Dysphagia (inability to swallow properly) is a common and significant complication that occurs in about 40-60% of stroke victims.

Patients with dysphagia have trouble swallowing solids or liquids without aspirating the contents into the bronchopulmonary tract. They may also find it hard to chew or move their tongues adequately to prepare food for the swallowing action. Proper assessment and early management is essential, as dysphagia is associated with high rates of morbidity and mortality.

Ideally, the nurse looking after a stroke victim should strive to observe for dysphagia, monitor for and report any complications such as infection, and monitor for signs of dehydration and malnutrition.

Dysphagia can lead to:

• Malnutrition
• Weight loss
• Starvation
• Dehydration
• Aspiration pneumonia
• Lower respiratory tract infections
• Longer time needed to recover from stroke
• Emotional distress – embarrassment or anger at requiring assistance with eating, especially as dining is often done in a social setting

Assessment findings indicative of increased risk of dysphagia, aspiration, and pneumonia:

• Comorbid diseases with pulmonary compromise (such as chronic obstructive airways disease)
• Smoking history
• A hoarse, wet voice or weak cough
• Dental decay
• Requiring assistance with eating
• Medications that list dysphagia as a potential adverse effect (such as potassium supplements)
• Poor posture control (cannot remain upright)
• Low level of consciousness/Glasgow Coma Scale (GCS)

Identification of dysphagia in stroke victims:

A patient is more likely to be suffering from dysphagia if some of the following factors are present: palatal asymmetry, impaired pharyngeal response, being male, being more than 70 years old, and not being able to clear the oral cavity completely. A nurse should also observe the patient’s ability to move the mouth spontaneously, e.g. licking lips, smiling, speaking well (i.e. is it intelligible?).

There are various screening methods for identifying dysphagia, such as a swallow test. Patients can be tested to see how well they swallow food of different consistencies and textures, e.g. water, then thickened fluids, then mashed foods, then more solid foods. Afterwards, patients should be assessed for any delayed coughing. Vital signs should also be monitored, as a patient’s temperature will rise when aspirating food, whilst oxygen saturation levels may fall.

Additionally, the incidence rate of identifying dysphagia was found in one study to be higher when a clinician trained in swallowing was involved, and highest when instruments such as videofluroscopy were involved. Dysphagia assessments are important – one multicentre study found that when a standardised screening protocol for dysphagia was used on stroke victims, the risk of aspiration pneumonia decreased.

The patient should also be referred to a speech pathologist for a thorough clinical assessment. Speech pathologists can formally assess for dysphagia, and recommend strategies for eating and swallowing. They can also teach patients how to exercise the muscles involved in swallowing.

Important practice points for managing patients with dysphagia:

• As with all patients, check vital signs regularly.

• Weigh the patient on admission to obtain a baseline weight. Regular weights throughout admission can then aid in monitoring for malnutrition and weight loss.

• Keep patients nil by mouth immediately following a stroke, until an assessment of their swallowing ability and risk of aspiration can be made.

• Don’t allow patients to eat/drink until there is a definite plan regarding what type of solids/texture they can safely eat.

• Refer to speech pathologists for a formal swallowing assessment, and assistance on helping patients improve their swallowing abilities.

• Refer to a dietitian, to assess for nutritional intake in the diet and any weight gain/loss. For malnourished patients, a high-protein, high-energy diet may be best. Nutritional supplements may be recommended. On discharge, they can also educate patients on planning snacks and meals so they can continue to get adequate nutritional intake.

• Patients may need foods of certain textures e.g. thickened fluids or pureed meals. Additionally, chilled foods may be beneficial as they stimulate the swallow reflex.

• Try placing a spoonful of food in the unaffected side of the mouth (if the stroke has affected one side of the face), whilst trying to avoid the teeth or pushing to food too far into the mouth.

• Make sure they remain upright whilst you are feeding them.

• Help maintain patients’ personal hygiene and dignity standards: keep napkins available, and assist them in washing their hands or cleaning their teeth if they wish to do so.

• Good non-verbal signs may assist the nurse helping to feed the patient, e.g. sitting in front of the patient, leaning forward and keeping good eye contact.

• If a patient aspirates: encourage them to cough to help clear their airway, keep them in an upright position, and if necessary, assist them to clear the oral cavity with use of suction.

• If patients are at risk of becoming dehydrated, it is likely that they will require intravenous fluids.

• If aspiration is suspected, the patient’s doctor will need to be informed and the patient will generally need a chest x-ray and possibly antibiotics.

Sources
• http://www.sign.ac.uk/pdf/sign119.pdf
• http://www.uptodate.com/contents/medical-complications-of-stroke
• https://www.stroke.org/sites/default/files/resources/NSAFactSheet_Eating_2014.pdf
• http://www.nursingtimes.net/clinical-archive/nutrition/nutrition-and-hydration-tips-for-stroke-patients-with-dysphagia/203500.fullarticle

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