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Flashcards in Exam 2: Class #8 Deck (27)
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1
Q

Clinical/Bedside Evaluation includes

A
Case history
Observation
Oral Mechanism
bedside swallow
initial swallowing activity.
Langamore & Logemann discuss why we should do clinical evaluation and instrumental evaluation. 
Used as a screening 
Use as an outcome measurement 
McCullough, Wertz, & Rosenbek (2000) only 50% reliable on clinical exams.  Need to standardize the clinical exam.
2
Q

Instrumental Evaluation includes

A

MBS and FEES.

Some facilities may not have the machines available.

3
Q

Pros of a bedside evaluation

A

Screener
Ask questions about swallowing, functional information
Tentative hypothesis of what is happening

4
Q

Cons of a bedside evaluation

A

Lengthy
Economic issue
Only 50% reliable

5
Q

Percentage of silent aspiration missed

A

38-40%

6
Q

Why does Langamore recommend FEES?

A

It is the most complete view about the pharyngeal stage of swallow

7
Q

Logemann’s 5 reasons to pursue a Clinical Exam

A

1) To define a potential cause of a swallowing disorder: define a etiology
2) To establish a working hypothesis
3) To establish a tentative treatment plan: try treatments in MBS or FEES, try different consistencies
4) To develop a potential list of questions that may require further study: prepared due to time
5) To establish the readiness of the patient to cooperate with further testing

8
Q

3 Main Components of a Clinical Evaluation

A

1.) Medical History-
Chart Review: The Source Handout
Questionnaire: What to evaluate more closely, handout from the textbook pg. 166, Barbara Sonies Questionnaire, The Source Handout
2.) Physical inspection of swallow mechanism
Cranial Nerve Exam
Oral-Mech. Exam
3.) Observation of swallow with test swallows
3-oz. water test- The Source, Tohara, et al., DiPippo, Holas, & Reding (1992); Garon, Eagle, & Ormistrin (1995)
Test swallow with 3 oz of water
Components include: drink without interruption, if they cough and choke, they fail, without coughing and choking, pass: Leder & Suiter Article
Prediction of Aspiration with screening tests
Various consistencies attempted

9
Q

Dysphagia Questionnaire

A

Ask client to describe their problems and symptoms
May not be able to describe problems
Unreliable or responses may not fit objective findings
Groher & Crary (textbook) found this is easier when problems are severe vs. milder dysphagic symptoms

10
Q

Samples of Questionnaire

A

Baker, Fraser & Baker (1991) (in text Box 9-1)

Burke Dysphagia Screening Test (DiPippo, 1994)

Wallace Dysphagia Screening Test (Wallace, et al., 2000)–Designed specifically for Parkinson’s Disease

11
Q

General Categories of Interview/Questionnaire Findings:

A
  • Obstruction: Globus or Globus sensation
  • Liquids vs. Solids: Solid Food Dysphagia=esophageal disorders, Liquid Dysphagia=Oropharyngeal Dysphagia. Choking on liquids and/or solids=more pharyngeal related causes. No choking reported=esophageal disorders
  • Gastroesophageal Reflux: GERD, may not associate GERD with dysphagia
  • Eating Habits: avoiding certain foods, take longer, to eat, avoid eating around others
  • Medical History
12
Q

Physical Examination

A
  • Feeding Tubes
  • Tracheostomy Tubes
  • Respiration- Oxygen Saturation, –Rate: below 90% indicates at risk for swallowing impairments
  • Mental Status: may be unable to cooperate
  • Cranial Nerve Examination: Which ones?Sonies assessment or screen
  • Facial Muscles: lips at resta nd at work, UMN vs. LMN damage
  • Muscles of Mastication
  • Tongue Muscles: look for fasiculations, atrophy, deviation
  • Oral Cavity: lesions, thrush infection, saliva, dentition
  • Oropharynx: velum at rest and at work, gag reflex( not an indication)
  • Pharynx: no clinical test of pharyngeal function, listen for vocal fold function
13
Q

Pharyngeal Function: Clinical eval

A

Vocal Fold function test
Digital Manipulation/ Laryngeal palpation test
Cervical Auscultation

14
Q

Digital Manipulation/Laryngeal palpation test

A

testing of elevation of the larynx during swallow by pressing on the thyroid notch

15
Q

Cervical Auscultation

A

testing of the pharyngeal stage of swallow
Three audible sounds
Stethescopes:
Littman Cardiology II (3M Corp.)
Rappaport-Sprague Pediatric Size (H-P)
Bell surface vs. Flat Surface
This is how you test structures you can’t see at bedside

16
Q

Testing Aspiration Clinically-Is it safe? Is it reliable?

A
-Mann & Hankey (2001)
Stroke patients N=71)
Regression Analysis of 23 Clinical features
6 variables predictive of aspiration:
Impaired pharyngeal response
Male
Disabling stroke
Incomplete oral clearance
Palatal weakness
>70 years old
-Leder & Espinoza (2002)
Stroke patients  (N=49)
Clinical exam = underestimated those 
           who aspirate and overestimated those 
           who did not aspirate
17
Q

Swallow Tests: Tohara, et al. Article Review

A

Three measures recommend for an effective alternative to instrumental examination
3 oz. purified water
4 grams of pudding
Plain X-ray of the pharynx

18
Q

Swallow Tests: Groher and Crary

A

Crushed ice first
5- 10 ml of water then 20-ml bolus of water
Cup versus straw, clinician presentation versus client presentation, cup is safer than a straw, clinician presented is more controlled for the amount
Solids in sequence of difficulty: safest-puree, pudding; next: nectar; most difficult: think liquid

19
Q

Swallow Tests: Modified Evans Blue Dye Test-MEBD

A

For individuals with tracheostomies
Test bolus’ with blue dye
Deep suctioning every 15 minutes for one hour to see if anything has gone into the lungs
Poor reliability
*Thompson-Heney & Braddock, 5 patients, MEBD found no aspiration but MBS/FEES found that all 5 aspirated.

20
Q

Feeding Eval: Consistencies Simplest to most difficult

A
Purees
Thickened liquids:
Pudding thick (easiest to swallow) 
Honey thick: will run of of the spoon
Nectar thick: slightly thick
Chopped/ground/diced
Mixed consistencies: soup, watermelon or fruits
Regular solids: mechanical soft (potatoes, chew without teeth, bananas, beans) to crumbly (cookie, crackers, biscuit, cornbread, nuts, chips, popcorn)
Thin liquids
21
Q

Feeding Eval: Tools Simplest to most difficult

A

Spoon: control bolus well
Cup
Straw

22
Q

A clinical Exam Tray

A

¼ cup thickening agent: Thick-it (powder), Simply Thick (gel in packet, more expensive), etc.
¼ cup puree fruit or pudding
¼ cup ground meat: any meat
¼ cup regular meat: sliced, ham, dietary needs
¼ cup diced mixed vegetables or chopped peaches
¼ cup rice or noodles
1 slice white bread: mechanical soft
1 pineapple ring: mixed
1 sugar cookie: crumbly solid
1 /2 cup Cheerios: crumbly solid, with milk-mixed
½ cup milk: thin liquid
½ cup apple juice, tea, or water: thin liquid
Cup, straw, spoon, knife, fork

23
Q

Results: The Functional Oral Intake Scale

A
  1. NPO: Non per oral, nothing by mouth
  2. Tube dependent with minimal attempts at food or liquid
  3. Dependent with consistent intake of liquid or food
  4. Total oral diet of a single consistency
  5. Total oral diet with multiple consistencies but requiring special preparation or compensations
  6. Total oral diet with multiple consistencies without special preparation but with specific food limitations
  7. Total oral diet with no restriction
24
Q

Non-Standardized Forms

A

ASHA Template

The Source Clinical Evaluation: add to notebook

Logemann’s Evaluation

Site Specific Forms/Samples:
SMC
St. Francis

25
Q

Available Clinical Evaluation Instruments Standardized

A

Mann Assessment of Swallowing Function (MASA): First with Psychometric Integrity
Normed on 128 first-stroke patients
Rating scale utilized
24 areas of assessment
McGill Ingestive Skills Assessment (MISA)
Standardized test, offers a predictive code
Clinically assesses in natural environment
Examiner prepares various food items, patient attempts to eat them.
Designed for clinicians working with older adults in a skilled nursing facility.
Five areas of performance, 43 test items, 3-point scale for each.

26
Q

In the article by Suiter & Leder (2008) the reserach question is asked, “Does the 3 oz. water swallow test identify individuals who aspirate thin liquids?” What were their conclusions?

A

Yes, it had good sensitivity for identifying aspiration of thin liquids.

27
Q

In the article by Tohara, Seitoh, Mays, et al. (2003) the combination of which three tests listed below provided the best predictors of aspriation when an MBS or FEES was not available (e.g. nursing home setting)?

A

3 oz water test
4 grams of pudding swallow
Still x-ray of lungs