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Legally speaking: Care of the dysphagic patient

Thursday February 20, 2014
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As nurses know, one of the common residual effects of a stroke for a patient is dysphagia. Dysphagia requires a thorough medical evaluation and nursing assessment of the patient to avoid additional complications such as aspiration, choking, pneumonia and death.

Upon admission, one of a nurse’s responsibilities is a thorough nursing assessment and evaluation of the extent of a patient’s dysphagia. The evaluation process, called a “nursing swallow screen,” involves the use of one or several techniques or tests. Based on the outcome of the screen, the patient then is placed on a special diet, a regular diet or remains NPO until he or she is evaluated by a speech pathologist.
Once the patient’s swallowing abilities are documented, a diet that fits the patient’s strengths and weaknesses is established in consultation with the speech pathologist. However, once the diet is ascertained, it becomes a nursing responsibility to ensure the diet is one the patient can handle successfully.

Monitoring the patient

Regular scrutiny of a patient’s meals is vital. The dysphagic patient should not be given food that requires extensive chewing or that may be difficult to swallow. A patient with difficulty swallowing may need clear liquids only or may do better with pureed foods.

Ensuring the ordered diet is the correct one for the patient also requires careful observation of the patient when he or she eats or drinks the first meal. In reality, observation may need to be ongoing, and depending on the patient’s condition, he or she may require assisted feeding during the initial phases of hospitalization. If difficulties arise with the diet prescribed for the patient, nurses should notify members of the care team. The patient may be placed on IV fluids for a time until further evaluation is completed. A speech pathologist usually is available for ongoing consult and help throughout the patient’s hospitalization.

Nursing Screening for Dysphagia

A small amount of applesauce or pudding is given to the patient, who is observed for mechanical difficulties
in swallowing

A patient’s condition is compared with risk factors associated with dysphagia, such as level of consciousness, inability to sit upright, slurred speech

Three ounces of water is given to the patient to swallow. He or she is observed for coughing, wet or hoarse voice and inability to swallow without interruption


Delegation of care

It may be necessary to delegate the observation and assessment of the patient’s swallowing abilities during meals. Delegation is a nursing responsibility that requires nursing judgment and critical thinking. Therefore, it cannot be passed on to just anyone on the nursing team. Delegating assistance with feeding for a dysphagic patient is a crucial nursing role. The “Five Rights of Delegation” reflect your standard of care in this role.

5 rights of delegation of patient care

Right task
Right circumstances
Right person
Right directions/
communications
Right supervision/
evaluation


If you decide to delegate the monitoring of the dysphagic patient during meals, or you are a nurse manager whose staff is delegating patient care, be certain that these delegation principles are followed. The patient’s very life may be at risk if not carefully assisted and observed during food intake. In addition, you may face liability for improperly delegating or for failure to properly manage your staff when they delegate this important nursing responsibility.

To see what else is trending in stroke, visit www.Nurse.com/Stroke.

References

American Nurses Association and the National Council of State Boards of Nursing’s “Joint Statement on Delegation”
— available at NCSBN.org

“Preventing aspiration in older adults with dysphagia,” by Norma A. Metheny
— available at ConsultGeriRN.org

“Management of dysphagia in stroke patients,” by Resa Shaker and Joseph Greenen, Gastroenterology & Hepatology
— available at NCBI.nlm.nih.gov

“Dysphagia screening for patients with acute stroke”
— Hospital of the University of Pennsylvania Clinical Practice Policy/Procedure, 1-4

Travaglini v. Ingalls Health System, 919 N.E. 2d 445 (2009)



Nancy J. Brent, RN, MS, JD, is Nurse.com’s legal information columnist and an attorney in private practice. This article is for educational purposes only and is not to be taken as specific legal or other advice. If legal or other advice is needed, the reader is encouraged to seek advice from a competent professional. Post a comment below or email specialty@Nurse.com.