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

8 comments:

siti suhaili said...

TQ Ayat =). Hm.. dulu ada terfikir nak wat master pasal post-stroke pt, tp tak dapat nak decide lg. Em, assessment ni dibuat bila ye? I mean adakah as soon as pt cautios ke, atau 24 jam lepas admit ke.. ke cane?

Kamek said...

practice kat sini, swallowing ax dibuat bile pt stable & dah transfer ke ward biasa (if pt dr i.c.u). or if pt ade tracheostomy, bile dah half-close the tracheostomy, dr. dah suroh try swallowing ax. nak tengok if off tracheostomy bleh telan tak.

Farhanah_Dietitianz said...

Tq ayat dear~

Farhanah_Dietitianz said...

Tq ayat...Good info..

Anonymous said...

Which hospital yang dietitian ada involve in swallowing assessment? pray tell. tq

sr. fathin

ayat said...

Hospital mane ek? Kat Malaysia ni tak sure pulak. Tp my colleague said, in western, it is one of dietitian's jobscope (my colleague half way blaja dietetic in Aussie, tuka nutritionist--sebab katenye susah, stress gile student dietetic dr sem 1 lg)

a. e said...

thanks for sharing. :)

Anonymous said...

nak share jer. kerja swallowing assessment ni memang kerja speech pathologist. dia memang specialist is dysphagia management, dan bukan setakat tengok boleh makan orally atau pasang NGT jer.

cuba kalau tak payah call dietician, doctor tu pepandai jer kasi orang tu Ensure milk sebab dia malnourished. tak kesah whether patient tu ada fluid restriction ker, DM ker etc. kan kerja yangbtak sempurna tu.