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  • Subject Name : Nursing


Case Study-Mr. Shepard
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Assessment of Mr. Shephard
The given study talks about Mr Sam Shepard who is a male patient and aged 82 years. He has been living in the Happy Valley Nursing Home since 2016. He presented as an inpatient at PA Hospital for two nights due to increasing confusion and difficulty swallowing since two days. The CAT scan of the patient was performed which showed no abnormalities. Currently, he has moderate weakness in the left side and needs assistance of people for ambulation or any kind of transfers. He is disoriented to place and is only oriented to person. In addition to this, he has a GCS score of 14. He is experiencing difficulty in swallowing and is only consuming thickened fluids and a soft diet. On assessment, his vital signs show his blood pressure at 130/80 mm Hg, along with heart rate at 78 bpm, respiratory rate at 20 breaths per minute and PEARL 2+. He has a past history of hypertension along with atrial fibrillation, a cerebrovascular accident associated with left sided weakness, diabetes mellitus, asthma and glaucoma. Previously, he was ambulating on his own with the help of his wheelie walker.
His latest assessment after returning from the hospital is post another fall after a failed attempt to ambulate himself on his own to the toilet. He has bruises and abrasion on the right side of his forehead post the fall. His GCS is 14 with orientation to person and disorientation to time and place. The other vitals are in the normal range. This case study will discuss his signs and symptoms and the pathophysiology behind his dysphagia and risk of aspiration.
Mr Shephard exhibited signs of dysphagia that is difficulty in swallowing because of his inability to take in liquids as exhibited on assessment by Nurse Margie. He was unable to swallow the liquid and had pain while swallowing as well. According to Ala'A, Katzka and Castell (2015), the patients suffering from the complication of dysphagia manifests the symptoms of delayed or abnormal swallowing of solid or liquid bolus at esopharyngeal or oropharyngeal stages. The patient also showed the sign and symptom of associated hoarse voice along with coughing and throat clearing when trying to swallow. It has been stated that patients suffering from dysphagia shows the symptoms of hoarseness, pain in throat and coughing due to compromised hypoglossal foramen and jugular nerves (Finsterer & Grisold, 2015). He also exhibited the sensation of food coming back up when trying to swallow it. He could not swallow properly and was hence, not administered his required medication for diabetes and hypertension. (Logrippo et al., 2017) stated that those patients who are suffering from dysphagia encounter problems in swallowing medicines at any phase (pharyngeal, oral or esophageal) due to nerve damage or reduction in production of saliva. All these symptoms show that he was suffering from dysphagia post his stroke two days ago and was at a greater risk of aspiration as well and needs to be assessed for the same.
Pathophysiology of increased risk of aspiration associated with dysphagia
Dysphagia is associated with a number of causes which includes deficits in the central nervous system, structural lesions that might be present locally, disorders of the muscular and neuromuscular system, due to pharmacological agents, and/or newly emerging causes like chronic obstructive pulmonary disease (Daniels et al., 2019). In the case study, it has been mentioned that the patient has the medical history of cerebrovascular accident (CVA) which could be a major cause behind his dysphagia. It is observed that out of a hundred patients who have had a (CVA), at-least 50–60% of the patients exhibit signs and symptoms of dysphagia, and around half of them have aspiration, and around 20% develop aspiration pneumonia (Rommel & Hamdy 2016). The main central cause of dysphagia in patients of CVA will include damage to the brain stem or the cortex. The peripheral causes will include damage to the nerves or muscles that are involved in the action of swallowing (Teasell et al., 2018). Dysphagia and other swallowing difficulties can develop when these damages can cause malfunction, lack of function or uncoordinated function of the muscles and nerves of the neuromuscular apparatus in the pharynx (Teasell et al., 2018).
The patients with dysphagia are at high risk of aspiration as in the case of Mr. Shepard. Aspiration will involve the movement of food material into the airway, below the true vocal cords ( Festic et al., 2016). Aspiration from dysphagia is caused when the pharyngeal muscles do not work properly due to dysphagia and prevent the epiglottis from closing the glottis while swallowing to prevent the food or water from entering the larynx or the vocal cords. When this reflex doesn’t work properly due to dysphagia as in the case of Mr. Shephard, it allows the food or drink to enter the trachea when the patient swallows. The material will go below the true vocal cord and can travel to the lungs and the bronchi via the larynx and become a cause of potential pneumonia due to aspiration (Festic et al., 2016).
Assessment for risk of aspiration due to dysphagia
There are two kinds of assessments that can be carried out for assessing for aspiration due to dysphagia- Subjective/Clinical and by using devices such as videofluoroscopy (Barrett & Hutchinson 2019). Nurse Margie in her assessment for risk of aspiration utilized the technique of bedside examination and presented Mr. Shephard with a small volume of fluid and watched for signs of aspiration such as coughing, throat clearing and change in voice quality-hoarseness. Additional assessments could have included – checking for any residue of the fluid or food in the mouth along with checking for regurgitation of fluid through the nares. This dysphagia screening will help reduce the chances of aspiration and associated pneumonia caused by it (Schrock et al., 2018).
Bedside examination for dysphagia remains tShe most sought after way of examination in clinical practice in most hospitals. Nurses, clinicians and language and speech therapists are taught to do a swallow screen where they present small volumes of liquid and solid to the patients in the form of food and water and to observe and watch for signs of dysphagia and aspiration (Festic et al., 2016). As a part of looking for other signs, nurses must look for any loss of liquid from the mouth, poor coordination of muscles, dyspraxia, breathlessness, changes in the quality of voice after swallowing or hoarseness, facial weakness, coughing and throat clearing, and delayed elevation of pharynx and larynx.
Nursing interventions to be implemented
Nursing interventions to be implemented to reduce the risk of Mr. Shephard from aspirating will include basic measures to prevent aspiration or precautionary measures. Placing the high-risk patient in a semi-recumbent position will help prevent aspiration. Keeping the head of the bed in an elevated position will help decrease the risk of aspiration after swallowing. If feeding something, only thickened liquids should be given (McCurtin et al., 2018). Keep suction machine available when feeding. So, if aspiration does occur, suction can be done immediately. Inform the physician about the current status and inform the physician for a videofluoroscopic examination and assessment (Barrett & Hutchinson 2019). Keep him nil per orally till further evaluation. It will help protect his airway and prevent aspiration. Other measures can include compensating for absent reflexes, assessing feeding tube placement, identifying delayed stomach emptying, and managing effects of prolonged intubation (Smithard 2016).
ISBAR communication Handover
This communication technique helps in improving patient safety (Muller et al., 2018). It consists of the following steps-
Identification – Mr Sam Shephard, an 82 year old male has been living in the Happy nursing home since 2016.
Situation- He has been experiencing dysphagia and difficulty in swallowing post his CVA attack two days ago associated with left-sided weakness as well. His CAT scan was NAD and he is unable to ambulate on his own. He had a fall and hit his head yesterday and has a GCS score of 13 with orientation to person only. He has also been complaining of lower back pain..
Background – He has a past history of hypertension, CVA, atrial fibrillation, left sided weakness, diabetes and asthma. He is on oral Metformin, Aspirin and Atenolol. He had a fall while trying to ambulate to the toilet and has bruises and abrasion on the right side of his forehead. He is disoriented to place and time. His blood glucose levels and vitals need to be assessed along with GCS. His risk for aspiration due to dysphagia needs to be assessed before his time for medicines and lunch.
Assessment – Have checked his vitals, BP is a little on the higher side along with all other vitals being normal. I have assessed his GCS for motor and verbal response along with eye opening. Have assessed his swallow screen for checking for dysphagia and risk for aspiration. He showed difficulty in swallowing along with coughing and throat clearing and hoarseness in voice after the intake of the thickened fluid. He was put in a semi-recumbent position then. No oral medications could be administered for diabetes and hypertension. Ventolin administered via inhalation for his asthma.
Recommendations- Continue monitoring and observation for his vitals. Inform the physician about his current status post the swallow screen to take action to prevent aspiration. Keep him nil per orally till further action. Continue his fall observations as well. Inform the physician about his complaint of lower back pain as well. Additional screening and assessment for his swallow reflex needs to be done such as looking for any loss of liquid from the mouth, poor coordination of muscles, dyspraxia, breathlessness, changes in the quality of voice after swallowing or hoarseness, facial weakness, coughing and throat clearing, and delayed elevation of pharynx and larynx by a speech language therapist (Pierpoint & Pillay 2020). Additional assessment will involve the use of videofluoroscopy after referral to the physician to check his dysphagia and risk for aspiration (Barrett & Hutchinson 2019). Additional referral to the physician should be done for NG tube insertion. Suction should also be kept ready for emergency situations as a precautionary measure.


Reference
Ala'A, A. J., Katzka, D. A., & Castell, D. O. (2015). Approach to the patient with dysphagia. The American Journal of Medicine, 128(10), 1138-e17.
Barrett, A., & Hutchinson, L. (2019). Factors associated with dysphagia assessed via videofluoroscopy. M. Cl. Sc SLP Candidates Western University: School of Communication Sciences and Disorders.
Daniels, S. K., Huckabee, M. L., & Gozdzikowska, K. (2019). Dysphagia following stroke. Plural Publishing. USA.
Festic, E., Soto, J. S., Pitre, L. A., Leveton, M., Ramsey, D. M., Freeman, W. D., & Lee, A. S. (2016). Novel bedside phonetic evaluation to identify dysphagia and aspiration risk. Chest, 149(3), 649-659.
Finsterer, J., & Grisold, W. (2015). Disorders of the lower cranial nerves. Journal of Neurosciences in Rural Practice, 6(3), 377.
Logrippo, S., Ricci, G., Sestili, M., Cespi, M., Ferrara, L., Palmieri, G. F., ... & Blasi, P. (2017). Oral drug therapy in elderly with dysphagia: between a rock and a hard place!. Clinical Interventions in Aging, 12, 241.
McCurtin, A., Healy, C., Kelly, L., Murphy, F., Ryan, J., & Walsh, J. (2018). Plugging the patient evidence gap: What patients with swallowing disorders post‐stroke say about thickened liquids. International Journal of Language & Communication Disorders, 53(1), 30-39.
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open, 8(8), e022202.
Pierpoint, M., & Pillay, M. (2020). Post-stroke dysphagia: An exploration of initial identification and management performed by nurses and doctors. The South African Journal of Communication Disorders, 67(1).
Rommel, N., & Hamdy, S. (2016). Oropharyngeal dysphagia: manifestations and diagnosis. Nature reviews Gastroenterology & Hepatology, 13(1), 49-59.
Schrock, J. W., Lou, L., Ball, B. A., & Van Etten, J. (2018). The use of an emergency department dysphagia screen is associated with decreased pneumonia in acute strokes. The American Journal of Emergency Medicine, 36(12), 2152-2154.
Smithard, D. G. (2016). Dysphagia management and stroke units. Current Physical Medicine and Rehabilitation Reports, 4(4), 287-294.
Teasell, R. W., Foley, N. C., Bhogal, S. K., & Speechley, M. R. (2018). An evidence-based review of stroke rehabilitation. Topics in stroke Rehabilitation, 10(1), 29-58.

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