LEVEL	RATIONALE	DESCRIPTION
Level 1: Puréed	Suitable for people with severely reduced oral preparatory stage abilities, impaired lip and tongue control, delayed swallow reflex triggering, oral hypersensitivity, reduced pharyngeal peristalsis, and/or cricopharyngeal dysfunction.	Thick homogeneous textures are emphasized. Puréed foods should be “spoon-thick” or “pudding-like” consistency. No coarse textures, nuts, raw fruits, or raw vegetables allowed. Liquid or crushed medications (refer to physician or pharmacist for pharmoefficacy of medications) are required and may be mixed with puréed fruits. Liquids and water are thickened with commercial thickening agent as needed to recommended consistency.
Level 2: Mechanically altered	Intended for patients who can tolerate a minimum amount of easily chewed foods. May be suitable for people with moderately impaired oral preparatory stage abilities, edentulous oral cavity, decreased pharyngeal peristalsis, and/or cricopharyngeal muscle dysfunction.	No coarse textures, nuts, raw fruits (except ripe or mashed bananas), or vegetables, except as noted. Puréed or slurried bread, if necessary. Liquid or crushed medications may still be required (refer to physician or pharmacist for pharmo-efficacy of medications). Liquids and water thickened as needed with commercial thickening agent to recommended consistency.
Level 3: Advanced	Designed for patients who chew soft textures. Based on a soft diet; may be appropriate for individuals with mild oral preparatory–stage deficits.	Textures are soft with no tough skins, no nuts or dry, crispy, raw, or stringy foods. Meats should be moist and tender or casseroles with small chunks of meat allowed. Fluid consistency ordered separately: may be thin, nectar-thick, honey-like, or spoon-thick. Moist potatoes, rice, and dressing allowed. All soups except those with tough meat or vegetables. Soft, peeled fruit without seeds. Moist breads and cereals allowed. All fats except those with chunky additives.

Data from American Dietetic Association: Nutrition care manual, Chicago, 2009, Author. Accessed February 28, 2010, from www.nutritioncaremanual.org.

When caring for patients with dysphagia, several aspects are of concern: bolus consistency, patient positioning, feeding rate, and specific swallowing techniques. Video-fluoroscopy swallow study (VFSS) determines the level of bolus consistency the patient can tolerate. Different physiologic problems dictate the necessity for different consistencies of food. For example, the most common swallowing disorder in older adults who have experienced stroke is a delayed or absent pharyngeal swallow.³

Patients with this type of disorder need puréed foods to provide stimulation that provokes the reflex to swallow. If the pharyngeal swallow is reduced (but not delayed or absent), liquids tend to be the most difficult consistency for patients. Thickening agents can be used to acquire the appropriate consistency. For patients who have lost coordination of the upper esophageal sphincter (cricopharyngeal dysfunction), thin liquids are the most appropriate (see the Personal Perspectives box, The Pain of Parkinson’s Disease).⁴

Personal Perspectives

The Pain of Parkinson’s Disease

When Don Kaemmer met his soon-to-be second wife, Yetta, he was a physically active 70-year-old widower. A few years after they wed, he developed a quickly advancing condition of Parkinson’s disease that significantly affected his ability to speak and swallow. Here are some of Mrs. Kaemmer’s reflections on dealing with her husband’s dysphagia.

The doctor approached me and said, “I know what your husband had for dinner tonight.” I just stared at him and thought how does he know? Hours after dinner that night, an ambulance brought Don to the hospital because of a kidney infection. While examining my husband, the doctor found partially chewed chicken in Don’s mouth and throat. I thought Don swallowed his dinner but apparently not. An example of Parkinson’s effect on daily activity became clear.

As the effects of the disorder progressed, my husband had trouble chewing and swallowing food and medications. I don’t know if he was just too tired, too depressed, or didn’t have an appetite to eat. He frequently looked as if he was wearing a mask with no emotion and said little. I often felt like a cheerleader trying to boost his spirits to get him to eat. How could he stay well if he didn’t eat? I made soft foods like chicken soup with pieces of cut-up chicken and vegetables, split pea soup, puddings, and ice cream. During one hospital stay he had a supplement drink that he was willing to drink at home. It was expensive, so we would get a supply of it from the Veterans Administration because Don was entitled to benefits, having served in WWII. But toward the end, only small spoonfuls of ice cream or sherbet felt good. It took too much energy to drink. Instead of feeding with food, I nourished him by being there.

Yetta Kaemmer

Tamarac, Florida

One of the safest eating positions for patients who have trouble swallowing is upright. If patients cannot sit up by themselves, the head of the bed should be raised to provide support, and pillows and wedges should be used to support arms, head, neck, or trunk when necessary. The upright position allows gravity to assist with the passage of food along the esophagus and helps prevent choking and aspiration.²

Sometimes patients eat too quickly or stuff their mouths too full of food and then choke when trying to swallow. Staff can observe and supervise patients while they eat to remind them to complete the swallowing sequence before taking their next bite of food.

Enlisting the aid of a speech therapist is usually necessary to teach the patient various techniques to compensate for swallowing problems. Techniques include the supra glottic swallow and the Mendelson maneuver. The supraglottic swallow is appropriate for patients with reduced laryngeal function. This method requires teaching the patient to take a breath before swallowing, consciously hold the breath during the swallow, exhale forcefully or cough gently after the swallow, and swallow again to clear the mouth. The Mendelson maneuver is helpful for individuals with cricopharyngeal dysfunction. The patient is taught to elevate the larynx voluntarily to the maximum level during a swallow to allow food to pass. When lubrication is a problem, nursing personnel can also use several techniques to assist the patient. Encouraging the patient to think or talk about food before mealtime can help stimulate the flow of saliva, which aids in the formation of a bolus and the chewing and swallowing process. Tart or sour foods can stimulate saliva production. Having the patient lick jelly from the lips, pucker them, hum, or whistle helps strengthen mouth muscles, which may help the patient, learn to close the lips around a fork or spoon.⁵

Feeding patients with swallowing difficulty is usually the responsibility of nursing personnel. The following safe procedures are recommended:2,6

1. Position patient upright, bent slightly forward, with the chin tucked and head tilted forward.

2. Eliminate distractions so the patient can focus all attention on the meal.

3. The person feeding should sit at or below patient’s eye level while feeding.

4. Avoid asking patient to talk while eating.

5. Instruct the patient not to use liquids to clear the mouth of foods; in fact, they should be used only after the patient has cleared the food from the mouth. Encourage frequent dry swallows or coughing to help clear food from the mouth between bites.

6. Encourage small bites ( to 1 teaspoon solid food or about 10 to 15 mL liquid), especially if patient’s ability to manage food is impaired.

7. Allow adequate time to feed.

8. Use spoons rather than cups because patients have less difficulty taking food and liquid this way.

9. While patient eats, check for voice quality. A wet or gurgled voice indicates food may be resting on the vocal cords.

During the early stages of feeding, nursing supervision is necessary at meals to prevent or minimize swallowing problems. Patients should be reevaluated regularly to determine whether any changes need to be made in the consistency of fluids or food. Evaluating and documenting the patient’s food intake are also prudent to ensure adequate nutritional intake and status. If the patient’s nutritional needs are not or cannot be met orally, alternative methods should be considered.⁷

For patients with dysphagia, mealtime can be made safe and nutritious, but it may be difficult to make eating the pleasure it once was. The one thing nursing personnel can do to make sure meals are as relaxing as possible is to let patients eat at their own pace. Patience on the part of nursing staff may be rewarded with patients who eat with minimal difficulty while maintaining their nutritional status.

Gastroesophageal Reflux Disease, Hiatal Hernia, and Esophagitis

More commonly known as heartburn, gastroesophageal reflux disease (GERD) is a frequent experience for some people. In fact, some consider it a normal state of being and never report the symptoms to their physicians. The reflux usually takes place within 1 to 4 hours after a meal.

Normally, the lower esophageal sphincter (LES) prevents stomach contents from entering the esophagus, but various factors often decrease sphincter pressure (Box 17-2 and Figure 17-3). Unlike gastric mucosa, esophageal mucosa can be damaged when exposed to gastric contents. If not treated, GERD can result in esophagitis (inflammation of the lower esophagus). The reflux is thought to be aggravated by reclining after eating, stress, and increased intraabdominal pressure. Increased intraabdominal pressure can occur with coughing, straining, bending, vomiting, obesity, pregnancy, trauma, ascites, tightly fitting clothing around the waist, lifting heavy objects, and exercising strenuously.² Older patients often experience respiratory symptoms of GERD, such as pneumonitis, chronic bronchitis, or asthma.

BOX 17-2 Causes of Lowered Esophageal Sphincter (LES) Pressure

• Increased levels of progesterone caused by pregnancy, oral contraceptives containing progesterone, late stages of the menstrual cycle

• Hiatal hernia (see Figure 17-3)

• Foods: chocolate, alcohol, mint, carbonated beverages, citrus fruits and juices, tomato-based products, caffeinated products, peppermint

• High-fat diets

• Smoking

GERD is treated medically by reducing intraabdominal pressure and gastric acid production. Medical management can be divided into six stages (Box 17-3 and Figure 17-4). Stages 1 to 4 entail medical management, and stage 5 involves surgical intervention.⁸ Table 17-2 summarizes medications that may be used to treat GERD, as well as their actions. Attention to medical metabolism of these medications and their interaction with other prescribed and over-the-counter medications should be considered, particularly among minority populations (see the Cultural Considerations box, Biologic Variations of Medication Metabolism).

BOX 17-3

Management of Gastroesophageal Reflux Disease

Lifestyle Modifications

• Head of bed elevated 6 inches

• Decreased fat intake

• Smoking cessation

• Weight reduction for obese patients

• Avoid recumbent positions for 3 hours postprandially

• Small, frequent meals

• Avoidance of certain foods (see Box 17-2)

• Avoidance of tight, waist-constricting clothing

As-Needed Pharmacologic Therapy

• Antacid or antacid product containing alginic acid

• Over-the-counter histamine H₂-receptor blocker

• Stool softeners

Scheduled Pharmacologic Therapy

• H₂-receptor blocker or prokinetic agent for 8 to 12 weeks

• For persistent symptoms, high-dose H₂-receptor blocker or proton pump inhibitor for another 8 to 12 weeks (or reconsider diagnosis)

• With documented erosive esophagitis, may use a proton pump inhibitor as first-line therapy

Maintenance Therapy

• Appropriate for patient with symptomatic relapse or complicated disease

• Lowest effective dosage of H₂-receptor blocker or proton pump inhibitor

Surgery

• May be appropriate in patient with severe symptoms, erosive esophagitis, or disease complications

• Laparoscopic fundoplication procedure

Endoscopy

• Stretta procedure (see Figure 17-4)

Data from Scott M, Gelhot AR: Gastroesophageal reflux disease: Diagnosis and management, Am Fam Physician 59(5):1161-69, 1999; Heitkemper MM: Upper gastrointestinal problem. In Lewis SM, Heitkemper MM, Dirksen SR, editors: Medical-surgical nursing, ed 6, St. Louis, 2004, Mosby.

TABLE 17-2

MEDICATIONS USED TO TREAT GASTROESOPHAGEAL REFLUX DISEASE

MEDICATION	ACTION	POTENTIAL ADVERSE EFFECTS
Antacids	Neutralize gastric acid
Aluminum salts (AlternaGEL, Alu-Cap, Amphojel, Basaljel)		Constipation, hypophosphatemia, accumulation in patients with renal impairment
Calcium salts, Tums, Tums E-X, Titralac (Amitone)		Constipation, milk-alkali syndrome with high doses, rebound hyperacidity (depending on dosage)
Magnesium salts (Phillips’ Milk of Magnesia, Mygel, Almacone)		Diarrhea
Sodium bicarbonate (Citrocarbonate)		Milk-alkali syndrome with high doses
Magnesium-aluminum combinations (Maalox, Maalox Plus, Mylanta, Mylanta Double Strength, Di-Gel, Gelusil)		Take iron or folic acid supplement separately by 2 hours; take separately from citrus fruit/juice or calcium citrate by 3 hours; minor changes in bowel function
		Magnesium-containing products may accumulate in patients with renal impairment
		Magnesium-containing products may cause diarrhea
Over-the-Counter H₂-Receptor Blockers	Inhibit histamine stimulation of gastric parietal cells, suppressing gastric acid secretion
Nizatidine (Axid AR) Famotidine (Pepcid AD) Cimetidine (Tagamet HB)		Take at least 2 hours after iron supplement; take magnesium supplement or magnesium-aluminum antacids separately by at least 2 hours; limit caffeine/xanthine; avoid alcohol
		Liquid cimetidine precipitates tube feeding
Prokinetic Agents	Increase gastric emptying and lower esophageal sphincter pressure
Metoclopramide (Reglan) Bethanechol (Urecholine)		Most effective when used in combination with acid-suppression therapy; drowsiness, psychiatric symptoms, and extrapyramidal reactions may occur with long-term use
H₂-Receptor Blockers	Inhibit histamine stimulation of gastric parietal cells, suppressing gastric acid secretion
Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid) Ranitidine (Zantac)		Take at least 2 hours after iron supplement; take magnesium supplement or magnesium-aluminum antacids separately by at least 2 hours; limit caffeine/ xanthine; avoid alcohol
		Liquid cimetidine precipitates tube feeding
Proton Pump Inhibitors	Strongly inhibit gastric acid secretion by irreversibly inhibiting the H⁺-K⁺ adenosine triphosphatase pump of parietal cells	Uncommon; include diarrhea, nausea, dizziness, and headaches
Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Rabeprazole (Aciphex) Esomeprazole (Nexium)		Optimal: take 30-60 minutes before a meal; swallow whole, do not crush; omeprazole only—may open capsule and sprinkle granules on 1 Tbsp applesauce; avoid alcohol