Written Assessment Part B
Improving Clinical Practice – Reviewing & Evaluating the relationship between learning strategies and practice improvement
In geriatric care, swallowing assessment is an important evaluative process because the results have important implications to the health of the elderly patients. In actual practice, nurses usually initially do the application of the swallowing assessment because they take charge of feeding and swallowing assessment is needed in determining the ability of the elderly patient to take in food (2002). Moreover, nurses frequently attend to the needs of geriatric patients (2000) as part of regular routine checks or evaluate changing conditions of patients that could become critical. This means that it is important for nurses to recognize the importance of conducting the swallowing test, master the application of the test, and accurately understand or interpret the results. Practical knowledge in applying swallowing assessment is achieved through the learning derived from theoretical sources that are tested through actual observations and case experiences of nurses. It is important for carers to become perceptive of learning derivable from experience and reflect on the new things learned as well as the corroboration of theoretical learning from actual practice or experience. The direction of continuous learning should be towards the enhancement of knowledge and skills directed towards improving the care for patients.
Existing literature points to the need for carers to view swallowing as an important assessment measure for the condition of elderly patients. Swallowing dysfunctions such as dysphagia constitutes a general problem for geriatric patients (2000) more than younger patients. Estimated pervasiveness of dysphagia for the younger age groups is from 25 percent to 45 percent in patients receiving acute care ( 2003) while in the elderly patients the dysphagia prevalence ranges from 60 percent to higher percentages. This means that carers of geriatric patients need to perceive swallowing dysfunctions as important determinants of the condition of the patient and recognize the need to use the swallowing test to assess the ability of the patient to ingest food and the overall condition of elderly patients.
Reasons for the higher prevalence of dysphagia in the older age group vary. (2000) explains that neurological conditions prevalent in the elderly cause swallowing dysfunctions. (2001) and together with S (2001) add that stroke diseases could contribute to the dysfunction in the swallowing capabilities of patients. (2002) and , (2002) explain that the neurological condition Parkinson’s disease could impair the speech and motor skills of patients resulting to swallowing disorders. (2001) discuss that dementia could also result to dysphagia because of changes in behaviour and physiology of swallowing of elderly patients exhibiting dementia. If the swallowing disorder of patients is not detected, this could lead to dehydration and malnutrition as well as the impairment of the overall quality of life or health of the elderly patient. (2002) further explains that ageing has a recognized link to changes in the physiology of the elderly that also affects the swallowing process. Swallowing assessment serves the important purpose of determining the symptoms of elderly patients, to determine the particular cause of the exhibited dysphagia and apply the appropriate intervention. The different causes of dysphagia also entail various interventions and the carer needs to identify the cause to determine the applicable intervention. Carers can achieve this by recognizing the importance of swallowing assessment and mastering this process.
Apart from the prevalence of dysphagia in the elderly, (2003) provide that swallowing dysfunction also constitutes a salient reason for morbidity and mortality for the older age group. Swallowing disorder constitutes a significant risk factor that could lead to aspiration pneumonia. This condition then has a strong link to the mortality rate reaching 45 percent of elderly patients receiving hospital care for aspiration pneumonia. This means that preventing and managing the aspiration of elderly patients together with the complications that could occur are important. Even during the early stages of hospitalization, carers should be able to identify the elderly patients experiencing swallowing difficulties to prevent and anticipate possible future complications. Again, competence of carers in applying swallowing tests becomes important in assessing the swallowing conditions of elderly patients from the commencement of their hospitalization and extending throughout the duration of the care.
In evaluating the swallowing condition of elderly patients, bedside assessment is the common screening tool. Dysphagia is a swallowing dysfunction occurring in four stages, which are oral preparatory, oral, pharyngeal and esophageal ( 2003). The severity of the swallowing dysfunction of the elderly patient depends upon the observed or recorded symptoms derived from the bedside swallowing assessment. This means that nurses should know what risk factors to look for in assessing the severity of the swallowing condition of the patient. In the case of determining whether the elderly patient can ingest food, the first level of observation is the whether the elderly patient exhibits LOC impairment, secretion management difficulties, wet voice sound, and coughing or choking when the patient is administered with small amounts of liquid or solid food based on the patient’s remarks or the family of the patient. In case the patient does not exhibit any or all of these symptoms, then this means that the patient can support the oral ingestion of food. Further test is the water swallowing evaluation. The elderly patient should be in a sitting position and administered with small amount of cool water while the nurse places the middle and index fingers over the tyroid cartilage of the patient. If the patient takes a sip and the nurse feels a difficulty of the patient in ingesting the water, then this means that the patient has a swallowing dysfunction and oral food should be stopped. If the patient can orally ingest fluids, a similar test should be made for solid food to determine the type of food that the patient can ingest orally. The severity of the swallowing dysfunction of the patient depends upon the observation of more symptoms.
Apart from conducting the swallowing test to determine the capability of the elderly patient to take in food, the bedside test could also determine the cause of the swallowing problem. Stroke disease is the cause of the swallowing disorder when the physiological changes in the elderly patient attributable to the stroke are directly linked to the concurrent difficulties of the elderly patient in swallowing. Parkinson’s disease is the cause of dysphagia when the elderly patient exhibits impairment of speech and motor skills that also affects the ability of the elderly patient to swallow. Dementia is the primary cause of the dysphagia when the elderly patient shows behavioural changes that affect the ability to swallow.
Depending upon the extent and the cause of dysphagia, the carer determines the intervention such as recommending the shift from oral to intravenous feeding if the cause is stroke or Parkinson’s disease and the treatment of the dementia to bring back the swallowing capability of the elderly patient. The determination of the proper intervention happens on a context basis since even patients with similar symptoms may require different interventions. This means that carers should be able to perceive specific needs based on the extent and range of their experience with dysphagia. However, the problem is the lack of simple clinical tools specially developed to test for swallowing dysfunction in the case of geriatric patients for application in a general ward context. Moreover, divergent views over the effectiveness of different swallowing tests without determining tests that work in the general ward context resulted to the minimal importance given to the development of swallowing tests or measures derived from best practices in the context of geriatric care.
Clinical indices used in swallowing tests have been subject to differing opinions. Earlier literature discusses the significance of using indices in determining swallowing dysfunction in elderly patients. Indices tested include the amount of water that geriatric patients are able to swallow and the extent that patients can manage saliva. In these studies, these indices were useful in determining elderly patients with dysphagia and the extent of their swallowing disorders. However, these indices have been criticized in a number of studies. (2000; 2003) criticize existing clinical indices as lacking in sensitivity to validly identify patients with swallowing dysfunction and lacking in specificity to determine the cause of the dysphagia. While the claims of these critical studies have pointed out the limitations of existing indices, these have not been able to provide alternative indices. This means that effectively applying the swallowing test depends upon the knowledge and experiences of healthcare professionals working in various areas of healthcare. In the case of the nursing practice, there is need to develop clinical indices for standard use in different major healthcare areas such as geriatric care. Indices find bases from the experiences of nurses in geriatric care so that reflective assessment of experiences coupled with information sharing becomes a crucial aspect of the determination of standard indices able to accurately identify the elder patients with swallowing dysfunction, determine the extent of dysphagia, and link the swallowing disorder symptoms to the specific cause or causes of the dysphagia.
Bulk of existing literature is highly focused on only two patient groups. The first group of patients comprises those who have recently experienced stroke. This group was not delineated according to age group so that these have not taken into consideration differences in the physiological factors that could differentiate the experiences of younger age groups and the elderly who have experienced stroke. The second group of patients is made of those patients who have been confined in facilities offering long-term care. This grouping also involves a wide range of patients from geriatric patients to the patients undergoing rehabilitation for physical or mental impairments. There could also be significant differences in the symptoms and causes of swallowing disorder among these different patient classifications requiring various interventions or treatments. Only a limited number of studies focusing on dysphagia as experienced by elderly patients who have become acutely ill have been made or dysphagia brought about by age-based causes. This is important in order to develop best practices on swallowing tests and indices that apply in the specific context of geriatric care. The development of best practices could also encourage healthcare workers to apply these tests in elderly patients receiving care even in the ward setting. Nursing practitioners would be able to apply swallowing tests for different patient contexts to derive accurate results and interpret the results based on the specific healthcare context of the patient. Due to these limitations in existing literature, reflective nursing practice is necessary to develop swallowing assessment measures based on geriatric care practice. Moreover, sharing of information is important to develop standards in swallowing assessment that comprises the criteria for applying swallowing tests but also assessing the accuracy of the reporting of observations, interpretation of observations, and recommendation of alternatives.
Apart from developing standard swallowing assessments and interpretation of results, (2000) suggest the need to introduce a simple but effective swallowing test for elderly patients. They suggested the swallowing test that measured age-based changes in the swallowing physiology of elderly patients such as delayed swallowing using the water test together with measures to determine aspiration risks such as coughing when swallowing, drooling, and dysphonia or voice alterations. The measures considered in the test recommended by the authors were based on the integration of various tests, which when considered individually will not lead to accurate results but if taken together increase the reliability of the results and the interpretation of the observations. This constitutes a simple swallowing assessment developed especially in the context of geriatric care. In relation to nursing practice, knowing this simple test would empower nurses to identify patients with swallowing disorder and collaborate with other healthcare professionals such as doctors and speech therapists in interpreting the results and determining the appropriate intervention or treatment that would improve the health and well-being of elderly patients. Moreover, in case of differences in interpretation or treatment recommended, the results of the simple swallowing assessment constitute the determining factor.
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