NURS 3614

Fundamentals
Dysphagia
Loree DuBose, RN, MSN

Dysphagia

Dysphasia

Difficulty with swallowing

Difficulty with
or chewing food or
language
liquids
Swallowing disorders, or dysphagia, is a general term used to
describe the inability to move food from the mouth to the stomach.
This condition should be differentiated from any other disorder that
prevents transfer of food to the mouth or food beyond the
stomach. Feeding disorder, which is the inability to get food to the
mouth, and gastric outlet obstruction, the inability of food to pass
from the stomach into the small intestine, should be differentiated
from swallowing disorders. An average of 10 million Americans
are evaluated for swallowing disorders annually. Many causes
have been identified for dysphagia. Dysphasia is spelled the same
way but the g is replaced with a s. This is how you can recall that
dysphasia is difficulty with speech or language.

Potter & Perry Textbook have one page

(1010) of information for dysphagia.
This is not enough for the responsibility
that you will have in clinical so I have
added multiple slides to assist you with
patient/resident care during clinicals &
Many of the
residents
and patients that we will take
future
nursing
practice.
care of in Long Term Care (LTC) or Long Term Acute
Care (LTAC) have a medical diagnosis of Dysphagia.
One of the objectives for clinical is assist with
feeding and feeding patients/residents that cannot
feed themselves. It is important for you to
understand this topic to avoid an issue of aspiration
during feeding of a patient.

Normal Swallowing A&P review

First, food must be chewed thoroughly. Then it is moved to

the back of the mouth by tightening the cheek muscles and
pressing the tongue against the roof of the mouth. From
this point on the process becomes automatic -- it is a reflex
that people do not actively control. In "rapid- fire"
succession, the soft palate closes the nasal airway to
prevent food from backing into it, the airway into the lungs
is closed, and the esophagus (food pipe) relaxes allowing
food and liquid to enter it. The muscular esophagus then
contracts in a wave-like action, sweeping the food along
into the stomach. A blockage or a malfunction anywhere in
this part of the body or in the nervous system controlling
swallowing can result in dysphagia. There are two
types.

Swallowing cont.

Pictures are (left) Pharangeal and (right) esophageal phase of

swallowing

Key Terms
Obstruction
Pocketing of
food
Globus sensation
Bolus
Regurgitation
Aspiration
pneumonia
Stricture

GERD
Myopathy
Pureed
Viscocity
Supraglottic
swallow
Mendelsohn
Maneuver
Silent aspiration
Mastication

Dysphagia Assessment includes

Difficulty in initiating swallowing
A feeling of obstruction as if food has become stuck in
the throat
Voice change
Difficulty with chewing or weakness of muscles of
mastication
Pocketing of food in the mouth
Globus sensation or pain in the hypopharynx
The nurse gathers data by observation, interview and
interventions associated with feeding or food intake. Some
of this data is reported by the patient and other data is readily
observed by the nurse. Ex: Pocketing of food in the mouth.
The nurse includes assessment of the mucous membranes
for each of his/her patients and can see, using a pen-light,
this assessment data. Every patient MUST have mouth
assessment. Apply what is learned in Health Assessment
class to this topic.

More Symptoms
Coughing after eating
Drooling
Impairment gag reflex and ability to clear
bolus, cough, and breathing
Nasal regurgitation
Inappropriate breathing or speaking while
swallowing
Weight loss
Recurrent pneumonia

Fluid & Caloric Replacement

IV fluids
Parenteral alimentation
NG tube/short term
Gastrostomy tube placed by percutaneous
endoscopic means (PEG tube)
Jejunostomy for known reflux & aspiration
(performed under general anesthesia)

 If a patient is unable to swallow without the risk of

aspiration then their nutrition must be provided
using an alternate method or the cells and tissues
will die from starvation.
Parenteral alimentation and IV fluid
replacement can be prescribed by the
physician or clinician to meet caloric and fluid
requirements. The necessary caloric/fluid
needs must be calculated to meet the patient's
daily needs. This method is expensive and
carries a risk of infection because it is an
invasive method for nourishment.
Esophagostomy is a procedure needed in patients in
whom other placements may not be possible and to
help in the control of pharyngeal secretions. You will
learn more about this in future med-surg courses.

 You learned about Nasogastric (NG) tubes in skills lab.

These are convenient for the short term use, but their
use is limited by complications including regurgitation,
irritation, bleeding, and discomfort. Medications such
as H2-blocker or proton-pump inhibitors should be
given as prophylaxis to prevent some of the above
complications that occur with NG tubes.
You also learned about feeding tubes in skill lab.
Recall that a Gastrostomy tube can be placed by
percutaneous endoscopic means (PEG), allowing
for continuous or bolus feedings. Risks are the
same as mentioned above, and reflux prevention
is performed by feeding the patient in a vertical
position, using H2-blockers to decrease gastric
pH, Chlorpromazine or Maxolon to facilitate
gastric emptying, and proton-pump inhibitor to
decrease gastroesophageal reflux. (GERD)
Jejunostomy may be indicated in patients with known
reflux and aspiration. This procedure is performed
under general anesthesia and could involve continuous
or bolus feeds.

Team Approach for Diagnostics &

Management of Dysphagia
Physicians
Nurses
Registered dietitian
Psychologist
Speech pathologist
Occupational therapist
A Common Priority Goal: Prevention of
aspiration pneumonia (prevent food &
liquids from entering into the lungs )

Often a team approach to the treatment

of dysphagia is needed. Several types of
health care providers -- physicians,
registered dietitian, psychologist, speech
pathologist, occupational therapist they
all work together to develop the best
program that will be specific to each
patients needs.
Refer to Box 44-7 for Multiple Causes of
Dysphagia
P&P page 1010

Endoscopy
Scope for: polyps, biopsies and
obtain images
Normal images

 The endoscope has revolutionized the field of

gastroenterology. Through it, the physician can directly
examine almost any part of the intestinal tract.
Biopsies can be obtained, polyps removed and clear
images obtained. This gallery of endoscopy images
provides views of the GI tract from top to bottom. The
gallery is separated into the various organs within the
abdomen - esophagus, stomach, colon, etc. Within
each section, there are normal images and then the
various diseases and problems can be seen by the
physician/clinician.
Esophagus
This picture is an image of the middle of the
esophagus. It has a wide open tubular appearance and
pink coloration. Seconds after this picture was taken, a
contraction occurred. These normal sweeping wavelike
contractions are what move food and liquid from the
mouth to the stomach. (Refer to A&P slide review)

 The Larynx
This is what your voice box looks like from above. You notice
the vocal cords on each side. These move back and forth as
air is forced out over the cords. Amazingly, these simple
fibrous bands of tissue allow us to talk, whisper, shout and
sing the entire range of melodious and rich bass tones. This is
a normal appearance of the larynx. When patient have
surgery to remove cancer of the larynx, they may loose the
ability to speak. Special equipment can be used and taught to
the patient for artificial vocal cords.
Lower Esophageal Sphincter
These are images of the end of the esophagus. There is a
specialized muscle here which acts like a valve and which is
called the lower esophageal sphincter (LES). It remains closed
most of the time, only opening to allow swallowed food and
liquid to be swept through into the stomach. When you belch,
the air pressure in the stomach overcomes the pressure of the
valve and the air you have swallowed bursts up the
esophagus past this valve. The LES in Image 1 is closed while
that in Image 2 is open.

Esophageal Dysphagia
Food/liquids stop in the esophagus
Consistent stomach acid reflux causes
inflammation
Narrowing (stricture) of the esophagus
Chest discomfort due to liquids sticking
in the middle and lower chest
Solid foods cause more problems than
liquids
Treatment: dilate/widen the space

Do you recall from an earlier slide that there are 2 types

of dysphagia?
1.Esophageal dysphagia occurs when food/liquid stops in
the esophagus. This happens most often because of
consistent stomach acid refluxing (backing up) into the
esophagus. Over time, the reflux causes inflammation
and a narrowing (stricture) of the esophagus. Food and
eventually liquids feel like they are sticking in the middle
and lower chest. There may be chest discomfort or even
real pain. Fortunately, physicians can usually dilate
(widen) this narrowing, and there is now treatment
available to keep it from returning. Cancer, hiatus
hernia, and certain muscle disorders of the esophagus
are less frequent causes of esophageal dysphagia.
Solid food is usually more of a problem than
liquids

Esophageal Strictures

Examples of Esophageal Strictures

A stricture is a narrowing in a tube. It is like a
dam across a stream which obstructs the flow.
Strictures most often are benign and caused by
acid refluxing into the lower esophagus. As this
inflamed tissue breaks, scar formation occurs and
causes contraction, much as a burn injury does to
the skin. In time, the narrowing can become quite
severe and obstruct the flow of food into the
stomach. Image 1 is that of a very tight fixed
stricture which measures only about 1/4 inch
across. In Image 2 the stricture is not as tight,
perhaps 1/2 inch. However, in this picture you
see the inflammation and ulceration of the
esophagus which leads to the stricture.
Fortunately, most strictures can be effectively
relieved.

Dilation of Strictures

Treatment
The physician can use a variety of methods to
gently but forcefully open, or dilate, a stricture.
Dilatation is often performed in conjunction
with an upper endoscopy exam. one of the
following dilatation methods may be used:
Bougie -- A series of increasingly larger, soft
rubber or plastic dilators are moved across the
stricture, gently opening it. Guided wire -- A
thin wire, placed across the stricture, is used to
guide increasingly wider dilators over it.
Balloons -- Different types of sausage-shaped
balloons can be placed across the stricture.
The balloon is sharply inflated to open the
narrowed area.
The physician chooses the type of dilatation
that is most appropriate for each patient.

Medications can cause Dysphagia

CNS depressants
Antipsychotics
Corticosteroids
Lipid-lowering agents
Colchicine
Aminoglycosides
Anticholinergic drugs
Some Medications produce effects
due to a decrease in cognition or
development of drug-induced
myopathies. These medications are
listed above.

Oropharyngeal dysphagia
Difficulty moving food to the back of the
mouth to start the swallowing process
Symptoms: drooling, choking, coughing
during or after meals, pocketing food
between teeth & cheeks, gurgly voice
quality, inability to suck from a straw,
nasal regurgitation, chronic respiratory
infection or weight loss
Liquids are more of a problem
Results from nerve or brain disorders

Recall there are 2 types of dysphagia.

2.Oropharyngeal dysphagia involves difficulty moving food to
the back of the mouth and starting the swallowing process. This
type of dysphagia can result from various nerve or brain
disorders such as stroke, cerebral palsy, multiple sclerosis,
Parkinson's and Alzheimer's diseases, cancer of the neck or
throat, a blow to the brain or neck, or even dental disorders.
Depending on the cause, symptoms may include drooling,
choking, coughing during or after meals, pocketing of food
between the teeth and cheeks, gurgly voice quality, inability to
suck from a straw, nasal regurgitation (food backing into the
nasal passage), chronic respiratory infection, or weight loss.
Liquids are usually more of a problem in oropharyngeal
dysphagia.

Mastication: Chewing food

Thickened liquids increase
oropharyngeal control.
A diet of chopped or pureed foods
decreases difficulties with
mastication.
Definition: Chewing food/breaking
down food using teeth

National Dysphagia Diet (2002)

To provide uniformity in/of diets provided
to clients with dysphagia
Dysphagia puree
Dysphagia mechanically altered
Dysphagia advanced
Regular

An important part of the treatment is

helping the patient get adequate nutrition,
while protecting against complications
such as pneumonia from food or liquid
getting into the lungs. Obviously, this
requires a specialized diet. There are four
different diet levels from pured to regular
diet. The diets vary in texture and
consistency, and are chosen depending on
which would be most effective for a
specific patient.

Dysphagia Puree
Pureed food
Smooth, mashed potato-like
consistency
Meat pureed to a smooth pasty
consistency
Caution with foods that do not blend
well
Example: zucchini seeds

 Foods in this group are pured to a smooth, mashed potato-like

consistency. If necessary, the pured foods can keep their shape with
the addition of a thickening agent. Meat is pured to a smooth pasty
consistency. Hot broth or hot gravy may be added to the pured meat,
approximately 1 oz of liquid per 3 oz serving of meat.
CAUTION: If any food does not pure into a smooth consistency, it
may make eating or swallowing more difficult. For example, zucchini
seeds sometimes do not blend well.
I have inserted a hyperlink that advertises food preparations for
people with certain diet modifications. This has become a profitable
business as the population of people live longer and non-professional
care providers (this includes spouses, adult children and etc.) may
need pre-made products with dietary modifications to assist with
feedings/nutrition intake.
http://www.pure-afoods.com/

Dysphagia mechanically altered

Minced foods
Chopped into very small pieces
1/8 inch similar to sesame seeds

Level 2
Minced Foods in this group should be
minced/chopped into very small pieces
(1/8 inch). The flecks of food are similar in
size to sesame seeds

Dysphagia Advanced
Ground or chopped foods
Diced into - inch pieces (similar to the size of
rice and up to the size of macaroni or bread cubes)

Ground Foods in this group should be ground/diced

into 1/4-inch pieces. These pieces of food are similar
in size to rice. Chopped Foods in this group should be
chopped into 1/2-inch pieces. These pieces of food
are similar in size to uncooked elbow macaroni or
croutons (small bread cubes).

Regular
Modified regular foods
Soft
Moist
Regularly textured foods
Modified Regular Foods in this group
are soft, moist, regularly textured
foods

Beverages & Liquids 4 Levels

Thin
= low viscosity
Nectarlike
=
medium
viscosity
Honeylike
= viscosity of
honey
Spoon-thick
= viscosity of
pudding

Commercial Thickening Agents

Thick n Easy
Thick It
Thick Set
Thixx

Commercial Thickening Agents are used

to add to the liquid to obtain the
desired viscosity. These can be
expensive for patients on fixed
incomes.

Medium Viscosity
Eggnog
Fruit nectars

(apricot, peach, pear)

Honey
Thick creamed soups
Soft set pudding with added
Milk
Tomato juice
Buttermilk
Ice cream
(no nuts or fruit chunks)

Milkshakes

The Registered Dietician and/or

Physician writes an order for a specific
modification for all liquids and/or foods
consumed by a patient with dysphagia.
As a patients condition improves and
it is determined that the risk for
aspiration is less then the order is
commonly written to advance a diet to
another level. This includes
beverages.

Spoon Thick Liquids:

Cooked hot cereal
Pudding
Custard
Gravy
Yogurt (no nuts or fruit chunks)
Cottage cheese mixed in
Blender with milk or fruit
Thick malt and milkshakes

How to Thin Liquids

Add hot milk-based liquids (hot milk or cream)
to pured soups, pured vegetables, or
cooked cereal.
Add other hot liquids (broth, gravy, sauces) to
mashed potatoes, pured or ground meats,
and pured or chopped vegetables. Butter or
melted margarine may also be used.
Add cold milk-based liquids to cream, yogurt,
cold soups, pured fruits, or puddings and
custards.

If too much thickener is added to a

liquid the viscosity allows the spoon
to stand up in the beverage without
support. To reverse the viscosity see
above slide. Care-givers must be
taught these adaptations when
preparing food and beverages for
patients with dysphagia.

How to Thicken Liquids and

Foods
Add:
Baby rice
Potato/banana flakes
Plain unflavored gelatin
Strained meat or baby food
Mashed white or sweet potatoes to
pureed vegetables

The following thickeners can be used as

substitutes for commercial thickeners and can save
the patient money.
Examples include:
Add baby rice to hot milk-based liquids.
Add potato flakes, mashed potatoes, or flaked baby
cereal to other hot liquids (soups, sauces, gravies).
Add plain unflavored gelatin, pured fruits, banana
flakes, or a commercial thickener to cold liquids.
Add potato flakes, mashed potatoes, thick sauces
or gravies, canned pured or strained meat (baby
food), or a commercial thickener to pured soups.
Add flaked baby cereal, flavored gelatin, cooked
cream of rice or wheat cereal, or a commercial
thickener to pured fruits.
Add mashed white or sweet potatoes, potato flakes,
sauces, or commercial thickener to pured
vegetables.

How to Reduce the risk of

aspiration:
Chin Tuck
Head Rotation
Head Tilt
Supraglottic swallow
Valsalva Maneuver
Mendelsohn Maneuver

 Chin tuck: The patient holds the chin down, increasing the epiglottic angles, and
pushes anterior laryngeal wall backward, thereby decreasing the airway diameter.
Head rotation: The ipsilateral pharynx is closed, forcing the food bolus to the
contralateral pharynx while cricopharyngeal pressure is decreased.
Head tilt: This technique guides the bolus to the ipsilateral pharynx using the effect
of gravity.
Supraglottic swallow: This technique involves simultaneous swallowing and
breath-holding, closing the vocal cords and protecting the airway. The patient
thereafter can cough to expel any residue in the laryngeal vestibule. The Valsalva
maneuver may be used to maximize vocal cord closing.
Mendelsohn maneuver: This maneuver is a form of supraglottic swallow in which
the patient mimics the upward movement of the larynx by voluntarily holding the
larynx at its maximum height to increase the duration of the cricopharyngeal
opening.

Adequate Fluids
Necessary for body functions
48-64 oz daily
Thin liquids difficult to swallow but
there should be progression within 4
weeks
Thickener added

Liquids
Fluids are essential to maintain body functions.
Usually 6 to 8 cups of liquid (48-64 oz) are
needed daily. For some dysphagia patients,
this may present problems because thin liquid
can be more difficult to swallow. In this case,
fluid can be thickened to make it easier to
swallow. However, close monitoring by the
dysphagia team is required for anyone drinking
less than 4 cups of thickened fluid a day or
anyone not progressing to thin liquids within 4
weeks. These patients are high risk for
dehydration and the complications that occur
with dehydration including dysrhythmias.

Calories Are Needed..

Eating is difficult & causes fatigue
Client wants to stop eating without
adequate calorie intake
Fortify the foods with calories &
especially protein

Supplemental Calories
The greater problem for some patients is eating enough
calories. The whole process of eating simply becomes
too difficult and too tiring. However, calorie and protein
intake can be increased by fortifying the foods the
patient does eat.
Fortify milk by adding 1 cup of dry powdered milk to
one quart of liquid milk. Use this protein fortified milk
when making hot cooked creamed soups, sauces,
milkshakes, and puddings. Also add margarine, sugar,
honey, jelly, or pured baby food to increase calories.
Add strained baby fruit to juices, milkshakes, and
cooked cereals.
Add 1 jar of strained baby meat to soup, such as
strained chicken noodle soup. Also add strained baby
meats to sauces and gravies, and mix with strained
vegetables.
Add juice to prepared fruit, cereal, or milkshakes.

Assistance with Feeding

Upright position/near 90 degrees/30 min. before
eating (rest) and again afterwards
Small bites only to 1 teaspoon
Eat slowly..one food at a time
Avoid talking while eating
Place food into strong side of the mouth
Check for pocketing inside cheeks
Bend forward, chin-down, when swallowing
Do Not Wash Food Down
Relaxed atmosphere..no distractions

 Nursing Interventions: The following are some general guidelines for

safe swallowing. Remember that dysphagia patients have individual
requirements, so all of these guidelines may not apply to every patient.
Use your judgement & critical thinking.
This is application learning.NOT just for a test or EXAM.
Learn this for accountability when providing patient care at the
bedside!
Maintain an upright position (as near 90 degrees as possible) whenever
eating or drinking.
Take small bites -- only 1/2 to 1 teaspoon at a time.
Eat slowly. It may also help to eat only one food at a time.
Avoid talking while eating.
When one side of the mouth is weak, place food into the stronger side of
the mouth. At the end of the meal, check

the inside of the cheek for any food that may have been pocketed.
Try turning the head down, tucking the chin to the chest, and bending the
body forward when swallowing. This

often provides greater swallowing ease and helps prevent food from
entering the airway.
Do not mix solid foods and liquids in the same mouthful and do not
"wash foods down" with liquids, unless

you have been instructed to do so by the therapist or dietician. (no

absolutes in medicine)
Eat in a relaxed atmosphere, with no distractions.
Following each meal, sit in an upright position (90 degree angle) for 30 to
45 minutes.