Clinical Case Report:

Nutritional Management Of
Dysphagia
• Candice Emrith
• Queens College Dietetic Internship
• October – December 2022
Pathology of Primary Disease (1)

❖Dysphagia
❖Dysphagia is difficulty swallowing
❖ Caused by the pharynx's inability to carry liquids, solids, or both, to the
stomach
❖ May be impacted by physical obstructions or conditions that impair motor
function
Classifications of Dysphagia (1)

Depending on where it develops, dysphagia is divided into

oropharyngeal and esophageal categories.
❖Oropharyngeal dysphagia:
❖Caused by faulty function close to the esophagus
❖May cause oral secretions, ingested particles, or both to be aspirated into the
trachea
❖Patients with neurologic problems or muscular abnormalities that affect the
skeletal muscles are most likely to experience oropharyngeal dysphagia
Classifications of Dysphagia cont. (1)

❖Esophageal dysphagia:
❖ Esophageal dysphagia is the inability to swallow food normally
❖ Results from either a mechanical obstruction or a motility problem
Signs and Symptoms
Signs and ❖Some common signs and symptoms associated with
dysphagia are:
Symptoms
❖Choking on food or fluids while coughing
Con't (2) ❖ Feeling like there is a lump in your throat
❖Smelly voice
❖ Reintroducing food (regurgitation)
❖ Sudden weight loss
❖Recurrent aspiration pneumonia
Risk Factors (2)

❖ Malnutrition
❖ Dehydration
❖ Aspiration pneumonia
❖Toxic aspiration syndrome
❖Social exclusion
❖ Mental and emotion health
MNT Recommendations for Dysphagia (3)

❖The goal of MNT is to increase food transmission and stop ambition

❖To address the need for a standardized global vocabulary, a group of specialists
established the International Dysphagia Diet Standardization Initiative (IDDSI) in
2013.
❖'Texture alteration' of food and liquids is typically used in dysphagia treatment to
reduce the risk of aspiration and choking
❖Consistencies are changed to:
❖ pureed, semi-solid, soft, or set, liquids are typically thickened.
Comorbidities (4, 5)

❖ Hepatitis B:
❖ Caused by the hepatitis virus, spread by tainted blood or blood products
❖ Results in a wide change of liver problems
❖ Antiviral medications and liver transplants are used to treat fulminant hepatitis B. Acute viral hepatitis,
particularly hepatitis B, cannot be treated.
❖ Hypertension:
❖ Chronically elevated resting systolic (130 mm Hg), diastolic (80 mm Hg)
❖ Common causes of hypertension include obesity, chronic kidney disease, sleep apnea, and renal artery
stenosis.
❖ In addition to modifying, one's lifestyle, treatment may involve the use of diuretics, ACE inhibitors,
angiotensin II receptor blockers, and calcium channel blockers
 Comorbidities cont. (6, 7)

❖Type 2 Diabetes Mellitus:

❖ Impairment of insulin production and varying degrees of peripheral insulin resistance cause
hyperglycemia in diabetes mellitus
❖ Polydipsia, polyphagia, polyuria, and impaired vision are some of the early signs of hyperglycemia
❖ Diet, exercise, and medications that lower glucose levels, including insulin, oral antihyperglycemic
medications, and injectable non-insulin medications, are used as treatments

❖Generalized muscle weakness:

❖ Weakness is the loss of muscle strength
❖ Eye movement abnormalities, dysarthria, dysphagia, and respiratory weakness can all be
brought on by the weakness of muscle groups.
❖ In general, physical therapy and rehabilitation are beneficial regardless of the cause of the
impairment
 Comorbidities cont. (8, 9)

❖Parkinson's Disease:
❖ Most cases of Parkinson's disease are idiopathic
❖ Unintentional or involuntary movements, such as shaking, stiffness, and issues with balance and
coordination, are brought on by a brain condition.
❖ Levodopa is the most common medication used to treat Parkinson's disease. Significantly improves
quality of life, should be started right once by clinicians if these medications are unable to adequately
control symptoms.
❖Crohn's Disease:
❖ The initial stages of Crohn's disease include crypt inflammation and abscesses, which develop
into small localized aphthoid ulcers
❖ Chronic diarrhea accompanied by fever, stomach pain, anorexia, and weight loss
❖ Loperamide oral dosages of 2 to 4 mg or antispasmodic medications up to 4 times per day can
treat cramps and diarrhea
 Comorbidities cont. (10, 11)

❖Acute Respiratory Failure with Hypoxia:

❖ PaO2 is below 60 mmHg without hypercapnia. Intracardiac shunting of blood from the right- to left-sided
circulation
❖ The symptoms include cyanosis, tachypnea, tachycardia, altered awareness, and diaphoresis
❖ Usually, noninvasively supplied 70 to 100% oxygen is used to treat AHRF

❖Pneumonitis due to Aspiration:

❖ Inflammation of lung tissue caused by aspiration.
❖ Signs and symptoms include: coughing, fever, dyspnea, and chest pain
❖ A beta-lactam/beta-lactamase inhibitor is suggested for aspiration pneumonia, with clindamycin
being saved for people who are penicillin allergic.
Comorbidities cont. (12)

❖Gout:
❖ A common form of inflammatory arthritis
❖ Onset of Pain: Podagra of the great toe, instep of foot, ankle, knee, wrist, and
elbow, cervical spine, sternoclavicular, sacroiliac, hip, and shoulder joints are
infrequently affected.
❖ Treatment for Gout include interleukin-1 (IL-1) antagonists, nonsteroidal anti-
inflammatory medications (NSAIDs), colchicine, corticosteroids, and other methods
of putting an end to an acute flare.
 Case presentation
• 80 y/o M (CH-1.1)
• Chinese American (CH-1.1)
• Country of origin: China (CH-1.1)
• Admitted to long term care facility from local acute care hospital
• Displaced fracture of right hip femoral head.
• Dysphagia
• PEG placement
• Alert and oriented to person (AOx1) (CH-2.1)
• Cognitively impaired
• Total dependance on staff for ADL's
• NKFA
Assessment: Client History

❖Medical Hx (CH-2.1):
❖Admitted dx: Displaced fracture of right hip femoral head.
❖PMHx: Crohn’s disease, Parkinson’s disease, viral hepatitis B without hepatic
coma, HTN, T2DM and generalized muscle weakness

❖ Social hx (CH-3.1):
❖ Married w/ daughter
 Assessment: Food/Nutrition Related History

❖Diet order (FH- 2.1.1): NPO

❖Rationale for tube feeding:
❖Dysphagia s/p displaced fracture of right hip femoral head.

❖ Enteral Nutrition Order (FH-2.1.1)

❖ Current GT feeds provides 1200 kcal (19 kcal/ kg), 55 gm PRO (0.9 gm/ Kg), 1256 mL free
water (20
❖ Jevity 1.2 (1000 mL) @ 55 mL until complete.mL/kg).(FH- 2.1.1) until complete (18.7 hrs.)
(FH-1.3.1).
❖ With water flush 25ml every hour (468 ml) (FH-1.3.1)
Assessment: Food/Nutrition Related History

❖Tolerance of tube feeding:

❖Formula is tolerated well
❖ No s/s n/v/c/d

❖ Vitamin intake (FH-1.6.1)

❖ Vitamin D3
❖ Ferrous sulfate
❖ Nephro-vite
 Medications (FH 3.1):
❖ Antihypertensive and Hyperlipidemia:
❖ Amlodipine: Avoid grapefruit and natural licorice
❖ Nebivolol: Avoid natural licorice
❖ Vascepa: Take with food
❖ Lipitor: Avoid grapefruit
❖ Flomax: Avoid natural licorice, take 30 mins after the same meal each day

❖ Anti-Parkinson:
❖ Pramipexole: Take with food
❖ Carbidopa-Levodopa: Avoid SJW and high tyramine foods
❖ Amantadine: Take 4 hrs before bed
 Medications (FH-3.1)
❖ Hyperglycemia (Diabetes):
❖ Januvia

❖ Anti-Gout:
❖ Allopurinol: Drink 2.5-3 L fluids/day, avoid large doses of vitamin C

❖ Antiviral Hep B treatment:

❖ Entecavir: Take on empty stomach or 2 hrs apart from food
Assessment: Nutrition Focused Physical
Findings (13)
Nutrition Focused Physical Findings

❖ Diaper rash (PD-1.1.17.7): Groin rash

❖ Dry skin (PD- 1.1.17.8): B/L heel
❖ Pressure injury of heel (PD-1.1.17.29)
❖ Impaired skin integrity (PD-1.1.17.15): Moisture associated skin damage (MASD)
❖ Sacrum
❖ Left buttock
❖ Right buttock

• No nutrition dx of malnutrition detected.

 Assessment: Anthropometric Measurments

❖Height (AD-1.1.1):
❖69"

❖ Weight (AD-1.1.2.1):
❖ CBW taken at current facility: 129.7 lbs

❖ Body mass index BMI (AD-1.1.5.1): 19.2

❖ Weight interpretation: Normal
❖ UBW (AD-1.1.2.5): 150.4 lb

❖ Weight trend:
❖ 11/17/2022; 135.8 Lbs.; -6.1 lbs.; -4.5 % x 30 days
❖ 9/17/2022; 150.4 Lbs.; -20.7 lbs.; 13.8% x 90 days
Assessment: Biochemical Data

Test Results Normal Range

Albumin 3.7 3.5-5.0 g/dL

BUN/Creatinine 15/0.78 BUN: 8-23 mg/dL

Creatinine: 0.4-1.2 mg/dL

Na 140 136-144 mEq/L

Cl 100 98-107 mEq/L

K 4.4 3.5-5.0 mEq/dL

Glucose 139 (H) 70-99 ml/dL

Assessment: Nutrient Needs

Nutrient Estimated Based on Meets Needs?

Nutrient Needs
Calories 1,475- 1,770 Based on the EAL Formula does not meet the
kcal/day requirements: normal BMI and needs for daily intake.
facility's guidelines for
maintaining weight Jevity 1.2 provides
1200kcal/day
Protein 89-118 gm According to the EAL older Jevity 1.2 provides: 55gm
protein/day. adults with stage III and IV PU PRO/day
requires 1.5-2.0 gm/kg protein
per day for wound healing Does not meet faily requirement
Fluid 30ml/kg: 1770 The European Society for Does not meet daily
ml/day Clinical Nutrition and requirements
Metabolism (ESPEN) guideline
1.5-2.0 L/day
 Diagnosis and Intervention # 1:
❖PES statement # 1:
Swallowing difficulty (NI-1.1) related to dysphagia as evidenced by NGT placement for nutrition
needs.
❖ Intervention # 1:
Enteral Nutrition (ND- 2.1)
• Insert Enteral Feeding Tube ND-2.1.7
• Recommend Jevity 1.2 (1000 mL) @ 55 mL providing 1200 kcal (19 kcal/ kg), 55 gm PRO
(0.9 gm/ Kg), 1256 mL free water (20mL/kg).
• Formula was used to monitor tolerance of feed, inadequate to meet needs.

❖ Medical intervention # 1
Nutrition support solutions offer protein, energy, minerals, and vitamins regardless of
the underlying medical condition.
 Diagnosis and Intervention # 2:
❖PES statement # 2:
Inadequate Energy Intake (NI-1.4) related to decreased oral intake as evidenced by significant
weight loss of 20.7 lbs. x 2 months.
❖ Intervention # 2:
❖ Enteral Nutrition (ND-2.1)
• Modify composition of enteral nutrition ND-2.1.1.
• Upgrade formula to Glucerna 1.2, 1500ml, 90gm protein and 1210 ml free water with a higher
kcal and protein concentration.
• Provides 1800 kcal, 90 gm PRO, 1845 mL free water, 2135 mL total volume.

❖ Medical intervention # 2
• Prescirbed Glucerna 1.2, therapeutic formula designed for diabetics to control glycemic index
 Monitor and Evaluation Goals:
❖ Enteral Nutrition Intake 41 (FH-1.3.1):
• Resident will tolerate tube feeding volume x 90 days
• Resident will tolerate composition with no signs or symptoms of n/v/c/d x 90 days
❖ Body Composition/ Growth/ Weight History: Weight 42 (AD-1.1.2):
• Resident will maintain current weight of 129.7 lbs. x 90 days
❖ Nutrition-Focused Physical Findings: Skin:
• Pressure injury stage 3 will be WNL x 90 days
❖ Glucose/Endocrine Profile 44 (BD-1.5.1):
• Resident will be free of glycemic episodes x 90 days
❖ Nutritional Anemia Profile (BD-1.10)
• Resident hemoglobin and hematocrit labs will be WNL x 90 days

❖ Energy Intake: (FH-1.1.1.1)

• Monitor energy intake x 90 days to ensure that 17kcal/mL is adequate to prevent weight loss of more than
4 lbs.
Monitor and Evaluation Follow up Care

Follow up Follow up with speech language pathologist regarding dysphagia

Follow up Follow up with endocrinologist regarding high blood glucose levels

Follow up with RD regarding tolerance and intake, provide nutrition intervention as

Follow up warranted

Follow up and Follow up and monitor new labs as available

monitor
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