[Dysphagia] What it is that I do

[sorriso at adelphia.net (sorriso@adelphia.net)]

I was asked, given my previous post (below) regarding an SLP's bag of tricks, what it is that I do.  

I work in skilled nursing/long-term care facilities.  The long-term goal I write for my patients is, "Pt will meet nutritional/hydrational needs on least restrictive diet texture."  I purposefully do not add anything regarding aspiration or penetration as I have learned that we likely all aspirate as we sleep, so given just that fact alone I'm not going to pretend that I'll prevent aspiration.

My short-term goals will generally refer to a patient being without overt signs/symptoms as it's those s/s which would interfere with a patient's intake (cough, cough, cough; choke, choke, choke; chew, chew, chew) and pt not demonstrating any dysphagia/increased dysphagia secondary to compliance with swallow guidelines.  The swallow guidelines would include all the basics (i.e. oral care, upright) plus personalized recommendations for the pt (i.e. effortful swallow, no straws, alternate bites and sips).  I teach the patient and/or caregivers the compensatory strategies and explain the rationale.  Another goal is that a patient will either maintain a certain intake percentage (if going from puree to mechanical soft for instance) or increase a lousy intake (the other way around perhaps).

In the skilled patient or the long-term patient who is sick, I wait for them to get better/plateau adjusting texture and recommendations as I go.  In the long-term care pt who doesn't recover in a timely fashion and I discharge on a more restrictive texture, I rescreen from time to time for improvement.  I identify patients who are admitted from home in rough shape and am usually able to upgrade a texture because they've responded so well to regular meds/food/drink/personal care.  I advocate for patients and educate the patient, families and the ever-changing staff.  I encourage patients to speak up about oral care if they are unable to provide it for themselves and staff overlooks.  I investigate reflux sx and ask the MD for a trial if there are sx and no RX.  If a patient coughs with drinking I determine whether or not it's distressful to the patient before making any recommendations/changes.  If a patient has to be on thickened liquids I request a serving of fruit on each tray for added hydration.  In the thickened liquid patient I discern whether that patient can tolerate ice cream without horrid cough/choke, many can.  In the patient with dementia who has poor attention to the bolus I see if perhaps a bite of ice cream before or after the food bolus will improve the AP transit.  If a patient is distracted by others, can I change his seating?  I might recommend nose cups, sippy lid cups, scoop bowls, bright red dishes for the dementia patient (and I'm sure to inform OT :)).  I confer with my registered dieticians and dietary managers.  When dysphagia pops up unexpectedly in a patient I alert nursing who sometimes forgets that dysphagia is a symptom not an isolated problem.  I review meds to the best of my ability.  I plead with MDs to take a patient off Haldol and Reglan.  I request extra gravy.  I discover some patients do better with a straw.  I make toast for the patient who can't stand the cold piece he gets on his breakfast tray.

This is mostly stuff we all do everyday; the list is endless but I wrote down what I could think of because there are always people who are learning.  I'm certain that the moment I click "send" I'll think of something really good!

Thanks for listening,
Linda A. Zanchi, MA CCC-SLP

 
 > Date: Sun, 26 Mar 2006 12:17:50 -0500 
> From: sorriso@adelphia.net 
> To: "Division 13 Discussion List" <asha-div13@lists.asha.org> 
> Subject: Re: [asha-div13] E-stim,DPNS,bag of tricks 
> Cc: Division 13 Discussion List <asha-div13@lists.asha.org> 
> 
> I would be one of the other therapists Amy mentioned who wondered how does one 
know what works (although I wouldn't be giving a chastising look, I truly 
wonder). 
> 
> As an SLP who practices in a medical environment I feel the responsibility of 
life and death for my patients.  I want to know that what I do with these folks 
is proven by research to work.  Period.  I'm not sure that I even like the idea 
of evidence based practice determining success or failure of a treatment 
strategy; we are not eliciting accurate sound production here.  I have to wonder 
how I would feel if my MD had a bag of tricks and trialed me with a treatment 
because that's what he was taught in school, everybody does it, but no one's 
ever been able to prove/cared to prove that it really works.  
> 
> If that wasn't enough to make myself crazy, I then imagine myself standing in 
a court of law defending what I did to a judge.  I can't imagine saying that 
such and such is an unproven but common practice which I (well, my company 
really) charged money for hoping it would work.  There is a reason we have 
liability insurance and a reason my company recommends I have my own in addition 
to what they provide.  If I screw up badly there is only so far they can defend 
me. 
> 
> I will jump up and down and advocate for my patients should estim even be 
proven clinically effective.  I have my doubts that DPNS ever will be but bring 
it on!  With regard to oral motor exercises, they could be effective if anyone 
were to actually do them enough to tire out those little muscles.  How about 
thermal tactile?  (I'm actually going to be posting again with a question about 
that.) 
> 
> I agree it would be a wonderful thing if insurers/payors did recognize all 
that we do for our patients and somehow we could all become researchers in our 
own practices; think of the information!  Insurance is a business and expects to 
turn a profit which trickles down to us and forces the productivity standards we 
all so despise and blame our employers for. 
> 
> Linda A. Zanchi, MA CCC-SLP 
>