[Dysphagia] flexible thinking with our pts

[lovdatsoap at gmail.com (donna w)]

  I think we do not need to be so concrete as to have blanket rules

   These pts require a lot of thinking not concrete statements on what not to do

We all have had pts who do OK on a MBS and not in real life that is
why they are 2 sides of the coin and the picture is only complete when
viewed together AND  why
MBS should be ind tailored for that pt alone

The bedside can give us the cognitive dysphagia factors( -fade out
safety issues
as we find out that the pt inadvertantly increases bolus rate/amt over
time-)  laryngeal closure issues(-dysphonia and talking during the
act) as well as protective mechanisms during the meal and
endurance/fatigue (with increasing s/s of asp as the meal progresses)

 The MBS can tell us if the food is still pocketed in pharngeal
recesses after 2-3 swallows and clarify extent of penetration and asp
and efficacy of strategies
Different patients need diff types of MBS and no one should be saying
"no food in a MBS " or "only with food " for all  It depends on the
questions which need
answers ---  which come from the profile from the meal or attempts


re thickened liquids
   Hydration was an issue in frail & spinal cord & confused  for
years and will be an issue when

1)Cognitively they do not initiate and then end up drinking only with
a meal (3x a day)

or

2) When dependent on others to remember to hydrate them as in frail or bedbound
or spinal cord


 That is when the team implements basic I&Os and has an ongoing plan
on data for keeping hydration logs

So hydration may be an issue with or without nectar  Either way one
monitors with data and uses a POC


1)  We cannot assume that a correlating factor is a causal factor
2)  If we have all known that pts with dysphagia with liquids are at risk for
hydration issues--then  ALL hospitals have dietitians who give the
hydration goals
and monitor the labs for issues  so we work as a team and review options

    a)  It is hard to hydrate via thin liquids via spoon or sip
     b) So we review our least invasive alternative (  vs I.V.)
      sometimes it is preferable to have

       nectar as primary
       thin as supplemental
       while posting daily liquid intake to avoid dehydration
        ( the dietitian gives the hydration goal)
       while working of the swallow and increased thin liquid tolerance

 rather than IV if it is primarily a liquid issue


Our team has followed patients over time closely with  dietitians to
make sure hydration was
NOT an issue
    If pts are only able to tolerate thin liquids when compliant-
sometimes that is
problematic and if staff/family are unable to consistantly cue then in
reality we
have to go to a lower diet level until compliance/safety issues resolve


3) Given the cuurent issues with nosocomial infections across the
country-  MDs are
trying not to be less invasive when possible--   NGTs only for liquids
cause such
grief as do IVs  and 3 days of necatr  as they wean to thin is not
such a terrible thing

4) Over time we have all seen pracice change when a study comes out
only to find out later that that technique was only good in a narrow
population
( think of when the SLP s stole the icing  brusing from Rood and used
in indiscriminately on  all  -- when it was for the flaccid dysarthics
only ) so

5) Research is a good thing but our patients teach us as well what is
effective and what is not  and we have all seen research contradict
itself    We all remember from stat class that folks can take the same
numbers and play it different ways so we need to
remember  what our profs said and read ALL with a critical eye and
remember to keep thinking and not blindly accept concrete statements
Every pt is a bit different and needs our attention not just routine
blanket POC
just my 2 cents
Donna Woehr MS CCC/SLP