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Ruby Jane Smith (Problem List (Difficulty swallowing food, Frequent…
Ruby Jane Smith
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Intervention Strategies
- Implement starting with lighter textures, soft foods, and smaller bites of food for Ruby. This technique will make swallowing less difficult and give her the ability to progress her swallowing (Paul & D'Amico, 2013). Along with implementing softer foods and lighter textures, educate Ruby on the importance of nutrition management to help in reducing the symptoms associated with GERD.
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- Verbal education for Ruby on the importance of pacing herself so that it is easier to swallow her meals and remain safe when eating to keep meal time an enjoyable part of her life (Boop, Smith, & Kannenberg, 2017). Ruby will verbally demonstrate understanding of pacing and through her performance of pacing during meal times.
Grade Up: Incorporate deeper levels of understanding towards GERD and Barrett's esophagus. This will give Ruby a broader scope with which to view her condition.
Grade Down: Incorporate visual cues in the form of meal time card reminders that will allow Ruby to know to pace her safe. When utilizing meal time cards, re-emphasize the importance of pacing to remain safe when swallowing.
- Ruby will participate in effortful swallow exercises to address the swallowing impairments she experiences from weakness (Clark & Shelton, 2014). Continuous use of effortful swallow exercises are shown to facilitate adaptations and improve swallow function (Clark & Shelton, 2014). Ruby will perform 4 effortful swallows 30 minutes before each meal time with a 20 second pause between each swallow.
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Grade Down: Ruby will perform 3 effortful swallows 30 minutes before each meal time with a 45 second pause between each swallow.
- Tongue hold exercises are shown to improve tongue and pharyngeal muscle activity (Hammer, Jones, Mielens, Kim, & McCulloch, 2014). Ruby will protrude her tongue holding it between her front teeth at comfortable position and swallow some of her saliva. She will do this 3 times, 1hr before each meal time, with a 20 second pause between each tongue hold.
Grade Up: Ruby will perform a total of 5 tongue hold exercises, 1 hr before each meal time, with a 20 second pause between tongue holds.
Grade Down: Ruby will protrude her tongue a less amount and perform 2 swallows, 1 hr before each meal time, with a 45 second pause between each tongue hold.
- To facilitate an easier swallow for Ruby and prevent aspiration she will be educated on proper positioning during eating by tucking in her chin and slightly rotating her head (Ra, Hyun, Ko, & Lee, 2014). These positions will be modeled and verbally described to Ruby. She will be asked to verbalize understanding and demonstrate this position with each meal time.
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Grade Down: Ruby will demonstrate understanding with the help of a visual reminder in the form of an instruction sheet showing her the proper positioning of her chin and head.
Occupational Profile
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Family: 3 children, 7 grandchildren, 1 great-grandchild
Goals
LTG: In 3 wks, client will take dime sized bites of food, with <2 verbal cues, to increase swallow ability, during each mealtime, per caregiver report.
STG: In 1 wk, client will demonstrate effective use of effortful swallow technique to increase swallow ability of soft foods, with <3 verbal cues, for 3/3 swallows, prior to 1 meal time, per therapist observation.
LTG: In 3 wks, client will demonstrate effective use of effortful swallow technique to increase swallow ability for soft foods, with <4 verbal cues, for 3/5 swallows, during 1 meal time, per therapist observation.
STG: In 1 wk, client will take dime sized bites of food, with <3 verbal cues, to increase swallow ability, during each meal time, per caregiver report.
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Assessments
Clinical Observations
Observe Ruby during a meal time and note where she is experiencing difficulties, how long it is taking her to eat. If possible, observe her consumption of a meal consisting of foods with different textures and note any differences in swallowing, pain, and enjoyment.
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