The Center for Life Enrichment
Resource: MTTP Student Manual
What is Dysphagia?
Dysphagia is a condition of having
difficulty swallowing
 Dysphagia is due to problems or
damage in nerve or muscle control in
the throat
 It is common after a stroke or in
individuals with cerebral palsy

Why does dysphagia occur?
Dysphagia occurs when there is a
problem with any part of the swallowing
process
 Weak tongue or cheek muscles may
make it hard to move food around in the
mouth for chewing. As a result, food
pieces that are too large for swallowing
may enter the throat and block the
passage of air

How are people affected?
People with dysphagia have difficulty
swallowing and may also experience
pain while swallowing
 Some people may be completely unable
to swallow or may have trouble
swallowing liquids, foods, or saliva
 Eating may become a challenge
 Often, dysphagia makes it difficult to
take in enough calories and fluids to
nourish the body

The Process of Swallowing
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The process of
swallowing involves
the interaction of
more than 20
muscles and several
nerves
The entire process
is completed in
several seconds
The Normal Phases of Swallowing:
Stage 1
1)

Oral Phase- Food is placed in the
mouth, chewed and turned into a bolus
(lump of chewed food mixed with
saliva)
The bolus is moved toward the throat
by the tongue
The Normal Phases of Swallowing:
Stage 2
2)
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Pharyngeal Phase- Food is moved by wave-like
muscle action down the throat to the esophagus
(tube to the stomach)
During this process, the epiglottis closes to protect
the trachea (breathing tube)
Next the food enters the esophagus (tube to
stomach)
If the epiglottis doesn’t close properly, the bolus
may enter the trachea and go into the lungs causing
aspiration
If there is abnormal muscle movement then the food
bolus can become stuck causing a
blockage/choking
The Normal Phases of Swallowing:
Stage 3
Esophageal Phase- Food is moved by
wave-like muscle movement through a
muscle ring into the stomach
 Normally, the food enters and stays in the
stomach where the digestive process
continues
 If the muscle ring does not function
properly, stomach contents may go back
up (reflux) into the esophagus
3)

This is associated with heartburn or indigestion
and is called Gastro-Esophageal Reflux
Disease (GERD)
What the individual might complain
about/What to look for?

There are identified “red flag indicators” that
should be watched for during meals. Some of
these include, but are not limited to:
 Pocketing food under the tongue, in cheeks or the
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roof of mouth
Food remaining on the roof of the mouth or on
tongue after swallowing
Food spilling out of the mouth
Diagnosis of stroke, cerebral palsy, GERD
Taking fluids to drink to facilitate swallowing without
chewing properly
Putting food in the mouth before swallowing the
previous bite
More “Red Flag Indicators”
 Not chewing food
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adequately
Tongue thrusting noted
Coughing noted while
chewing, when swallowing
or after swallowing
Regurgitating food or liquids
from nose or mouth
Eating quickly
Eating very slowly
Spitting food out of mouth
Talking with food in mouth
Stealing food
Food stuffing
PICA behavior (persistent
and compulsive cravings to
eat nonfood items)
 Excessive drooling
 Choking
 Throat clearing during meals
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or fluids
“Wet” vocal sounds
(gurgling)
Multiple swallows of the
same mouthful of food
Gagging/retching
Putting hands in mouth or
forcing self to vomit
Weight loss
Complaining that food feels
“stuck”
Refusing to eat
How is dysphagia diagnosed?


Individuals with dysphagia or choking issues may self
identify their signs/symptoms or family or staff may
identify signs/symptoms
A Choking Monitoring Tool has been developed by DDA
and the following protocol should be followed in this order:
1. Staff notices a “red flag indicator” of choking as listed on
the previous slides
2. Staff reports to the RN that a “red flag indicator” was
observed
3. RN instructs the staff to complete the Choking Monitoring
Tool
4. Staff completes the Tool as instructed by the RN and
returns info to the RN or the RN completes the tool
5. RN evaluates the completed Tool and determines if
further intervention is needed by the individual’s HCP
The Choking Monitoring Tool
Based on the information provided on the
Choking Monitoring Tool, the HCP may
recommend texture alterations in the diet
or that the individual undergo a Swallowing
Study where the mechanics of the
swallowing process can be observed and
aspiration determined
 If aspiration is an issue, then a G or J tube
may be recommended
 In addition to the Choking Monitoring Tool,
the RN may complete a “Choking Risk
Screening Tool”

What is the treatment?

The HCP may order an alteration in diet
consistency to address eating difficulties
 Puree- Blended
 Ground- Minced
 Chopped- Mechanical Soft
 Bite Size
 Regular
Puree- Blended
Description- smooth with no lumps,
pudding like
 Consistency- smooth and thick enough
to mound on a plate
 May need to add extra liquid when
preparing

Ground- Minced
Description- foods are moist and soft
textures
 Food processed to the size of rice or
taco meat
 May add some liquid or condiment to
help mix

Chopped- Mechanical Soft
Description- meats chopped ½ inch in
size, other foods soft
 Meat cut into ½ inch pieces, fruits, and
veggies chopped into fruit cocktail-size
pieces
 Sandwich cut into 8 pieces or more- use
soft breads and fillings

Bite Size & Regular
Bite Size
 Description- all
foods cut or broken
into 1 inch pieces
Regular
 No preparation
needed
Liquids
Liquids can be very difficult for an
individual with a swallowing disorder to
handle safely
 Liquids can be thickened to facilitate safe
swallowing
 The HCP may order thickened liquids in
the following manner:
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Nectar Consistency
Honey Consistency
Pudding Consistency
Thin Consistency
Nectar Consistency
Description- able to go through straw,
glides off spoon
 Examples- fruit nectars, shakes,
eggnogs, smoothie

Honey Consistency
Description- will not go through a straw,
flows slowly off a spoon
 Examples- honey, karo syrup, molasses

Pudding Consistency
Description- needs to be fed with a
spoon
 Examples- pudding, yogurt

Thin Consistency
Description- no preparation needed
 Examples- water, tea, coffee, thin juices,
soda

Warning!
Individuals who have been ordered
thickened liquids should not be given foods
that become liquid at room temperature.
For example, gelatin, ice cream, sherbet,
water ices, smoothies, shakes
 Follow directions on thickener packaging to
achieve consistency as ordered
 Liquids given with medication must also be
thickened as ordered
 The consistency of thickened liquids
changes over time (continues to thicken)

Your Responsibility
Always be alert and observant while
individuals are eating
 Choking Monitoring Tool should be
completed when “red flag indicators” are
noted
 Report any problems to the RN as soon
as possible!

Check out:

Swallow: A Documentary - Dysphagia
http://youtu.be/MrbEUDO6S5U

Normal vs. Abnormal Swallowing
http://tcle.org/employee-resources/
Part 2
Aspiration Pneumonia
Aspiration of foreign material into the
lungs may develop into pneumonia
 Aspiration occurs when the body’s
normal defense against aspiration are
breached
 For example, when the muscles used in
normal swallowing do not function
properly, material from the mouth can
enter the trachea and lungs rather than
the esophagus and stomach

Individuals at Risk for Aspiration
include, but are not limited to:

Those with…
 Impairment of consciousness
 Seizure Disorder
 Impairment of esophageal function
(including Hiatal Hernia, GERD)
 Impairment of swallowing mechanism
(including cerebral palsy)
 Impairment of cough mechanism (including
neuromuscular weakness, cerebral palsy)
 Oral/dental/sinus infections
What the individual might complain
about/What to look for?
The individual may have experienced a
one-time episode of aspiration or may
experience on-going subtle aspiration
 These experiences may or may not be
identified or witnessed
 The individual may present with
shortness of breath, low blood oxygen
levels, low blood pressure, fever, and
chest x-ray changes

How is it diagnosed?
Aspiration pneumonia is usually
diagnosed by clinical presentation and
x-ray findings
 Failure of a swallowing study supports
the diagnosis of aspiration pneumonia

What is the treatment?
The individual may be hospitalized for
treatment of aspiration pneumonia
 Treatment may include suctioning and
intubation (the insertion of a tube into
the patient's airway) to protect the
airway from further aspiration
 Supplemental oxygen may be needed
 Antibiotic therapy is required

Your Responsibility
If you identify “red flag indicators” for
choking as described in the previous
slides, the RN should be notified
immediately
 Any symptoms of respiratory distress
should be reported to the RN
immediately

Questions?