Posts Tagged With: dysphagia

Rehabilitation Hospitals

This past week I have been interning at Health South, a rehabilitation hospital here in town. Health South not only operates in West Virginia; it also has rehabilitation hospitals, outpatient rehabilitation satellite clinics, and home care in 27 states as well as Puerto Rico.

What makes a rehabilitation hospital different from a “normal” hospital?  Rehab hospitals provide care for patients who are ready to be discharged from the hospital, but are not yet able to function safely at home.  Many patients leave their stay at the hospital to return to a skilled nursing facility or nursing home, but rehab hospitals are for those that have the goal of returning to a certain level of independence at home.  Rehab hospitals assist in bridging that gap.

A patient’s progress at a rehab hospital is measured by a FIM (Functional Independence Measure) which is a scale that measures physical and cognitive disability.  The scale is made up of 18 components which are ranked from a scale of 1 to 7.  A score of 1 means that the patient contributes to <25% of the task or is unable to contribute (total dependence), and a score of 7 represents total independence. Scores can then range from 18 to 126, with the higher number denoting a higher level of physical and cognitive independence.  The FIM scale includes assessing self-care (eating, grooming, bathing/showering, dressing upper body, dressing lower body, and using the toilet) as well as mobility (transfers from bed to chair/wheelchair/toilet, stairs, walking/using a wheelchair), sphincters (bowel and bladder management), communication (expression and comprehension), and cognition (problem-solving and memory).

Who would be a good patient for a rehab facility? According to Health South’s website, “Anyone who is limited functionally from an injury or illness can benefit from rehabilitation. As a next step in the continuity of care, rehabilitation hospitals restore function and strength so patients can return to their highest level of independence.”  This could be someone who has a traumatic brain injury from a motor vehicle accident, recovering from a stroke/CVA (cerebrovascular accident), a recent amputation, spinal cord injury, pulmonary issue (COPD – chronic obstructive pulmonary disease), or someone recovering from an accident such as a bad fall.

What I’ve noticed in the past week is that you see a lot less tube feedings and parenteral nutrition in rehab hospitals. That is not to say that patients have no troubles with eating, however! Many patients have chewing and swallowing difficulties due to esophageal strictures, dysphagia from a recent stroke, and may have no teeth or use full/partial dentures.  I was able to be in the room and witness 2 barium swallow tests that assessed the patients’ level of swallowing and chewing function in front of an x-ray.  Thin liquids, nectar-thickened, and other foods were tested to see what patients are able to safely swallow.  The National Dysphagia Diets (NDD) have three levels, all of which I have seen on diet orders at the rehab facility:

  • 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).

A dietitian at a rehabilitation hospital will assess and evaluate patients when a physician orders a diet consult, or when the patient triggers for another reason. General questions to ask the patient during the assessment include questions about the patient’s appetite, bowel function, any chewing/swallowing difficulties, changes in weight and other questions that apply to the individual patient.  There may be recommendations for a diet change, the addition of an evening snack, or the addition of a nutrition supplement such as Glucerna or Ensure to promote weight gain, weight maintenance, or protein intake.

In addition to dietitians, rehab hospitals also employ a multitude of different health professionals, including physical therapists, occupational therapists, speech language pathologists, x-ray technicians, doctors, nurses, case managers, and pharmacists.  There really is a multitude of different professions working together to help patients regain their strength, endurance, and independence.

Categories: Clinical Nutrition | Tags: , , , , , , | 2 Comments

Modified Barium Swallow Study

On Friday, Mary and I had an opportunity to view a modified barium swallow study in the radiology department. It was a neat opportunity to have, and I’m glad we were able to squeeze it into our last day of rotations at Mon Gen hospital!

If a patient appears to have a problem or claims to have a problem with swallowing (dysphagia), they can get a referral from their doctor to get a modified barium swallow study done. The patient we saw was an older gentleman who claimed he had been occasionally experiencing a choking sensation when eating foods so he was sent in to see if there was any aspiration.  Aspiration of liquids or food into the lungs can be a serious problem as it can cause partial or complete obstruction of the airway and can even cause aspiration pneumonia.

Dysphagia can be seen in patients who have had a traumatic brain injury, stroke, cancer of the head and neck, recent intubation, or those with Parkinson’s disease, Multiple Sclerosis, Lou Gehrig’s disease (ALS), Alzheimer’s, Cerebral Palsy, Huntington’s disease, Down’s Syndrome, or dementia.

A patient who is participating in a modified barium swallow study will sit down in front of an x-ray machine and are told to drink/eat certain foods that have had barium added to it; the barium is a chalky-white powder that is easily identified on the x-ray image.  The swallow study I observed used a regular/unthickened liquid, nectar-like, honey-like, and pudding-like consistencies. There were also canned peaches cut up into small bite-sized pieces that were mixed and coated with barium and graham crackers dusted with barium as well. The swallow study went in order from unthickened liquid, to gradually thicker liquids, to the solid foods.  The patient we observed had no abnormal swallowing patterns, so the choking sensation he said he has when eating may be an occasional symptom due to an esophageal stricture.  Here is a video showing what a modified barium swallow study looks like:

While radiologists, speech pathologists, and physicians are more involved with the modified barium swallow study, registered dietitians are involved to some extent as well.  Dietitians can see patients and through asking questions or observing the patient, they may come across signs of dysphagia. In my experience during clinical rotations at Mon Gen, I came across several patients with dysphagia. One patient was an elderly woman who had recently had a stroke. She had some trouble swallowing so her meals were all mechanical soft.  Other patients have more severe forms of dysphagia so their diets consist of thickened liquids, as swallowing liquids of thin consistency (juice, water) require the most coordination and control and are easily aspirated into the lungs.  Foods can be thickened to nectar-like, honey-like, or pudding-like consistency, or patients can be put on a puréed or mechanical soft diet.  The diet they are put on at the hospital depends on the results of their swallow study.

Liquids, such as coffee, water, tea, soups, soda, and juice are thickened in the kitchen before they go out to the patient’s room. Nurses can also thicken the liquids on the floors as well.

An example of a thickener is shown above.  Liquids can be thickened with nonfat dry milk powder, cornstarch, modular carbohydrate supplements, or commercial thickeners that contain a modified cornstarch thickener.

It is important to evaluate a patient for dysphagia so they can be put on a safe diet that is adequate in calories and nutrition.  Dysphagia often leads to malnutrition because of inadequate intake, so weight loss is a key concern.  In addition, patients with dysphagia can be dehydrated due to their decreased liquid intake, which can lead to fatigue and malaise.

Nutrition intervention depends on each patient’s severity of dysphagia and the extent of their malnutrition, dehydration, or weight loss. Dietitians should ensure that a patient with dysphagia is put on is palatable and nutritionally adequate diet. Patients may need to have vitamin or mineral supplementation, and some patients may benefit from nutritional support such as 8oz of Ensure or 4oz of Healthy Shakes BID or TID.

Ensure Immune Health provides extra nutrition for those that are unable to get adequate nutrition from their meals, which can be due to dysphagia.

  Nestle Health Shakes also provide extra nutritional support, in a smaller (4oz) carton…chocolate, vanilla, or strawberry.

Categories: Clinical Nutrition | Tags: , , , , , , , , , , , , | 1 Comment

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