Management of dysphagia in stroke patients

Running head: Hughes, S. M. (2011). Management of dysphagia in stroke patents. Nursing

Older

People, 23(3), 21-24.

Nursing 260 Scholarly Assignment: Journal Article Review

Management of Dysphagia in Stroke Patients
Student name: Mathota Samaraweera
Student Number: 823 069 448
College: Humber College
Course Name and Code: Nursing Theory, 170441: NURS 260
Professor's name: Franklin Gorospe
Date submitted: February 28, 2014

Management of dysphagia in stroke patients

Management of dysphagia in stroke patients

Today stroke is a worldwide common health problem with a greater disability rate than
any other medical condition among the elderly population over 65 years of age. During the early
stages of a stroke about 80% of patients suffer from swallowing problems such as dysphagia.
Dysphagia is defined in Mosby's Dictionary as difficulty in swallowing typically related to
obstructive or motor disorder of the esophagus. Also it is a common problem in stroke patients
and its management is a significant part of the rehabilitation. Some of the common complications
of dysphagia are aspiration pneumonia, malnutrition, oral hygiene problems and social isolation.
According to Sarah Michelle's Managements of Dysphagia in stroke patients, problems of
swallowing increase the risk of morbidity and mortality due to aspiration pneumonia.
Considering the common prevalence of stroke especially in the category of elderly patients
which makes up a considerable portion of our patient population, I have chosen to review this
article on Management of Dysphagia in Stroke Patients.
It would also be noteworthy to add, that in the near future in my intended nursing career,
the likelihood of being entrusted with the nursing care of stroke patients with dysphagia is going
to be very high due to the ageing baby boomers in the Canadian society. In this short essay, I am
going to briefly explain the assessment of swallow, positioning, and nutritional assessment of
dysphagia patients since they have been proven to be the key areas of nursing management of
this condition. Generally, on admission of dysphagia patients, performing a swallowing
assessment is important to ensure the safety of oral hydration and feeding. Because pneumonia
makes up about 34% of all stroke-related deaths, reducing the risk of aspiration pneumonia is
very critical and to achieve that goal the positioning of patient in my point of view, is crucial in

Management of dysphagia in stroke patients

its management. Finally, it should also be mentioned that performing a nutritional assessment
throughout the nursing care is essential to prevent the patient from malnutrition.
Stroke rehabilitation is a long process that starts from the moment of admission to the
hospital and continues even long after the discharge with the aim of regaining independence and
motivating recovery. Within 24 hours of admission, assessing the patient's swallowing ability by
a Speech and Language Therapist (SLT) or a dysphagia trained nurse is essential to ensure that
patient's nutrition and hydration needs are accurately managed. In addition to that, this
assessment also helps nurses to decide on the form of suitable nutrition and hydration according
to patient's level of swallowing. According to Heather Morris's article in Blackboard, she realizes
that swallowing assessment is crucial in order to reduce the risk of aspiration pneumonia.
In the swallowing assessment, by administering a small amount of water judgements are
made on voice quality changes, patterns of respiration, fluid pooling within the oral cavity and
leakage from it. However, this test doesn't completely stop "silent" aspiration which could go
unnoticed. If the patient has "passed" the swallow screen, it is important to observe and monitor
patient carefully. On the other hand, if the patient fails a swallow screen, he is referred to another
assessment which is more comprehensive.
As highlighted in these articles, this assessment is important for nurses, because it can be
done beside the bed side of the patient without having to move the patient elsewhere. Also, this is
believed to be a more accurate assessment method than gag reflex to identify dysphagia since the
absence of a gag is not a definitive indication of patient's ability to swallow safely (Nutrition and
hydration tips for stroke patients with dysphagia). Moreover, the swallowing assessment

Management of dysphagia in stroke patients

helps to determine the texture of food that the patient needs. Even though, texture is determined
from this screen, sometimes patients may face other complications like pocketing food which
refers to the condition of gathering food especially on weaker side of the cheek. By extensive
discussion in the article it became quite evident to me that the assessment of swallowing is the
first important step for nurses to manage dysphagia patients and to restore their normal
swallowing functions.
Another critical step in preventing patient from aspiration pneumonia is by positioning
safely. During swallowing, in either horizontal or upright positions, muscles related to
swallowing are found to be functioning quite differently. One of the studies concluded that the
safest position would be sitting upright. Blackboard article Corcoran (2005) suggests that it is
critical to position the patient correctly due to the fact that after a stroke physical and
neurological changes such as reduced muscle tone or paralysis can obstruct the airway and result
in aspiration. Therefore, it is necessary to have suctioning facilities available at bed side or in an
easily accessible location within the healthcare facility (Gerontology & Healthy aging). At home
settings, however, the most important step is to teach the care givers to get emergency help in
case of serious signs of aspiration such as trouble breathing or apnea (stop breathing).
According to article on Nutrition and Hydration tips for Stroke patients with Dysphagia,
nurses are required to perform risk assessment of moving and handling of patients to confirm the
safety of both the staff and the patient. The article further states that, Occupational Therapists
advise patients to avoid using cutlery until they recover enough to start self-feeding. Another
significant point is placing food on the plate according to patient's visual field. For instance, to

Management of dysphagia in stroke patients

homonymous hemianopia patients who can only see one side, a simple test like drawing a clock
and asking to write the numbers around the clock could be performed to confirm the visual side
so that the nurses are better equipped to increase the nutritional needs of the patients.
As I have observed, nutritional assessment of dysphagia patients represent a vital aspect
of management because due to dysphagia most of the patients are often affected by malnutrition,
weight loss, starvation and as a student nurse it is very important to develop necessary skills to
prevent patients from having these negative consequences. Statistics indicates that 25%-40% of
stroke survivors suffer from malnutrition due to feeding difficulties such as dysphagia (Heart &
Stroke Foundation of Ontario). Poor oral hygiene can lead to decreased social interaction and
reduced nutritional intake as a result of pain or infection in the oral cavity. According to
Blackboard article nutritional assessment is defined as a detailed report performed by a dietician
and it includes the current level of nutrition, recent blood results and history of the patient
(Fletcher, 2009). However, in general nurses are responsible for the nutritional status of the
patients in their day to day practice since they care for the patients and stay with them 24 hours.
As far as the management of dysphagia is concerned among many different types of
screening, Malnutrition Universal Screening Tool (MUST) is recommended as effective and it
includes five stages of screening processes that reveals whether patients are at low, medium or
high malnutrition risk and guides appropriate interventions to meet patients needs. Usually,
MUST is used to assess nutrition on admission and thereafter repeated weekly or as necessary.
Finally, the safety and effectiveness of dysphagia management depends upon the good
communication among everyone involved in the circle of care including Physicians, nurses, SLT,

Management of dysphagia in stroke patients

physiotherapist and the family. In this context nurses play a very important central role since they
are with the patient all the time. Moreover, the assessment of nutrition further helps to determine
the therapeutic diet and to make modification to the texture of some favourite foods such as
pureed foods, minced or ground foods, and thickened foods to make them safe for dysphagic
individuals (Heart & Stroke Foundation).
In conclusion, I must admit that this brief exercise of reviewing the related literature has
improved my awareness of stroke and associated complications such as dysphagia. Statistics and
data related to stroke and its complications certainly alerted me to the ever increasing rate of
stroke among ageing global population making it a global health problem. Further, in these
articles under review, it has been repeatedly emphasized the importance of early and accurate
assessment of stroke patients in order to identify early symptoms of dysphagia to prevent serious
undesirable outcomes like aspiration pneumonia, malnutrition and social isolation. I have further
gained insight into the importance and effectiveness of assessing patient with dysphagia and how
to manage them in order to ensure proper hydration and nutrition. In the present context as a
student nurse, I can identify my role in the management of dysphagia by careful observation and
monitoring to prevent aspiration pneumonia and also by assisting in positioning while taking part
in nutritional assessment within my permissible limits.

Management of dysphagia in stroke patients

References
College of Audiologists and Speech-Language Pathologists of Ontario. (2007). Practice
Standards and Guidelines for Dysphagia Intervention. Retrieved from www.cno best
practice guidelines.ca
Hughes. & Michelle, S. (2011). Management of Dysphagia in Stroke Patients. Nursing older
people. 23(3), 21-24. Retrieved from http://library.humber.ca/.
Marie, T. (2013). Mosby's Dictionary of Medicine, Nursing & Health Professions. Ninth
Edition. Mosby Elsevier Canada.
Martino. R., Mascilelli, A., Knutson, P. & Powell-Vinden, B. (2006). Management of
Dysphagia in Acute Stroke. An educational Manual for the Dysphagia Screening
Professional. Heart and Stroke Foundation of Ontario.
Middleton, J. (2005). Nutrition and Hydration tips for Stroke patients with Dysphagia.
Retrieved from www.nursingtimes.net/nursing-practice/dysphagia/203500.artile
Morris, H. (2009). Assessment and Management of Dysphagia after Stroke. Nursing and
Residential Care, Volume 11, No 8. Retrieved from http://library.humber.ca/.
Touhy,T.A., Jett, K. S. (2012). Ebersole and Hess' Gerontological Nursing and Healthy Aging.
1 st Canadian Edition. Elsevier Canada.