Clinical+or+Mealtime+Observation

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(5:e) A clinical/mealtime observation has been called a bedside swallowing examination in the past. It can be performed in any setting so the fore mentioned term is not commonly used presently (Groher & Crary, 2010). A clinical observation is presenting the patient with several trials of various consistencies. A mealtime observation involves the clinician being present during the entire meal. The setback of the clinical/mealtime observation is that there is no way to definitively assess aspiration. Clinical judgement can be used to evaluate a patient who has been NPO and appears ready for oral intake however instrumental assessment is required to be completely certain that silent aspiration is not occurring.
 * Clinical/Mealtime Observation **

Groher & Crary (2010) recommend observing the three meals of the day and the entire meal duration. In practice, due to a heavy caseload this is not usually possible. Observation of an entire mealtime as well as talking to the patient and/or the person who feeds the patient if they are not eating independently is better than observing a few swallows of each food texture and fluid consistency. The reason for this is that towards the end of a meal swallowing competency can change due to fatigue. Oral trials can be presented only if the oro motor examination showed that it would be safe and the patient in alert (Murray, 1999).

A clinical swallowing examination should be executed in an orderly way to ensure a thorough exam. A clinical swallowing examination form has a suggested progression which may be resequenced or adapted at the clinician’s discretion. Many clinicians begin with pudding or thickened fluids as thicker more cohesive boluses are often managed better than radidly moving thin liquids (Cicero & Murdoch, 2006). Others begin with thin liquids as this is the most common consistancy and then progressively thicker consistancies. Thin liquids require a high degree of oral and pharyngeal coordination and control. Thin liquids may be easier for a patient with oral cancer as they often have xerostomia.

The clinician will elicit swallows by presenting various volumes and consistencies of food and liquid (Murray, 1999). The reasons for varying volumes is that for patients with sensory loss, a large bolus may be required in order for a swallow to be triggered. Other patients with reduced swallowing control may need a smaller bolus to prevent pre-mature spillage. Clinicians tend to start with soft solids and move progressively to those that require extensive chewing (Cicero & Murdoch, 2006).

Physiologic measures of heart rate, respiration rate, and oxygen saturation can help to predict aspiration (Cichero & Murdoch, 2006). As the oral stage and laryngeal excursion are of concern for this patient population one should pay extra attention to the following during clinical/mealtime observation or oral-trials

· ability to control the bolus orally using lips, cheeks and tongue and to form a cohesive bolus that is suitable to swallow (Cichero & Murdoch, 2006, p.163).

· check for oral residue in the buccal sulcii noting if there is a greater amount on one side (Cichero & Murdoch, 2006, p.163).

· if a cough response is present, timing of the cough is likely to be after the swallow due to weakened tongue base propulsion and/or reduced laryngeal elevation (Cichero & Murdoch, 2006, p.163). This means that residue will flow over into the laryngeal vestibule (Groher & Crary, 2010).

There are various types of water tests which are used for screening of aspiration however they all differ and some have poor predictive value (Groher & Crary, 2010). An example of one such widely-used water test is the 3-ounce water swallow test. Individuals are required to drink 3 ounces (90 cc) of water. Criteria or referral for further assessment of swallowing include inability to complete the task, coughing, choking,or a wet-hoarse vocal quality exhibited either during or within 1 min of test completion. No clear consensus of reliability and validity has been developed because of small sample sizes and varying methods. This test has a high false-positive rate and low specificity
 * Standardised Swallowing Examination: Water tests **

A report should be composed for the patient's file and family members. It should include medical history and symptoms, signs of dysphagia observed, changes observed due to trialed compensatory methods, patient/family goals, red flags for aspiration pneumonia, recommendations and eduction (Rosenbek & Jones, 2009).
 * Reporting **

An example of a report can be seen here. This has been created using Murray (1999), Cichero & Murdoch (2006), and Groher & Crary (2010).



Additional Areas for Consideration 