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Homer Xiang, Sr.
82 yo Male (Interventions (Swallow Techniques (Swallow…
Homer Xiang, Sr.
82 yo Male
Assessments
- COMP
- FIM
- Berg Balance
- Client observation
Client Profile
Problem list
- L MCA aneurysm
- Right hemiplegia
- Postoperative fever
- Increased lethargy
- Electrolyte Abnormalities
- Hypertension
- Dysphagia
- Weakness and poor memory
- Limited Verbalization
- R Axillary DVT
- Bowel and Bladder control (Max. assist)
- Dependent in feeding
- PEG tube for feeding
- Smokes a pack daily for 30 years
Strength List
- Functional history: client was independent prior to hospitalization
- Patient is responsive commands and voice
- Bilateral upper and lower extremity voluntary movements
- Uses hand gestures
- Does not consume any alcoholic beverages
- Review of systems indicate normal results with no complications
- Responds in 1-2 word answers
- He is retired and married
- Hobbies consist of fishing, reading, and building model cars.
Goals
STG 1
Client will perform swallowing exercises with 3/3 verbal cues from OT, to practice safe swallow, in 3 weeks.
LTG 1
Client will perform swallowing exercises independently with no verbal cues, to practice safe swallow, in 6 weeks.
STG 2
Client will sit in a safe and appropriate upright position, to perform a safe swallow, with mod assist from caregiver, instructing on correct posture, to decrease aspiration, in 3 weeks.
LTG 2
Client will sit in a safe and appropriate position, to perform a safe swallow, independently, with no aspiration, in 6 weeks.
Interventions
- Swallow strategies can be implement with client to practice a safe swallow.
- Such as having a chin down posture which changes pressure in the hypopharyngeal structures and upper esophageal sphincter (Wirth, Dziewas, Beck, Clave, Heppner, & Volkert, 2016).
- Performing swallow techniques such as Mendelsohn maneuver, thermal stimulation, gustatory stimulation, and shaker exercises to strengthen the neck and laryngeal muscles can help patient to achieve a better swallow over time as he makes progress (Wirth et al., 2016).
Grade up: Asking the patient to perform learned swallow strategies to perform a safe swallow.
Grade down: As the patient swallows, guiding the patient through the swallow stages.
- Diet and texture modification to reduce aspiration
- Dietary modification such as altering the consistency of foods and liquids is a fundamental aspect of managing dysphagia (Garcia & Chambers, 2010).
- For Homer, solids can be brought to a puree pr pudding consistency to prevent coughing and choking during the swallow.
- Liquids can be thickened to a consistency that does not require bolus formation.
Grade up: Patient eating small minced semi-solid (meat) and soft foods and performing a safe swallow.
Grade down: Consistency of food is modified to puree or pudding consistency.
- Adaptive Equipment for feeding
- Adapted utensils can be used to help support successful feeding.
- Equipment such as weighted utensils, utensil holder, and utensils with contoured handles.
- By using these adapted equipment Mr. Homer can work towards requiring mod to min assist in feeding since he requires max assist at the moment.
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- Restorative/Rehabilitative and compensatory strategies for swallowing
- Strategies for safe swallow can be implemented with Homer, by applying techniques such as effortful swallow, Masako, and pacing during meal time (Benavente, 2018).
- Compensatory strategies such as using sensory stimulation to promote safe swallow have shown effectiveness in acute settings (Ortega, Rofes, Martin, Arreola, Lopez, & Clave, 2016).
- Rehabilitative treatment consists of swallowing exercises, effortful swallow in combination with biofeedback, and expiratory muscle stregngth training (Smith, Roddam, & Sheldrick, 2012).
- These strategies can help client to participate during meal times safely without having to worry about choke or aspirate. By doing so, client can return to a healthy weight and come off of the PEG tube.
Grade up: Client performing swallow exercises to strengthen muscles on his own before mealtime.
Grade down: Instructing client to perform swallow exercises before mealtime.
- Caregiver education on positioning and feeding
- Caregiver education should be provided on proper positioning techniques such as chin tucked and place the client in an upright position when feeding, which will help with proper bolus formation and normal swallow.
- Mr. Homer currently is receiving nutrition through a PEG tube, the caregiver should be informed on how to feed client through this tube and also maintain the integrity of incision site.
- Oral care is important to prevent the risk of developing pneumonia and other complications.
- As stated by Maeda, Shamoto, and Furuya (2017), poor oral hygiene, inactivity, malnourishment, appetite loss, eating problems, and swallowing occur during the early phases of post-injury.
- Therefore, the caregiver should be informed about proper feeding techniques to ensure that the patient is not malnourished because of eating problems, and is implementing an oral hygiene routine.
Grade up: Allowing the patient to position himself appropriately.
Grade down: Guiding the patient with verbal cues to sit up in an upright position, chin tucked, and head rotation.
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Client Priorities
- The client wants to become independent in all ADL's and return to prior level of function.
- Mr. Homer would like to independently be able to feed himself and participate in leisure activities without having to depend on his wife.
- Mr. Homer would like to engage in his hobbies such as fishing, reading, and building model cars without any functional limitations.
- He is hopeful to return to PLF through OT, PT, and SLP services and would like to be discharged and return home.