Journal of Community Nursing - page 81

2013,Vol 27, No 4
dysphagia and which community
nurses are most likely to encounter,
are summarised in
Table 1
. Where
adults with learning disabilities are
unable to communicate effectively,
it is strongly recommended that
the presence of such symptoms is
discussed with his or her carer.
Additionally, the nurse might
wish to observe the patient during
a meal in order to evaluate the risk
of aspiration.
Table 2
provides an
outline of the symptoms that may be
seen during feeding and which are
associated with the risk of aspiration.
In all instances where dysphagia
is suspected, a more formal diagnosis
should be made and concerns should
be raised with the patient’s GP, who
should determine the most appropriate
action. A detailed referral pathway
is provided within the guidelines
(Wright et al, 2012), which identifies
when the patient can be adequately
managed within primary care, when
a speech and language therapist
should be involved and at what
point secondary care intervention is
required. Subsequent active treatment
of dysphagia with drugs, i.e. Botulinum
toxin injections, and/or surgery is left to
specialists within the field.
The community nurse is, however,
ideally located to support the
administration of food and medicines
in this patient group.
Speech and language therapists will
assess a patient’s swallowing action
and identify the most appropriate
food texture. Texture can help
compensate for motor difficulties by
aiding the manipulation of solid food
in the oral cavity of patients with oral
preparatory or oral phase difficulties.
The British Dietetic Association
recommends a hierarchy of textures
according to need (Whelan, 2001;
British Dietetic Association, 2012):
Fork-mashable diet
Pre-mashed diet
Thick puree
Thin puree.
The type of food texture
recommended will be individual to
the patient and dependent upon the
patient’s oral motor and swallowing
needs, with the aim being to
minimise the risk of aspiration.
It is important that any
recommendation made by a speech
and language therapist regarding
texture is effectively communicated
to all individuals responsible for
care and that this is taken into
account when determining how best
to administer medication, e.g. the
thickness of any liquid medicines
requires consideration as does any
recommendation to disperse or
Table 1:
Symptoms commonly associated with dysphagia
Oropharyngeal dysphagia
Oesophageal dysphagia
Difficulty initiating a swallow
Delayed initiation of swallow
Tongue pumping
Table 2:
Symptoms associated with risk of aspiration
Mild aspiration risk
Moderate aspiration risk
Severe aspiration risk
Poor tongue control
Poor bolus formation
Reduced laryngeal elevation
Pocketing of food
Absent protective reflexes
Coughing associated with feeding
Variable feeding status
Tongue pumping
Changes in voice quality
Immature feeding patterns
Increased respiration rate
Wet respiration
Sudden change in colour
Nasal regurgitation
Change in facial expression
Sudden sweating
Delayed initiation of swallow
Figure 2.
The phases of swallowing: a.oral, b.
pharyngeal and c. oesophageal.
Problems within the oral phase can
cause inadequate bolus preparation,
while it is in the pharyngeal phase
that aspiration occurs (Cichero and
Murdoch, 2006).
Identifying which phases of the
swallow are impaired can help in
the development of management
strategies during feeding (Harding
and Wright, 2010). Dysphagia is
classified into oropharyngeal or
oesophageal, and determining the
location of the problem can help
nurses to identify the most suitable
While comprehensive lists of
symptoms are provided within the
guidelines (Wright et al, 2012),
those commonly associated with
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