DYSPHAGIA IN STROKE

ROHMAN AZZAM, SPd, S.Kep, M.Kep, Ns, Sp.Kep.M.B.

 Objectives
Student will be able to:
• Understanding standardized terminology
• Defined dysphagia appropriatly
• Find the facts about incidence of dysphagia
• Understanding swalowing mechanism
• Identiciation neural regulation of swallowing
• Dampak dysphagia
• Mengidentifikasi fokus perawatan ps dysphagia
• Mengenali tanda dan gejala dysphagia
• Manajemen nutrisi dan mencegah pneumonia aspirasi
 Terms
1. Aspiration: removal of substance by suction; breathing of
fluids or foods into the trachea and lungs
2. Bolus: a feeding administered into the stomach in large
amounts and at designated intervals
3. Duodenum: the first part of the small intestine, which arises
from the pylorus of the stomach and extends to the jejunum
4. Enteral nutrition: nutritional formula feedings introduced
through a tube directly into the gastrointestinal tract
5. Gastrostomy: surgical creation of an opening into the
stomach for the purpose of administering foods and fluids
 Terms
6. Nasoduodenal tube: tube inserted through the nose into the
proximal portion of the small intestine (ie, duodenum)
7. Nasoenteric tube: tube inserted through the nose into the
stomach and beyond the pylorus into the small intestine
8. Nasogastric (NG) tube: tube inserted through the nose into the
stomach
9. Nasojejunal tube: tube inserted through the nose into the second
portion of the small intestine (ie, jejunum)
10. Orogastric tube: tube inserted through the mouth into the
stomach.
11. Parenteral nutrition (PN): method of supplying nutrients to the
body by an intravenous route
12. Percutaneous endoscopic gastrostomy (PEG): a feeding tube
inserted endoscopically into the stomach
 Definition
• Difficulty swallowing (dysphagia) means it takes
more time and effort to move food or liquid from
your mouth to your stomach. Dysphagia may also
be associated with pain. In some cases,
swallowing may be impossible.
• Dysphagia is a condition in which disruption of
the swallowing process interferes with a patient’s
ability to eat. It can result in aspiration
pneumonia, malnutrition, dehydration, weight
loss, and airway obstruction.

(Paik, 2014; Mayo Clinic Staff, 2014)

 Incidence Rate
• The incidence rates are: 29-67% in acute
stroke patients.

(Martino et al. 2005 dalam Teasell, Foley, Martino, Richardson, Bhogal, & Speechley, 2013).
 Normal Swallowing (1)
Swallowing has four sequential coordinated
phases:
1. Oral preparatory phase,
2. Oral propulsive phase,
3. Pharyngeal phase
4. Esophageal phase.
 3 Phases of swallowing
Dysphagia can be secondary to defects in any of
the 3 phases of swallowing, which are as
follows:
• Oral phase: Which involves the oral
preparatory phase and the oral transit phase
• Pharyngeal phase
• Esophageal phase
 Normal Swallowing (2)
1. Oral Preparatory Phase.

• Food in the oral cavity is manipulated and

masticated in preparation for swallowing.
• The back of the tongue controls the position
of the food, preventing it from falling into the
pharynx.
 Normal Swallowing (3)
2. Oral Propulsive Phase.

During the oral propulsive, the tongue transfers

the bolus of food to the pharynx, triggering the
pharyngeal swallow.
 Normal Swallowing (4)
3. Pharyngeal Phase.
• During the pharyngeal phase, complex and
coordinated movements of the tongue and
pharyngeal structures propel the bolus from the
pharynx into the esophagus.
• The closing of the vocal cords and the backward
movement of the epiglottis prevents food or
liquid from entering the trachea.
 Normal Swallowing (5)
4. Esophageal Phase.

During the esophageal phase of swallowing,

coordinated contractions of the esophageal
muscle move the bolus through the esophagus
towards the stomach.
 Neural Regulation of Swallowing (1)
• Swallowing is initiated by sensory impulses transmitted
as a result of stimulation of receptors on the fauces,
tonsils, soft palate, base of the tongue, and posterior
pharyngeal wall.
• Sensory impulses reach the brainstem primarily
through the 7th, 9th, and 10 cranial nerves, while the
efferent (motor) function is mediated through the 9th,
10th, 12th cranial nerves.
• Cricopharyngeal sphincter opening is reflexive,
relaxation occurring at the time when the bolus
reaches the posterior pharyngal wall prior to reaching
this sphincter.
 Neural Regulation of Swallowing (2)
• Cranial Nerves
– CN V -- Trigeminal
• contains both sensory
and motor fibers that
innervate the face
• important in chewing
– CN VII -- Facial
• contains both sensory
and motor fibers
• important for sensation of
oropharynx & taste to
anterior 2/3 of tongue
– CN IX -- Glossopharyngeal
• contains both sensory and motor fibers
• important for taste to posterior tongue,
sensory and motor functions of the
pharynx
– CN X -- Vagus
• contains both sensory and motor fibers
• important for taste to oropharynx, and
sensation and motor function to larynx
and laryngopharynx.
• important for airway protection
– CN XII -- Hypoglossal
• contains motor fibers that primarily
innervate the tongue
 Dampak Dysphagia
• Berisiko tersedak, drooling, aspirasi, atau
regurgitasi.
• Berisiko kekurangan nutrisi

Smeltzer, Bare, Hinkle, & Cheever. (2010). Brunner & Suddarth’s textbook of med-Surg nursing. (12th ed.). Lippincott: Williams & Wilkins.
 Fokus Keperawatan
• Mempertahankan keamanan/keselamatan
pasien melalui pencegahan aspirasi
• Memastikan status nutrisi adekuat

Smeltzer, Bare, Hinkle, & Cheever. (2010). Brunner & Suddarth’s textbook of med-Surg nursing. (12th ed.). Lippincott: Williams & Wilkins.
 Signs & Symptoms (1)
Oral or pharyngeal dysphagia:
• Coughing or choking with swallowing
• Difficulty initiating swallowing
• Food sticking in the throat
• Sialorrhea
• Unexplained weight loss
• Change in dietary habits
• Recurrent pneumonia
• Change in voice or speech (wet voice)
• Nasal regurgitation
 Signs & Symptoms (2)
Esophageal dysphagia:
• Sensation of food sticking in the chest or
throat
• Change in dietary habits
• Recurrent pneumonia[1]
• Symptoms of gastroesophageal reflux disease
(GERD), including heartburn, belching, sour
regurgitation, and water brash
 Pemeriksaan Saraf Kranial IX (Glosofaringeus)
dan X (Vagus)
Cara pemeriksaan Kemungkinan temuan abnormal

Berikan minum sedikit air, lalu obs kemampuan
menelan.
Observasi kesimetrisan peningkatan soft palate
dan uvula saat pasien mengatakan “ah”
Kaji reflek muntah (gag) dg menyentuh bagian
belakang tenggorokan menggunakan spatula
lidah
Kaji kemampuan pasien untuk merasakan asin,
manis, sour/asam pada bagian sepetiga posterior
lidah.
Dysphagia (kesulitan menelan) adalah
masalah yang sering ditemukan. Hal
ini terjadi akbiat gangguan aliran
darah ke arteri vertebrabasiler dan
bagian posteroinferior, anteroinferior,
atau arteri serebral superior.
Kehilangan reflek menelan unilateral
terjadi pada lesi yang mengenai saraf
kranial IX dan X.
 Assisting With Nutrition
• Dispagia pada stroke akibat terganggunya fungsi mulut,
lidah, palatum, larynx, pharynx, atau bagian atas esopagus.
• Obs pasien thd:
– Batuk paroksisme (tiba-tiba),
– Pergerakan makanan keluar mulut
– Terkumpul makanan ke salah satu sisi mulut
– Makanan tertahan lama di mulut
– Pengeluaran makanan melalui hidung
• Kesulitan menelan meningkatkan risiko:
– Pneumonia aspirasi
– Dehidrasi
– Malnutrisi.
 Assisting With Nutrition
• Evaluasi kemampuan menelan.
• Jika fungsi menelan sebagian terganggu, maka:
– Pikirkan alternatif teknik menelan
– Sarankan menelan bolus makanan lebih kecil
– Makan makanan yang lebih mudah ditelan
– Mulailah diet cair, tingkatkan bertahap sesuai kemajuan ke makanan
cair kental
– Posisikan pasien tegak, lebih baik lagi jika di kursi, bukan di tempat
tidur
– Instruksikan sedikit fleksi ke arah dada untuk cegah aspirasi.
– Jika tidak dapat menerima intake via oral, maka dapat dipasang
gastrointestinal feeding tube.
 Assisting With Nutrition
• Selang nasogastric (hingga gaster) atau nasoenteral (di
duodenum) untuk menurunkan risiko aspirasi.
• Tanggung jawab keperawatan:
1. Elevasikan tempat tidur bagian kepala sedikitnya 30o untuk
mencegah aspirasi
2. Periksa posisi selang sebelum memberikan makan
3. Pastikan cuff tracheostomy (jika terpasang) dalam keadaaan
mengembang
4. Berikan makan perlahan.
5. Aspirasi selang secara periodik untuk memastikan makanan
telah melawati saluran gastrointestinal. Makanan yang
tertahan/tersisa akan meningkatkan risiko aspirasi.
• Untuk poemberian makan jangka panjang, lebih baik
menggunakan gastorstomy tube.
Tips Keamanan Saat Pasien Makan
1. Pastikan posisi pasien duduk tegak.
2. Pastikan leher pasien sedikit fleksi.
3. Makana saring atau lunak.
4. Berikan makanan/ajarkan pasien agar menempatkan
makanan di sisi mulut yang sehat.
5. Mintalah pasien menelan satu makanan pada satu waktu.
6. Bila selesai makan, periksalah mulut akan kemungkinan
adanya makanan terselip terutama di sisi mulut yang sakit.
7. Selalu siagakan peralatan suction disisi tempat tidur untuk
antisipasi terjadinya sumbatan jalan napas atau aspirasi

Le Mone & Burke (2000). Med-Surg nursing: Critical thinking in client care. (2nd ed.). Toronto: Prentice Hall Canada Inc.
 Treatment (2)
Dietary treatment:
• Dietary modification is the key component in the general
treatment program of dysphagia.
• Diets for patients with dysphagia include the following:
– Dysphagia diet 1: Thin liquids (eg, fruit juice, coffee, tea)
– Dysphagia diet 2: Nectar-thick liquids (eg, cream soup, tomato juice)
– Dysphagia diet 3: Honey-thick liquids (ie, liquids that are thickened to a honey consistency)
– Dysphagia diet 4: Pudding-thick liquids/foods (eg, mashed bananas, cooked cereals, purees)
– Dysphagia diet 5: Mechanical soft foods (eg, meat loaf, baked beans, casseroles)
– Dysphagia diet 6: Chewy foods (eg, pizza, cheese, bagels)
– Dysphagia diet 7: Foods that fall apart (eg, bread, rice, muffins)
– Dysphagia diet 8: Mixed textures
 Treatment (3)
Because fluid intake is restricted in most patients with
dysphagia, these individuals are at risk of dehydration.
Therefore, the patient's hydration status must be
closely monitored.
 Treatment (4)
Exercise and facilitation techniques
The following types of exercise can be recommended to
patients with dysphagia:
• Indirect (eg, exercises to strengthen swallowing
muscles)
• Direct (eg, exercises to be performed while
swallowing)
 Treatment (5)
• Facilitation techniques used in the treatment
of dysphagia include the following:
– Somatosensory stimulation: In the form of an
electrical current applied to the pharynx
– Deep pharyngeal neuromuscular stimulation
(DPNS)
– Tactile-thermal stimulation (TTS)
 Treatment (6)
Compensatory techniques
Maintaining oral feeding often requires compensatory
techniques to reduce aspiration or improve pharyngeal
clearance. These include the following:
• Use of the chin-tuck position (sedikit fleksi)
• Rotation of the head to the affected side
• Tilting of the head to the strong side
• Lying on one's side or back during swallowing
• Supraglottic swallow
• Bolus-clearing maneuvers
 Treatment (7)
Enteral feeding:
• Nasogastric tube (NGT) feeing
• Oroesophageal tube feeding
• Percutaneous endoscopic gastrostomy (PEG)
 Treatment (8)
Surgery for chronic aspiration
• Medialization:
This helps to restore glottic closure and subglottic pressure during
the swallow
• Laryngeal suspension:
The larynx is in a relatively protected position under the tongue
base
• Laryngeal closure:
This may be performed to close the glottis off, in this way
protecting the airway at the expense of phonation
• Laryngotracheal separation-diversion:
This procedure may be done to separate the airway from the
alimentary tract
 Treatment (1)
• Medications:
– Botulinum toxin type A (BoNT-A)
– Diltiazem
– Glucagon
– Cystine-depleting therapy with cysteamine
– Nitrates
 Diskusi
Pertanyaan Jawaban:
• Loly: nervus berapa dan bgmn • Diet: pasang ngt, diet cair,
tindakan keperawatan utk bedah.
dysphagia.
• Fatimah: Penanganan
dysphagia menurut jenis
dysphagia.
• Agus: dapat krn kelainan saraf,
tetapi tretmentnya
pembedahan?
• Sulaili:
– edukasi utk keluarga,
mengingat kasus ini dapatr
berlangsung lama
•
 Diskusi, Senin, 22-12-2014
Tanya Jawab
Adeline:
Tampak, lebih mudah makan padat dari
pada cair.
Sakitnya
Eni: Cukup besar pengaruhnya thd asupan
Seberapa besar pengaruh dispagia thd gg nutrisi.
nutrisi? Jika di rumah, pada dispagia berat
dipasang ngt, tetap latihan menelan,
kontrol 3x seminggu bagi kasus berat,
Ari:
Outcome: