Dysphagia In-service for
Certified Nursing
Assistants(CNAs) and Cafeteria
Staff in a Nursing Home
Blair Ridgley, MCD CCC-SLP
Presentation is the handout for the in-service
What is Dysphagia?
• Dysphagia means difficulty eating or swallowing
▫ Dys: Difficult
▫ Phagein: To eat
• A person can have difficulty with eating or
swallowing, classified as dysphagia, relating to
any of these three stages:
▫ Oral
▫ Pharyngeal
▫ Esophageal
(Nazarko, 2008)
Four Phases of a Normal Swallow
Phase
Oral
Preparatory
Oral
Pharyngeal
Esophageal
Relevant Anatomy
•Lips
•Teeth
•Hard/Soft Palate
•Cheeks
•Floor of mouth
•Mandible
•Tongue
•Tongue
•Hard/Soft Palate
•Cheeks
•Faucial Arches
•Pharyngeal Muscles
•Soft Palate
•Epiglottis
•Valleculae
•Pyriform Sinus
•Hyoid Bone
•Larynx
•Cricopharyngeal
Muscle
•Esophagus
•Upper Esophageal
Sphincter
Actions
•Accepting and
holding bolus in
mouth
•Chewing of food
•Mixing/grinding
bolus with saliva
•Centering bolus
into position on
tongue in
preparation for
swallow
•Tongue moves
bolus to back of
mouth by pushing
up against hard
palate
•Triggering the
pharyngeal swallow
when the bolus
passes the faucial
arches
•Soft palate elevates
•Pharyngeal
constrictor muscles
push food through
the pharynx
•Larynx moves
forward, elevates,
and closes to protect
the airway
•Larynx lowers
•Esophageal
peristalsis moves
food from the
esophagus to lower
esophageal
sphincter
•Cricopharyngeal
muscle contracts to
prevent reflux
•Peristalsis
continues to move
bolus to stomach
(Terrado, Russell & Bowman, 2001)
Anatomy in View
Valleculae
More Anatomy!
Take Note of All the Structures!
Signs/Symptoms of Problems in
Swallowing
Oral Preparatory/Oral
•Drooling
•Spitting food out of the mouth
•Takes too long to chew
•Difficulty chewing
•Dry mouth
•Meal times are prolonged
•Changes in taste
•Excessive oral secretions
•Excessive or uncontrolled
tongue movements
•Difficulty managing foods of
specific tastes or textures
•Avoids foods that require
chewing
•Cannot suck threw a straw
Pharyngeal
•Food sticking in the throat
•Voice sounds hoarse or
different
•Nasal sounding voice
•Nasal burning or dripping,
sniffling during a meal
•Nasal regurgitation
•Wet or gurgly voice after
swallow
•Coughing or choking before,
during , or after a swallow
•Stridor
•Excessive saliva or mucous
•Saliva is difficult to swallow
•Fluids difficult to swallow
Esophageal
•Unpleasant taste to mouth
when waking up
•Acidic smelling breathe
•Excessive burping
•Regurgitation of gastric
contents or wet burps
•Food sticking in the throat
•Heartburn or epigastric pain
•Repetitive swallowing
(Terrado, et al, 2001)
Possible Risks Without Management
• Penetration
▫ Material moves into the area above the true vocal folds
• Aspiration
▫ Material breaches vocal folds into trachea and potentially into lungs
▫ Aspiration Pneumonia
▫ When material is in the lungs
▫ Please note Aspiration does not occur only at meal times**! It can occur any time!
▫ Silent Aspiration
 Aspiration occurs but without any coughing or choking
• Malnourishment/Undernourishment/Dehydration
▫ Due to decreased intake of the appropriate amount of nutrients and liquids
• Permanent Lung Damage
• Inability to take required oral medications
• Death!!
Signs and Symptoms of Silent
Aspiration
• Just because a patient is not coughing or choking after a
swallow does not mean that they have not
ASPIRATED!!
• This may occur due to the patient losing the ability to
feel that something is in their mouth or has entered their
airway.
• Around 50% of patients who aspirate are silent (Logemann, 1998)
aspirators
• Some signs to recognize silent aspiration:
▫ Eyes watering
▫ Nose running
▫ Patient turning a different color
Treatments
• Dietary/Texture Modifications
▫ Will go over in depth
• Adjusting the Environment
▫ Have the patient eat in the cafeteria instead of
their room.
• Patient Training in Compensatory Techniques
▫ i.e. chin tuck, head turn
How Can We Modify the Patient’s
Diet?
• No Set Standard
▫ The American Speech-Language Hearing Association
(ASHA) has no set standard for textures or modified
foods and thickened liquids.(American Speech-Language Hearing Association, 1997-2014)
• ASHA does not have guidelines currently about food
types that should be included on different diet
texture levels.(American Speech-Language Hearing Association, 1997-2014)
• The National Dysphagia Diet (NDD)
▫ Published in 2002 by the National Dietetic Association
▫ It outlines 3 modified solid textures and 3 thickened
liquid levels (McCullough, Pelletier, & Steele, 2003)
National Dyphagia Diet: 3 Solids
• NDD Level 1: Dysphagia-Pureed (homogenous, very
cohesive, pudding-like, requiring very little chewing
ability).
• NDD Level 2: Dysphagia-Mechanical Altered
(cohesive, moist, semisolid foods, requiring some
chewing).
• NDD Level 3: Dysphagia-Advanced (soft foods that
require more chewing ability).
• Regular Diet: all foods allowed
(McCullough, et al, 2003)
Level 1:National Dysphagia Diet
• Appropriate foods possibly included in Level 1:
▫ Purreed meats (pureed to pudding like consistency; hummus like consistency;
pureed bread mixes
▫ Pregelled slurried breads, pancakes, french toast, waffles, or sweet rolls; smooth
cooked cereals, such as farina-type cereals with a pudding like consistency
▫ Pureed fruit; well mashed fresh bananas; pureed vegetables without lumps, pulp,
or seeds; tomato sauce without seeds
▫ Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour
cream; well cooked pasta, noodles, or pureed rice (blended to smooth consistency)
▫ Smooth pudding custards; yogurt; pureed desserts and soufflés
(Nutrition411, 2011)
Level 2: National Dysphagia Diet
• Appropriate foods possibly included in Level 2:
▫ Moistened ground or cooked meat, poultry, or fish (serve with sauces); casseroles
without rice; moist, well cooked pasta; moist meat loaf or meatballs; poached,
scrambled, or soft cooked eggs; tofu; well-cooked and moist mashed potatoes
legumes and beans
▫ Soft well, moistened pancakes; pureed bread mixes or slurried breads; cooked
cereals with little texture, including oatmeal; slightly moistened dry cereals with
little texture
▫ Soft and drained canned or cooked fruits without seeds or skin; ripe bananas; all
soft, well cooked vegetables that are in small pieces and mashable with a fork;
well cooked and moistened boiled, baked, shredded, or mashed potatoes; well
cooked pasta noodles in sauce
▫ Pudding and custards; soft fruit pies (bottom crust only); crisps and cobblers with
soft topping and no seeds; moist canned fruits; soft moist cakes with icing or
slurried cakes
(Nutrition411, 2011)
Level 3: National Dysphagia Diet
• Appropriate foods possibly included in level 3:
▫ Thin sliced, tender, or ground meats or poultry well moistened; fish; eggs (any
preparation acceptable); yogurt (no nuts or coconut); casseroles with small
chunks of tender or ground meat
▫ Well-moistened breads, biscuits, muffins, pancakes, waffles, etc (add jelly,
margarine, and other topping to moisten well); well moistened cereals
▫ All canned and cooked fruits, soft, peeled, ripe fresh fruits, such as peaches, kiwi,
mangos, cantaloupe; soft berries with small seeds, such as strawberries
▫ All cooked tender vegetables; shredded lettuce; rice; and tender fried potatoes
(Nutrition411, 2011)
National Dysphagia Diet:
Thickened Liquid Levels
• Nectar-like
• Honey-like
• Pudding (spoon) thick
(McCullough, et al, 2003)
Now You Try It!!
• First open the prepackaged
nectar thick.
▫ How was it?!
• Now try the prepackaged
honey thick.
▫ How was it?!
• Last try the pudding thickened water
▫ This one has been mixed with
water for each of you already in the
styrofoam cup
▫ How was it?!
What should you do while feeding the
patient?
• When feeding the patient be on the look out for those signs and symptoms we talked
about earlier.
▫ Choking, coughing, wet or gurgly voice quality, eyes watering, nose running, etc.
• If the patient is known to have weakness on one side make sure to place the food on
the strong side of the mouth, so chewing can be done appropriately.
• Give verbal and visual cues if necessary for the patient
▫ “alright now let’s clear the side of your mouth, so take your finger and move that
food onto your tongue”
▫ Say this while showing the patient what to do with your finger in your mouth
• Make sure the patient is using compensatory strategies while eating
▫ Chin tucks, head turns, etc.
▫ If the patient has a delayed swallow a functional way to help the problem is to give them a
bite of food then give them a bite of sherbet to wake up the swallowing system and initiate a
swallow reflex
• Look for any signs above or near the patient’s bed for specific diets!
• Position the patient appropriately!
Positioning is HUGE!!!
• Make sure they are sitting at a 90° angle!!
▫ The patient also needs to stay at this position for at least 30 minutes
after feeding
• Not 30!
• Not 45!
An Example of What You May See
in Patient’s Room
What should you NOT do while
feeding a patient?
• DO NOT:
▫ Add ice or water to already thickened liquids
 This makes the liquid thin again which can cause the patient to
possibly aspirate
 We want to follow the diets given strictly!!!
▫ Feed the patient when they are lethargic or sleeping
▫ Use straws when giving the patient thickened liquids
 Instruct them to take small sips of their liquid
▫ Let the thickened liquid sit for a long time
 It will get thicker as it sits and may cause problems for the
patient
You Are a Part of Our Dysphagia Team!
• All of us use standard recipes for food preparation to ensure the texture and
consistency are appropriate for the patient.
• Nursing Assistants make sure food for every meal is of the right texture.
• Nursing Assistants also help us educate the family of what foods are safe for
the patient.
• Cafeteria staff can present any modified food in a way that is appealing to
the patient.
▫ Shaping pureed food into something it would look like if not pureed.
 i.e. food molds
• Cafeteria staff prepare the meals for our patients with modified diets.
▫ Knowing the importance of the diet helps keep our patients HEALTHY!
• You are our eyes and ears for any possible issues when we are not
around!!
Let’s Test What You’ve Learned!!
• If the patient complains their thickened water isn’t cold enough,
you can put ice chips in it to make it cold.
▫ True or False?
• What angle should a patient be sitting at when eating?
▫ 30°, 40°, 90°
• You shouldn’t worry about aspiration if the patient isn’t
coughing or choking, but their eyes are watering.
▫ True or False?
• What are some examples of signs and symptoms involved with
issues in swallowing?
• If a patient is recommended a Level 1 diet, they are able to eat
foods that need a large amount of chewing.
▫ True or False?
Questions???