Impaired Swallowing: A Case Study

The nursing diagnosis for Mr. K is impaired swallowing (dysphagia) related to new diagnosis, inadequate management, unilateral neglect, lack of familial support, and lack of oral care secondary to stroke as evidenced by inability to clear oral cavity, delayed swallowing, coughing, drooling, saliva buildup, and facial muscle weakness (Lewis et al., 2015).

Early identification and nursing interventions of dysphagia are important to prevent complications associated with dysphagia including risks of malnutrition, dehydration, aspiration, and pneumonia (Lewis et al., 2015).

Assessments for Mr. K related to impaired swallowing are outlined in the table below:

Assessment (Lewis et al., 2015) Rationale (Lewis et al., 2015)

Perform bedside swallow assessment to

assess for signs of impaired swallowing: coughing, choking, inability to clear oral cavity, delayed swallowing, drooling, saliva buildup, decreased mastication of food, slow speech. These signs and symptoms are indications of impaired swallowing.
Evaluate facial muscle strength. Cranial nerves V, VII, IX, XI, and XII are involved in swallowing and coordinated function of these muscles are necessary for controlled swallowing.
Ensure patient is alert and awake prior to meal.

Swallowing response decreases as patient alertness decreases.

Planning

Nurses provide patients with around the clock care in hospitals are in an ideal position to identify patients with impaired swallowing and implement interventions that may prevent further complications. The following are nursing interventions for impaired swallowing:

1. Consult interprofessional team to increase effectiveness of swallowing long term (Lewis et al., 2015). Optimize care by collaborating with the interprofessional team. These professionals are qualified in assessment and management of swallowing impairments related to stroke.

2. Crush medications and administer mixed with food for modification of texture to support effective swallowing (Wagner, Hardin-Pierce, & Welsh, 2018). Consult the pharmacist around what pills should not be crushed and substitute medication in liquid form if possible as indicated (Wagner, Hardin-Pierce, & Welsh, 2018).

3. Have suction equipment available at bedside to decrease drooling, salivary buildup (Lewis et al., 2015).

4. Provide periods of adequate rest prior to meals to limit fatigue and promote optimal muscle function (Lewis et al.,

2015)..
5. Provide oral care before and after meals and as needed to promote oral health. Adequate oral care prior to meals helps stimulate sensory awareness and aid swallowing (Lewis et al., 2015).
Chipps et al. (2014) conducted a randomized control study on poststroke survivors which compared a group with standardized oral care intervention to group usual care in a stroke rehabilitation setting. The results of this study showed that both groups improved in oral health and swallowing overtime, however, there was no statistical difference between groups (Chipps et al., 2014). This research informed my care since the population and intervention studied corresponds to my patient, as Mr. K is a poststroke survivor. Criticisms of the study are that is a small scale study and the settings of care differ slightly. The study takes place in a rehabilitation setting in which there may be allotted time to implement oral care, whereas my patient is in an acute care setting where the importance of oral care is not as emphasized. Additionally, there is a lack of insight and recommendations about best practices to deliver oral care.
6. Eliminate distracting stimuli from environment and provide protected meal times to allow patient to focus on safe swallowing (Lewis et al., 2015).
7. Position patient in upright position (90 degrees) during and after feed to use gravity to facilitate swallowing (Lewis et al., 2015).
A study investigating the effect of body position on the swallowing process of healthy individuals reveals that changing body position was found to have a statistically significant effect on effective swallowing (Cedborg et al., 2010). Recommendations states that subjects should be sitting at angle of at least 45 degrees to facilitate swallowing (Cedborg et al., 2010). This study informs my care as positioning of the patient has a vital influence on swallowing mechanisms. Limitations of this study are that investigations were done on healthy subjects, unlike Mr. K. Therefore, recommendations should be critically examined and tailored to stroke patients before implementation.
8. Give patient specific directions for swallowing and monitor accordingly to promote awareness of effective swallowing techniques.
9. Place food on the unaffected side to promote sensory stimulation to trigger swallowing mechanisms (Lewis et al., 2015).
10. Praise patient for appropriate swallowing techniques to reinforce behavior (Lewis et al., 2015).
11. Educate patient and family about rationales for diet to promote awareness of risks and benefits, encourage adherence and emphasize importance food consistencies (Chipps et al., 2014). Patients and families are often unaware that stroke can cause swallowing problems at admission to hospital following an acute stroke, therefore it is critical to provide them with adequate teaching and education.
12. Educate family about how to monitor patient for effective swallowing methods during meals (Lewis et al., 2015).
13. Educate patient and family about swallowing exercise prescribed by SLP to improve the patient’s ability to swallow and evaluate accordingly (Lewis et al., 2015).
14. Monitor body weight weekly and keep a record of fluid/food intake to evaluate nutritional status and inform efficacy of swallowing interventions (Lewis et al., 2015).
Implementation
Please refer to Appendix A for implementation of 12-hour shift plan of care. The interventions outlined above for the patient’s nursing diagnosis and fundamentals of care are included in this plan to ensure quality of care (Kitson et al., 2010).
Evaluation
Expected outcomes related to interventions implemented include effective ability to swallow (Lewis et al., 2015). The patient will demonstrate effective swallowing as evidenced by Patient will demonstrate effective ability to swallow as evidenced by adequate management, awareness of right side, familial support and, adequate oral care, as well as, ability to clear oral cavity, absence of drooling and saliva buildup, and strengthened facial muscles (Lewis et al., 2015).

Patient reports difficulties related to swallowing.

Objective Data:

Inability to clear oral cavity, delayed swallowing, drooling, saliva buildup, unilateral neglect and facial muscle weakness.
Nursing Diagnosis:

Impaired swallowing (dysphagia) related to stroke as evidenced by inability to clear oral cavity, coughing, drooling, saliva buildup, facial muscle weakness, and delayed swallowing. Desired Goals/ Outcomes:

Patient will demonstrate effective ability to swallow as evidenced adequate management, awareness of right side, familial support and, adequate oral care (Lewis et al., 2015).

Consult interprofessional team to increase effectiveness of swallowing long term (Lewis et al., 2015).

Crush medications and administer mixed with food for modification of texture to support effective swallowing (Wagner, Hardin-Pierce, & Welsh, 2018).

Have suction equipment available at bedside to decrease drooling, salivary buildup (Lewis et al., 2015).

Provide periods of adequate rest prior to meals to limit fatigue and promote optimal muscle function (Lewis et al., 2015).

Provide oral care before and after meals and as needed to promote oral health (Lewis et al., 2015).

Eliminate distracting stimuli from environment and provide protected meal times to allow patient to focus on safe swallowing (Lewis et al., 2015).

Position patient in upright position (90 degrees) during and after feed to use gravity to facilitate swallowing (Lewis et al., 2015).

Give patient specific directions for swallowing and monitor accordingly to promote awareness of effective swallowing techniques (Lewis et al., 2015).

Place food on the unaffected side to promote sensory stimulation to trigger swallowing mechanisms (Lewis et al., 2015).

Praise patient for appropriate swallowing techniques to reinforce behavior (Lewis et al., 2015).

Educate patient and family about rationales for diet to promote awareness of risks and benefits, encourage adherence and emphasize importance food consistencies (Chipps et al., 2014).

Educate family about how to monitor patient for effective swallowing methods during meals (Lewis et al., 2015).

Educate patient and family about swallowing exercise prescribed by SLP to improve the patient’s ability to swallow and evaluate accordingly (Lewis et al., 2015).

Monitor body weight weekly and keep a record of fluid/food intake to evaluate nutritional status and inform efficacy of swallowing interventions (Lewis et al., 2015).
Goal partially met:

Patient demonstrates signs of improvement toward effective ability to swallow as evidenced by compliance with interventions, improvement of signs and symptoms; will continue to work with patient to improve swallowing.