[DYSPHAGIA] Adult with MR who is NPO with s/s of aspiration with saliva

[misbell@mail.state.tn.us (Marie Isbell)]

Karen - I agree with everything Irene Campbell included in her response.  I work with the adult DD population in the community setting.  Most have lived in an ICFMR prior to their move into the community.  In addition to the GER information offered by Irene Campbell, I would like to suggest that in addition to medical management of the GER, you consider working with your Team on positioning for the gentleman throughout his day.  He should never lie flat, even during bathing or brief changes.  You could consider inclined sidelying as an alternate position to be used throughout the day as he tolerates.  You could also consider using a bedrail sidelyer attachment to allow him to be comfortable in bed when it has been raised on blocks.  

Also concerning is the constipation.  It is concerning that he requires a Fleets every three days, and this could lead to bowel problems.  Could it possibly be due to some level of dehydration, muscle tone, or GI dysmotility?  Increasing fluid intake carefully, because of the GER, may lead to a decrease in constipation.  In addition, prone on forearms or quadruped on forearms used as alternate positioning when his stomach was empty might increase bowel motility.  You might consider testing to look at GI motility also.

Also, your team might want to look at his wheelchair positioning.  It would be important for him to be in an upright, well supported position for at least one hour following all tube feedings and med administration to allow his stomach to empty.  It is usually suggested that an individual with GER should not have a tube feeding within 3 hours of going to bed.  

Oral hygiene will be extremely important if the aspiration is occurring from the top down.  We sometimes recommend that suctioning tooth brushing occur with individuals who are NPO because of aspiration.  We also recommend more frequent brushing throughout the day, and sometimes the dentist wants to do a cleaning quarterly when s/he knows the individual aspirates.  

You might also consider completing some type of oral motor assessment (I use Beckman's Protocol) to determine his functional skills and develop an intervention that may assist him with handling his oral secretions.  This gentleman has many needs that you and his treatment team might look at systemically.  Problems in one area flow over into other areas; he needs more than discipline-specific intervention.  When we work with people this involved, we use physical nutritional management principles to guide our interventions.  You might also consider obtaining a PharmD assessment and a DD MD assessment to help guide your treatment team's interventions.  Hope this helps.  Marie     

>>> Karen Reed <kar_44060@yahoo.com> 12/06/01 08:20PM >>>
Hi everyone,

Thank you in advance for your responses.  This is one
of the greatest tools we have available today.  This
is my first case presentation on the listserve so
it'll be a little long.

I have a 39 year old male resident residing in an
ICFMR facility on my caseload.  

Dx: MR, CP, spastic quadriplegia, athetosis,
scoliosis, kyphosis, congenital rib anomaly,
strabismus ou, hyperopia, nystagmus ou, alternating
esotropia, possible anoxic brain damage, dysphagia,
chronic constipation, osteoporosis, astigmatism, h/o
fuo 3/98, recurrent UTI 5/99, OD subjunctival
hemorrhage with dry eyes 7/99, chronic sinusitis
12/99.

Routine meds:  beconase aq nasal, calcium carbonate
susp, diazepam, miacalcin nasal spray, mineral oil
heavy, multivitamin adult liq, styptic pencil, feet
enema after 3 days without bowel movement,
acetaminophen, guanifenesin syrup, pseudophedrine HCL
syrup, tears naturale II, trimethobenzamide supp.

Feeding via PEG tube.  NPO due to aspiration.  Chronic
drooling.  Extremely spastic at times.

Communication status:  Nonverbal with occassional
vocalizations (appropriate laughter).  Appears to have
excellent receptive skills (He finds the movie "Liar
Liar" extremely hilarious and enjoys slapstick
comedy).  Communicates yes/no appropriately via eye
gaze up/down, choices via R/L eye gaze, Step-by step
with levels for commenting, and facial expression.  

Current situation:  This resident had a virus that
went through the general population just before
Thanksgiving.  The symptoms of the virus included a
cough.  He currently coughs several times a day for
several minutes to point that he appears very
distressed by it.  The cough appears to be on his
saliva.  This has happened since the virus occurred.

Thoughts and Questions:  Would a scopalomine patch be
of benefit to dry the secretions if the PEG flush was
increased to prevent any dehydration?  Are there other
meds that could decrease the secretions?  Are there
other strategies that could be tried?  Due to extreme
spasticity, I don't think this man would be able to
complete pharyngeal exercises.   

This resident is a potential candidate for a baclophen
pump after the holidays.  Would any other meds for
controlling secretions present a problem with the
potential for the pump?

Thanks for your help!

Karen

PS I asked this resident if he would like help from
the listserve members and he responded yes. I will be
seeing him on Tuesday and will be reading this letter
with replys to him.




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