“If you know this, you're good to go! Nursing plan for dysphagia - assessment, care methods and mechanisms”

 Dysphagia is a condition in which the swallowing function deteriorates due to aging or illness. If not properly treated, patients may struggle to intake necessary nutrients, leading to poor nutrition. Additionally, there's a risk of aspiration, which can result in pneumonia or choking. While swallowing problems are most common in the elderly, they can occur in individuals of all ages. Symptoms can vary, including difficulties with swallowing, the sensation of food getting stuck, or food residue remaining in the mouth.

 In this context, we will discuss assessment tips for planning nursing care for patients with dysphagia. Furthermore, we will provide instructions on how to care for and prevent this condition.


Message from the Supervisor Dr. Jun Kayashita,

Faculty of Community Development, Prefectural Hiroshima University:

 When there is suspicion that a patient may be experiencing dysphagia, it is essential to conduct a thorough swallowing assessment. Based on the findings of the assessment, appropriate adjustments to food forms and thickness should be made and served accordingly. We hope that the information provided in this content will be beneficial in guiding nursing care for individuals with dysphagia. If you have any questions or require further clarification, please feel free to reach out. Thank you for your dedication to providing quality care.


Understanding Dysphagia: Causes and Mechanisms

Dysphagia refers to "the inability to properly swallow food or drink."

 Swallowing difficulties not only diminish the pleasure of eating but can also pose serious threats, increasing the risk of malnutrition due to the inability to absorb essential nutrients and aspiration pneumonia resulting from food and saliva entering the trachea.


Causes of Dysphagia:

 In most cases, dysphagia stems from a combination of factors, with four primary causes:

Functional Causes: Impaired movement of organs and structures involved in swallowing.

Organic Causes: Abnormalities in the organs or structures directly related to swallowing.

Psychological Causes: Factors such as depression, psychosomatic illness, or anorexia.

Aging: Decline in swallowing function due to generalized muscle weakness, dementia, etc.


Mechanisms of Swallowing Dysphagia:

 Swallowing involves a series of five processes, and in dysphagia, some part of this intricate process is impaired.

Understanding the intricacies of dysphagia is crucial for effective care and management.


<1> Antecedent Phase:

 This marks the stage where food is identified through sight and smell, and subsequently brought to the mouth. The quantity of food to be swallowed is determined by the texture and shape of the food.

<2> Preparatory Phase:

 During this phase, the jaw, tongue, cheeks, and teeth collaborate to chew the food, creating a cohesive mass that is easily swallowable.

<3> Oral Phase (Initial Swallowing Phase):

 This phase involves the utilization of the tongue to propel food lumps towards the back of the mouth. Simultaneously, the soft palate is elevated to block access to the nasal cavity.

<4> Pharyngeal Phase (Secondary Swallowing Phase):

 In this stage, the swallowing reflex propels the food mass through the pharynx and into the esophagus. The epiglottis descends, and the glottis closes to prevent aspiration.

<5> Esophageal Phase (Final Swallowing Phase):

 During this period, the food lumps that have entered the esophagus are transported to the stomach. Muscles at the esophageal entrance contract to prevent the regurgitation of the food mass.

 Understanding these sequential phases of swallowing is integral to comprehending the intricate process of food ingestion.

Symptoms of Dysphagia

 The primary indicators of dysphagia encompass both mealtime and post-meal experiences:

Symptoms during meals:

- Frequent swallowing.

- Coughing.

- Producing excessive phlegm at the onset of eating.

- Difficulty swallowing with a sensation of retention in the throat.

- Opting for easily swallowable foods.

- Prolonged food retention in the mouth.

- Alternating between consuming soup and solid food.

- Food spillage from the mouth.

- Fatigue during eating.

Symptoms post-meals:

-requent coughing after eating.

-Presence of food mixed with phlegm.

-Sensation of food lingering in the throat.

-Voice changes or hoarseness after eating.

-Reduced food intake (due to choking or difficulty swallowing).

-Food remnants in the mouth.


Nursing Plan and Objectives for Dysphagia:

 Dysphagia not only robs patients of the pleasure of eating, diminishing their quality of life, but it also poses risks such as aspiration pneumonia and malnutrition. Therefore, a timely and appropriate response to dysphagia is a crucial facet of nursing care. Establishing a comprehensive nursing plan and setting achievable goals are vital for effective management.


Nursing Challenges and Objectives

 Patients facing dysphagia may encounter various nursing problems, each requiring specific goals for effective care:

Nursing Challenge: Anorexia due to dysphagia

Nursing Objective: Restore appetite by alleviating symptoms

 Patients experiencing dysphagia may struggle with swallowing during meals, leading to decreased appetite. Our goal is to enhance symptoms through swallowing rehabilitation, incorporating commercially available thickening agents, and introducing nutritional supplements to boost food intake.

Nursing Challenge: Reluctance to participate in swallowing training

Nursing Objective: Foster active engagement in training and enhance training content

 By emphasizing the significance of training and the consequences of untreated dysphagia, we aim to create a positive training environment. Developing a training menu tailored to encourage the patient's proactive involvement is crucial in achieving this objective.

Nursing Challenge: Recurring Pneumonia

Nursing Objective: Minimize the frequency of aspiration

 In cases where recurrent pneumonia is linked to aspiration, precise assessment of dysphagia severity and its stage is crucial. Providing appropriate care involves checking the food form and thickness to mitigate the risk of aspiration. This comprehensive approach aims to reduce the incidence of pneumonia associated with dysphagia.

Nursing Challenge: Reduced Food Intake

Nursing Objective: Enhance swallowing function and increase food consumption

 When patients encounter difficulty swallowing, the prolonged duration of eating can lead to fatigue, resulting in inadequate nutrition intake. To counteract this and prevent malnutrition, the focus is on improving swallowing function through rehabilitation measures and introducing nutritional supplements.


Nursing Plan for Dysphagia:

 The nursing plan for dysphagia is introduced in the following sections: Observation Plan (OP), Plan of Care (TP).

Observation Plan for Dysphagia (OP):

 The OP aims to identify the root cause and stage of dysphagia based on careful observations.

-Factors contributing to dysphagia:

 Impaired swallowing function can stem from various conditions, including diseases and the natural aging process. A thorough review of the patient's current and past medical history, as well as an examination of medications, is essential. Additionally, assessing the condition of the mouth, checking for stains, pain, and monitoring saliva quantity is crucial in understanding the complete picture of the patient's dysphagia

-Assessing the Extent and Severity of Dysphagia

 Examine the extent of dysphagia by analyzing eating behaviors, including the frequency of swallowing during meals and the duration of eating. Symptoms occurring outside of mealtime, such as recurrent pneumonia, weight loss, and persistent coughing, offer valuable insights into the severity of dysphagia.

 By juxtaposing the swallowing mechanism with distinct symptoms, it becomes possible to pinpoint the specific phase that is impaired. This comprehensive evaluation aids in understanding the overall impact of dysphagia on the individual's swallowing function.

- Dysphagia Examination Findings

 A comprehensive evaluation incorporates insights from interviews, oral examinations, as well as findings from diagnostic tools like x-rays, endoscopy, and additional tests.


Care Plan for Dysphagia (TP):

 The TP outlines specific interventions for effective care.


-Meal Form Adjustment (e.g., Introduction of Thickening Agents):

 Incorporate commercially available thickening agents to enhance the swallowability of liquids such as tea and miso soup. Adjust liquids to the appropriate viscosity for the individual, collaborating with the dietitian to tailor meal forms that consider swallowing function. Given the potentially low nutritional density of a modified swallowing diet, incorporate nutritional supplements as needed.


 For patients consuming meals in bed, a reclined position of 30° with a slight forward bend in the neck (cervical forward flexion position) is considered to minimize the risk of aspiration. Another approach is serving meals with the patient in a side-lying position.

-Nutrition and Fluid Management:

 When a patient refuses water due to swallowing difficulties, incorporating a thickening agent to ease food swallowing is advisable. In cases where dysphagia symptoms lead to deteriorating nutritional status, symptom-based observations can guide the use of nutritional supplements, preventing further decline in nutritional health.

-Swallowing Training:

 Prior to meals, engaging in swallowing exercises, ice massages, breath-hold swallowing, and other targeted training can enhance swallowing function. Pre-meal oral care plays a crucial role in preventing pneumonia.


Risks and Associated Conditions of Dysphagia

 Patients with dysphagia face several known risks:

Decreased Quality of Life (QOL):

 Eating orally symbolizes vitality and serves as a source of joy in daily life. Dysphagia, making oral eating challenging, significantly diminishes the patient's QOL.


 Dysphagia often leads to the provision of low-nutrient-density swallowing-adjusted diets, contributing to the risk of malnutrition. Persistent malnutrition results in muscle weakness and decreased swallowing strength, creating a reciprocal relationship where dysphagia becomes more likely, impacting both malnutrition and dysphagia.

Aspiration Pneumonia:

 Aspiration of food, liquids, or saliva into the airway can lead to pneumonia due to bacterial infection in the oral cavity. A significant cause of death in Japan, aspiration pneumonia is particularly prevalent among the elderly.


 Choking, resulting from food obstructing the airway due to aspiration, is a critical risk associated with dysphagia. Especially in individuals with decreased cognitive function, behaviors like overloading the mouth with food may occur, necessitating increased vigilance against choking.

 Understanding these risks is crucial for the comprehensive management of dysphagia and its associated complications.


(Note: The translation has been provided to the best, but there may be slight variations or interpretations. Please refer to the original Japanese article for complete accuracy.)

References :  nestle health science, expert commentary

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