficit in
9:46so in your alzheimer's you're going to
9:49see
9:50a lot from the different standpoints
9:52there's neurological damage that happens
9:56um they're prone to aspiration during
9:59the later stages
10:01because their body kind of doesn't
10:03remember how to respond correctly
10:05um they might be eating or drinking too
10:09quickly and in some videos that i'll
10:11show you during lab you can see what
10:13happens when somebody eats or drinks too
10:16quickly or if it's
10:17too thin of a liquid what truly happens
10:21and then later they prefer things that
10:23are sweet
10:25and more pureed texture
10:28because sweet is what stays intact
10:32kind of think remember when we talked
10:34about the alzheimer's disease what
10:36happens
10:37that regression so
10:40what do when you're if you're in a late
10:42stages of alzheimer's think about what
10:44chronolog chronological age they're in
10:46probably more that infant toddler but
10:49there's an infant toddler for fun
10:51they prefer the sweets because it tastes
10:53good
10:54that's one of their first tastes that
10:56they have
10:57and then they puree food because they
10:59don't have to work real hard at chewing
11:02so not only is that preferred but it's
11:04much easier for them because they don't
11:06have to worry about
11:08chewing up and making sure everything is
11:11in small enough bites and chewed up well
11:14before they swallow it
11:16so knowing this could be a way to
11:20get your patients with alzheimer's to
11:22eat a little more
11:23sometimes you might have to sweeten the
11:25food a little bit i've kind of
11:27dipped a little bit of you know one food
11:30and then dipped it into some peaches or
11:32something so it's sweet so that first
11:34thing they taste is sweet so they're
11:36more likely to swallow and eat it
11:41and then with any of the brain injuries
11:43there's
11:44over here you see that there's a lot of
11:46the neurological
11:47damage that happens so your brain does
11:50not remember
11:51all of the involuntary responses that
11:54it's supposed to make
11:57in order for this world to occur
11:59remember that first
12:00slide those first couple stages are all
12:03voluntary the person that the patient
12:05does
12:06does them all on their own they can
12:08control when the food goes into their
12:11mouth
12:12but then that pharyngeal phase is all
12:15involuntary
12:16all of that is the brain talking to
12:19the esophageal muscle what it needs to
12:22do
12:22if there's neurological damage it won't
12:25happen correctly
12:28same thing will happen with parkinson's
12:30many psychiatric disorders
12:33you know the brain is not sending the
12:35correct signals to that
12:36area so it's just like if we have
12:38paralysis on the left side the brain
12:41isn't communicating correctly with the
12:43left side of the body
12:45saying here the brain is just not
12:46communicating
12:49with the swallowing muscles correctly
12:53and then any head and neck cancer will
12:56cause mechanical
12:57issues you know they might have had to
13:00take out part
13:00you know some pieces put in a
13:02tracheotomy so they could breathe better
13:05that's going to cause mechanical issues
13:07to certain areas
13:09or if they've had any oral
13:12cancer if there's pieces that are
13:14missing or damaged to the oral area
13:18that's also going to affect the oral
13:20stage of swallowing
13:24and then all of the what's going to
13:26happen
13:27we've got a huge disposition problem
13:30and we're going to get the secondary
13:32diagnosis of debilitation
13:34lack of appetite and a decline in
13:36overall nutrition
13:39if you look at all of the diagnosis that
13:42we talked about earlier in the last
13:43couple weeks
13:45so many of them have a huge nutritional
13:47component making sure they're eating
13:49correctly
13:51well if they're not able to swallow
13:53correctly they're not going to get the
13:55proper nutrition
13:57so it's very important that we are aware
14:00of what's going on with their swallowing
14:02so we can somehow make sure they're
14:04getting the nutritional content that
14:05they need
14:10how do we decide if they've got a
14:12swallowing difficulty
14:14there are several different um
14:17evaluations that can be
14:19done um there's an electromyography it
14:23records the contractions of the muscles
14:26during the swallow there's a fiber optic
14:29endoscope
14:30so they would be taking um the small
14:33tube and going down in through the
14:35throat
14:36to kind of check out see what's going on
14:38what does the fairness and
14:40larynx look like is there any you know
14:44abnormalities in that area that we need
14:47to be aware of
14:51um the monography is a catheter
14:54that goes in to measure the measure of
14:56the pressure of the esophagus
14:58because as you saw in that video there
15:00needs to be a certain amount of
15:02pressure in order for the muscles in the
15:05esophagus to make it
15:06move down so if there's not enough
15:09pressure in those muscles going down the
15:11food's going to get stuck
15:13so that's one way they can figure okay
15:15what's going on okay this will tell us
15:18exactly where the deficit is coming from
15:27is radioactive isotope and it's mixed
15:29with the food
15:31this one is done very similar to
15:34the fluoroscopy and your ultrasound
15:39i'm sorry not the ultrasound but there's
15:41your
15:43video philosophy they're going to be
15:45looking at the different structures
15:48and measuring how
15:51they which one is acting correctly and
15:55which one's
15:56not you can see
16:00with the video fluoroscopy the images
16:03are recorded on video
16:06and then the therapist can perform this
16:08procedure
16:09to then and then use it to track the
16:11progress they'll start and see how
16:13they're doing
16:15and then do it a little later to see if
16:17it's gotten better
16:19this one is usually otherwise known as
16:21an mbs it's a modified barium swallow
16:25this will be the main one the main one
16:29that you'll see frequently done
16:32speech therapists are the ones that
16:34perform this
16:35but in some hospitals the ots are
16:39actually there to help perform
16:41um the mbs and what happens
16:46is they will put a little barium in the
16:49food or the liquid that they're having
16:51the patient
16:52swallow that way the barium will come up
16:55in the radiographic image as it's being
16:58swallowed so they can see
17:00exactly where it's not going down
17:03correctly
17:04so that's how they're going to determine
17:07what kind of liquid
17:09and what kind of food the patient can
17:11tolerate
17:12they will start with thicker liquids
17:16and then progress depending on
17:20if they know there's an issue right off
17:23the bat
17:24or if they're just checking to see if
17:27there could possibly be
17:29because if there was somebody for
17:31instance who
17:32has been on the tracheotomy or the
17:35ventilator for
17:36several months they know there's going
17:37to be an issue
17:39they will probably start with the more
17:41thickened things
17:42just to see will that even go down
17:44correctly
17:46because thin liquids is the last stage
17:49if you're giving someone thin liquids
17:51who's not ready for it
17:53that liquid will go right into the
17:55trachea and then go right into the lumps
17:58so that's why it's very important to be
18:00able to have this
18:02modified barrier while done so you know
18:05what's going on
18:10they said it could either be speech or
18:12ot it kind of depends on the treatment
18:15setting
18:15and it's honestly it does depend on
18:18staffing as well there's more ot's that
18:20are becoming
18:21um certified in doing despaja therapy
18:25so if there's not a speech therapist
18:26available the ot
18:28is able to do it as well so that is
18:30really nice with as much as we co-treat
18:33with pt
18:34here's the one huge area that we can be
18:36co-treating with speech as well
18:39you know i think we tend to forget that
18:41we can do so much with our speech
18:43therapist that we kind of just do our
18:44code treats with our pt
18:47so it's really important to remember our
18:49speech therapist and do some co-training
18:50with them as well
18:52you can sit with the patient at a meal
18:55the speech therapist can be working on
18:57their exact swallowing you can be
18:59working on their hands and mouth
19:01and you're doing your poetry
19:05it is best with a multi-disciplinary for
19:08that reason
19:09you know a lot of times we'll be working
19:11on hand to mouth getting the food from
19:13the plate into their mouth and then the
19:14speech therapist is going to work on
19:16getting it down
19:18well a patient's going to want to do
19:19that all at once they're not going to
19:21want to just practice hand to mount and
19:23then
19:24quit that doesn't make sense they're
19:26going to want to continue with the
19:27swallow
19:29so that's why it's important to kind of
19:30tank team and work together on that
19:33so you know what the speech therapist is
19:35doing for the swallow and they know what
19:37you're working on with the hands now
19:41as you can see most of your patients
19:44that are gonna have the diagnosis of
19:45this budget happen in your nursing home
19:48so 59
19:50at some points would have received ot
19:53for dispages so this
19:55is huge it's not saying that they don't
19:57ever recover from their disaster but 59
19:59of them will have required some sort of
20:02treatment for it
20:07so interventions what are we going to be
20:09doing
20:11for dysphagia you're going to be getting
20:13several
20:14handouts in lab on thursday
20:17um with several interventions that we're
20:20going to be practicing
20:21but some huge things that you want to
20:23make sure of is
20:25very very important for ensuring proper
20:27positioning
20:28that's a huge one no matter what else
20:30you do after this one's
20:32huge so ideal
20:35obviously to be sitting up in a chair in
20:37the wheelchair that's the best way to be
20:39eating to be totally sitting up
20:42but if that's not possible if they
20:44cannot get
20:45up out of bed into a chair
20:48they need to be up and elevated at least
20:51to 45 degrees
20:53otherwise it makes it even more
20:54difficult to swallow
20:56imagine if you were laying flat in the
20:57bed and i asked you to try and swallow
20:59something to drink
21:01it's really hard and we have a normal
21:03swallow
21:04so imagine someone who's having
21:06swallowing difficulties
21:08you need to be able to sit up so you can
21:11drink better and ensure
21:13that the liquid goes down the esophagus
21:15and not the trachea
21:20when we're talking about remedial
21:22interventions remember this remedial
21:24means we're going to rehab it
21:26and get it better there's two distinct
21:31types of therapy that we'll do one is
21:33indirect
21:35and then the next one is direct when
21:38you're thinking about
21:39indirect these are the things that
21:42happen
21:42before you put the food in the mouth
21:46it does not require having a food
21:49or liquid ingested it's all the free
21:52things that
21:53happen before the swallowing occurs so
21:58that's going to include
21:59any of the range of motion and
22:01strengthening
22:02exercises that you need to do for the
22:04oral and pharyngeal muscles
22:07that happens without food
22:10remember the indirect does not have any
22:12food involved it's things you're doing
22:14beforehand
22:17there's a lot of sensory stem or
22:21desensitization that happens to the oral
22:24area
22:25during your peace class in the fall
22:27you'll be going over
22:28a lot more of the sensory stem with mrs
22:31birth
22:33so make sure you're paying attention and
22:35kind of correlating that that's an
22:36indirect strategy because you're doing
22:38that before you introduce the food
22:42and then manipulating the environment to
22:45optimize the behaviors that affect the
22:47swallow so what would be something you
22:49might want to think about
22:50how are they sitting okay i'm going to
22:52manipulate my environment
22:54and make sure they can that they're in a
22:55well-supported chair that they can
22:57sit up correctly you know is the room
23:01brightly lit that they can find
23:03their food correctly those
23:06things affect the slalom so you want to
23:10make sure that you are giving your
23:11patient a good
23:12mealtime experience so that's all the
23:15indirect things
23:18now we're going to look at the direct
23:20things these are the things you're going
23:22to do while they have the food or the
23:24liquid
23:27and it can be just a little snack or it
23:30can be a meal but remember the direct is
23:32once we actually have the food or liquid
23:37so this is when you're going to be
23:39practicing the different
23:40swallowing maneuvers in order to get the
23:44food done correctly
23:46we will practice these in lab but this
23:48would be like if you're having your
23:49patient do a chin
23:50tuck in order to swallow
23:54so you might practice the actual chin to
23:56okay this is how i want you to tuck your
23:58chin
24:00now i'm going to give them something to
24:02drink and have them put that strategy
24:04into place
24:05so once we're drinking with the chin
24:07tucks
24:08that's the dirt that you're using direct
24:10you have the actual bolus that you're
24:13using
24:13during the strategy
24:18sometimes the indirect continues and
24:21it's concurrent with the direct therapy
24:24a lot of times this could be with your
24:26sensory synth so you might need to be
24:28stimulating the outside of the oral
24:31muscles
24:33or in the neck muscles in order to
24:35encourage the swallow
24:37okay so you might be doing both at the
24:39same time
24:42so this is especially important to work
24:44with your speech therapist because
24:46they're gonna
24:46look and okay do they respond really
24:50well to an ice massage to the teeth
24:52because cold is really good for a
24:54swallow
24:55it kind of helps wake everything up
24:58so have they discovered that that works
25:00what works really well in between the
25:02swallows
25:03if so that's what you need to continue
25:05while you're working on self-beating
25:13here's a nice chart on the progression
25:16of your food and your fluid textures
25:20so again i'm gonna get the fullest is
25:22the food or liquid that's in the mouth
25:25okay here is our progression of
25:28food so we would it would start as
25:32thick puree so clean or applesauce
25:36it's going to be a very thick think that
25:38consistency of
25:40pudding it's very thick
25:44and then they're gonna progress to
25:45something that's soft but chewable so
25:48something
25:48very so soft cooked vegetables
25:51fruits pastas but those pastas
25:57they need to be very well cooked so
25:58they're soft
26:01you won't want to give someone any
26:04raw vegetables or any raw fruits at this
26:07time
26:08there's too much chewing involved if
26:11they're having
26:12trouble smalling you you want to
26:14eliminate how much chewing is involved
26:18then you're they're gonna move on to
26:21some dryer chewables
26:23so like a cookie or some bread
26:26usually because those they're a little
26:28drier they're not as
26:30moist and easily manipulated in the
26:34mouth
26:35so it's going to be a little harder to
26:39when you watch the video they start with
26:41the front of the mouth and as it goes
26:43back
26:44if it's nice and moist
26:47your tongue can easily move it to the
26:49back of your mouth but the drier it is
26:51the more difficult
26:52it kind of is you know think about um
26:55maybe that dry piece of chicken that
26:57you've tried eating you just feel like
26:58you're
26:59chewing too and then it just doesn't go
27:00down quite right it's just not moist
27:04enough
27:07then you start with firmer chewables so
27:10this would be when you would get more of
27:13the
27:13meats or anything else that would
27:16require a little bit more
27:18biting maybe having it more of a
27:21sandwich type thing where there's more
27:22chewing
27:23involved
27:27and then you would go to spoons with
27:30mixed textures so what that would be
27:33would be like
27:34cereal and milk so the milk would be the
27:37plain liquid but now we've added the
27:39cereal to it so it's got a different
27:41texture in your mouth so that's a little
27:44bit more difficult because your mouth is
27:46saying okay what do i do with these
27:48different textures i have to manage the
27:51thin liquid of the milk
27:54and manage the texture of the cereal and
27:57what do i need to do with
27:59it so it's hard when we perform you know
28:02it's just kind of automatic you take it
28:04but you know you're eating your morning
28:05cereal you take a spoonful you chew it
28:07up if you need to when you swallow it
28:09it all happens so quickly but when
28:12you've got the swallowing difficulty
28:14you know things are kind of delayed and
28:16you're trying to figure out okay
28:17what does my mouth do with the milk or
28:20is this the cereals
28:21is it going down the correct way what am
28:24i going to do
28:26and then you've got pills and water
28:29i don't know how many of you have had or
28:31still you know even still do
28:32it's hard to learn to swallow a whole
28:34pill in water
28:36it's just really hard because you've got
28:37that thin water and then you've got this
28:39pill that's a solid
28:41you're not supposed to chew it you gotta
28:44somehow
28:44get it to go down right and there's
28:46always a trick to figure it out
28:49and i've always been amazed at my
28:51patients that can take a handful of
28:52literally like 15 to 20 pills throw them
28:55all in their mouth and chug them all
28:56down at once
28:58i've always been in amazement and then
28:59there's the other patients you'll see
29:01that has to do one at a time
29:02it's hard so that's why you'll see
29:06you know pills getting crushed if they
29:09can crush them they'll crush them and
29:10put them in a pudding or applesauce
29:12because it'll slide down a lot easier
29:13for them
29:16the muscles in the brain don't have to
29:17work together quite as hard to get the
29:19pill and the water
29:20down correctly
29:24because what happens with your fluid
29:27is we automatically think that water
29:30will be the easiest
29:31because it'll it'll go right down
29:34there's no work to it
29:36well because there's no work to it
29:39there's also a little control that's
29:41involved
29:41it will slide down so quickly
29:45that if not all the mechanisms are
29:47working correctly
29:50the water will easily go into the
29:52trachea instead of moving right down
29:54into the esophagus because there's no
29:57control involved
29:59so that's why sometimes when you add the
30:01pills in the water
30:03the water will go down first because
30:05this doesn't slide right down but then
30:06you're
30:06stuck with the pill because you had this
30:10quick water go down that you're trying
30:12to control
30:13the water to go down correctly but now
30:15you're stuck with this pill
30:20so what happens if when someone's having
30:23dysphoria or any other swallowing
30:25difficulties they'll start with no
30:26fluids
30:29um that's nothing by mouth
30:32this person will typically be on some
30:34other nutritional
30:36supplement they'll have the nasal
30:39gastric tube that
30:40the tube that goes from their nose to
30:42their stomach giving them the
30:44supplement nutrition or it will be
30:47the engine it'll be the tube in their
30:49stomach
30:50giving them the nutrition and then once
30:52they're able to start
30:54liquids it will be honey thick and it
30:57really is the consistency of honey
31:01because it's so thick it can be easier
31:04control
31:04to go down a little slower
31:08so the muscles don't have to control
31:10quite as much
31:12to keep it to go down correctly
31:16and then as it moves once they've gotten
31:19better with the nectar thick that will
31:21go
31:21or honey thick then it'll go to a nectar
31:23thick it's a little
31:25thinner but it's still not totally thin
31:28okay it will look
31:32kind of like a
31:35a runny jello texture
31:40and then we've got thin and flavored
31:42fluids
31:44okay so thin would be normal like some
31:47apple juice
31:49nothing in it at all most
31:52fluids can easily be thickened with a
31:55commercial thickener
31:57and if you haven't seen it we will be
32:00practicing
32:01in lab and practicing does mean that we
32:04are going to create some honey thick and
32:06nectar thick liquids
32:08and you are going to try them nobody is
32:11ever very excited about trying them
32:14um but i do think it's important that
32:16number one you get to see
32:17how the textures look you know so in
32:20case someone you know your patient wants
32:22a drink of water and you know that
32:24they're on honey thick
32:25you know what that looks like so you can
32:27prepare them some honey thick water so
32:29they can have something to drink
32:31but you also need to you know you kind
32:33of know what it feels like to be
32:34drinking this
32:35thickened water or juice
32:40you know that you kind of build some
32:42empathy for your patients as well
32:44this is very difficult to
32:47have to foods i don't usually see as
32:50many people
32:51yeah they want to get away from their
32:53purees
32:54but it's usually the fluids people have
32:56more difficulty with than accepting
32:59so if we can be a positive coaching
33:02influence there we can help them get
33:04through
33:05um having to have some thicken liquids
33:13other considerations just kind of if
33:15they're unsafe to swallow this is how
33:17they'll get their nutrition either
33:19intravenously
33:20or through a tube
33:24once they're able to start taking some
33:27oral intake it's going to take the
33:29direct supervision and they need to
33:32monitor calorie counts very
33:35closely this is usually the hard
33:38part because the patient is used to
33:43maybe being on a constant flow
33:46from the tube getting all the nutrition
33:50well that's keeping them from being
33:52hungry
33:53usually most of us if we're not hungry
33:56we don't want to eat
33:57now there are those of us who can put
33:59some food in front of us we'll eat no
34:01matter what
34:02but most of patients at this point if
34:04they're not hungry they're not going to
34:05want to eat
34:07well it's hard to get them back to food
34:09if they don't want to eat
34:11so it's working very closely with
34:14nursing the speech therapist with us
34:17trying to figure out okay
34:18when are they getting their feeding
34:20through the tube and when are we going
34:22to be trying some
34:23food so we can encourage them to start
34:27eating some food
34:28you know it's it's really hard to work
34:31on the correct strategies that they
34:32don't even want to eat the food
34:34because they're not even hungry
34:37so they but they can't there has to be
34:40an equal balance you don't want to make
34:41sure you're taking
34:43the tube feeds away entirely because
34:45they're not quite getting all the
34:47nutrition that they
34:48need orally so it's got to be a real
34:50balancing act
34:55then there's the caregiver education
34:57this is huge
34:59i've seen several patients like their
35:02family comes in thinks they're being
35:04helpful by giving them some water
35:06you know mom said she was hungry so i
35:08gave her a glass of water
35:10you know she didn't cough or anything so
35:12i think she's okay
35:14well if they're having swallowing
35:15difficulties that water may have very
35:17well gone down into the trachea and
35:19caused
35:20huge problems so family needs to be
35:23very well aware of what their swallowing
35:25precautions are and why
35:27so they understand you know because
35:30their loved one is going to complain
35:32about that thickened liquid
35:33they're not going to want to drink that
35:35thick gross looking water
35:38but you need to get the family on your
35:39side as well so they can be supportive
35:42you know this is why you need to have
35:43this thickening you know this thickened
35:45water for right now until things get
35:47better
35:48this is the way we have to drink
35:52also oftentimes the straws are a greater
35:56risk
35:56so if you think there's even ever an
35:59inkling of having a swallowing
36:00difficulty
36:01please check with your speech therapist
36:03before you have a patient drink from a
36:05straw
36:07what happens when you drink from a straw
36:09is you're going to swallow even quicker
36:11you're not only going to swallow quicker
36:13but you're also going to take more
36:15in imagine when you're drinking from the
36:17straw how much liquid you kind of suck
36:20up in all at once
36:21versus if you just maybe take a bottle
36:23of pop and take a sip from it
36:26you can be more controlled with your
36:28swallow when you're taking
36:29small sips so when you're sucking
36:32through the straw when you get a lot
36:33more
36:34in if you're taking in a lot more
36:37fluid there's more likely a chance of
36:40some of it aspirating and going into the
36:42lungs
36:44so just always double check before you
36:46give a straw it might seem easier
36:49but it might not always be the right
36:51thing to do so
36:53also that's a huge thing to make sure
36:54that that's getting carried over to the
36:56family
36:57because families aren't going to know
36:58they're going to think kind of like how
36:59we did oh a strong make it easier
37:01they can just get it down they won't
37:04realize
37:05the danger they're putting their loved
37:07one in until we explain what's going on
37:10so make sure that they're aware of
37:12whether they can have a straw or not
37:15and usually hopefully the speech
37:18therapist or maybe the ot if they know
37:20from the beginning we'll be putting
37:21signs up to let you know no straws
37:24thicken liquids you know whatever to
37:27kind of remind everybody what that
37:28patient needs
37:32okay here's your homework
37:35i want you to read chapter 34 of that
37:38great big blue book
37:39and i told you you you know have really
37:42good chapters in but you don't have to
37:43bring it in
37:44so i want you to read chapter 34 and
37:46then i want you to read chapter 18 from
37:49your elders book
37:51once you read that i want you to create
37:53your own top
37:5410 for the intervention strategies for
37:57dysphagia
37:58between the two books they give some
38:00really good
38:02strategies and intervention techniques
38:05that can be
38:06used for someone with this project and
38:09then what we're going to do on thursday
38:11is practice some of these techniques so
38:14we're not only going to try all the
38:16picking liquids but we're going to go
38:18over the intervention strategies that
38:20you've come up with and practice
38:22all of them as well so come thursday
38:26excited and
38:27prepared um to try some yummy liquids it
38:31won't be bad i promise
38:34and just make sure you have your top 10
38:36strategies
38:37um ready to go

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