|
KATHY PANTHER, M.S., CCC
LOUISVILLE, KENTUCKY
After several years of a conventional dysphagia program, Frazier’s
swallowing management protocol changed dramatically. Concern over
patient and family non-compliance with thin liquid restrictions both
within the facility and after discharge led us to alter our protocol
in 1984. Previously prohibited, oral intake of water became a major
feature in both treatment and day to day hydration. Features of
Frazier’s program include the points listed below:
Safety of Water
- The human body is about 60% water. Small amounts of water
taken into the lungs are quickly absorbed into the body pool. (Discussion
initiated by program’s pulmonologist.)
- Unlike other liquids, water
has a neutral pH.
- Water provides a safe means of assessing patients
with thin liquids. All
patients (of any diagnosis) referred to Speech Pathology are screened
for dysphagia with water sips.
- Water is safely utilized in daily treatment
of thin liquid restricted patients. Unlike in a conventional
program, swallow compensations can be practiced with thin liquid.
- Drinking
water during swallowing therapy allows ongoing assessment of swallow
improvement and permits better recognition of patient readiness for
repeated videofluoroscopy or endoscopy and diet advancement.
Hydration
- Free water consumption is encouraged for all patients and makes a
significant contribution in hydration for many.
- The risk and cost of
IV fluids should be decreased.
- Post-discharge surveys of Frazier dysphagic
patients indicate water often is the primary means of hydration.
Compliance
- Complaints of thirst were frequently voiced prior to 1984. Patients
reported thickened liquids did not quench thirst. Water eliminates
thirst and patient complaints are now much less frequent.
- Many patients
and families object to thickened liquids. Since
water is an option, patients appear more likely to comply with the
thin liquids restriction.
- Once home, preparation of thickened liquids
often becomes burdensome. After
days or weeks at home the family may tire of patient complaints and
abandon thickened liquids.
- Availability and cost of thickening agents
and/or prepackaged thick liquids may preclude patient compliance.
- Thick
liquid preparation, in addition to other time and energy consuming
patient care tasks, can overwhelm many families.
THE FRAZIER REHAB INSTITUTE WATER PROTOCOL
WATER BETWEEN MEALS
BY POLICY, ANY PATIENT NPO OR ON A DYSPHAGIC
DIET MAY HAVE WATER.
- All patients are screened with water. Patients exhibiting
impulsivity or excessive coughing and discomfort will be restricted
to water taken under supervision. Patients with extreme choking
may not be permitted oral intake of water due to the physical stress
of coughing.
- For patients on oral diets, water is permitted between
meals. Water
intake is unrestricted prior to a meal and allowed 30 minutes after
a meal. The period of time following the meal allows spontaneous
swallows to clear pooled residues.
- After the screening described above,
NPO patients are often permitted water.
- Patients who are thin liquid
restricted wear yellow wristbands to communicate the liquid restrictions
to all staff. Typically,
the band reads, “No thin liquids except water between meals.” The
wording on the band is individualized as appropriate when specific
compensations are recommended. For example, a band may read “No
thin liquids except water by teaspoon between meals.” All
rehab staff are oriented to the yellow bands and check for bands before
offering liquids to patients.
- Water is freely offered to patients according
to the guidelines documented on the yellow bands throughout the day.
- Patients
for whom compensations, i.e. chin tuck, head turn, etc., have proven
to be successful are encouraged to use compensations while drinking
water. This information is also included on the yellow
bands.
- Aggressive oral care should be provided to those patients who
are unable to clean their own teeth and mouths so that pathogenic bacteria
are less likely to contaminate secretions.
- Medications are never given
with water. Pills are given
in a spoonful of applesauce, pudding, yogurt, or thickened liquid.
- Family
education includes emphasis on the rationale for allowing water intake. The Speech-Language Pathologist, Dietician, and
Nurse repeat the guidelines for water intake during the education process. Written
material is provided as well. Education is documented in the
medical record.
FRAZIER WATER PROTOCOL
REFERENCES
Olson, M. (1990).
The benign effects on rabbits’ lungs of the aspiration of water
compared with 5% glucose or milk. Pediatrics, 46:538-547.
Splaingard, M.L., Hutchins, B., Sulton, L.D., Chaudhuri, G. (1988).
Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical
assessment. Archives of physical medicine and rehabilitation, 69:637-640.
Schmidt, J., Holas, M., Halvorson, K., & Reding,
M. (1994).
Videofluoroscopic evidence of aspiration predicts pneumonia and death
but not dehydration following stroke. Dysphagia, 9:7-11.
Holas, M.A., DePipppo, K.L., & Reding, M.J.
(1994).
Aspiration and relative risk of medical complications following stroke. Neurology,
51:1051-1053.
Feinberg, M.J., Kneble, J., Tully, J., & Segall,
L. (1990).
Aspiration and the elderly. Dysphagia, 5(2):61-71.
Feinberg, M.J.,, Kneble, J., & Tully, J. (1996).
Prandial aspiration and pneumonia in an elderly population followed over
3 years. Dysphagia, 11(2):104-109.
Langmore, S.E., Terpenning, M.S., Schork, A., Chen,
Y., Murray, J.T., Lopatin, D., &
Loesche, W.J. (1998).
Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia,
13:69-81.
Katz, S., & Akpom, A. (1976).
A measure of primary sociobiological functions. International Journal
of Health Services, 6(3):493-508.
Sansevero, A.C. (1997).
Dehydration in the elderly: strategies for prevention and management. The
Nurse practitioner, 22(4):63-66.
Chernoff, R. (1994).
Thirst and fluid requirements. Nutrition Review, 52:S3.
Kleiner, S.M. (1999).
Water: An essential but overlooked nutrient. Journal of the American
Dietetic Association, 99:200-206.
Xiao, H., Barber, J., & Campbell, E.S. (2004).
Economic burden of dehydration among hospitalized elderly patients. American
journal of health-system pharmacy, 23:2534-2540.
Copeman, J. (2000).
Promoting nutrition in older people in nursing and residential homes. British
Journal of Community Nursing, 5:277-284.
Vogelzang, J.L. (1999).
Overview of fluid maintenance/prevention of dehydration. Journal
of the American Dietetic Assoiation, 99:5.
Chidester, J.C., & Spangler, A.A. (1997).
Fluid intake in the institutionalized elderly. Journal of the American
Dietetic Association, 99:200-206.
Gross, C.R., Lindquist, R.D., Woolley, A.C., Granieri,
E., Allard, K., & Webster,
B. (1992).
Clinical indicators of dehydration severity in elderly patients. The
Journal of emergency medicine, 3:267-274.
Whelan, K. (2001).
Inadequate fluid intake in dysphagic acute stroke.
Clinical indicators of dehydration severity in elderly
patients. Journal
of Emergency Medicine, 3:267-74.
Finestone, H.M., Foley, N.C., Woodbury, M.G., & Green-Finestone,
L. (2001).
Quantifying fluid intake in dysphagic stroke patients: a preliminary
comparison of oral and nonoral strategies. Archives of Physical
Medicine and Rehabilitation, 82:1744-1746.
Volkert, D., Kreul, K., & Stehle, P. (2004).
“Nutrition beyong 65”- Amount of usual drinking fluid and motivation
to drink are inter related in community-living, independent elderly people. Zeitschrift fur
Gerontologie und Geriatrie, 37:436-443.
Kositzke, J.A. (1990).
A question of balance-dehydration in the elderly. Journal of gerontological
nursing, 16:4-11.
Davis, J., & Sherer, K. (1994).
Applied nutrition and diet therapy for nurses. Philadelphia: W.B.
Saunders Company.
Hoffman, N.B. (1991).
Dehydration in the elderly: insidious and manageable. Geriatrics,
46:35-38.
Lavisso-Mourey, R.J. (1987).
Dehydration in the elderly: a short review. Journal of the National
Medical Association, 79:1033-1038.
Meyer, D., Leventhal, H., & Gutmann, M. (1985).
Common sense models of illness: The example of hypertension. Health
Psychology, 4:115-135.
MacDonald, E.T., MacDonald, J.B., & Phoenix,
M. (1977).
Improving drug compliance after hospital discharge. British Medical Journal,
2: 618-621.
Marlatt, G.A., & Gordon, W.H. (1984).
Relapsse prevention: Introduction and overview of the model. British
Journal of Addiction, 79:261-273.
Stone, G. (1979).
Patient compliance and role of the expert. Journal of Social Issues,
35:34-59.
Leiter, A.E., & Windsor, J. (1996).
Compliance of geriatric dysphagic patients with safe-swallowing instructions. Journal
of Medical Speech-Language Pathology, 4:289-300.
Mayer, J., Skrickova, J., Vorlicek, J., & Kubalek,
V. (1994).
Use of bronchoalveolar lavage in the diagnosis of pulmonary complications
in immunocompromised patients. Vnitrni lekarstvi, 40:179-183.
Martin, W.J., Smith, T.F., Sanderson, D.R., Brutinel,
W>M., Cocerill,
F.R., & Douglas, W.W. (1987). Role of bronchoalveolar lavage in the
assessment of opportunistic infections: utility and complications. Mayo
Clinic proceedings, 62(7):549-57.
Reynolds, H.V. (1998).
Bronchoalveolar lavage. In J.T. Murray & J.A. Nadel (Eds.) Textbook
of Respiratory Medicine (p598). Philadelphia, PA: W.B. Saunders Co.
Effros, R.M. (1997, October).
Defense of the lungs following aspiration of acid and hypotonic
solutions. Paper presented at Dysphagia Research Society Meeting,
Toronto.
Schwartz, D.J., Wynne, J.W., Gibbs, C.P., Hood,
C.I., & Kuck, E.J.
(1980).
The pulmonary consequences of gastric contents at pH values greater than
2.5. The American review of respiratory disease, 1212:119-126.
Crossley, K.B., & Thum, J.R. (1989).
Nursing home-acquired pneumonia. Seminars in respiratory infections,
4:64-72.
Whitmire, S.J. (2000).
Water, electrolytes and acid-base balance. In L.K. Mahan & S.
Escott-Stump (Eds.) Krause’s Food, Nutrition, Diet Therapy (pp153-163). Philadelphia,
PA: W.B. Saunders Co.
Mashiba, K., Hamamoto, T., & Torikai, K. (1993).
A case of Legionnaires’ disease due to aspiration of hot spring
water and isolation of Legionella pneumophila from hot spring water. Kansenshogaku
Za sshi, 67:163-166.
Kool, J.L., Carpenter, J.C., & Fields, B.S.
(1999).
Effect of monochloramine disinfection of municipal drinking water on
risk of nosocomial Legionnaires’ disease. Lancet, 23;353(9149):272-277.
Venezia, R.A., Agresta, M.D., Hanley, E.M., Urquhart,
K., & Schoonmaker,
D. (1994).
Infection control and hospital epidemiology, 15(8):529-533.
Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama,
H., Okamoto, H., Hosiba, K., Iharia, S., Yanagisawa, S., Ariumi,S.,
Morita, T., Mizuno, Y., Ohsawa, T., Akagawa, Y., Hashimoto, K., & Sasaki,
H. (2002).
Oral care reduces pneumonia in older patients in nursing homes. Journal
of American Geriatrics Society, 50(3):430-433.
Garon, B.R., Engle, M., & Ormiston, C. (1997).
A randomized control study to determine the effects of unlimited oral
intake of water. Journal of Neuro Rehab, 11:139-148.
Castellanos, V.H., Butler, E., Gluch, L., & Burke,
B. (2004).
Use of thickened liquids in skilled nursing facilities. Journal
of the American Dietetic Association, 104(8):1222-1226.
|
