Bedside Assessment and Evaluation 2023 with complete solution GRADED A+

Bedside Assessment and Evaluation 2023 with complete solution GRADED A+ Assessment vs Evaluation - Evaluation: Gathering and calculating data. Coming up with a rehab diagnosis Rehab Dx Medical Dx Assessment: Determining the course of action. Coming up with a plan of intervention. A vs E cont - Gathering information Relating information to the patient -History -Current status -Diagnosis -Prognosis -Wishes Planning and Recommendations Flowchart - Data/Observations By themselves, are simply pieces of information. Must be related to comorbidities and other considerations Comorbidities = additional diagnoses and the effects of those diagnoses on the organism. In our case, the cumulative effect on swallowing, tolerance of aspiration, risks of malnutrition, dehydration Patient wishes (don't forget about the Px, have another party make the informed choice) - Talk to potential risk and benefits (cognizant and aware of all the information) Every evaluation begins... - ...with a QUESTION. For example: "Can this patient be fed?" Can this px eat? "Can this patient tolerate thin liquids?" What can this px eat? Without complications of aspiration. "Can this patient eat coleslaw?" "She hates her ground meat. Does she need it?" "Can she take her pills with water?" "She's coughing; what should we do?" "This child's not gaining weight." ("failure to thrive" cases) Etc..... The Questions... - ...will differ by PATIENT ... tend to differ by SETTING More likely to have the PO/NPO question in acute care (certainly can have it in the SNF!) - HIGH PRIORITY (esophageal compression) - breast CA met then press on esophagus More likely to have the 'advancing consistency' question in the Rehab hospital/ SNF (can have it in the hospital!) Nutrition/weight less of an issue for adults in acute care (except inpatient kids who are admitted with issues)...people generally have a NEW EVENT. KNOW THE QUESTION... but don't be LIMITED to the question For example - If the question was about thin liquid tolerance, and you see a huge Zenker's, REFER to GI. If the question was about solid consistency, and you find .... Clinical (not bedside) Assessments - Evaluations should begin with a bedside assessment, also known as a "CLINICAL EXAM". CSE. BSE. Bedside. Chairside. EVERY swallowing evaluation SHOULD have a bedside or clinical exam. Even outpatient videos SHOULD HAVE a clinical component. The bedside assessment should provide you with much information such that you may not need an instrumental exam (If you are doing an outpatient video, obviously you do it anyway.) (No swallow response = no need for video) If you decide you do need an instrumental exam, the bedside should help you to determine what questions you need to answer. *Components - BIG interview, OPM Components of the Clinical Swallowing Exam (CSE) (instead of Bedside) - Chart review Patient Interview Clinical Examination (many steps) Impressions/recommendations further assessment? if so, what kind of further assessment? Reporting and communicating findings Follow-up Medical Record Review - We have spent a lot of time over the past months discussing medical conditions. It's important to have an understanding of the medical conditions that the patient presents, as well as the history. (physical capabilities, medication, dx, comorbidities) The history is a VITAL part of the assessment. The history is what makes this patient "more than a mouth and a pharynx." How has her problem developed? How is she dealing with it? First, you must know what you're dealing with - How many items from the medical record can you think of? MD order, H&P, consultations, lab results, x-rays, MD notes, nursing notes, medications, operative reports, progress notes from various disciplines. Advance directive* (end of life) Standard end of life orders* Current MD orders* (NPO = not automatically means tube feeding, they can't get anything until you evaluate px) Current DIET orders* Current Allergies* - e.g. if px is allergic to latex (gloves) List of Diagnoses (Dx)* Attending = Hospitalists PHYSIATRIST - rehabilitation medicine (see your px during acute care) - see your px's ability to rehabilitate/ transition to rehab Narrowing the focus (Murray, 1999) - Review reports that provide information regarding medical conditions contributing to the presence of dysphagia (when did it happen, what kind, how they managed it, is in anticoagulants now? tPA?) Review any prior dysphagia evaluation reports, progress reports Review reports that provide info related to the physical condition of the patient that may be affected by the presence of dysphagia (weight loss, skin breakdown) Questions I Can Answer from a Chart Review - What disease processes are present? What surgical procedures have been done? What is airway status - and history? What is the pulmonary status? Recent CXR ? How does she currently obtain nutrition/hydration? How has meal completion/compliance been? How is TF (tube feeding) tolerated, if present? How has her weight been? Any evidence of dehydration ? What disease processes are present? - Look for vascular disorders like (diabetes, hypertension, atherosclerosis (ASCVD), aneurysm) Look for degenerative disorders, like (PD, ALS, Alzheimer's, MS, Huntington's) - insidious cognitive issues Look for neuromuscular disorders, like (dysarthria, AOS, CP, polymyelitis) Look for potential medication reaction. Look for GI disturbances (reflux, GERD). Look for evidence of long term difficulty, like malnutrition, dementing conditions, anorexia/ cachexia - muscle wasting (dementing conditions - affects tissue generation), skin breakdown/ bed sores What surgical procedures have been done? WHAT TO LOOK FOR! - Anterior cervical spine surgery - these patients (dx such as spondylosis, fractures, etc.) require an ANTERIOR access to the spinal column. Can result in neurological damage, PARTICULARLY TO PHARYNGEAL CONSTRICTORS . Dysphagia ~50% of cases (most common is pressure on nerves due to edema) - education, counseling, re-eval Carotid Endarterectomy - 5-50% of patients have CN damage. Esophageal surgery (stretching of esophagus, anastomosis) Head/neck surgery - esp. oral cavity, laryngectomy (neopharynx, neosophagus) Any surgery can have side effects from intubation and/or anesthesia (airway don't close) - voice = overlaid function, biological function = airway protection Radiation therapy/chemotherapy (preventative - ROM, oromotor program - prior and all the way through radiation) What is airway status - and history? - Is there a tracheostomy? Was there a tracheostomy or was the pt orally intubated? Is there a stoma? Any evidence of FISTULA (air escape) (radiation pxs don't heal well)? (Patients who have had radiation tx often have difficulty healing and are more prone to fistula) Is he currently on O2, n/c (nasal cannula), or face mask, or on the ventilator? Pulse oximetry = oxygenation in the blood Is it reasonable to do the eval? (trial of oral diet = follow policies and protocol) (nursing assessment? MD permission?) (We are going to talk more about artificial airways another day) (**lab**) What is the pulmonary status? - "What's up with his lungs?" Any congestion , pneumonia ? What does the most recent CXR (chest x-ray) suggest? Aspiration pneumonia receive more reimbursement compared to other pneumonia dx. Is he running a temp? If so, is there a UTI ? Or an infected bedsore ? (These can also cause a temp) Is he congested ? Can he clear his secretions ? Is he a chronic COPD (chronic obstructed pulmonary disease) patient? (shortness of breath that impacts timing of swallow) Is he a CHF (congestive heart failure) patient? They often sound congested. (pneumonia = elevated white blood count = infection) 4,500-10,000 white blood cells/mcl (cells per microliter) Pitting edema (sx of CHF px) What does the CXR tell me? - Back in the day, they used to say that "aspiration was located in a Right Lower Lobe (RLL) infiltrate." (upright bias) R tracheal branch leaves carina at higher level. However, now it is more often NOT assumed that R base infiltrate = aspiration; it depends on the position of the px when she aspirates It is difficult to impossible for the radiologist to DX pneumonia with a film. "consistent with sypmtoms seen", clinical correlation recommended. Additionally, there is no evidence on film as to where the infiltrate originated. There are financial reasons for a dx of aspiration pneumonia to be listed, as well. How does she currently obtain nutrition/hydration? - Is she currently on an oral diet, or is she NPO ? If on an oral diet, what consistency? What other factors impact her p.o. intake- diabetes, allergies, religious, etc.(NCS - no concentrated sweets, sugar substitutes provided), 2gNA - no salt, no ham; NKA (no known allergies), NKD