Thursday, February 5, 2015
I admire those who've signed on for the GeriPal Thickened Liquid Challenge. I’m thinking of using my video to issue a Failed Nausea Management Challenge.
I’ve encountered the detestable goop through turns in neuroscience and hospice nursing, and have never been a fan - most probably because of some unwise decisions involving Jell-O shots at ‘Manequins’ on Disney’s old Pleasure Island.
My intense dislike is also based on the expressions of everybody who tries the stuff. You all look just like I felt years ago, when I first caught my reflection on a shiny surface in the “dirty” utility room, while standing at the hopper with a nasty bedpan.
Hopefully we’re all a bit queasy now, so let’s consider what to address before thickened liquids come up again - pun intended.
I don’t provide much care as a hospice case manager, compared to other settings. Rather, I help establish and operate a fluid network of nursing schools. Our learners don’t really enroll voluntarily, and they must learn new concepts and apply new skills during the most difficult times of their lives. Much of the curriculum is clinical, so the techniques we teach have to be based on sound reasoning, safe, and effective.
Some caregivers are so determined to insure their charge continues eating or drinking that their interventions increase the risk of aspiration. Food and fluids are matters rife with emotion, bound to many things - culture, caring, control, peaceful acceptance. Safe swallowing can often be the least-threatening way to start a discussion, or to redirect care that’s unsafe or inconsistent with patient/family goals.
Here’s the simple approach to dysphagia screening and safe swallowing that I've learned. Family and other caregivers need this information to provide safe, effective, and compassionate care. Hospice volunteers and all other members of the IDG should also be prepared, because you never know who’s going to be standing there when somebody thinks it’s time for a drink. In complex cases, it is important to enlist the aid of speech therapy.
Swallowing is a complicated task. It can be tiring for someone who is very ill or debilitated. There are three risks associated with impaired swallowing (dysphagia):
1. Choking - the airway is completely obstructed and the person can't breath. This is a medical emergency requiring the Heimlich maneuver if the person is conscious, CPR if they’re not.
2. Acute aspiration - the sudden experience of food or liquid bypassing the epiglottis and irritating the upper airway. It provokes the cough reflex, which may not be strong enough to fully protect against distress.
3. Chronic microaspiration - the slow infiltration of small quantities of oral secretions and other substances into the airway. Chronic low-intensity coughs can be under-appreciated, or the process may not provoke a cough and go unnoticed. People who are weak and debilitated, have neurological disorders, altered mental status, or advanced disease are at risk for chronic microaspiration, which in turn can lead to pneumonia.
Use these 3 simple steps to identify potential dysphagia and hopefully lower the risk of aspiration (and as always talk with your clinicians, use common sense, and don’t mistake this for personalized medical advice):
Step 1. Is the person awake, alert, and interactive? Swallowing is a conscious act with some involuntary components. We must be alert to initiate a safe swallow. Look for eye contact, appropriate verbal responses, and the ability to follow simple commands.
If the answer is 'no,' do not proceed.
If you're satisfied, based on your knowledge of their baseline, go to step 2.
Step 2. Can they sit upright? An upright posture is essential for safe swallowing. ‘Upright’ means sitting in a straight back chair or wheelchair, at the edge of the bed with feet on the floor, or in bed with the head elevated more than 60 degrees.
If the answer is 'no,' do not proceed.
If 'yes,' go to step 3.
Step 3. Give a SMALL amount of thin liquid (water, coffee, juice), or thick food (pudding, yogurt, ice cream) as a trial. SMALL = about 1/3 to 1/2 ounce (10-15cc) thin liquid. Use a 30cc medicine cup. Do not use straws or large cups - they make it difficult to control the amount and speed of a substance entering the mouth. If feeding pudding, yogurt, or ice cream, just use the front of a teaspoon.
Does the food/liquid sit in the mouth, or between the cheek and gums, instead of being promptly swallowed? An inability to promptly move food or liquid from the front of the mouth back to the oropharynx is a sign of dysphagia called ‘pocketing.’ The need for anything more than a single simple cue to swallow the full amount is also considered ‘pocketing.’
If 'yes,' remove the material from the mouth and do not proceed.
If swallowed, does the person cough, or is the quality of their speech altered - thick, hoarse, gurgling, gagging, etc.?
If 'yes,' do not proceed. Provoking the cough or gag reflex, or an altered voice, are indications of acute or near-aspiration.
If 'no,' repeat the trial amount (10-15cc). Assess the person’s response after each attempt. Continue or stop based on the response. Feed slowly, and be ready to stop whenever indicated, as previously described.
Important note: Always provide frequent and thorough oral care regardless of swallowing status.
Jerry Soucy, RN, CHPN (jerry.soucy- at- gmail.com) has worked with patients and families facing end of life in critical care, hemodialysis, and hospice. He developed and presents “So you’re going to die…” an adult ed course on advance care planning and end of life inspired by an episode of The Simpson’s. He hopes to grow a 500-pound pumpkin this year.
Photo Credit: lymang via Compfight cc