Worried about difficulty swallowing . . . (dysphagia)

If you've come to this blog entry, perhaps it's because you may have concerns about the swallowing ability of yourself or a loved one. Difficulty swallowing is frightening and it can obviously be dangerous.  Many of the underlying factors that make a person vulnerable for difficulty swallowing are related to muscle weakness from a variety of causes:  stroke, multiple sclerosis, and generalized developmental difficulties, etc.

Asphyxiation and Aspiration

Weakness of the muscles that allow food to pass from the mouth, down the esophagus, and into the stomach can cause  choking.  If the choking doesn't dislodge the food from the windpipe, it can become lodged there and result in asphyxiation when air can't pass into the lungs.

Choking can result in some food or liquid actually entering the lungs.  The medical term for inhaling food or liquid is aspiration.  Aspiration can hurt the lungs in various ways, often a severe case of aspiration pneumonia results..

Swallow Screening for Stroke Patients--Always Necessary

When a stroke is suspected, hospitals require that a "swallowing screen" be performed before a patient is allowed to have anything by mouth.  In addition, among the questions patients are asked when they are admitted to the hospital for any reason is, "Do you experience any difficulty swallowing?"  If they answer, "yes," or give any other clues that make the admitting RN suspicious, the swallowing screening test is easily performed.

RN Swallow Screening Guidelines

Each hospital will have their own particular screening procedure.  This is an example taken from my personal experience in a facility where I was employed, and I'm presenting it to give you an idea about the factors that help define swallowing difficulty.  The RN performing the screening needs applesauce (or if patient is allergic something of the same consistency, like pudding), a graham cracker, and a spoon.  The patient cannot be lying down for this exam.  They need to be sitting almost at a right angle, and suction needs to be readily available in case the patient needs quick intervention.

Positioning

• Elevate the head of the bed at least 70 degrees
• Support the weak side of the body with a pillow if appropriate.  (This keeps the patient from slouching to the weak side.)
• Perform each step of the screening  (bites or sips) in this order and STOP if any item would cause a check on the documentation checklist at any point in the screening.

Procedure

1.  Give 1 teaspoon of applesauce. Watch for any signs and symptoms of dsyphagia (see checklist below.) STOP if any item is checked. If no signs or symptoms Repeat with a second teaspoon. If no signs and symptoms after the second spoonful, proceed to step 2.

Checklist:
__Holds food in mouth without initiating swallow or spits food out
__Significant facial droop with food or liquid coming out of mouth (Facial droop:  one side of the face droops from muscle weakness)
__Pocketing of food/drink in mouth or cheeks (Pocketing:  instead of swallowing, the food/fluid is kept in the mouth, usually held in the "pocket" between the bottom cheek and gums--like a chipmunk holds nuts.)
__Suctioning required during assessment
__Food or liquid coming out of nares (the nose "holes")
__Choking or persistent coughing during any stage of the swallowing screen
__Eyes reddening or tearing
__Wet, gurgly voice
__Patient reports painful swallow or food lodged in throat
__Labored breathing or moist breathing sounds (known medically as "rales")


2.  Give patient one teaspoon size of thin liquid (nurse is to control the amount of liquid placed on the spoon for patient to sip.)  If successfully swallowed, allow the patient to give self a second sip independently. STOP if any sign or symptom occurs.
 
Checklist:
__Holds food in mouth without initiating swallow or spits food out
__Significant facial droop with food or liquid coming out of mouth
__Pocketing of food/drink in mouth or cheeks
__Suctioning required during assessment
__Food or liquid coming out of nares (the nose "holes")
__Choking or persistent coughing during any stage of the swallowing screen
__Eyes reddening or tearing
__Wet, gurgly voice
__Patient reports painful swallow or food lodged in throat
__Labored breathing or moist breathing sounds (known medically as "rales")


3.  Give the patient a graham cracker and ask him or her to take a bite, chew it up, and then swallow.  If successful, offer the rest of the cracker. STOP if any sign or symptom occurs.
 
Checklist:
__Holds food in mouth without initiating swallow or spits food out
__Significant facial droop with food or liquid coming out of mouth
__Pocketing of food/drink in mouth or cheeks
__Suctioning required during assessment
__Food or liquid coming out of nares (the nose "holes")
__Choking or persistent coughing during any stage of the swallowing screen
__Eyes reddening or tearing
__Wet, gurgly voice
__Patient reports painful swallow or food lodged in throat
__Labored breathing or moist breathing sounds (known medically as "rales")


4.  Document results on the sticker and place it in the physician's progress notes.
5.  Obtain an order for a Speech Therapy consult if patient fails screening.
If one or more items are checked in any phase of the screening, the swallowing screen is FAILED.  The patient is to be kept NPO or "nothing by mouth."  Speech pathology consult is ordered.

• If NO items are checked, then the screening is PASSED.
• If the patient passes only on the applesauce (step 1), check with the physician to see if medications may be given crushed and mixed in applesauce while wating for the speech consult.

What can you do?

If you live with someone who is at risk for aspiration because of difficulty swallowing, make sure that their physician is aware of this and follow his or her advice and recommendations.  If they haven't suggested it already, ask for a Speech Pathology evaluation for your loved one.  In some cases, thickened liquids and specific consistency of foods will be recommended.  There are other important tips that a Speech Pathologist will teach you to help you or your loved one prevent aspiration and asphyxiation because of dysphagia.

Also, if you haven't already done so,  learn CPR and the Heimlich Maneuver so that you will be able to quickly intervene on behalf of your loved one. 

• Find a CPR class via the American Heart Association or the American Red Cross

Read more about dysphagia, check out the hyperlinks in this article for additional reading.


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Corneal Abrasion, Corneal Scratch, Pain and Sensation of Something in the Eye

“It feels like something is in the eye, and it's very painful.”

Why I’m compelled to write about this topic today: Recently one of my patients was expected back from surgery after undergoing a complicated procedure to repair a fracture. Shortly before the young man was due to arrive in his hospital room, the nurse from the surgical recovery care unit called to report that he was experiencing severe pain in one eye along with a sensation of “something in the eye.” The surgeon was aware and had ordered an eye flush. Although the nurses in recovery had copiously irrigated the eye with sterile water, the patient’s extreme discomfort persisted. The pain from his orthopedic surgery was nearly eclipsed by the pain and irritation in his eye. Close examination hadn’t revealed any obvious reason for the persistent eye pain. When he arrived on our floor, the patient’s affected eye was “bloodshot,” very sensitive to light, and he was writhing due to the combination of both eye and surgical incision pain. The surgery resident physician was soon at his bedside. She ordered an application of “Lacrilube” ointment to soothe the eye and diagnosed a corneal abrasion. Having participated in the surgery, she remarked that the affected eye “really wasn’t taped closed well enough” during the lengthy surgical procedure.

Corneal Abrasions

There are a number of reasons why a cornea might be scratched or irritated resulting in an abrasion. Although they are extremely tiny, corneal abrasions, are very painful . . . and why not? After all, even a paper cut to our fingertips can cause startling pain. Often a small corneal abrasion will heal itself within 24 hours. There is treatment that may soothe the affected eye, such as sterile artificial tears (see below for further discussion of additional treatments). Keep in mind, however, not all eye pain is due to a corneal abrasion, and not all corneal abrasions may be treated with home care alone.

Some Structures of the Eye

To understand what the cornea is, it’s useful to think of the eye as a room with the cornea being a window. The eyelids are similar to shutters that can be opened or closed. The space between the shutters and the window glass is the conjunctiva. The cornea functions as the window glass does; that is, the light flows through the cornea to enter the eye. Directly behind the cornea is the round, colored iris which functions in much the same way as curtains; the muscles of the iris expand and contract to allow more or less light inside of the “room.” The pupil is the space through which the light passes between the open curtains. The lens is yet another “window pane” that the light passes through before it enters the room. My suggestion is to think of the lens, for this example, as a large glass “sun catcher” suspended from the ceiling just inside the window. Vitreous humor is the gelatinous substance that fills the center of the eye just as normal atmospheric gasses fill up a room in your home. The retina is the back wall of the room just opposite from the window. As light strikes the “wall” (retina) there is inevitably a particular spot where the sunlight is more concentrated. The macula in the back of the eyeball is similar to that part of the room with the brightest exposure to the light. The fovea is an area of the macula which provides the sharpest vision; similarly the brightest spot in the room is best for reading or performing tasks that require sharp visual acuity.

(See a nice depiction of the eyes' anatomy here:  http://www.eyecareamerica.org/eyecare/anatomy /).

A Little More About the Cornea

As mentioned in the preceding paragraph, the cornea functions like the glass of our windows. It’s a protective structure for the more delicate features behind it, and it functions to let light flow into the eyeball. Although the cornea consists of five distinct layers, it is very thin—with a depth of only about 1 mm at its deepest point.

The cornea has an abundance of nerve endings, as a result it’s very sensitive to both touch . . . and pain.. That trait helps protect our vision from trauma as all of our instincts quickly react to try to prevent an injury to the eye. However, corneal abrasion is still one of the most common eye injuries.

How Does a Corneal Abrasion Occur

A person may have no recollection of trauma to the eye and there are numerous scenarios that may result in a corneal abrasion. A poke in the eye (particularly if a fingernail is involved), a branch from a tree, flying glass or metal shards, or a surgical drape or equipment brushing across your eye if it is exposed during a surgical procedure . . . any of these things can cause a corneal abrasion. Debris in the eye can also cause an abrasion, particularly when the eyes are rubbed vigorously or if a contact lens causes friction.

Prevention during Surgery

Taping the eyes closed is a standard preventive measure aimed at protecting the eyes from corneal abrasion. Some surgeries pose a greater risk of a corneal abrasion occurring. Those in which the patient is positioned face down, surgery on the head or neck, and any lengthy procedure carries more risk. Of course in some surgeries taping is contraindicated as the eyes may need to be opened during the procedure. In such cases the anesthesiologist or nurse anesthetist will use their judgment to make the appropriate decisions. Instillation of eye drops, gels or eye ointments may be the decided course of prevention, or special goggles, eye cushions or pads may be used.

Diagnosis

Your doctor may use a combination of fluorescent dye and either a cobalt-blue filtered ophthalmoscope or a “slit-lamp” to make a definite diagnosis of a corneal abrasion. The physician may instill drops to temporarily numb the eye during the exam. If they observe a foreign body present in the eye, it will also be removed during this examination.

Treatment

At one time eye patches were applied when patients suffered a corneal abrasion. This is no longer a standard treatment; however, in some cases your physician may determine that an eye patch is in your best interest. It’s more likely that eye drops or ointment will be prescribed for home use. The drops and/or ointments may include a medication to control the pain, an eye lubricant, a topical antibiotic, or a steroid. Steroid eye drops may be prescribed to reduce inflammation. (Please note, some of the eye drops and ointments may result in temporarily blurred vision). Occasionally, a pain medication to be taken by mouth will be prescribed as well.

If metal shards were responsible for your eye injury, a tetanus booster shot will be needed. If it has been more than 5 years since your last tetanus shot--or if you cannot remember when your last tetanus shot was given--you will should be given a booster shot after the eye examination.

Follow your physician’s orders and use the medications exactly as prescribed. Do not stop the medication sooner than the directions tell you to simply because the eye “feels better.” Continuing the full course of prescribed treatment is important to prevent possible complications later on.

If you have questions about your doctor’s ordered treatment, ask him or her. You have a right to know the reason for the treatment decisions that are made on your behalf.

How long to heal

A small corneal abrasion may heal in a few hours. Often after a night’s sleep the cornea has healed. In the case of a larger abrasion, it may take several days time for complete recovery. It is important to keep from rubbing the affected eye as that may delay healing. If the symptoms suddenly recur after the initial healing phase, consult your physician right away.  Inadequate treatment of a corneal abrasion can sometimes lead to complications such as a corneal erosion.

First Aid for Eye Emergencies

Plan to seek treatment at your urgent care center or ER for any bleeding from the eye, chemical splash, visible scratch or penetrating injury, eye pain, double or blurred vision, nausea and headache.

Do not rub the injured or irritated eye. Wash your hands with soapy water. Remove contact lenses if they are in place. Do not attempt to use any tweezers or cotton swabs to try to treat eye emergencies at home.

Chemical splash to the eye: Start flushing the eye with cool clean water from a sink, bottle, hose, etc. Tilt the head back and to the side. Keep the affected eye wide open and pour the clean water gently but directly into the eye. Make sure the head is tilted away from the “good eye” so that chemicals which are rinsed out don’t flow into that eye during the flushing process. (A child might be more comfortable laying down in an empty bath tub to have the eyes irrigated.) Continue to flush chemicals from the eye continuously for at least 15 minutes. Call 911 or have someone drive you to the ER. If the chemical that splashed into the eyes is known, be sure to provide the name to the healthcare providers at the hospital. For more information see:  
First aid tips for a chemical splash to the eye from the Mayo Clinis.  

Foreign body in the eye: Do not rub the eye. With clean hands, open the eye and allow tears to move the foreign body (such as an eyelash or speck of dirt). Rinse the eyes with cool clear water as explained above if tearing isn’t effective. If an object is embedded in the eye—do not attempt to remove it. Seek medical help in the ER or urgent care center immediately. For more information see: Mayo clinics advice on corneal abrasion and Mayo's first aid advice for a foreign body in the eye.

Bleeding from an eye: Do not put any pressure on the eye, gently cover it with a clean cloth and go directly to the Emergency Room. (The person with the injured eye should not drive).


2009 All rights reserved for content and photos, Carolyn Cooper, MPH, RN
References:

WebMD: http://www.webmd.com/eye-health/tc/objects-in-the-eye-home-treatment and http://firstaid.webmd.com/corneal-abrasion-treatment

Eye Safety for Emergency Response and Disaster Recovery from the CDC: www.cdc.gov/niosh/topics/eye/eyesafe.html

Wilson, S.A. and Last, A. (2004). Management of Corneal Abrasions. American Family Physician. Retrieved 12/16/2009 from: http://www.aafp.org/afp/2004/0701/p123.html

Verma, A. (2009). Corneal Abrasion. Emedicine from WebMD. Retrieved 12/15/2009 from: http://emedicine.medscape.com/article/1195402-overview

First Aid for Eye Emergencies from Prevent Blindness:  http://preventblindness.org/safety/firstaid.html

Tarmey, N. & White, L.A. (2009). Chapter 5, Damage to the Eye. Risks associated with your anaesthetic, Information for patients: the Royal College of Anaesthetists. Retrieved 12/16/2009 from:
http://www.rcoa.ac.uk/docs/Risk_5Eye-damage.pdf


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Bloody nose: Stop a nosebleed and prevent recurrent bleeding

Why do nosebleeds occur?

In medical terminology, a nosebleed is properly called "epistaxis." Trauma from an injury is probably the most common way to develop a nosebleed. Dry weather and irritation from fingers in the nose are also commonly associated with nosebleeds. Anyone who takes blood thinning medication (such as Coumadin) or even some vitamins and supplements(such as fish oil, vitamin E, etc.) are more susceptible. Cancer patients undergoing chemotherapy may have nosebleeds due to loss of clotting factors called platelets that are destroyed by the chemo. Patients who receive oxygen therapy by means of a nasal cannula (also called "nasal prongs") may suffer nosebleeds because of the dry stream of air against the nasal tissue unless some humidity is added to the oxygen set-up. Uncommon reasons such as inherited problems of the blood vessels are disorders such as Osler-Weber-Rendu Syndrome (Hereditary Hemorrhagic Telangiectasia) or an inherited blood clotting disorders such as a type of hemophilia.

How to Stop a Nosebleed:

1. Sit or stand the person with the bleeding nose UPRIGHT with their head tilted FORWARD. This keeps the blood from going down the back of the throat and into the stomach which will cause irritation and often results in vomiting. Allow the blood to flow into a basin or onto a cloth if available. Stopping a bloody nose is the priority--you can worry about cleaning a mess later.

2. Have the person with the bleeding nose breathe through their mouth as they (or you) pinch the nose together to apply pressure. You'll know that you are doing this correctly if there is no longer visible blood coming out while you are applying the pressure. Make sure to pinch the soft part of the nose to apply pressure--the lower third of the nose, just above where the nose flares outward. Obviously if you try to pinch against the bony part of the nose you won't really be applying any pressure to the blood vessels underneath. Remember to encourage them to sit upright with their head tilted forward. In addition to applying pressure, you can also put an ice pack over the bony bridge of the nose to constrict the blood vessels even more.

3. Don't let up the pressure for at least 5 minutes--not even to take "a peek." Time this by the clock, don't wing it. You are trying to establish a clot in the bleeding vessels--steady, constant pressure is important in doing this. After 5 minutes of direct pressure, check for bleeding. If the nose is still bleeding, repeat step 2, only this time keep the steady continuous pressure going for at least 10 minutes.

4. Have you done all this with no improvement? In that case, it's time to visit the doctor or ER. Don't forget to continue pressure during transport and in the waiting room. Depending on the circumstances the ER doctor may have to resort to nasal cautery to stop the bleeding, by packing the nose with a gauze "nasal tampon," or by some other means to apply compression to the bleeding vessels.

5. All fixed? What now? After the nosebleed ask the patient to rest in a reclining position with the head elevated above the heart, limit strenuous activity for the rest of the day, and avoid bending and heavy lifting. It's okay to gently sniff, but avoid blowing the nose and if the patient must sneeze--encourage them to do so with an open mouth to minimize pressure through the nose.

6. What if the nosebleed starts up again?

• Follow steps 1-3 again.
• If unsuccessful in stopping the bleeding, or if the patient is experiencing any associated symptoms such as severe headache, body sweats, weakness, or shortness of breath--it's time to go to the ER. Remember to ensure that pressure is maintained in an effort to control the bleeding during the ride to the ER.
• If the patient has already seen the doctor--review the discharge instructions and follow the written advice the physician gave--phone the doctor's office for any questions or concerns. Proceed to the ER if indicated.
• On their website, the Ear, Nose, and Throat Associates of Corpus Christi suggest this additional advice for recurrent nosebleed: "Clear nose of all blood clots by sniffing in forcefully," and "Spray nose four times on both sides with decongestant spray (such as Afrin,® Duration,® Neo-Synephrine,® etc.)"

Quick sources for additional reading:
Ask Dr. Sears: About Nosebleeds
The Children's Hospital, Aurora, Colorado



Below: Jay Dolitsky, MD, Clinical Professor and Director of Pediatric Otolaryngolgy at the NY Eye and Ear Infirmary offers his expert opinion about nosebleeds in this YouTube video.