1. Lesson #5 Impairments of Communication Swallowing
Rehabilitation Nursing

2. Impairment of Communication

3. Impaired Communication Terms
Aphasia
Neurological condition
Normal language function absent or disordered
Inability to, in any combination:
Form/speak words
Read written words
Listen to words read or spoken
Understand words read or spoken
Dysphasia
Indicates the degree of language difficulty
Does not indicate total inability to communicate

4. Impaired Communication Terms
Agnosia
Total or partial loss of ability to recognize something or someone familiar
Perceptual difficulties
Every sense may be working
But fails to accurately interpret or recognize what they are sensing
Agraphia
Inability to write
Writing is usually unintelligible words
May be able to form the letters/words but they mean nothing

6. Impaired Communication Terms
Alexia
Inability to understand written words
AKA “word blindness”
Anomia
Form of aphasia
Inability to name objects
Ability to recognize and
describe object

7. Impaired Communication Terms
Dysarthria
Difficult, poorly spoken speech
Inability to use and control muscles for speech
Usually disorder of CNS or peripheral nerve damage
Important Note!!!!
How does nurse tell difference?

8. Normal Speech Requirements
Basic Requirements
Levels of Language Production

9. Communication Basic Requirements for any language
#1 Linguistic Competence
Appropriate order of sounds(syllables)
#2 Cognitive Competence
Appropriate application of word meaning
#3 Practical or Pragmatic Competence
Appropriate use or application of words during speech in plurality and tense
In all situations and social settings

10. Communication Level of Language Production
#1 Autonomic Speech
Habitual response
#2 Imitation Speech
Copycat speech
Must have ability to:
Hear /Understand the message
Answer appropriately
Reminder at this level!!!!
#3 Symbolic Speech
Most advanced
Speaks voluntarily
Follows all language rules

11. Specific Language Patterns Communication Problems
Brain Damage Areas
Specific Language Patterns
Communication Problems

12. Aphasia

13. Normal Brain Normal Speech Center
Located in the dominate cerebral hemisphere
Left hemisphere for a right hand dominate
Right hemisphere for left hand dominate

14. Speech Aphasia Defect in use of language
Any combination of difficulty possible:
Speech
Reading, Writing
Understanding
Can be receptive, expressive or both
AKA Fluent or Non-fluent aphasia
RT ease or lack of ease in speaking the words

15. Types of Aphasia

16. #1 Non-Fluent Aphasia Knows what to say Inability to get the words out
Patient will:
Work hard at trying to talk
Get frustrated while getting words out
May say something they did not mean to say
May have impaired writing or not make sense
Two types of non-fluent Aphasia:
#1 Broca’s Aphasia
#2 Global Aphasia

17. #1 Broca’s Aphasia Discovered 1861 French Dr. Pierre Broca
Through autopsies on several patients
who could not talk
Discovered damage to their brains in same consistent area which is named after him

18. #1 Broca’s Aphasia Usually from stroke
Occurs in left frontal hemisphere
Reminder of Normal Left frontal hemisphere responsibilities:
Imitation of autonomic gestures
Elaboration of thought(development or working out details)
Ability to produce automatic and willed speech
Syntax
Appropriate use of words in a sentence or phrase

19. #1 Broca’s Aphasia Characteristics
Auditory Understanding
Good
Understands what is said
If stroke extends…..
Speech
Deficits show up
Difficulty starting a conversation (willed speech)
Difficulty in using names
Difficulty with repletion (fluency)
Recognizes when making verbal mistakes
Speech telegraphic and inconsistent
Reminder!!

20. #1 Broca’s Aphasia Characteristics
Writing
Writing reflects how they talk
Related impairments:
Apraxia
Inability to easily move tongue, mouth or throat used in speech
Note:
Same muscles used in eating
Can eat, just difficulty with speech

21. #2 Global Aphasia Damage occurs in frontal area
Great extension of damage leaves little perception response
RT little sensory perception is getting to brain and able to be interpreted

22. #2 Global Aphasia Characteristics
Auditory understanding
None
Speech
Inappropriate word use
May use automatic speech
May appear fluent(repletion), but words meaningless
Use of perseveration or echolalia
If dysarthria, then speechless
Writing
Impaired and unintelligible
Reading
Same as writing

23. #2 Fluent Aphasia

24. #2 Fluent Aphasia Ability to easily talk
Problem is spoken words make no sense
Client does not understand:
Spoken words
Written words
One type of Fluent Aphasia:
Wernicke’s Aphasia

25. Wernicke’s Aphasia Damaged area is left superior temporal area
Major problem is Semantics
Normal Left Temporal brain responsibilities:
Analysis of sensory impulses
Understand detail
Recognizes and understands sounds
Understands language
Correctly interprets visual information

26. Wernicke’s Aphasia Characteristics
Auditory
Impaired
Does not understand what is heard
May hear talk, but lost on meaning of words
Speech
Speaks fluently
Gives impression they understand what is going on
Most cases, they haven’t got a clue
Speech smooth with normal rhythm, tone, phrase length, grammar
Abnormal semantics- meaning of words
May use word substitutions

27. Wernicke’s Aphasia Characteristics
Writing characteristics
Impaired writing
Reading
Impaired
May be impaired understanding of visual perception
Important note when working with Wernicke’s Aphasia clients:
Key is use whole body commands

28. Nursing Process Interventions
Communicating to patient with Aphasia

29. Major Assessments for Aphasia Impaired Communication
Education level
Developmental level
Native spoken language
Previous speech problems
Any previous sensory perception issues/corrections
PT assesses physical strength to carry out commands
Auditory comprehension

30. Impaired Communication Nursing Diagnosis or Priorities
Impaired Verbal Communication
Impaired Social Interaction
Social Isolation

31. Impaired Communication-Aphasia Goals and Expected Outcomes
#1 Find some way to communicate with patient
#2 Protect/maintain patient’s self-esteem
#3 Listen to them/observe body language/gestures for clues
#4 Assess for changes
#5 Encourage/Monitor for at least ONE positive social interaction per day

32. Impaired Communication Aphasia Interventions
Encourage techniques of communication that should:
Limit frustrations
Reduce distractions
Help correct misunderstandings
Some helpful techniques:
Treat patient as an adult
Encourage independence in their communication
Build self-esteem by encouraging decision making
Use appropriate eye contact
Keep distractions to a minimum
Consider their level of fatigue

33. Impaired communication Aphasia Interventions
To help patient understand or comprehend:
Speak normal tone
Keep communication clear/ brief
Support words with gestures/motions to describe actions
Use commercial aids(picture boards)

35. Impaired Communication Aphasia interventions
To help patient to express self and build self confidence:
Maintain open body language
Respond to all communication efforts by patient
Do not finish the patient’s statement for them

36. Impaired Communication Aphasia Interventions
Patient’s without speech need to communicate:
Use picture boards
Facial expressions
Computers (Dynawrite)
I phone App (My voice)

37. Impaired Communication
Dysarthria
Impaired Communication

38. Dysarthria A problem in forming or articulating words of speech
RT nerve difficulty
CNS nerve damage
Peripheral Nerve damage

39. Dysarthria Signs and Symptoms
Drooling
Chewing motion
Swallowing problems
Important Note:
Can understand language/speech
Dysarthria seen in many neurological disorders

40. Types of Dysarthria Flaccid Spastic Ataxic Hypokinetic Hyperkinetic
Mixed

41. Dysarthria Assessment of Cranial Nerves
CN 5= Trigeminal Nerve
Ability to chew/move jaw
CN 7= Facial Nerve
Assess symmetry and fatigue!!!
CN 9= Glossopharyngeal Nerve
Assess gag reflex
Assess ability to speak/cough
CN 12= Hypoglossal Nerve
Assess tongue for symmetry, size, shape
Paresis causes tongue to protrude toward weak side
Speech/nurses:
Assess ability of tongue to be coordinated and rhythmic in movement

42. Impaired Swallowing
Dysphagia

43. Impaired Swallowing Terms
Dysphagia
Difficulty with oral prep for swallowing
Difficulty in moving the material from mouth to stomach
Difficulty with pain or discomfort with swallowing

44. Impaired swallowing More Terms
Bolus
Soft mass of chewed food
Collection of saliva
Deglutition
Swallowing process by which anything passes from mouth through pharynx, esophagus to stomach
Ataxic
Lack of coordination of muscle action of swallowing
Aspiration
Inhalation of foreign substance into the lungs

45. Normal Swallow Process
Required to normally function and work together:
Swallow muscles
Swallow nerves
Food must be placed in mouth for process to begin
There are four stages in the normal process of swallowing
Note: Difficulty can happen at any of these stages or a combination of these stages

46. Normal Swallowing Process Stages
Stage 1 Stage 2 Oral Preparatory Oral(lingual)

47. Normal Swallowing Stages
Stage 3 Stage 4 Pharyngeal Stage Esophageal Stage

48. Normal swallowing Very fast process Mouth to top of esophagus:
Takes less than 2 seconds
Esophagus to stomach:
Takes 8-20 seconds
Depends on length of esophagus

49. Normal Swallowing Very safe process Larynx closes as food passes by
Food is moved efficiently from mouth and pharynx:
Works in sequence
No food left behind

50. Swallow Problem If too big a bite at one time
Swallow takes longer
Mouth and pharynx
Muscles fail to work in sequence which is normal
Muscles must work at same time
Often causes patient to hold breath to swallow

51. Normal Swallowing Swallowing changes based on type of food
Some things do not change:
Safety
Efficiency of swallow

52. Risk factors indicating possible Impaired Swallowing
Any change in LOC
Poor head/neck control
Impaired cough/gag reflex
Using therapeutic devices to eat

53. Immediate Dysphagia intervention- Assess!!!
Place patient on Special Feeding Precautions
Customized instructions come from speech therapy after:
Assessment of swallow
Bedside Swallow Evaluation on admission
Gives safety guidelines immediately until further testing done
Barium Swallow Evaluation ASAP
Assists in detailed discovery of degree of difficulty with swallowing process and all involved stages

54. More Speech Therapy Assessments!
Assess foods causing symptoms:
Thin liquids
Milk/nectar
Certain foods(rice)
Assess patient’s eating habits(3 day history)
Speech may come and sit alone with client observing:
Length of time to eat
Speed of eating
Fatigue level
Cough/gag reflex triggered anytime during meal

55. Nurses/Speech Therapist Even more assessments!!
Voice changes(nerve Innervation)
Sleep problems (pharynx)
Any esophageal problems
Cardiac symptoms(chest pain)
Respiratory Symptoms
Current medications
General medical history
Neurological history
Typical family diet
Work history

56. Speech Therapy Dysphagiagram or Barium Swallow
Defines specific areas of weakness
Bedside Swallow Evaluation
Done within 4 hours of admission
NPO until done
Makes recommendation to physiatrist who then gives diet order
Uses various forms of water/ other food
May attempt use of straw
Observes patient’s response to different consistencies
Notifies OT for necessary adaptive tools
Notifies nursing of safety precautions for eating

57. Silent Aspiration VS. Aspiration
S&S
Tachycardia
Dyspnea
Cyanosis
HTN
Delayed cough
Possible elevated temperature
101° F with 30 minutes of aspiration
Gurgled voice
Aspiration
Shows all the above
Except has immediate cough

58. Choking Considered a protective mechanism of airway Interventions:
Have client flex at waist or neck
May help clear airway
If food lodged, then Heimlich Maneuver appropriate
Prudent to have portable suction available

59. Nursing Diagnosis Interventions
Dysphagia

60. Dysphagia Nursing Diagnosis/Priorities
Impaired Swallowing
Risk for Aspiration
Nutrition: Less than Body Requirements, Imbalanced
Deficient Fluid Volume

61. Dysphagia Goals/ Interventions
#1 Prevent Aspiration
Staging diet helps improved control and safety over food bolus
Often these patients are also supplemented through PEG tube
Food likes/dislikes do not change with dysphagia
Caution: Normal Healthy food intake should take minimum of 20 minutes, so do not hurry these individuals with Dysphagia
Change and monitor liquid consistencies

62. Diet Stage 1 Pureed

63. Diet Stage 2 pureed
More texture found in food

64. Diet Stage 3 Ground Mechanical Soft
Mashed food with small pieces

65. Diet Stage 4 Chopped or Cut Mechanical Soft

66. Diet Stage 5 Regular Texture

67. Prevent Aspiration Liquid Classifications
Thin liquids cause most aspiration problems
Liquid consistencies can be changed by adding thickeners to change consistency
Thickened liquids take a longer time to swallow. This increases patient’s ability to control bolus
Warning: Do not mix consistencies! Can cause patient to choke!

68. Liquid Classifications

69. Thickeners Added to obtain a safe swallowing consistency
Used until throat muscles are stronger and able to react faster
Products can be pre-thickened or may need to add thickener
Thick-it product

70. Thin Liquid Consistencies

71. Medium Thick or Nectar Consistencies

72. Medium Thick Plus or Honey Consistency

73. Spoon Thick Consistencies

74. Goal #2 Assess/Maintain Nutrition Level
Ensure enough calories intake:
Repair
Coping with stress of injury
Coping with exercise activity in PT
Maintain body weight
Report any weight changes!

75. Feeding Program Interventions

76. Feeding Interventions Correct Position
Ordered by ST
Upright
Head midline
Arms supported on table
Chin tuck with neck flex
Food placed on unaffected side
Lip of cup on client’s lower lip for sipping
Client remains upright for minutes after meal
If in bed, HOB to at least semi-Fowlers position

77. Feeding Interventions Environment
Well lighted
Minimal distractions
TV off
Quiet environment
No talk with mouth full
Mouth care prior to meal
May require one-on-one during meals
Mandatory check tray for diet accuracy
Ensure all required adaptive equipment is used and protected
Sit down with client
Encourage client to see and smell food
Identify the food placed in patient’s mouth

78. Feeding Interventions Rate of eating
Encourage rest prescription prior to mealtime
Coordinate medications to ensure comfort and safety during mealtime
Check swallowing before giving next bite ensuring mouth has completely emptied
If changed the diet which requires more chewing watch closely for fatigue!!!!!!
Allow minutes to assist these patient’s with their meal. DO NOT RUSH!!!

79. Feeding Interventions Amounts of Eating
Patients initially are fed small amounts to ensure ability to control
Alternate liquid and solid to help empty mouth
Avoid Straws!!!

80. Feeding Interventions Texture
May not be able to safely swallow more than one texture
Avoid mixing foods
Use pulp free drink
Avoid bland food!
Use thickeners as needed

81. Feeding Interventions Adaptive Devices/techniques
Suction machine should be available in dining room
Client chokes:
Lower chin
Flex forward at waist
Heimlich maneuver
Use lightweight utensils:
Modified built-up handles
Velcro straps
Drinking cups
Plate guards

82. Feeding Interventions Extra Techniques
Promote independence
Cue and coach to swallow before next bite or swallow
Stroke digastric muscles to encourage swallow
Encourage ST exercises to strengthen involved muscles
Points to Remember about Medications:
Medications may be given in custard, jelly or blended fruit gelatin
Avoid applesauce RT it falls apart during swallow process
Reminder to thicken all liquid medications to appropriate consistency

83. Review What did you learn?
How will you put this into your practice as a nurse?

84. References http://www.neurology.org/content/70/5/391/F1.large.jpg

85. References http://webdoc.nyumc.org/nyumc/files/rusk/u2/speech-1.jpg

86. References