Teaching Swallowing to Dysphagia Patients - Research Paper Example

? Teaching Swallowing To Dysphagia Patients Teaching Swallowing To Dysphagia Patients Patient condition The patient is a 95 year old living at JML and undergoing Dysphagia II with no smoking, alcohol or drug use history. She was hospitalized due to UTI, HTN, AFIB, diverticulitis, GERD and sepsis. The previous and present diagnosis indicates fever, shortness of breath, decrease appetite and increase chest congestion. The patient presents signs of aspiration, particularly coughing and choking when eating or drinking. Patient produces “drenched” and “gurgled” vocal quality sounds during meals due to amplified congestion following oral intake. Patient also experiences slothfulness when eating, or “pocketing” of food, and as such, takes various swallows in a lone mouthful of food; otherwise, there is an impediment in swallowing reaction or grasping food in mouth. Furthermore, she has impaired swallowing, with a history of tubing feeding, as evidenced by her dysphagia diet, a 1:1 feed and nectar liquids with no straw. In terms of cardiovascular assessment, pedal pulse is present with palpitation. Her Capillary Refill reveals a Blood return of > 3 sec. Her gastrointestinal assessment reveals weight loss within the past six months. Besides, she has undergone surgical procedures on her left hip replacement, right hip pinning after a fracture; she has a history of left rotator cuff repair and venous ligation in the past. Chest X-ray indicates diminished atelectasis, with aerated left upper lobe, and continued left lower lobe atelectasis/pleural effusion. Patient upper extremities indicate both hands swelling, while her lower extremities reveal legs swelling, with unsteady balance/gait, and she has slightly impaired vision. Her activity/exercise pattern entails use of assistance device, wheelchair, and she needs total help with ADL's and meals. She also has a foley, which is incontinent of bowel, thus she needs assistance to transfer from bed to chair. She has all meals served to her with 1:1 feed approach. The patient also has impaired skin integrity, physical immobilization, as evidenced by destruction of skin layers, as well as being on coccyx area. Her cognitive/perceptual pattern reveals impaired self awareness due to frontal lobe injuries which may result in emotional and behavior variables. The patient short term memory assessment indicates that she remembers few things but has lost short term memory overall. Her long-term memory reveals that she recalled some events from the past. The patient has limited knowledge of her current situation. The patient experiences depression, which can be attributed to cognitive deficits, fatigue and difficulty with managing her eating frustration. She is alert to people around her, even her speech is clear. Moreover, the patient experiences imperfect controls of her impulses; hence, she feels tired all the time and sleeps all day and all night. Her impulsivity has led to social isolation from some of her immediate family members and friends. Her coping and stress tolerance has been aided by good friends, and her five children who come to visit her when they can. Health Management Patient perception of overall health reveals that she is good, and even though she has limited knowledge of her current situation, she understands her health care needs and she is going to be discharged to JML She is adaptive in terms of coping and stress tolerance through prayers, support from family. However, she is maladaptive since she has no effort to get better. Patient has also learned to accept physical changes related to her age. Patient status of values and beliefs patterns is based on her Catholicism, and she values respect as the key for a good relationship. Teaching and Learning Theory Behaviorism learning theory is based on the proposal that behavior can be explored scientifically devoid of recourse to the learner’s internal mental states (Nielsen, 2009). Thus, it is a structure of materialism, with no independent connotation for mind. The Behaviorist Learning Theory key supposition is that the learner free will is deceptive since every behavior is shaped by the environment through connection or reinforcement (Kozier, Erb, Berman, & Snyder, 2000). Therefore, the learning needs of this patient can be attained by observation of behavior, especially when investigating her psychological plus mental progression. This is because general psychological terms like belief and goals do not have referents, and they simply direct to behavior. Behaviorists like Watson or Skinner interpreted knowledge as being an inventory of behavior (Carpenito-Moyet, 2009). Knowledge is action, and individuals do not just utilize knowledge to direct their action. That is why it is a collection of passive and mainly mechanical reactions to environmental spurs (Nielsen, 2009). However, behaviorist learning theory is unable to enlighten on define social behavior, such as modeling fresh behavior days or even weeks following first preliminary observation devoid of being reinforced to that behavior. Therefore, cognitive theory acknowledges that a great deal of learning entails relations established via contiguity and replication. It also seeks to emphasize reinforcement in issuing feedback regarding the rightness of responses due to its function as a motivator (Nielsen, 2009). Therefore, the learning of this patient will entail acquisition and reorganization of her cognitive structures via which she processes and amasses information. Also, meaningful information will be easier for her to learn and memorize since practicing and rehearsing advances retention, particularly when it is disseminated practice. Through hands out practices, she will associate material with numerous diverse contexts instead of the solitary context accorded by group practice (Clark, 1977). On the other hand, the humanism learning theory believes that learning is an individual deed in attaining one potential. Thus, the key supposition is that individuals take steps with intentionality and values. This contradicts the behaviorist learning theory argument that every pattern of behavior is an outcome of the function of consequences, or the cognitive theory, which stipulates that realizing knowledge and constructing denotation are essential to learning. Therefore, it is essential for the patient to be viewed as a whole, particularly through looking at her growth and development over her lifespan. Thus, it calls for self-motivation, advancement of self-actualization, autonomy and goals inside a cooperative and sympathetic environment (Nielsen, 2009). There are powerful imperatives that are needed to maximize the effectiveness and efficiency of the manner in which nurses dealing with dysphagia patients can develop their teaching plans. Thus, adult learning theory acknowledges that adults are repeatedly more self-guided and answerable for their individual decisions. It is crucial to begin talking with her to determine what she perceives as her health-care goals and what her priorities for learning are. To assess her learning style, she needs to be asked about something she lately learned along with how she learned it and if it was by reading, paying attention to information, or through real hands-on learning.  Thus, the affective learning concept will comprise shifts in attitudes, principles, and feelings (Lin et al., 2003). The most important aspect is motivation since it is the thrust for every ordinary behavior pattern. Notably, she will be constantly asking, “What is in it for me?”, and that is why there needs to be the formation of a respectful and supportive environment whereby for a nurse must model the values essential to become caring and capable practitioner (Nielsen, 2009). Therefore, learning plan should entail breaking down further the three major aspects she would want from the education sessions. That is to see something accomplished, acquire personal recognition and influence, and finally to attain semblance of social interaction and enjoyment. This necessitates forming an atmosphere which will awaken her entire brain as well as senses through communication at a subconscious level and which will be enjoyable due to the desirable position and activity. For instance, test questions associated with the patient presentation can be used to assess the possible worst-case scenario (Kozier, Erb, Berman, & Snyder, 2000). The locus of control supposition illustrates the degree to which individuals believe they are in direct control of their personal health. Accordingly, when the patient believes she is in control of her own health condition, she will be more likely to modify her behavior in reaction to the health information presented than patients who do not believe they have such power. In addition, the self-concept of any older person with a learning difficulty is to have the capability to direct her, besides being mature and optimistic (Nielsen, 2009). She wants to make her own resolution and take the accountability for the outcomes of any decisions, and as such respect ought to be shown for her needs, preferences and desires. Her experiences should be supported and endorsed so that positive feelings could come into play and constitute her self-identity. Eagerness to learn and develop her analytical skills will be enhanced through role-plays and group work with her family members. Since older people learning approach is behaviorist oriented, she should be offered practical solutions and assistance with hands-on-practice as well as problem-solving sittings (Kozier, Erb, Berman, & Snyder, 2000). Social cognitive theory calls for health behavior transformations through the use of environmental and social factors. It is a behavioral premise of prediction having neutral advancement towards health behavior modification. This theory will help in changing her thinking about her unhealthy behavior and its impact (Nielsen, 2009). This helps in imparting several concepts, such as self-control parameter, and environmental factors and thus her perception of environment and behavioral capability. Furthermore, there ought to be compatibility between her and her family goals. She should learn how to verbalize and communicate her thoughts, especially through communication aid (McHale, Phipps, Horvath, & Schmelz, 1998). The diffusion theory implies that some individuals tend to try fresh behavior more willingly than others, and it helps in teaching the family members so that they could adopt changes that can influence her or change agents (Gaberson & Oermann, 2010). Specific Learning Need The role of the nurse in fulfilling specific learning needs for the dysphagic patient starts with assessing her limitations formally with the help of specialists like physiotherapists, occupational therapists, speech therapists, psychologists, and nutritionists (Galvan, 2001). The nursing diagnosis identified with this patient involves impaired physical mobility or intolerance to activity, decrease strength and endurance, in addition to being weak and unable to perform ADL. She also has self care deficit, particularly bathing, hygiene, and not being able to wash and get dressed. This calls for formation of a precise training package which lessens the time demands for preparation of each session by the patient. The training scheme needs to be interactive and motivating as possible, and this can be achieved by creating awareness about the purpose of mood when it comes to engagement (Nielsen, 2009). It also entails providing the patient space and occasions to reclaim control and appreciate the significance of exercising preference, especially by normalizing reactions along with emotions experienced. Furthermore, it is important that both the patient and family members learn how to use complementary therapies, e.g. massage, the role of vitamins and food in addition to acupuncture so as to have a holistic approach in dealing with her physical, emotional, and spiritual adaptation (Griffith, 2005). The patient has a limited capability to observe risk-free swallowing recommendations due to her cognitive impairment. Moreover, given that she is a dysphagic stroke patient, she seldom perceives to be having swallowing problem. Therefore, one of the learning needs made by her speech therapist is to practice and observe compensatory swallowing exercises in form of a diet or pre-thickened drinks modification (Daniels & Daniels, 2004). She should learn to get accustomed to position herself upright or 90 degrees when taking meals, in addition to being situated at 90 degrees for around 30 minutes after the meals (Metheny & Palmer, 2009). Such techniques will help minimize danger of aspiration pneumonia. For instance, in facilitating the learning, it will be helpful to alter the color of her swallow advice sheet so as to make it more visible. In terms of nutrition, the swallowing strategies need to be those recommended by her speech therapist, in particular the provision of suitable texture and constancy of food. The liquids need to be thickened as required. Moreover, she should learn to adequately time her verbal prompts when chewing or swallowing in order to avoid constant pocketing of food and partial swallowing when administering medications (Langmore, Skarupski, Park, & Fries, 2002). She also needs to learn how to use various types of sensory stimulation, especially plane electromyography bio-feedback, during swallowing so that she can enhance her optimal position (Kawashima, Motohashi, & Fujishima, 2004). Pureed food needs to be smooth, uniform, cohesive, and more pudding-like. The patient and the family need to learn how to regularly apply suitable liquids during pureeing food feeding, like broth for meats, milk and cream with vegetables and starches, and juice for fruits and desserts (Cabre et al., 2010). After a meticulous training, her family members will aid her in feeding since it is evident that most patients will eat more when fed by family member than by outside personnel. The nurse role is to educate the family on her pathology and then illustrate practical troubles that she will fac, before outlining the technique of averting a repetition of dysphagia (Langmore, Skarupski, Park, & Fries, 2002). For instance, they need to learn about supraglottic swallowing, which is important in determining how she holds her breath when swallowing, in addition to coughing after a swallow. The aim is to facilitate the clearance of any residual food material from her hypo-pharynx. The family members need to learn that when she is undergoing nasogastric feedings or oral feedings, they have to discontinue tube feedings around 1-2 hours before so as to assist in stimulating her appetite (Brady, 2008). The family need to become skilled in attending to her oral care, mostly after meals as this will aid in airway protection. In managing her secretions, this will call for teaching her how to get accustomed to preferred bed position, notably placing her head at 30 degrees or greater on her bed. Secondly, when the management of her secretions becomes significant, she needs to get accustomed to suction connections at her bedside. Thirdly, she needs to learn how to carry out persistent oral care, together with respiratory assessment after every four hours, and this entails suctioning of her posterior pharynx while assessing her stability and patency of airways. Given that most elderly patients do at all times put up with nasogastric feeding, self extubation will likely be an occurrence (McHale et al.,1998). Therefore, it is crucial for the patient and responsible family member to learn how to judge her tube location prior to each feeding. She also needs to learn how to judge that she experiences gag reflexes and that the NG tube feeding should be discontinued. Teaching the patient oral or pharyngeal muscle amplification exercises, is also crucial as this will help improve her bolus formation along with transition as this offers a postural compensation useful in accommodating any unilateral weak points (Kawashima, Motohashi, & Fujishima, 2004). Nursing Care Plan In terms of Nursing diagnosis of impaired swallowing r/t dysphagia: AEB recurrent aspiration pneumonia. The short term nursing care plan involves patient beginning practicing exercise taught by speech therapist, and will do that once every hour while awake until re- evaluation. In the long term, she will pass food and fluid from mouth to stomach safely and will not aspirate. The second nursing diagnosis observed was excess fluid volume r/t decrease urine output, and etention of water as evidence by I&O imbalance. The expected short term goal includes maintaining ideal body weight without excess fluid. Patient will maintain normal range and clear lung sounds by discharge. She will verbalize understanding dietary fluid restrictions by the end of the shift. Patient will demonstrate behaviors to monitor fluid status and reduce fluid excess. Nursing Interventions The first intervention is to remind patient to perform exercise. Secondly, provide thickened liquid and then transfer her to chair every meal. Furthermore, remind her to swallow twice each bolus of food while conducting mouth care. Thirdly, weigh patient daily and monitor and record I&O. Assess for signs of circulatory overload and monitor Hr, CVP, and RR. Auscultator her lung sounds, heart sounds for signs of fluid overload while administering IV medication in least amount of fluid possible to minimize fluid intake. Assess patient compliance with dietary and fluid restriction at home. Advise patient to elevate feet when sitting down. Teaching Plan Objectives The main objective is to offer the patient most favorable swallowing safety via routine screening for any swallowing impairment and to facilitate referral and communication by involving her physicians, speech and language pathologists, together with her dieticians (Metheny & Palmer, 2009) Short term goal The patient is able to swallow 70% of pureed food with around 30% verbal and visual cueing as defined by speech therapist so as to enhance safety and competence of PO intake in terms of ample nourishment (Brady, 2008). The patient will begin to have swallowing delay of between 1-2 seconds due to the enhancement of thermal tactile stimulus and thus reduce the danger of food residue moving into her airway (Kawashima, Motohashi, & Fujishima, 2004). The patient will do her every day oral-motor exercise so as to increase the buccal tension inside her functional confines and avoid pocketing of food within her anterior and lateral sulci (Lin & al, 2003). The patient will be able to demonstrate the capability to sufficiently self-monitor her newly taught swallowing skills. Long Term Goals The patient will be able to use compensatory approaches with maximum safety and competence when swallowing without unconcealed signs and indicators of aspiration. The patient will recuperate strength from poor to moderate, and this can consist of mobility and activities of daily living, in particular eating. The patient will comprehend tolerations of constancy for solid foods and so tolerate food and recuperate nutritional values. The patient will maintain sufficient hydration and/ or nutrition under optimum safety and competence in swallowing role concerning P.O. intake devoid of overt signs and symptoms of aspiration in terms of highest suitable diet level. The patient will be able to masticate her food sufficiently and begin safely consuming minimal restrictive diet. Improvements in her verbal, visual as well as tactile cues will increase to almost 40% effectiveness (Galvan, 2001). Learning Styles, Cultural Variables, Terminology for Dysphagia Dysphagia is a widespread indication of head and neck cancer, and it entails disruption of swallowing during bolus transfer from oral cavity to stomach (Brady, 2008). Dysphagia is defined as impairment in swallowing concerning any composition of the upper gastrointestinal tract, arising from the lips to the lower esophageal sphincter (Cabre et al., 2010).The strictness of swallowing deficit is reliant on the extent and position of the lesion, the scale and scope of the surgical resection, and the side effects of surgical ablation. From the data collected, the patient is going through oropharyngeal dysphasia, which may be due to her previous neuromuscular disease, obstructions and surgery. The dysphagia brings about the swallowing problem prior to food reaching her esophagus, and hence experiencing obscurity in beginning a swallow, as food moves through a wrong pipe, making her choke and cough. The consequence of dysphagia is poor nutrition, dehydration, and aspiration. Aspiration is more common, since it involves accidental sucking of food into her lungs when swallowing, and this can result in pneumonia or chronic lung disease. The cultural basis of the patient with dysphagia communication and swallowing involves making a distinction between her speech differences and the disorder. This entails defining her major cultural variables which influence her communication. Family relationships are altered when considerable lifestyle alterations are involved. Therefore, post-treatment psychosocial and behavioral learning includes dealing with ensuing communication impairment. Furthermore, education is focused on her changed body image, nutrition, and lifestyle changes (Potter & Perry, 1993). The patient culturally fitting care involves respecting the dissimilarities in her belief systems, her sensitivity to behaviors as well as practices and accommodation of differences as long as they are not detrimental to her health. In particular, listening to her cues during conversation provides unique and individual belief concerning her etiology (Doenges, Moorhouse, Geissler, & Geissler-Murr, 2000). Most patients with dysphagia articulate a powerful desire for independent decision making. To them, their families need to make decisions based on their perceptions of their personal beliefs and predilection (Brady, 2008). Thus, honoring her whole person within a supportive environment will encourage her learning. Learning will be fostered via structuring information properly and presenting it in consequential divisions with suitable feedback (Gulanick & Myers, 2010). The first content to be taught includes postural modifications as part of compensatory swallowing administration. The patient is taught how to swallow food with her head and body, being in a particular position. For instance, placing the chin tucked when the head is turned in order to minimize aspiration. The second content to be taught is applying the double breath-control technique, in tackling pre-swallow aspiration, notably the supraglottic swallow along with super-supraglottic swallow (Metheny & Palmer, 2009). Thus, the patient is trained to volitionally grasp before swallowing and after that carry out airway clearance procedures, in particular coughing and throat clearing. The method utilized during teaching of super-supraglottic swallowing includes Valsalva maneuvers as they help in enhancing cardiac arrhythmia (Langmore, Skarupski, Park, & Fries, 2002). She also needs to learn to verbalize her understanding of dietary fluid restrictions and learn the behavior for monitoring her fluid status and reduce fluid excess. For instance, elevating her feet when sitting down. Materials The materials used include dysphagia screen for teaching detection of aspiration. Training on good oral hygiene involves using tooth models and brush to explain how to clean her dentures while rinsing her mouth using a mouthwash. Another item to be used includes nursing dysphagia screening tool developed for the U.S. Department of Veterans Affairs. Questionnaires and checklists will be use to acquire information concerning her learning needs, and learning keenness. Given that she is a kinesthetic learner, hands-on experiences such as diet upgrade trials, hand gestures, and role play exercises, are important tools in aiding her learning. Teaching aids comprises auditory processing charts and online videos about preventing and tackling aspiration will be used: http://links.lww.com/A227. Strategies The strategy to be used includes stressing what is essential, and this includes maintaining ample hydration and nutrition, with most favorable and competent swallowing function. Given that many people fear losing their autonomy, it is important to motivate the patient to learn what is required for her to care of herself (Nielsen, 2009). The second strategy is selecting the appropriate time as this will help her to plan appropriately how to cope with her situation and learn how to deal with it. Since she is going through a sense of grief, weakness, fear, and susceptibility, it is important not to allow such feelings to cloud her ability to learn. The third strategy is to regularly search for teachable moments, to help her remember her new skills such as when she receives a small amount of pureed food, the question to ask her could be why is it vital for her to apply maximum safety when swallowing (Kozier, Erb, Berman, & Snyder, 2000).  It is also equally important to apply basic principles by considering her cultural background and educational level when teaching since she is not a native English speaker and may possibly not be able to fully read English handouts and understand intricate medical terminology. Moreover, it is crucial to plainly define goals and objectives prior to commencing teaching. A list of goals and objectives should be formulated in conjunction with her. Finally, it is critical to document it when teaching new skills as it permits any oncoming nurse and specialist to observe what has been completed and where to pick up from. There will be a room in accommodating additional instructions (Nigolian & Miller, 2011). Evaluation Evaluation will involve asking her direct questions about the identified goals such as allowing her to perform revisit demo on any ability she has learned. Secondly, assessment of the patient comments will typically provide feedback on whether or not she comprehends information being imparted. Thirdly, return demonstration by telling her to perform procedures as they were demonstrated will help in evaluating know-how of her psychomotor skills. Evaluation may reveal that the teaching plan should be revised. Her evaluation revealed that she is not able to do the exercise as required, but she is doing well with thickened liquid. However, she stills swallows twice, and she still needs help to brush her teeth after meals. The goals she achieved include maintaining normal range clear lungs sounds, no s/s of edema. She also attained verbalized understanding of dietary fluid restrictions, as well as verbalized understanding of s/s of fluid overload Revision of the teaching-learning will be to incorporate fully motivational counseling since the patient is sometimes reluctant to partake in learning activities. Also, teaching sessions will be rescheduled, given that time and regularity of sessions will affect the process. Patient will also revise on how swallowing exercise and nurse ensure thick liquids every time, and revises on how she should brush her teeth after every meal. Alternative strategies that can be employed include simulation, role playing, and problem based learning (McHale et al., 1998). References Brady, A. (2008). Managing the Patient With Dysphagia. Home Healthcare Nurse , 26 (1), 41 - 46. Cabre, M., Serra-Prat, M., Palomera, E., Almirall, J., Pallares, R., & Clave, P. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing, 39 (1), 39-45. Carpenito-Moyet, L. J. (2009). Nursing Care Plans & Documentation: Nursing Diagnoses and Collaborative Problems. Lippincott Williams & Wilkins. Clark, C. C. (1977). Nursing concepts and processes. Delmar Publishers. Daniels, R., & Daniels, R. (2004). Nursing Fundamentals: Caring & Clinical Decision Making. Boston, MA: Cengage Learning. Doenges, M. E., Moorhouse, M. F., Geissler, A. C., & Geissler-Murr, A. (2000). Nursing care plans:uidelines for individualizing patient care, Volume 1. F.A. Davis. Gaberson, K., & Oermann, M. (2010). Clinical Teaching Strategies in Nursing, Third Edition. Springer Publishing Company. Galvan, T. J. (2001). Dysphagia: Going Down and Staying Down. American Journal of Nursing , 101 (1), 37-42. Griffith, R. (2005). Managing difficulties in swallowing solid medication: the need for caution. Nurse Prescriber , 3 (5), 201-203. Gulanick, M., & Myers, J. L. (2010). Nursing Care Plans - E-Book: Nursing Diagnosis and Intervention. Elsevier Health Sciences. Kawashima, K., Motohashi, Y., & Fujishima I. (2004). Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Dysphagia , 19 (4), 266-71. Kozier, B., Erb, G., Berman, A., & Snyder, S. (2000). Fundamentals of Nursing: Concepts, Process, and Practice. New York: Prentice Hall. Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17 (4), 298-307. Lin, L.C., Wang, S.C., Chen, S.H., Wang, T.G., Chen, M.Y., & Wu, S.C. (2003). Efficacy of swallowing training for residents following stroke. Journal of Advanced Nursing , 44 (5), 469–478. McHale, J. M., Phipps, M. A., Horvath, K., & Schmelz, J. (1998). Expert Nursing Knowledge in the Care of Patients at Risk of Impaired Swallowing. Journal of Nursing Scholarship , 30 (2), 137–142. Metheny, N. A., & Palmer, J. L. (2009). How to Try This: Preventing Aspiration in Older Adults with Dysphagia. American Journal of Nursing , 108 (2), 40 - 48. Nielsen, A. (2009). Concept-Based Learning Activities Using the Clinical Judgment Model as a Foundation for Clinical Learning,. Journal of Nursing Education , 48 (6), 350. Nigolian, C. J., & Miller, K. L. (2011). Teaching Essential Skills to Family Caregivers. American Journal of Nursing , 111 (11), 52 - 58. Osborne, S., & etal. (2006). Using a Monitored Sip Test to Assess Risk of Aspiration in Postoperative Patients. AORN Journal , 83 (4), 908-928. Potter, P. A., & Perry, A. G. (1993). Fundamentals of nursing:concepts, process & practice. Mosby Year Book. Read More