How do you make that into a functional short term goal? Start nectar thick for 100 fast hard swallows without aspiration then move up to the next food. to facilitate safe feeding may elicit a swallow in pt with absent swallow. The patient will develop a positive commitment to sobriety. Principal treatments for selected disorders that affect swallowing are listed in Table 4. 2. treating a delay when the problem is reduced CP functioning). What is the effortful swallow technique? For example, if your patient with aphasia answered yes/no questions at 80% accuracy but open-ended questions at 50% accuracy, write a goal for open-ended questions. when do you modify food or liquid consistency? treatment plan. 2. what would the short term goal be? Ranked No. feeding techniques or use of special devices (e.g., cups, etc.) Similarly, chapters address-ing special populations, including neu-rogenic disease (Chapter 15) and head and neck cancer (Chapter 16), provide details regarding the unique features of these pathologies, as well as incorpo-rating the latest information regarding dysphagia and approaches to treatment pertinent to each group. Patient will safely ingest presentation of dysphagia advanced solids with adequate mastication, AP transit, timely swallow initiation, and no overt clinical signs/symptoms of aspiration/penetration or difficulty swallowing in 90% of all attempts given min-mod verbal/visual cues to utilize safe swallow strategies. The patient will learn the skills necessary to maintain a sober lifestyle. Make the food weight heavier*. What is the Mask Maneuver? Just print out these simple directives so your patient can do their homework. what does it help with? The patient is taught to take a small breath, swallow, cough immediately and then swallow again. What are the observations during a clinical exam for reduced base of tongue retraction? What are some treatment techniques for reduced esophageal transit? For only $10.99 you can purchase this wonderful cheat sheet/guide to dysphagia treatment. What does it help with? When possible, treatment is directed at the underlying disorder, such as Parkinson's disease or polymyositis. What are some treatment techniques for reduced UES relaxation? What are the different exercises that can be done? T/F: some treatments provide both compensation and faciliation? •Puree or liquids enter the valleculae and/or pyriform sinuses before the swallow is triggered (n/a to foods requiring mastication). With indirect treatment, the clinician sets up an individualized plan of care incorporating environmental modificat ions, adaptive equipment/assistive devices, safety strategies, etc., that are used by a … Dysphagia, 18:284-292. What happens in reduced esophageal transit? They should discuss the treatment protocol with the patient and their family; how it will help them achieve the safest and least restrictive diet, what's … Neuromuscular stimulation (NMES)-vital stim, improves cricopharyngeal functioning when there is a CP bar. intake without overt signs and symptoms of aspiration for the highest appropriate diet level • Client will utilize compensatory strategies with optimum safety and efficiency of swallowing function on P.O. GOAL BANK AUDITORY COMPREHENSION Long-term goal: Auditory comprehension of _____. If the SIGN is the pt loses food from the front of the mouth. what is velopharyngeal exercises techniques for poor velar elevation? Used to increase laryngeal excursion and width and duration of UES opening,  Can be used on patients who exhibit reduced upper esophageal sphincter opening and who demonstrate food residue in the pyriform sinuses. and condition at a time, and make each goal one sentence. what do you observe during a clinical exam for reduced velar elevation? terabyte exercises (break contraction so can open mouth if have trismus (cant open mouth) for pt with TMJ. 2. What would the short term goal be? when do you use a chin tuck? Done with traditional dysphagia therapy and not alone (uses Effortful Swallow), surface electromyography- measures muscle recruitment in microvolts, Madison Oral Strengthening Therapeutic Device. Purpose: Improves your ability to swallow food. Respiration and Swallowing Hardemark Cedborg Al, Sundman E, Boden K, Hedstrom HW, Kuylenstierna R, Ekberg O, Eriksson LI (2009) Coordination of spontaneous swallowing with respiratory airflow and diaphragmatic and abdominal muscle activity in healthy adult humans. pt swallows on 3. why would the sour bolus be a rationale for a delayed swallow? In addition, some people with dysphagia benefit from other treatments, including surgery, dietary modifications, and drug therapy, depending on the underlying cause of the swallowing disorder. What happens with reduced cricopharyngeal relaxation? Used with a delayed swallow. what are some treatment strategies that might work for reduced pharyngeal wall contraction? The Centers for Medicare and Medicaid Service… more effort may facilitate increased BOT retraction. This strategy would reduce epiglottis deflection and facilitate epiglottis deflection especially if there is an osteophyte impeding deflection, This strategy may increase strength of swallow, improving epiglottis deflection. All of our very popular Dysphagia Treatment & Assessment documents have been bundled together in this very easy to use big bundled document at $63.99!! Loses food from the front of the mouth (anterior spillage) or can't form a cohesive bolus. •Reflux of material back into the pharynx. Completion of this course will not grant competency to use the VitalStim or VMS portion of the Experia unit. What is expiratory muscle strength training? The patient is taught to hold the larynx at the most elevated position during the swallow for 3 to 5 seconds. Get the sign then make it into a short term goal, Because it doesn't man anything to the non-SLP e.g., insurance. What phase is this SIGN an example of? Indicate the rationale (how the service relates to functional goal), type, and complexity of activity. diet recommendations and modifications. [] Surgery is rarely indicated for patients with swallowing disorders, although in patients … Solid clinical documentation has long been a focus for many providers. This course provides an overview of the documentation requirements for Medicare reimbursement for dysphagia-related services, including evaluation, treatment plans, treatment notes, progress notes, discharge summaries, and common diagnostic and procedure codes. Absent or decreased gag reflex 2. Tell patient to swallow hard. It will be a lot stronger and quicker. What will you maybe observe on a clinical exam for delayed pharyngeal swallow? Among the treatment type segment, surgery segment is expected to dominate the dysphagia lusoria treatment market. Excursion of muscles or decreased strength involved in mastication 3. why would modify bolus size be a rationale for delayed swallow? Perspectives on Swallowing and Swallowing Disorders (Dysphagia) , October (2010); 19: 80-85. If the sign is poor oral transit-can't move bolus to back of mouth. Used to improve upper esophageal sphincter (UES) opening during the swallow. What are the facilitation/therapeutic treatment objectives designed to do? intake … Start nectar thick for 100 fast … ***, *is to swallow and should be included in the treatment objective, Involves diet changes in texture or temperature to help compensate for lost function. Tracheostomytube 6. suck and swallow in finger of glove filled with ice may elicit a swallow. It is a good idea to have the patient try using these postures during the VFFS/MBS; this way you can get an idea of how well or what will really work or not work for that patient. After much demand, I put together a 120-page comprehensive documentation guide that has everything you need to get started documenting if you are new to working with adults. Food/liquid in pharynx or airway before the swallow or residue in valleculae or pyriform sinuses after the swallow. DYSPHAGIA GOALS LONG TERM GOALS - SWALLOWING • Client will maintain adequate hydration/nutrition with optimum safety and efficiency of swallowing function on P.O. exercises involving blowing and producing stop consonants. in oral prep: if there is a problem with mandibular strength and range of motion what are is the treatment? Is it successful? what are questions to determine goals in dysphagia therapy. What are some techniques/strategies which may be indicated for a delayed/absent pharygneal swallow? May even decrease delay, but no evidence one way or the other regarding efficiency. What is the rationale for alternating liquids and solids? Examples of direct dysphagia treatment interventions include sensory stimulation, di et modification, muscle strengthening, ROM exercises, and caregiver training in feeding assistance. Pt will decrease loss of food from front of mouth. The difference between this document and the, Speech and Language Services & Payment Options. Note: Treatment requires understanding the relationship between signs to short term goals, based on physiology that determines what is wrong or impaired which will then determine functional short term goals. Patients who exhibit reduced laryngeal movement and consequent reduced cricopharyngeal opening. if there is a problem in the oral prep phase for labial seal what is the treatment? If the short term goal is to decrease residue in the valleculae what would the functional short term goal be? What are alternating liquids and solids technique? What is the supra-superglottic swallow technique? Tongue is placed b/w teeth. "Thinking out of the box” is a familiar concept to the speech-language pathologist providing dysphagia services. The Super - Supraglottic Swallow is the Supraglottic swallow with Effortful swallow. take a gauze pad and hold out and then trigger the swallow. What techniques are used for reduced laryngeal elevation? what are the different types of lingual exercises? Facial paralysis (cranial nervesVII, IX, X, XII) 4. Knowing WHY to treat requires the SLP to understand what? How should treatment objectives be chosen? Knowing WHAT to treat is important, it requires the SLP to do what? T/F: Functional STGs can reflect compensation rather than faciliation. On the basis of treatment type, the dysphagia lusoria treatment market is classified into surgery and medications. May help to clear residue from vallecuale and pyriform sinuses with each swallow. Am J Speech Lang Pathol 5:23-30, 1996: Authors concluded that the  Masako improved posterior pharyngeal wall bulging which could improve pharyngeal pressure generation by making contact with the BOT. Short-Term Goals: • In 90% of trials—with moderate verbal cues during 30-minute meals, Mr. J will check and clear pocketed material. Larger boluses, for some patients can trigger a faster pharyngeal swallow. tiny laryngeal mirror and ice it and ice up the fossa pillars. What do you see for reduced laryngeal elevation? Stimulate the area but there is NO EVIDENCE BASE that it will facilitate pharyngeal swallow! Head is tilted toward the stronger side so bolus goes down the weaker side. Widens the vallecular space, so that the bolus will hesitate in the valleculae rather than falling into the airway. To me, it is a lifesaver! Edema 2. A limit of 12 seconds made the activity more complex than that tried in the last session. Knowing how LONG to treat requires understanding of what? The patient will learn to express negative feelings to his or her spouse. Wha is the rationale for effortful swallow for reduced base of tongue retraction? The goals of dysphagia therapy are to reduce aspiration, improve the ability to eat and swallow, and optimize nutritional status. 2.2k. intake without overt signs and symptoms of aspiration for the The goals of dysphagia treatment are to maintain adequate nutritional intake for the patient and to maximize airway protection. when other treatment and strategies are not feasible, thin, smh-thick (nectar), and thick (honey), NOTE:****** THICK consistencies are used as the last resort and is temporary. -You might select a treatment technique or method that is wrong for the problem (e.g. Examples of acceptable goals include: patient and/or caregiver training on safe swallowing techniques. What is the rationale for multiple swallows for reduced BOT retraction? May help clear residue, This strategy is to facilitate clearing or reduce residue from the valleculae and pyriform sinuses which might be aspirated after the swallow when there is reduced epiglottis deflection, This strategy: one may help clear residue of other. T/F: functional short term goals should address WHY the skill needs improvement. Morris, S.E., (2010) Food for Thought Creating Mealtimes for Children Who Receive Tube Feedings. SImprove strength and frequency Ex: weight lifting not start with 50 pounds but start lighter. What will you observe on instrumental exam for delayed pharyngeal swallow? The care plan must include goals that are specific to each identified problem. Knowing HOW to treat requires the SLP to understand what? improve strength at certain weight and frequency then build up from there. Disorders of oral and pharyngeal swallowing are usually amenable to rehabilitation, including dietary modification and training in swallowing techniques and maneuvers. It has everything you need from our bedside swallow evaluation, to both of our very well known treatment guides to help choose the right strategies to utilize with patients as well as our new patient handout package, the videoflouroscopy form, and of course the Bedside Dysphagia Evaluation. 3. •Elevation of thyroid notch is delayed (wide range of delays). Perceptual impairment Mechanical: 1. The patient puts their chin to the chest before the swallow and maintains this position until the swallow is completed. get pt into a mental set to swallow. Oral Transit: if there is a problem with lingual control what is the treatment? what are observations on a clinical exam for reduced epiglottis retroflection? Payers, consumers and other health professionals so everyone understand improving the pt's health and safety. The patient is asked to turn their head to the paretic side (weaker side) until the swallow is completed. gravity helps keep liquid from moving further into nasopharynx. Measurable, time-limited goals Patient will score 20 or below on the Beck Depression Inventory for 5 consecutive sessions. Limited awareness 4. What are some techniques/strategies that may be indicated for poor velar elevation? It is a quick cheat sheet which itemizes each Oral Pharyngeal Dysphagia Diagnosis and possible therapy strategies to attempt along with their appropriate rationales. What is the supraglottic swallow technique? What happens if you don't have knowledge of the underlying physiology? If the short term goal is pt will improve ability to move food back of mouth. medical diagnosis/syndromes, GERD, dysphagia, airway issues 25 Delivering Next Generation Care Goal of evaluation/treatment – G-tube wean, increase variety, increase weight gain, eat what family is eating, social acceptance, etc. what are the types of treatment objectives? 1. Used to Increase laryngeal elevation and thereby increase the extent and duration of cricopharyngeal opening. If the short term goals is pt will reduce anterior loss of food what would the functional short term goal be? intake Traditional methods do all of the following, however the swallow is not “normal.” Again, the Dyspahgia Bundle includes all of the following items: The NEW Dysphagia Patient Handout Package includes easy to read Dysphagia Exercises to hand to the patient, aspiration precautions, meal log, breathing exercises, and suggestions on how to gain weight. Examples of Goals 1. What is the rationale for using a chin tuck for reduced base of tongue retraction? Long-Term Goals 1. Supraglottic Swallow. The patient is instructed to "squeeze hard with all your throat muscles" during the swallow. •Residual seen in the pyriform sinuses only after the swallow. The thicker the liquid the hard to get out because it covers the lungs. For dysphagia, identify the diet level that the patient is currently safe with and write goals for the next diet level. This is an example of what phase for this SIGN? Fujiu M, Logemann J: E?ect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. why would thermal stem be a rationale for delayed swallow? -Identify signs of oral, pharyngeal and esophageal dysphagia. One consistency may help to clear residue of the other consistency. protects airway before the swallow and expels penetration after the swallow. decrease residue in the valleculae THAT MIGHT FALL INTO THE AIRWAY AFTER THE SWALLOW. Work for delayed swallow. Examples: 1x/week, 30 mins, 12 visits 1x/every other week, 60 mins, 8 visits Developing Goals Feeding Goals Reducing mealtime behavior Goals Chewing Goals Swallowing Goals Diet Expansion Goals Developing Goals Feeding Goals: LTG: Patient will safely obtain optimal levels of oral nutrition via the least restrictive an age appropriate diet. Many of my CFs and mentees have stated what helped them the most in learning how to document for adult medical patients was reading and looking at my sample reports for wording ideas. T/F: short term goals cannot be written from the SIGNs observed, FALSE! what are observations that would be seen on an instrumental exam for reduced epiglottis retroflexion? Once you have the functional short term goals then you can identify what? Opposite of head rotation. To document skilled services, the clinician applies the tips listed below. Should be chosen based on the physiologic cause of the sign/symptom. Mr. Smith presents to the department with aspiration pneumonia. He is very motivated to participate in treatment, is cognitively intact and has great potential to benefit from treatment. What is theory? Note: signs>short term goal>functional short term goal>treatment objectives, on either the clinical swallow study or during an instrumental examination like MBS. There are many causes to the dysphagia sign. The patient is asked to take 2 or 3 swallows per bolus of food or liquid. 2. may keep bolus higher up in pharynx until the swallow is triggered. 2 in the country and the top in Ohio by The patient is taught to alternate taking a solid then a liquid bolus. Used to improve posterior pharyngeal constriction wall by making contact with the BOT. What are the observations made on an instrumental exam for reduced base of tongue retraction? DYSPHAGIA GOALSLONG TERM GOALS - SWALLOWING - Client will maintain adequate hydration/nutrition with optimum safety and efficiency of swallowing function on P.O. American Journal of Speech-Language Pathology, 18, 65-73. :  Examined manometric measures during the Masako and concluded that while the technique should not be done during PO trials as it reduces oropharyngeal pressure generation, there may be increased pharyngeal constrictor strength after regular training. What do you observe during an instrumental exam for reduced velar elevation? The Mendelsohn Maneuver helps to normalize the timing of the pharyngeal swallow and improve the coordination of the swallow. It is estimated that between 29 and 50 percent of acute stroke survivors are dysphasic. Tumor the functional improvement that is sought. Is this facilitation, compensation, or diet: mendholsons because improve range of motion of base of tongue, Thin liquids because need more tongue retraction for thicker liquids, Look at treatment objectives for vallecular residue. Here are some factors that may be related to Impaired Swallowing: Neuromuscular: 1. Using Modalities in the Treatment of Dysphagia, is an introductory orientation to the Experia equipment only. why would the 3 second prep be a rationale for a delayed swallow? What are the different types of facilitation/therapeutic techniques? smaller, more measurable steps used to achieve the functional short term goal. what does it do? decrease distance between BOT to posterior pharyngeal wall. Used to increase BOT retraction and pressure during the pharyngeal phase of the swallow and reduce the amount of food residue in the valleculae of the throat & thereby possibly aspiration/penetration. Various swallowing maneuvers are used to change the swallow physiology. Then they complete a supraglottic swallow. In these situations, therapy is individualized based o… 1. What is McNeil Dysphagia treatment program? What happens in reduced pharyngeal wall contraction? Specific postures are used to compensate for particular types of dysphagia by changing the way that the food moves through the pharynx. • With minimal cues, Mr. J will use customized scanning strategies to locate and consume food and drink during a meal. pt will increase pharyngeal wall movement to reduce pyriform sinus residue which may cause aspirated after the swallow, Note: Have the short term goal but need to know why the residue is there. Voluntary breath hold closes VF’s before and during swallow thus protecting the airway. dysphagia lusoria treatment market is expected to have significant growth over the forecast period. It is always necessary to consider other factors which may change your treatment program (i.e, etiology, patient awareness & ability, etc.). A larger size may help tirgger a more prompt swallow. what is surgical management for poor velar elevation? What are some techniques to do for reduced base of tongue retraction? The clinician choosing to specialize in the assessment, treatment, and management of swallowing and swallowing disorders, for example, must look at the anatomy and physiology previously learned in the context of speech production, and gear that knowledge to another … what does the Oral Bulbar exercises help with? improve strength at certain weight and frequency then build up from there. What is the best exercise for swallowing? what type of treatment is this? Postural strategies are used to help change the way bolus flows through the swallowing mechanism. Examples of Measurable and Non-Measurable Treatment Goals Non-measurable goals Patient will effectively manage their depression. Before pt resumes breathing, pt will clear throat. What are compensatory treatment objectives? improve strength at certain weight and frequency then build up from there. How to Perform: Take a deep … Check all that apply. However, many of the disorders that cause dysphagia, such as stroke or progressive bulbar palsy, are not amenable to pharmacologic therapy. Keeps larynx elevated longer prolonging the opening of upper esophageal sphincter. pt blows into a part and turn to increase resistance. DYSPHAGIA MANAGEMENT BEST PRACTICES •If abnormal screen refer to healthcare professional with expertise in swallowing assessment •Close monitoring for changes in swallowing ability •Individualized management plan should be developed to address therapy for dysphagia, nutrition needs & … Effort increases posterior tongue movement thus improving bolus clearance from the valleculae. Target Date: 10/1/2014. •Residual material in the valleculae and pyriform sinuses, bilaterally or unilaterally. pt will improve ability to move food back of mouth TO REDUCE ORAL RESIDUE THAT MIGHT FALL INTO THE AIRWAY. It should be noted that this is simply a "guide" and not meant to be used as a one fits all. At Cleveland Clinic, we’ve assembled an entire team of all the specialists you need – including gastroenterologists, radiologists, pathologists, thoracic surgeons and swallowing therapists – to offer leading-edge diagnosis and treatment options. This is when the head of bolus is going beyond the head of the mandible to the pyriform sinuses, Rationale: helps bolus propulsion because narrows the space between the base of tongue and the posterior pharyngeal wall (oropharygneal space). The patient is asked to hold their breath tightly and bear down. functional Short term goals are written in terms that who can understand? •Penetration and/or aspiration DURING the swallow. Maintain a “safe” swallow or reduce the risk for penetration/aspiration (decrease risk of infection) 2.Increase p.o. they can be written fro the signs observed. What is the modify volume and speed of food presentation technique? What is the rationale for exercises to increase BOT retraction? Designed to compensate for, not improve the lost function. dysphagia. Can't move the bolus to the back of mouth or loses bolus over back of tongue while trying to move bolus back (premature spillage). Various exercises can be done to improve the range of motion (ROM) of the lips, tongue, and jaw, to improve coordination, to improve vocal fold adduction, laryngeal elevation, or tongue base retraction. •Base of tongue does not make contact with posterior pharyngeal wall. Compensatory treatment objectives are most often used when? 1. To address word retrieval skills, patient named five items within a category. I created this document while in graduate school and have since kept it updated. This is an example of what phase for this SIGN? Why would a chin tuck be a rationale for a delayed swallow? Patient will expectorate the residual material left above Pharynx after the swallow. (2) single words and simple expressions (3) simple directions and conversation about immediate environment. smaller size may accumulate less before the swallow. Rationale: Poor bolus propulsion for solids but liquids help wash it OR he has liquid residue in the valleculae that is washed away or taken away with a solid bolus of food because muscles put more effort for the solid bolus. What does it increase? what is chin up for technique for poor velar elevation? Attending to physiology helps determine what? If the SIGN is the pt has residue in the valleculae. Doeltgen, S. H., Witte, U., Gumbley, F., & Huckabee, M. (2009). Dysphagia Treatment is decided upon once a diagnosis is confirmed however many facets should be involved in that determination The clinician will choose a treatment program, based on the etiology, mental and physical capacity, and quality of life. Evaluation of manometric measures during tongue-hold swallows. The Treatment Plan 77 Goals and Objectives DYSPHAGIA GOALS LONG TERM GOALS – SWALLOWING • Client will maintain adequate hydration/nutrition with optimum safety and efficiency of swallowing function on P.O. For purchase is a two page document I never leave my house without! Goal writing exercise In the following examples, identify which of the required elements is missing or incomplete. Use terminology that reflects the clinician's technical knowledge. dysphagia and feeding varies greatly among caregivers. What would the short term goal be? Patient will decrease their depression by 50%. pt will reduce anterior loss of food SO THAT MORE FOOD WOULD BE CONSUMED. zExample 37 Caregiver Interview The goal of the caregiver interview is to gain more understanding of the patient’s dysphagia in their everyday (natural) setting, including: • When the behavior occurs (time of day) • How often the behavior occurs (frequency) Fatigue 3. 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