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  • Patients may decreas their intake of foods and fluids due to a variety of reasons including but not limited to: (Sheperd, 2010) Fatigue with eating Pain with eating Sensation of fullness with small amounts of intake Sensation that food is stuck Fear of choking Increased coughing Dis-satisfaction with diet textures Decreased alertness Decreased mental status
  • Texture modification can be temporary or permanent depending on the patient’s diagnoses, condition, and recovery (Terrado, Russell, & Bowman, 2001) Environmental adjustments could include reducing distractions such as television, excess noise, reducing the number of people, turning lights on or off, seating and positioning, specialized eating utinsels or equipment such as silverware with larger handles for gripping, etc… (Terrado, Russell, & Bowman, 2001) Patients can be trained to use techniques to increase their ability to swallow safely such as chin tuck, head tilt, special manuevers, alternating bites and sips, reducing bite and sip sizes, using hard swallows or multiple swallows, etc… (Terrado, Russell, & Bowman, 2001)
  • Depending on the thickener base the liquid may continue to thicken as it sits and may change depending on temperature exposure (McCullough, et.al., 2003) Thicker is not necessarily better. Thicken according to recommendations by SLP because: Too thick may be more difficult for some patients to swallow safely Too thick may be less appealing to patients and may decrease compliance or intake leading to aspiration or dehydration The keys are to: Practice thickening Serve thickened liquids promptly Re-check thickness levels after time has passed and adjust or replace as needed
  • Peer reviewed research support for the Frazer Water Protocol is limited: There is one controlled randomized study for the adult population(Garon, Engle, & Ormiston, 1997), and there are no studies for the pediatric population. The study by Garon, et. al. (1997) is limited in its clinical implications due to the limited number and diagnoses of it’s participants. Usually implemented based on the assumption that aspirated water can be safely absorbed by the lungs for the purposes of increasing patient compliance with diet modification and/or decreasing the incidence of dehydration (Panther, 2005), but studies are limited here as well: Safe Aspiration of Water: An extensive search for evidence that small amounts of water can be safely absorbed by the lungs yielded only one study by Olson (1970) which evaluated amounts of damage to the lungs of rabbits when small amounts of water were aspirated compared to a 5% glucose liquid and milk. Results indicated that significantly less damage was found in the lungs of those who aspirated water compared to the other two liquids. Results of the Garon, et.al. (1997) study support the safe aspiration of water because neither the control group nor the study group developed aspiration pneumonia or other complications during the study or within 30 days after the study. (Clinical implications remain limited due to the limitations of the study: length of study, characteristics of participants) Hydration: Results of the Garon, et.al. (1997) study do not support use of Frazier Water Protocol as compared to typical dysphagia protocol in an effort to maintain hydration because neither the control group(on thickened liquids only) nor the study group (given access to water between meals) became dehydrated Study by Vivanti, Campbell, Suter, Hannan-Jones, & Hulcombe (2009) found that the greatest contribution to oral fluid intake was from food (over 2/3 of the total daily oral fluid intake) as opposed to thickened fluids in patients who were not reported to be on a water protocol. This study also cited other research that indicated a greater increase in fluid intake with more frequent meals as opposed to increasing the amount of thickened fluids on meal trays. Water absorption rates: (Sharpe, Ward, Cichero, Sopade, & Halley, 2007): Study examining the absorption rates of thickened liquids versus water in rats and humans. (only 6 human participants) Researchers found no significant differences in the absorption rates of thickened liquids (regardless of type of thickener) and water in either rats or humans. Other Possible Factors in hydration: (Batchelor, Neilsen & Sexten, 1996) Dehydration may be a result of many factors including: decreased thirst decreased ability to recognize and/or satiate ones own thirst due to age and/or medical conditions Increased patient and family compliance: There is weak evidence that the FWP may increase patient compliance from the study by Garon, et.al. (1997): Patients filled out a satisfaction survey after the study. All study group participants reported great satisfaction with the allowance of water with most of the comments relating to thirst satiation and reduction in dry mouth. All study participants also reported that thickened liquids were not thirst quenching and did not taste good. ninety percent of control group participants reported they were displeased with thickened liquids and desired ice chips or water for thirst. Results indicate increased patient satisfaction when they are allowed water which MAY increase patient compliance to other diet restrictions.
  • 1. When in doubt about a food texture contact an SLP 2. Sometimes families may want to bring in food as a way of caring for their loved one so if nursing is able to provide a few safe options this can help to increase compliance with the diet modifications 3. Some studies indicate that using food-shaped molds for pureed textures can increase the patient’s compliance with the diet texture modifications 4. Thickened liquids may continue to thicken over time or may need to be thoroughly mixed to avoid a mixed consistency depending on the base of the thickener used (startch versus gum based thickeners). Temperature may also interact to change the thickness level. Thicker is not necessarily better for all patients: sometimes patients may have more difficulty swallowing thicker liquids, thicker liquids may be less appealing and may decrease the patient’s consumption leading to dehydration or may decrease compliance leading to consumption of thinner liquids which may be unsafe and lead to aspiration. It is VITAL to present liquids at the appropriate consistencies to avoid these problems… practice, practice, practice, thickening and re-check consistencies if they have been sitting for long periods of time and/or have been refrigerated or heated.

Kimberly Jones Dysphagia Diets presentation Kimberly Jones Dysphagia Diets presentation Presentation Transcript

  • Dysphagia Diets: Kitchen and Nursing Staff are part of the Dysphagia Team Kimberly Jones Nova Southeastern University SLP 6057 11/12/11
  • Overview
    • What is Dysphagia?
    • Normal Swallowing Process
    • What can go wrong during the swallow?
    • Risks without appropriate Management
    • Treatments
    • National Dysphagia Diet – Solids
    • National Dysphagia Diet – Liquids
    • Water Protocol
    • Kitchen and Nursing staff on the Dysphagia team
    • Review
    • Questions
  • What is Dysphagia?
    • According to Nazarko (2008):
      • Dysphagia literally means: “Difficulty Eating”
    • Dys = Difficult
    • Phagein = To Eat
      • A person can have difficulty with eating classified as dysphagia related to any of 3 stages:
    • 1. Oral
    • 2. Pharyngeal
    • 3. Esophageal
  • Normal Swallow Phases (Terrado, Russell, & Bowman, 2001)
  • Dysphagia
    • What can go wrong?
    (Terrado, et.al, 2001)
  • Risks without appropriate Management
    • Aspiration Pneumonia:
      • About 50% of patients with Dysphagia silently aspirate (Logemann, 1998)
      • Aspiration occurrs in 43%-54% of Stroke Patients, almost 40% of these develop pneumonia, and almost 4% of these will die of aspiration pneumonia if not diagnosed and properly managed (Terrado, et.al, 2001)
    • Malnourishment/Undernourishment/Dehydration (Sheperd, 2010)
      • Resulting from decreased intake of the appropriate balance of nutrients and liquids
    • Inability to take required oral medications (Terrado, et.al, 2001)
    • Death (Terrado, et.al, 2001)
  • Treatments
    • Primary Treatment Methods include:
      • Dietary Texture Modifications
      • Adjusting the Environment
      • Patient training in compensatory techniques
    (Terrado, et.al, 2001)
  • Dysphagia Diets
    • No set standards by the American Speech and Hearing Association (ASHA) for the textures of modified foods and thickened liquids. (American Speech-Language-Hearing Association , 1997-2011)
    • ASHA does not currently have guidelines about food types that should be included on different diet texture levels (American Speech-Language-Hearing Association , 1997-2011)
    • The National Dysphagia Diet (NDD) was published in 2002 by the National Dietetic Association and outlines 3 modified solid textures and 3 thickened liquid levels (McCullough, Pelletier, & Steele, 2003)
  • National Dysphagia Diet: Solids
    • The Following information is taken from McCullough, et.al., (2003):
      • NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
      • NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
      • NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
      • Regular (all foods allowed).
  • National Dysphagia Diet – Level 1
    • Possible food choices according to RD411, (2011):
      • Pureed meats (pureed to pudding-like consistency, smooth soufflés, soft and moist tofu, hummus, pureed bread mixes
      • Pregelled slurried breads, pancakes, French toast, waffles, sweet rolls, smooth cooked cereals, such as farina-type cereals with a pudding-like consistency
      • Pureed fruit, well-mashed fresh bananas, pureed vegetables without lumps, pulp, or seeds, Tomato sauce without seeds
      • Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour cream, well-cooked pasta, noodles, or pureed rice (blended to a smooth consistency)
      • Smooth pudding custards, yogurt, pureed desserts, and soufflés
  • National Dysphagia Diet – Level 1 Pictured example taken from: (Dieticians Association of Australia, 2007)
  • National Dysphagia Diet – Level 2
    • Possible food choices according to RD411, (2011):
      • Moistened ground or cooked meat, poultry, or fish (serve with sauces), casseroles without rice, moist, well-cooked pasta, moist meat loaf or meatballs, poached, scrambled, or soft-cooked eggs, tofu, well-cooked and moist mashed legumes or beans
      • Soft, well-moistened pancakes, pureed bread mixes or slurried breads, cooked cereals with little texture, including oatmeal, slightly moistened, dry cereals with little texture
      • Soft and drained canned or cooked fruits without seeds or skin, ripe bananas, all soft, well-cooked vegetables that are in small pieces and mashable with a fork, well-cooked and moistened boiled, baked, shredded, or mashed potatoes, well-cooked pasta noodles in sauce
      • Puddings and custards, soft fruit pies (bottom crust only), crisps and cobblers with soft topping and no seeds, most canned fruits, soft moist cakes with icing or slurried cakes
  • National Dysphagia Diet – Level 2 Pictured example taken from: (Dieticians Association of Australia, 2007)
  • National Dysphagia Diet – Level 3
    • Possible food choices according to RD411, (2011):
      • Thin-sliced, tender, or ground meats or poultry, well-moistened, fish, eggs (any preparation acceptable), yogurt (no nuts or coconut), Casseroles with small chunks of tender or ground meat
      • Well-moistened breads, biscuits, muffins, pancakes, waffles, etc (add jelly, margarine, and other toppings to moisten well), all well-moistened cereals,
      • All canned and cooked fruits, soft, peeled, ripe fresh fruits, such as peaches, kiwi, mangos, cantaloupe, soft berries with small seeds, such as strawberries
      • All cooked, tender vegetables, shredded lettuce, rice and tender fried potatoes
  • National Dysphagia Diet – Level 3 Pictured example taken from: (Dieticians Association of Australia, 2007)
  • Dysphagia Diets - Liquids
    • Nectar-like
    • Honey-like
    • Spoon-thick
    • Practice with your materials to get these three consistencies right now… feel free to taste! 
    (McCullough, et.al., 2003) Pictured examples taken from: (Dieticians Association of Australia, 2007) (McCullough, et.al., 2003) (McCullough, et.al., 2003)
  • Water Protocol?
      • No ASHA Statements or Guidelines on the use of Water Protocols for patients with Dysphagia could be located
      • Facilities will often implement use of a free water protocol to increase patient compliance with diet texture modifications and decrease dehydration(Panther, 2005), HOWEVER:
        • Peer-Reviewed evidence supporting the use of a free water protocol is limited
      • Use of any water protocol should include careful adherence to good oral hygiene routines to reduce risk of aspiration pneumonia. (Panther, 2005)
  • Kitchen and Nursing staff on the Dysphagia team
    • All staff uses standardized recipes for food preparation to help ensure appropriate texture and consistent quality of flavor
    • Nursing makes sure that food between meals consists of the right texture
    • Nursing can be sure that the family is aware of foods that are safe for the patient
    • PRESENTATION, PRESENTATION, PRESENTATION!!!
      • Shape puréed food into something that resembles what it would look like if not puréed
        • Use food molds if available
      • Make sure that thickened liquids are presented at the appropriate thickness level and desirable temperatures
    (Garcia & Chambers, 2010)
  • Review
    • Dysphagia is difficulty with eating/swallowing and can result from a variety of etiologies (Nazarko, 2008)
    • Dysphagia can be classified according to three areas: oral, pharyngeal, and esophageal (Nazarko, 2008; Terrado, Russell, & Bowman, 2001)
    • Without appropriate diagnosis AND management , dysphagia can lead to aspiration pneumonia, dehydrations, malnutrition, inability to take needed oral medications, and possibly death (Sheperd, 2010; Terrado, Russell, & Bowman, 2001)
  • Review
    • Primary treatment methods include dietary texture modifications, environmental adjustments, and compensatory techniques (Terrado, Russell, & Bowman, 2001)
    • The NDD outlines 3 modified solid textures and 3 thickened liquid levels (McCullough, Pelletier, & Steele, 2003)
      • If a water protocol is implemented it is vital to ensure that the patient maintains good oral hygiene (Panther, 2005)
    • To increase success of diet texture modification treatment kitchen and nursing staff can make food textures and flavors consistent and educate patients and families about safe foods. (Garcia & Chambers, 2010)
  • ??? QUESTIONS ???
  • References
    • American Speech-Language-Hearing Association. (1997-2011). Dysphagia diets . Retrieved from http://www.asha.org/SLP/clinical/dysphagia/Dysphagia-Diets/.
    • Batchelor, B., Neilsen, S., Sexten, K. (1996). Issues in maintaining hydration in nursing home patients who aspirate thin liquids. Journal of Medical Speech-Language Pathology, 4 , 217-221.
    • Dieticians Association of Australia. (2007). Australian standards for texture modified foods and fluids . Retrieved from http://www.speechpathologyaustralia.org.au/resources/termin ology-for-modified-foods-and-fluids
    • Garcia, J.M., Chambers, E. (2010). Managing dysphagia through diet modifications: Evidence-based help for patients with impaired swallowing. American Journal of Nursing, 110(11), 26-33.
    • Garon, B.R., Engle, M. & Ormiston, C. (1997). A randomized controlled study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation, 11 , 139-148.
    • Logemann, J. (1998). Evaluation and treatment of swallowing disorders (2 nd ed.). Austin, TX: Pro-ed.
    • McCullough, G. , Pelletier, C. & Steele, C. (2003, November 04). National dysphagia diet: What to swallow?. The ASHA Leader .
    • Nazarko, L. (2008). The clinical management of dysphagia in primary care. British Journal of Community Nursing , 13(6), 258. Retrieved from EBSCO host .
    • Olson, M. (1970). The benign effects on rabbit’s lungs of the aspiration of water compared with 5% glucose or milk. Pediatrics, 46 , 538- 547.
    References
  • References
    • Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14 , 4-9.
    • RD411. (2011, March). Dysphagia level 1 diet . Retrieved from http://www.rd411.com/index.php?option=com_content&view =article&id=496:dysphagia-level-1-diet&catid=91:diseases- and-medical-conditions&Itemid=385
    • RD411. (2011, March). Dysphagia level 2 diet . Retrieved from http://www.rd411.com/index.php?option=com_content&view =article&id=496:dysphagia-level-2-diet&catid=91:diseases- and-medical-conditions&Itemid=385
    • RD411. (2011, March). Dysphagia level 3 diet . Retrieved from http://www.rd411.com/index.php?option=com_content&view =article&id=496:dysphagia-level-3-diet&catid=91:diseases- and-medical-conditions&Itemid=385
  • References
    • Sharpe, K., Ward, L., Cichero, J., Sopade, P., & Halley, P. (2007). Thickened fluids and water absorption in rats and humans. Dysphagia, 22 , 193-203. DOI: 10.1007/s00455-006-9072-1
    • Terrado, M., Russell, C., & Bowman, J. (2001). Dysphagia: an overview. MEDSURG Nursing , 10(5), 233-250. Retrieved from EBSCO host .
    • Vivanti, A., Campbell, K., Suter, M., Hannan-Jones, M., & Hulcombe, J. (2009). Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. Journal of Human Nutrition & Dietetics , 22(2), 148- 155. doi:10.1111/j.1365-277X.2009.00944.x