George Banks

Occupational Profile:

Goals

Intervention Strategies

Past medical hx

Hx of HTN (takes HCTZ and Lisinopril), coronary heart dx, high cholesterol (takes Simvastatin), Type II DBM (takes metformin and glucotrol), non compliant c therapy; broken leg at 18yo

Social hx

retired police officer, married for 40 years to Susan, one daughter who lives near, smoke 1 pack/day for 50 years, occasionally drinks

Family hx

Father died of massive stroke at 75 yo, mother died of natural causes at 90 yo, no siblings

Effortful Swallow

Oral Care: Decreases risk of pneumonia is aspiration does occur. Oral hygiene aids in safe eating, preservation of dentation, and inc self image

Adaptive equipment to compensate for dec strength and function in UE to promote self-feeding performance

Oral and facial exercises: used to increase swallow strength to promote full clearance of food from oral cavity through the stages of swallowing. Promote a more efficient swallow performance (Cohen, Roffe, Beavan, Blackett, Fairfield, Hamdy, & Bath, 2016). Also used to target facial weakness secondary to the stroke.

Postural Interventions

In 2 days, the client will MODI demonstrate proper positioning techniques for safe feeding, with <3 verbal cues, while seated upright in a chair with arm rests.

In 2 days, the client will use effortful swallowing techniques, with >5 verbal cues, during a meal, to promote a safe swallow

In 5 days, the client will MODI feed self, with built up handle fork to scoop and transfer food from plate to the mouth, while seated upright in a chair at a table, to promote feeding.

Client Priorities

Be able to IND feed

Dec messy feedings

Assessments

MBSS: Rule out aspiration and view mechanisms of swallow (Scott & White, 2008)

Clinical observations to evaluate for swallow difficulties (AOTA, 2015).

Oral prep Phase: Client shows issues in scooping food with spoon and transferring food to mouth, due to R UE muscle weakness and loss of gross and fine motor control. Shows issues in holding upright posture during feeding; inc leaning trunk and head to left

Oral phase & Swallow: Shows weak lip closure and ability to hold liquids and solids in mouth. Has to swallow multiple times to feel like food in no longer stuck. Requires extra time and effort during meals.

Muscle Testing: MMT

Oral Phase: Client shows dec ability to transfer bolus ant to post; freespill with thin liquids prior to swallow; delayed swallow transit and inefficient oral cavity clearing

R UE: 3/5; L UE: 5/5

R LE: 3/5; L LE: 5/5

NIH Stroke Scale = 16 - Severe stroke shows high probability of disability or death (Muchada, Rubiera, Rodriguez-Luna, Pagola, Flores, Kallas, Molina, 2014)

Built up handles for utensils

Massey Bedside Swallow Screen to rule out aspiration and determine swallow issues (Jiang, Fu, Wang, & Ma, 2016)

Inability to manage thin liquids and coughing during screening shows implications for a follow up MBSS study to rule out aspiration

Client oriented and able to follow instructions. Chin tuck and postural corrections were recommended and showed a more efficient swallow during the study. Nectar thick liquids were well managed. Client did not aspirate during study, but freespill shows high risk of aspiration with thin liquids

R hand dominant. Dentation intact. Pleasant and eager to eat/drink. Shows R UE muscle weakness and limited ROM.

Based on clinical observations, refer to SLP

Get back to PLOF of IND with all occupations.

Opening and closing lips, puckering and pursing lips, whistling, moving tongue side to side (Levy, 2016). Perform exercises before each meal. Encourage more talking throughout the day.

Instruct client to swallow hard and push tongue up against roof of mouth to produce a strong swallow to move the bolus (American Speech Language Hearing Association, 2018).

Grade up: Incorporate food with swallow

Grade down: Provide verbal cues to swallow harder and stronger

Sit upright with all oral intake

Grade up: Sit in chair or EOB for meals

Grade down: Sit with elevated HOB and postural supports

Chin tuck: Incorporate chin tuck to dec risk of aspiration and increase transit time during swallow (Ra, Hyun, Ko, Lee, 2014)

Recommendations: modified diet to nectar thick liquids; OT or SLP present during feeding; SLP referred for feeding/dysphagia therapy, OT recommended for eating and feeding interventions

Modified Diet: Thin liquids were difficult for the client to manage. He showed freespill, which increases risk of aspiration. No use of a straw.

Use Thick-It to increase viscosity of liquids to a nectar consistency (Leder, Judson, Sliwinski, Madson, 2013)

Brush all areas of mouth thoroughly, with use of a built up handled toothbrush or electric toothbrush

Grade up: Have client IND brush teeth, following each meal, including IND use of mouthwash and spitting/clearing mouth.

Grade down: OT will brush clients teeth and suction if client is unable to spit/clear mouth

Grade down: OT or nurse must be present during consumption of liquids

Grade up: Client will mix Thick-It into liquids to create the nectar-thick consistency

Grade up: Incorporate more reps of exercises, more times throughout the day. Encourage client to talk and sing more throughout the day.

Grade down: Perform exercises with OT present, providing verbal cues to complete each

Frazier Free Water Protocol: Provide the client with thin-liquids in between meal times to dec risk of dehydration and to introduce thin liquid. OT or nurse will be present for each trial.

Grade up: Client will IND use chin tuck during all oral ingestion, without verbal cues

Grade down: OT will provide verbal cues and/or physical assistance to incorporate chin tuck

Increase R UE strength through exercises and occupational performance to promote functional performance .

An exercise protocol will be implemented to increase strength and ROM through use of stretching, modalities, and the client will progress through PROM, AAROM, AROM

The client's strength and ROM will increase through use of the R UE during ADLs of feeding, dressing, toileting, bathing, and leisure.

Grade up: Increase reps and incorporate weights to inc strength and ROM

Grade down: PROM Will be used to increase ROM in the R UE

Grade up: Incorporate endurance training during occupational performance

Grade down: Incorporate more rest breaks through energy conservation techniques

Plate guard

Be able to swallow without food feeling stuck

In 5 days, the client will IND utilize a chin tuck and effortful swallowing maneuvers during eating, while seated upright in a chair with arm rests, to promote safe swallowing.

Occupational performance deficits

R side paresis affects ability to perform self-care tasks, toielting, bathing, feeding, functional mobiltiy, oral hygiene, and dressing

Secondary effects on the stroke may account for dec performance in feeding a swallowing due to dec oral motor muscle power

Client at risk for aspiration during eating

Dysartria limits social interaction and ability to ask for assistance

Problem List

NIH Stroke Scale = 16

R UE paresis

Dec strengthin R UE & LE

R side facila weakness

Garbled speech

Hx of smoker and Type II DBM

Strengths

Supportive wife

Intact hearing, vision, and congition

Dentation intact

Alert and oriented

Intact CN II-XII

Shows intact rapid alternating movement from finger to nose and heel to shin

Hx of present illness

Chief complaint: awoke with right sided weakness and facial drooping

Arrived to ED 3 hours after initial symptoms. Currently paretic on R side c dec strength in UE & LE, R side facial weakness, garbled speech. Wife reports client has felt "uncomfortable" over past couple of days

Dec R UE & LE strength will effect performance in ADLs including self-feeding