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has a history of eating or swallowing prob lems. If the admitting diagnosis includes terms such
as dysphagia, dehydration, eating difficulties, swallowing prob lems, failure to thrive, aspiration
pneumonia, and so forth, the dysphagia evaluation usually includes a video swallow study. (See
the section Instrumental Dysphagia Diagnostics for a detailed discussion of this radiographic
procedure.) Admission with a previous diagnosis of swallowing impairments usually warrants
an instrumental assessment, although a bedside screening may also be conducted. Review of the
patient’s medical history also provides information about disorders that compromise the patient’s
respiration, such as chronic obstructive pulmonary disease, emphysema, and pneumonia. The
review includes previously diagnosed speech pathologies, including laryngeal dysfunctions that
may impair the vocal folds’ protective functioning during the swallow. It also provides information
about the patient’s general cognitive functioning and use of medi cations affecting awareness,
saliva creation, and motor control.
In the clinical/bedside evaluation, the patient’s swallowing normalcy or functionality during
the three swallowing phases is checked. This can be scored by using a modified Likert scale,
where normalcy or functionality is listed as a numerical range (Tanner & Culbertson, 1999a).
For patients who are NPO (nothing to be given to them orally), their be hav iors are assessed
indirectly by observing their oral- motor functioning. If the patient is receiving food and liquids
orally, the best time to do the clinical/bedside evaluation is during mealtime. In the oral phase,
the patient’s ability to accept food, masticate, and create a bolus is assessed. For liquids, lip seal
and containment are also observed. Food and liquid transportation to the posterior oral cavity is
assessed, and observations are made about impulsivity and pocketing, in which the patient places
the bolus or particles of food in the cheek and neglects to clear them.
In the pharyngeal phase, the clinician determines whether the patient can initiate the swallow
purposefully and automatically. Velopharyngeal competence is tested by having the patient say
“ah” and observing the movement of the soft palate and pharyngeal walls. The gag ref lex is tested
Figure 7-1. Three stages of the
swallow.