Call the patient by their name and observe |
Is there difficulty in keeping awake?
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Does not respond, drowsy, needs verbal and tactile stimulation in order to stay alert |
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Check their clinical history |
Was there intubation for more than 24 hours?
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- |
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Check their clinical history and observe the patient |
Was there use of a tracheostomy tube?
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- |
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Observe the respiratory pattern |
Are there signs of respiratory discomfort?
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Shortage of breath, difficulty to breath, tiredness, use of accessory muscles, increased respiratory frequency |
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Ask the patient, Escort or check the patient’s chart |
Is there history of swallowing difficulty?
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Choking, coughing during feeding, use of alternative feeding pathway, need to previously adapt the diet. |
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Position the patient sitting down with their elevated decubitus |
Is there difficulty in being sitting down with a straight head?
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Does not control the head and/or torso even when supported |
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Ask the patient their names and request them to open and close their eyes |
Is there difficulty in understanding simple verbal commands?
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Is not able to respond, cannot or has difficulties to follow commands, needs gestures in order to perform the commands |
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Observe the voice of the patient during the conversation |
Is there alteration in voice?
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Hoarse voice, no sonorization, or little sonorization |
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Observe the speech and language of the patient during the spontaneous conversation |
Is there difficulty in speech and/or language?
|
Does not speak, dragged speech, alterations in articulation (dysarthria), difficulty to understand the speech, fragmented oral expressions, incoherent speech |
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Observe their face at rest and request a pout and a smile |
Is there facial asymmetry?
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Reduction or total absence of movement of one of the sides of the face |
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Ask the patient to move their lips and tongue |
Is there difficulty in moving lips and tongue?
|
Does not present movement, slow movements, movement deviation |
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Observe if the patient swallows their saliva (rising larynx movement) spontaneously or on command |
Is there difficulty in swallowing or managing saliva/secretions swallowing spontaneously or on command?
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Does not observe swallowing, saliva accumulation in the oral cavity, drooling, wet voice, noises in respiratory trait |
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Stage II (Signs and symptoms)- observations of the first meal |
Instructions |
Questions |
Possible outcomes |
Yes |
No |
Does not apply |
Observe the swallowing of food (larynx rising) |
Is there difficulty in swallowing the volume in the mouth?
|
Take too long to swallow, does not swallow, needs constant verbal orientation to swallow |
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Observe the oral region |
Is there leakage of any food consistency from the oral cavity?
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Leakage of food from the mouth |
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Observe the larynx rising |
Was there swallowing of more than 3 times the portion placed in the mouth?
|
Swallows more than 3 times |
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Observe the signs |
Is there throat clearing, coughing, and/or choking during meals?
|
Coughing, throat clearing, and/or choking during meals |
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After the patient swallows, observe their oral cavity |
Is there residue of any food consistency in the oral cavity after swallowing?
|
Food accumulation inside the mouth |
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Observe the respiratory pattern during the meal (disregard previous discomfort) |
Are there signs of respiratory discomfort during meals?
|
Shortage of breath, difficulty to breath, tiredness, use of accessory muscles, increased respiratory frequency, fall in oxygen saturation |
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