Saturday, October 16, 2010 | By: MiraculousSigns

Uhuk.. uhuk.. did I fail the Swallowing Ax?

Lapar.

Bosan.

Rafiq sudah hilang sabar. Tiub yang dimasukkan ke dalam perutnya itu cuba dicabut berkali-kali. Ibunya di sisi mula bingung, cuba menenangkan anak yang dikasihinya.

"Sudahlah aku tak suka minum susu. Dipaksa lagi minum guna tiub nih!! Aii."

Rafiq hanya mampu mendengus dalam hati. Penyakit Acoustic Neuroma yang dihidapinya mengganggu kemampuannya menelan makanan.

Hilang sudah satu nikmat besar. Segala makanan yang suatu ketika dahulu menjadi kegemarannya, sudah tidak mampu dirasai lagi.

Doktor yang menjaganya lantas meminta SN Lya, seorang swallowing assessment nurse untuk membuat penilaian sama ada Rafiq selamat untuk menelan makanan atau tidak.

***

Senario di atas memberi kita gambaran tentang salah satu isu dlm transitional feeding (from enteral feeding to oral intake). Kebiasaannya, pesakit stroke menghadapi masalah sebegini -> susah nak telan makanan. Melalui pengalamn (yang tak seberapa), Ayat perasan swallowing assessment ni dibuat antaranya utk menjangka berapa lama pesakit memerlukan tube feeding tu. Kalau failed, Dr. akan plan untuk pasang PEG TF instead of continuing using NGTF.

Sebenarnya, tugas swallowing assesment ni -> speech pathologist. Tapi disebabkan di sini takde, jadik, nurse yang ambil alih tugas ni. Tapi dia pernah dapat training dengan visiting speech pathologist sebelum nih. Ni sedikit sebanyak dpt membantu / menggalakkan lagi pt untuk ke oral feeding instead of biar diorang lame2 pakai NGTF. Sedangkan mungkin dia mampu eating orally (meskipun perlahan) kan? kan? Jadi, di kesempatan ni, Ayat nak kongsikan sikit tentang swallowing assesment nih. Good to know i reckoned (",)

***

1. Role of swallowing assessment personnel
-Identify pts at risk and requiring dysphagia ax-new ax or review
-Facilitate oral/enteral intake as per speech pathologist/ dietitian's recommendation
-Maintain pt's oral hygiene
-Educate pt & family members on safe swallowing strategies.

2. Purpose of doing swallowing ax
-Prevent complication such as aspiration pneumonia
-Promote pt's sense of well being-eating/drinking on their own
-Provide oral stimulation -initiate swallowing process


A session of swallowing assessment comprise of :
1. Introduction - digging social info of the pts etc
2. Oromusculature examination
3. Oral trial

***

Oromusculature examination

Dlm sesi ni, kita akan examine pt's muscle strength kat muka. Melalui ini, kita akan dpt idea kemampuan pt dlm menelan makanan. Agak subjektif sebenarnya. Need a lot of experience to give the judgment actually. hmm.. Semua ni berkaitan dengan damaged nerves. Nerves yg rosak akan memberi impak dlm fungsi muscle kita kan? Ni, spesifik kpd muscle utk telan makanan :

1. trigeminal-v : if damaged, reduced chewing movements, poor bolus preparation, reduced facial sensation
Question to be aked (QTA): can u sense my finger (run fingers to pt's face)?

2. facial-vii : if damaged, food /drink spilling from mouth, facial asymmetry, buccal pocketing, loss of taste (by report), decreased salivation
QTA : Can u smile/ wrinkle for me? Would you balloon up your mouth for me?

3. glossopharyngeal-ix : if damaged, delayed swallowing, impaired taste (by report)

4. vagus -cn x : if damaged, absent or changed voice, weak or absent cough, multiple reflexice swallows.
QTA : Try to cough for me? Is this voice the same as before admitted here?

5. Pharyngeal plexus ix & x : if damaged, effortful swallow, reduce swallow effectiveness, pharyngeal residue

6. spinal acessory -cn xi : if damaged, nasal regurgitaton, nasal voice.

7. hypoglossal - cn xii : if damaged, difficulty initiating swallowing, impaired lingual movement, lingual weakness, oral residue post swallow.
QTA : Put up your tongue? (midline or not?) put your tongue side to side?

***

Oral trial

Lepas dah buat OME examination kat atas, basically dah dapat idea lah pt mampu telan fluid jenis ape. Kat sini, guna thixer . so ade 3 level. level 1-nectar like, level 2- honey like & level 3- spoon thick. Kalau nampak pt tu mcm lemah sikit, drooling face, agak2 mcm susah nak telan, mula dgn level 2 dulu ke

video



biasanya cuba 2 kali. masa suruh pt telan, pegang leher dia, rasa swallowing process die. berapa lama. kadang2 mmg slow, 10-15 seconds after prompting baru telan. kadang2 tak dpt nak telan pun, bukak mulut, nampak lagi residue. so, takpelah, keluarkan balik makanan tu.

Mulakan dgn yg thickened, then if 'ok' try yg level 1 pulak. if ok jugak, boleh suggest change 1 NGTG to oral feeding hari tu. try bg bubur but mesti under supervision dulu.

what you should observe during supervision :
-fluid leaking/drooling from the corner of the mouth
-delay in initiating swallowing process
-trying very hard to swallow but unable to clear fluid/food in mouth
-hyolaryngeal elevation and excursion
-sign & symptoms of aspiration : coughing, increase RR, choking
-fluid / food residual inside the mouth.

***

Basically, lebih kurang macam tu lah. Kat sini, tugas ayat monitor intake pt mase tengah 'trial' ngan oral intake tu. tengok berapa byk yg pt boleh makan, then top up dgn tube feeding. Kalau pt dah mampu makan sampai 800 ml sehari, biasanya, cabut terus NGTF, galakkan pt makan. Yelah, NGTF biasanya ganggu orang nak makan, lepas dah cabut, lagi banyak pt dapat makan.

Sekian dulu.

Semoga bermanfaat.

Rindu nak jumpa semua.

Wslm
Tuesday, October 5, 2010 | By: MiraculousSigns

Gout : Kekacang, soya, paku pakis x bley makan eh?

Bismillahirrahmaanirrahiim..

Jom ulangkaji diet mx for GOUT.
Bila sebut tentang gout, kebiasaannya memang kita akan teringat akan --> PURINE
Tapi, apa kata kalau kali ni, kita lihat dietary mx gout ni dlm konteks yang menyeluruh, meliputi setiap kumpulan makanan dlm piramid makanan tuh. Sebelum tu, apa yg CPG kata ttg gout nih

Jom mulakan satu persatu ikut kumpulan makanan..

Kump 1 : Nasi, roti, bijirin.
Makan secukupnya.
Urate excretion tends to be enhanced by carbohydrates (50-55% CHO). (Dorfman,2004)

Kump 2 : Sayur-sayuran
Makan banyak

...increased risk of gout was not associated with vegetable protein. (ADA,2009) ...vegetable intake, REGARDLESS of purine content, may be protective as it may increase urate excretion (ADA,2009)

Kump 3 : Buah-buahan

Makan secukupnya

Choi & colleagues also observed a direct correlation between the degree of fructose intake, measured as soft drink consumption, and the risk of both hyperuricemia and gout (ADA,2009)
Higher vitamin C intake is independently associated with a lower risk of gout (ADA,2009)

Kump 4 : Susu & produk tenusu

Minum secukupnya

High intake of dairy products seem to have an inverse relationship with hyperuricemia, as they may have a uricosuric effect (ADA,2009)


Kump 5 : Daging

Makan secukupnya & kawal pengambilannya
Elakkan makanan tinggi purine & hadkan pengambilan makanan sederhana kandungan purine

Increased risk of gout was associated with a higher consumption of meat and seafood but not with a higher consumption of animal (milk, egg or cheese) protein. (ADA,2009)


Lemak & gula

Kawal pengambilannya & pilih kaedah memasak yang lebih sihat.

Urate excretion tends to be reduced by fats, the diet should be relatively low in fat (30% of calories) and modified in cholesterol (<300)

Air
Minum air sebanyak-banyaknya

Intake of fluids (3 L/day) should be encouraged to assist with the excretion of uric acid and to minimize the possibility of renal calculi formation. (Dorfman, 2004)


Kesimpulannya seperti pamphlet yang dihasilkan di bawah: tadaa..



Sekian, semoga bermanfaat


References:

Dorfman, L. (2004). Medical Nutrition Therapy for Rheumatic Disorders. Krause's Food, Nutrition & Diet Therapy, Elsevier : USA

American Dietetic Association. (2009). Gout: Is a purine-restricted diet still recommended?
Journal of American Dietetic Association (7) : 22