teaching and learning to patients with dysphagia. The situation involves the researcher’s own personal experience teaching a Mom of 16-month-old diagnosis with dysphagia and how to learn how to feed him. This paper discusses the client’s background, learning objectives, learning needs, outcomes, teaching strategies, and evaluation of outcomes and provides guidance for a mother facing these same issues.
Infants and children need to consume sufficient amount of nutrients in order to grow. Swallowing difficulties has an effect on dietary intake and affects a child’s growth and development. For this reason, it is important to manage dysphagia in pediatrics.
Dysphagia is a disruption in swallowing that compromises safety, efficiency, or adequacy of nutritional intake. Swallowing and breathing share a common space in the pharynx, and problems in either of these processes can affect a child’s ability to protect their airway during swallowing and ingestion of fluid or food safely.
About 1% of children in the population will experience swallowing difficulties. Children who have cerebral palsy, traumatic brain injury, and airway malformations are more at risk of developing dysphagia.
During normal swallowing, the laryngeal vestibule closes, which protects the airway and ensures that the food or fluid ends up in the gastrointestinal tract and not in the respiratory tract. Aspiration occurs when the food enters the airway. Choking occurs when food blocks the airway, causing airway obstruction and affects the child’s ability to breathe (Dodrill & Gosa, 2015).
Oropharyngeal dysphagia is used to diagnose a child who has unexplained respiratory complications. Oropharyngel dysphagia can be diagnosed using a video fluoroscopic swallowing study (VFSS). VFSS is different from a barium swallow that the focus is more on the oral cavity, pharynx, and esophagus as the patient ingests multiple volumes of solids and liquids. The goal of VFSS is to determine swallowing safety, identify effective strategies, establish an appropriate diet, and evidence-based plan. The VFSS focuses more on the oropharyngeal function whereas the barium swallow is pharyngoesophagel structures (East, Nettles, Vansant, & Daniels, 2014).
The management of dysphagia should be tailored to a patient’s needs. The treatment is mostly delivered by speech language pathologists (SLT). SLT play a primary role in the evaluation and treatment of infants, children, and adults with swallowing and supported nutrition disorders. Speech-language pathologists are qualified to assume this responsibility because of their knowledge of the aero digestive tracts. They evaluate the stages of the swallow and make recommendations to physicians, nurses, dieticians, and family members regarding dysphagia management (Tanner & Culbertson 2014).
It is important for the clinical staff to recognize the importance of dysphagia and adhere to treatment. Nursing staff play an important role in the management of a dysphagic patient, starting with the screening for suspected swallowing difficulties. (Tanner & Culbertson 2014).
Personal Interaction
A patient who I took care of was admitted with increased respiratory distress after having tonsillectomy and adenoidectomy. He was not gaining weight and failed his swallow study. NB is a 16-month-old with chronic history of acute respiratory distress, bronchopulmonary dysplasia, pulmonary hypertension, hypertrophy of tonsils, developmental delayed, hypoxemia, obstructive sleep apnea, had left germinal matrix hemorrhage without extension, and ROP. ROP was treated with laser therapy. PDA was closed via indocin. He has mild pulmonary hypertension by echo but no treatment was required. He was born at 26 weeks SVD, spent 3 months in the NICU at BWH. He was incubated for 8 weeks, had ecoli/MRSA at 10 weeks, on CPAP for 3 weeks, and was discharged home with 02 via nasal canal. He takes 0.125 liters NC at home. He is followed by Dr. Rhein for bronchopulmonary disease. He takes beclomethasone BID, and Albuterol prn.
He was admitted on 3/10/16 to the MICU with increased respiratory distress and fever after planned DLB, tonsillectomy and adenoidectomy, and maxillary frenulectomy. He was incubated because he was positive for the flu. He was on mechanical ventilation because his 02 saturation ranged from 86% to 97%. From 3/16 to 3/26 he was incubated and mechanically ventilated and extubated to CPAP on 4/1. He was then weaned to nasal cannula. Based on his exam was found to be hypotonic, had difficulty swallowing, and failed his swallow study. He had an NG tube placed. He is on pediasure 30 kcal/oz, intermittent feeds 170 ml through NG tube 5 times a day, smooth purees, and liquid to nectars/needs to be thicken.
NB and Mom live with paternal grandparents. Mom is not working, and looking for a place to live. Mom left job to care for NB full time, and housing is an issue.
Below is a plan of care of NB:
Learning Objectives
Upon discharge, NB’s Mom will be able to:
Identify factors that affect nutrition.
Recognize barriers to good nutrition.
Explain treatment options for improvement nutrition.
Describe how to evaluate successful nutrition.
Expected Outcomes
Nursing Interventions
Rationales
Evaluation
Patient will not aspirate during oral or tube feedings by the time of discharge.
Patients can effectively demonstrate swallowing food without choking or coughing.
a) The nurse will ensure proper placement of NG tube before starting feedings.
b) The nurse will verbalize and demonstrate to the Mom how to keep the head of the bed elevated at 30° while tube feedings and after.
c) Review the patient’s ability to swallow and make sure suction equipment is available during feeding.
a) Chest x-ray is used to confirm proper placement of NG tube.
b) The head of the bed should be elevated at 30° to prevent aspiration.
c) If chocking occurs suction is necessary to prevent aspiration.
Mom thickened patient’s food and he did not aspirate during feedings. He had no difficulty eating his yogurt. He did not show any signs of choking and was happy during while he eat eating.
Mom will minimize the risk of aspiration during oral feedings.
a) The nurse will educate Mom to thicken thin liquids. Avoid foods that are sticky such as peanut butter. Serve foods that are hot or cold instead of room temperature.
b) Keep the head of the bed elevated at 30° while eating, drinking and have it raised for 30 minutes when done feeding.
c) The nurse will teach Mom to have NB drink slowly and more frequently. Nurse will make sure Mom give small bites.
d) Report difficulty swallowing immediately.
a) The more extreme temperatures stimulate the sensory and swallowing reflexes.
b) Sitting upright position ensures that food stays in the stomach and to prevent aspiration.
c) Eating and drinking slowing can prevent aspiration.
d) If NB cannot tolerate liquids or solids, aspiration can occur.
Mom had him sit up during feedings and when he was drinking liquids. He had no difficulty swallowing and no signs of aspiration. I got Mom a cup of water for NB to drink it, and told her to make sure she thickens it with rice cereal. Mom said she understands and she going to thicken the water. I offered to help Mom, but she declined my help.
Patient’s mouth will be clean and free of food.
a) Provide oral care before meals and snacks.
a) Oral care stimulates sensory salivations which facilitates swallowing.
Mom did not provide oral care during to NB. She did give feed him yogurt without any complications.
Patient will gain weight by the time of discharge and be able to discontinue tube feedings
a) Weigh NB daily to keep track of nutritional status. Watch for signs of malnutrition and dehydration. Make sure distress free environmental/no distractions when feeding.
a) Daily food intake record will help the nurse and dietician to determine if NB has adequate nutritional intake.
b) Want to make sure patient is not distracted while feeding.
NB was weighed but did not gain any weight. He was wetting his diapers and decreased po intake. He would smile and interact with the nurses while he was eating. Mom was told if by dinner time didn’t eat at least 30 oz would have to start NG tube feedings.
Overall, it is important to adhere to dysphagia treatment. Modification of food, fluids and feeding strategies are frequently the first line of support for the dysphagic patients. In the case of NB, he did not show improvement with his feedings. Mom would feed him but took a long time. She was given multiple opportunities to try to feed him more often, so NB would not have to use his NG tube. Mom did not should interest in trying to feed him more often. She would like to sleep all day and slowly feed him. The nursing student offered to help feed NB but Mom declined. As a nurse, it is important to remind Mom to feed frequently to prevent weight loss. Also, remind Mom to thicken fluids to prevent aspiration.
References
Dysphagia and swallowing disorders. Retrieved from http://nursing.advanceweb.com/Regional-Articles/Features/Nurses-Role-With-Dysphagia.aspx.
East, L., Nettles, K., Vansant, A. & Daniels, S. Evaluation of Oropharyngeal Dysphagia With the Videofluoroscopic Swallowing Study. Journal of Radiology Nursing.
Gosa, M. & Coleman, J. Thickened Liquids as a Treatment for Children with Dysphagia and Associated Adverse Effects A systematic Review.
Nurses’ Role With Dysphagia. Retrieved from https://consultgeri.org/try-this/general-assessment/issue-20. Preventing Aspiration in Older Adults with Dysphagia
Palmer, Janice L. MS, RN; Metheny, Norma A. PhD, RN, FAAN. Preventing Aspiration When a Patient Eats or During Hand Feeding of the Patient.
Tanner, D., Culbertson, W. Vol 19 2014No 2 May 2014. Avoiding Negative Dysphagia
Outcomes http://www.nursinginpractice.com/article/dysphagia-and-swallowing-disorders.
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