CNA Training Advisor

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1 CNA Training Advisor Volume 12 Issue No.5 MAY 2014 DYSPHAGIA Persons with dysphagia are at great risk for weight loss, malnutrition, dehydration, choking, aspiration (inhaling a foreign substance into the lungs), and pneumonia. Eating rapidly or talking and laughing during meals increases the risk of aspiration. Residents with normal reflexes or a strong cough and gag reflex can usually dislodge food from the airway, but residents with dysphagia may not have this ability. This issue of CNA Training Advisor will address the symptoms of dysphagia that long-term care residents may experience. It will also focus on the various diets for dysphagia. There are many ways to care for elderly patients with dysphagia, and it is important to know how to adjust to each resident s needs. This lesson will discuss the connection between diet and exercise techniques to improve swallowing and prevent aspiration. CNAs will take a closer look at the importance their role plays in effective dysphagia management. Have a good day of training, and stay tuned for next month s issue of CNA Training Advisor, which will cover reducing the risk of workerrelated injuries. Tips to Remember There are several ways a CNA can assist a resident with dysphagia, including: Altering the texture of the resident s food Cutting the resident s food into smaller pieces Adjusting the resident s head or neck posture Encouraging muscle exercises to strengthen weak facial muscles or improve coordination Adopting a carefree attitude for spills and food messes Quiz answer key 1. a 2. d 3. b 4. a 5. a 6. d 7. a 8. d 9. b 10. a Program Prep Program time Approximately 30 minutes Learning objectives Participants in this activity will be able to: Identify the signs and symptoms of dysphagia Implement techniques that will improve care for residents with dysphagia Recall specific strategies for handling difficult behaviors while providing quality care Preparation Review the material on pp. 2 4 Duplicate the CNA Professor insert for participants Gather equipment for participants (e.g., an attendance sheet, pencils, etc.) Method 1. Place a copy of CNA Professor and a pencil at each participant s seat 2. Conduct the questionnaire as a pretest or, if participants reading skills are limited, as an oral posttest 3. Present the program material 4. Review the questionnaire 5. Discuss the answers SEE ALSO hcpro.com/long-term-care

2 CNA Training Advisor May 2014 This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Senior Director Erin Callahan Product Manager Adrienne Trivers STAY CONNECTED Interact with us and the rest of the HCPro community at HCPro.com Become a fan at facebook.com/hcproinc Follow us at twitter.com/hcpro_inc us at customerservice@hcpro.com Questions? Comments? Ideas? Contact Product Manager Adrienne Trivers at atrivers@hcpro.com or , Ext Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to CNA Training Advisor, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving CNA Training Advisor, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at At the time of your call, please share with us the name of your replacement. CNA Training Advisor (ISSN: [print]; [online]) is published monthly by HCPro, a division of BLR, 75 Sylvan Street, Suite A-101, Danvers, MA Subscription rate: $159/year; back issues are available at $15 each. Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division or BLR, or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro. com. Visit our website at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CTA. Mention of products and serv ices does not constitute en dorse ment. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. A focus on dysphagia People with dysphagia have difficulty swallowing and may experience pain while swallowing (odynophagia). Studies have shown that approximately 53% 74% of long-term care facility residents have dysphagia. It is most frequently found in older adults and is common in residents who have experienced strokes. Due to the high prevalence of dysphagia, CNAs must be able to recognize its symptoms and be able to work with residents for treatment. Dysphagia occurs when there is a problem with the neural control or structures involved in any part of the swallowing process. Any condition that weakens or damages the muscles and nerves used for swallowing may cause dysphagia. For example, people with diseases of the nervous system, such as cerebral palsy or Parkinson s disease, often have problems swallowing. Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing. Additionally, stroke, head injury, or other nervous system disorders may weaken or affect the coordination of the swallowing muscles or limit sensation in the mouth and throat. Another difficulty is when weak throat muscles cannot move all of the food toward the stomach, a problem that sometimes occurs after cancer surgery. Some of the signs of dysphagia include taking a long time to begin a swallow; food leaking from the nose or mouth; coughing or choking on food, fluids, or saliva; or a feeling of fullness, tightness, or pain in the throat or chest when swallowing. Symptoms of dysphagia Food or liquids may be aspirated when swallowing or when food is coming up, such as during vomiting or reflux (heartburn). When a resident aspirates, the lungs recognize the substance as foreign material. This should cause the resident to reflexively cough or gag. If he or she successfully coughs the substance out, no airway damage occurs. If the food or liquid remains in the lungs, however, the stage is set for a chemical reaction that may lead to pneumonia or even death. A CNA can help residents by recognizing the many signs and symptoms of dysphagia. They include: Difficulty controlling liquids and secretions in the mouth, drooling, or food falling out of the mouth A wet or gurgly-sounding voice A weak voice in combination with other signs or symptoms Taking a long time to begin a swallow Swallowing several times for a single bite of food Food leaking from the mouth or nose 2 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 May 2014 CNA Training Advisor Frequent throat clearing Lack of a gag reflex Weak cough before, during, or after a swallow Coughing or choking on food, fluids, or saliva Pocketing food A feeling of fullness, tightness, or pain in the throat or chest when swallowing A sensation of food or saliva sticking in the esophagus or sternal area Feeling as if a foreign body or lump is sticking in the throat Drooping appearance of lower face in combination with other signs or symptoms If a resident experiences any of these signs or symptoms, you should notify the restorative nurse. An isolated symptom such as coughing or refusing to eat is likely not a problem. Having a pattern of problems, or many signs and symptoms, suggests dysphagia. Consultation with a speech-language pathologist is needed. Treatment of dysphagia There are different treatments for various types of dysphagia. Medical doctors and speech-language pathologists who evaluate and treat swallowing disorders use a variety of tests that allow them to look at the stages of the swallowing process. One test, the flexible endoscopic evaluation of swallowing with sensory testing (FEESST), uses a lighted fiber-optic tube, or endoscope, to view the mouth and throat while examining how the swallowing mechanism responds to stimuli such as a puff of air, food, or liquid. A videofluoroscopic swallow study (VFSS) is a test in which a clinician takes a videotaped x-ray of the entire swallowing process by having a patient consume several foods or liquids along with the mineral barium to improve visibility of the digestive tract. The x-ray helps identify where in the swallowing process the patient is experiencing problems. Speech-language pathologists use this method to explore strategies that will allow a patient to swallow food safely. Speech pathology exercises Speech-language pathologists usually work with residents in treating dysphagia. The therapist will develop a plan that may include changing food texture to an easily swallowable consistency. He or she will recommend resident-specific techniques for improving swallowing and preventing aspiration. Common approaches are: Tucking the chin Turning the head Avoiding eating when fatigued Swallowing twice with each bolus of food Strengthening exercises for the muscles used with swallowing Your restorative program may involve working with the resident on these exercises, as most residents with dysphagia require one-to-one supervision during meals. The resident s care plan may include the following: Making sure the resident is fully awake and alert before beginning a meal. Adopting a So what? attitude for spills and food messes. Positioning the resident upright, providing support if necessary. Positioning the head facing forward, with the neck flexed forward slightly. Avoid extending the neck. This technique changes the position of the airway, which is effective for some but not all types of dysphagia. In some residents it may actually increase the risk of aspiration. Minimizing conversation. Although you would normally converse with residents during meals, this increases the risk of choking and aspiration in persons with dysphagia. Limiting environmental distractions as much as possible. Focus the resident on eating. Cutting the food into small (dime-size) pieces. Directing the food to the unaffected side of the mouth if the resident has had a stroke. Encouraging the resident to eat slowly, taking small bites. Feed at a rate that is comfortable for the resident. Reminding the resident to chew thoroughly HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 3

4 CNA Training Advisor May 2014 Instructing the resident to cough or clear the throat after each bite of food. Using straws with caution; they may cause the resident to drink at an unsafe speed and volume. Following the therapist s instructions for tucking the chin during swallowing. For some residents, the head should be slightly down during swallowing. With others, it should be slightly back or turned to one side. Instructing the resident to avoid swallowing when the head is tipped back. Checking the mouth for food particles after meals and assisting with oral hygiene. Monitoring the resident throughout the day. Swallowing problems often worsen when the resident is tired. The speech-language pathologist may order other special positions and exercises, depending on the resident s needs. For example, the muscle activity involved in swallowing food is slightly different than in swallowing liquid (the latter is more difficult), and the resident may have difficulty adjusting the swallowing muscles if trying to switch between the two. The therapist may recommend consuming food and fluid separately. For items such as soup, taking in one consistency at a time may work best. If this does not work, serve food with mixed consistency (e.g., soup, cereal with milk) separately. The resident may need to avoid very dry foods entirely; they are difficult to swallow, and crumbs may end up in the airway. Moistening dry foods with gravy or cream-based soup may also help. The CNA s role in effective dysphagia management The speech-language pathologist may order a particular consistency of food, or a dysphagia diet, to effectively treat a resident with dysphagia. One of four diet levels is usually ordered: Level 1: Dysphagia pureed. Foods in this level are pureed or of similar consistency, cohesive, and pudding-like. Level 2: Dysphagia mechanically altered. Foods in this level are cohesive, moist, and semi-solid, requiring some chewing ability. They include ground or minced meats as well as fork-mashable fruits and vegetables. Some examples of excluded foods are most bread products, crackers, and other dry foods. Level 3: Dysphagia advanced. Foods in this level are soft-solid and require more chewing ability. They include easy-to-cut meats, fruits, and vegetables. Disallowed foods include hard, crunchy fruits and vegetables, as well as foods that are sticky or very dry. Level 4: Regular. Any solid textures. Nursing and dietary personnel must work closely with the speech-language pathologist and dietitian to ensure altered food remains acceptable to the resident. Attractive food appearance and proper temperature are important. Some residents refuse pureed food, for example, because it resembles baby food. Generally speaking, pureed diets should not be watery or runny. When properly prepared, regular pureed items should be about the consistency of pudding and support a plastic spoon in the upright position. It is important for CNAs to understand that the goal of food preparation is to ensure: The food is the proper consistency to meet the resident s needs and reduce the risk of aspiration The food must look and taste as close to normal as possible The food consistency should be altered as little as possible; sometimes extra gravies or sauces are all that is needed The speech-language pathologist will work with the resident and nursing staff to teach individualized approaches for eating and drinking. He or she may recommend using food thickeners to slow the movement of food and fluid through the esophagus. Thickeners alter the consistency of food and liquid to resemble nectar, honey, or pudding. There is a great margin of error in mixing powdered thickeners, so it is important for the CNA to follow the therapist s instructions exactly. Dysphagia can be serious. You are an important partner in managing each individual s dysphagia symptoms and treatment plan. H 4 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 MAY 2014 Volume 12 Issue No. 5 CNA Professor DYSPHAGIA QUIZ Mark the correct response. Name: Date: 1. Dysphagia occurs when there is a problem with the neural control or structures involved in any part of the swallowing process. 2. When caring for a resident with dysphagia, a CNA should.. a. position the resident lying down b. become offended during the meal c. try to engage in a full conversation d. make sure the resident is fully awake and alert before beginning a meal 3. All of the following are signs associated with dysphagia, except. a. coughing or choking on food b. a feeling of emptiness c. food leaking from the nose or mouth d. pain in the throat or chest when swallowing 4. One of the main concerns with dysphagia is the potential for aspiration. 5. Speech-language pathologists typically work with residents in treating dysphagia. 6. Dysphagia can be a result of. a. a stroke b. cancer surgery c. Parkinson s disease d. all of the above 7. For a resident with dysphagia, liquids can often be the most difficult to swallow. 8. The goal of food preparation for a resident with dysphagia is to. a. change the food consistency as much as possible b. make the food look and taste completely different c. use solids to help boost consistency d. make the food the proper consistency to meet the resident s needs 9. There are three levels of diet for dysphagia residents. 10. Speech pathologists often use two different tests, FEESST or VFSS, to examine how the swallowing mechanism responds to various stimuli. A supplement to CNA Training Advisor