Protocol of nursing care in hospitalized dysphagic patients

ABSTRACT

Purpose:

To investigate nursing care for patients hospitalized with oropharyngeal dysphagia.

Method:

This is a descriptive study of a qualitative approach, developed during the year 2017, in a Public hospital in Rio de Janeiro that offers a nursing residency program. The sample consisted of 17 nursing residents who work in the care of dysphagic patients. Data collection was realized by applying the problem-based learning methodology and data were analyzed according to the content analysis technique.

Results:

The data analysis allowed for the identification of the main aspects of nursing care in the patient hospitalized with oropharyngeal dysphagia and the elaboration of a nursing care protocol for the patient, based on a discussion of thematic categories.

Conclusion:

This study allowed for the identification of the relevant nursing care for the patient hospitalized with oropharyngeal dysphagia, which could provide assistance for nurses, thereby improving the quality of care and safety of the service provided for hospitalized patients.

Keywords
Speech; Language and Hearing Science; Nursing; Deglutition Disorders; Problem-Based Learning; Teaching

RESUMO

Objetivos:

investigar os cuidados de enfermagem para o paciente hospitalizado com disfagia orofaríngea.

Método:

trata-se de estudo descritivo de abordagem qualitativa, desenvolvido durante o ano de 2017, em um Hospital da rede pública do Rio de Janeiro que oferece programa de residência em enfermagem. A amostra foi constituída por 17 residentes de enfermagem que atuam na assistência a pacientes disfágicos. A coleta de dados foi embasada nas etapas da metodologia da aprendizagem baseada em problemas e foram analisados segundo a técnica de análise de conteúdo.

Resultados:

a análise dos dados permitiu identificar os principais cuidados de enfermagem no paciente hospitalizado com disfagia orofaríngea e a elaboração de um protocolo de cuidados de enfermagem no paciente hospitalizado disfágico a partir da discussão das categorias temáticas.

Conclusão:

este estudo promoveu a identificação dos principais cuidados de enfermagem no paciente hospitalizado com disfagia orofaríngea, podendo, dessa forma, fornecer subsídios para a atuação de enfermeiros, melhorando assim a qualidade da assistência e segurança do serviço prestado aos pacientes hospitalizados.

Descritores
Fonoaudiologia; Enfermagem; Transtornos de Deglutição; Aprendizado Baseado em Problemas; Ensino

INTRODUCTION

Oropharyngeal dysphagia (OD) is characterized as a change in the swallowing process and can lead to serious consequences, such as malnutrition, dehydration, aspiration pneumonia, longer hospital stays and increased mortality.

Its prevalence in the hospital population has been estimated at 12%, while hospital malnutrition can affect 50% of hospitalized patients and appears frequently in patients with dysphagia. Thus, its occurrence reflects a significant increase in the length of hospital stays and in spending on bed occupation⁽¹⁾.

Therefore, the treatment of patients with dysphagia requires the involvement of several health professionals, with this multiprofessional assistance allowing for the elaboration of more accurate diagnoses, and more complete and detailed therapeutic plans, which favors more effective outcomes⁽²⁾.

The speech-language therapist is the professional trained to assess swallowing early and establish the safest route for food. However, he is not the only professional who works with patients with dysphagia. The effectiveness of the therapeutic intervention also depends on the contributions of other professionals.

In this context, nurses play a fundamental role, as they are always attentive to patients’ needs, given that their work process is centered on comprehensive care for the individual. In addition to the importance of the work process, nurses are usually the largest team and are on call 24 hours a day, facilitating more effective observation of the hospitalized patient and the early identification of alterations.

However, there is a lack of a broader focus on this subject in the curriculum of nurse training courses⁽³⁾. Studies highlight the need to increase the nurses’ awareness of care for dysphagic patients in terms of the signs and symptoms of dysphagia, so that the problem is identified sooner^(4,5).

Most publications confirm the nurse’s ability to identify patients at risk of dysphagia earlier and even carry out the initial assessment, provided that they are properly trained. The American Speech Therapy Association recommends that the speech-language therapist be the professional responsible for training nurses in this early identification, as identifying dysphagia early is vital to prevent additional complications⁽⁶⁾.

Therefore, the main objective of this study is to investigate nursing care for hospitalized patients with oropharyngeal dysphagia.

METHOD

The research project was approved by the Research Ethics Committee, in order to comply with Resolution No. 466/12, approved under report 1962726 of 3/13/2017 and all participants signed a Free and Informed Consent Form.

This is a descriptive study with a qualitative approach, developed during 2017, in a public hospital in Rio de Janeiro that offers the nursing residency program.

Seventeen nursing residents were included in the study based on the inclusion and exclusion criteria. The research participants formed a heterogeneous group with respect to age (23 to 40 years), with a maximum of two years since graduation, most of whom were single and born in Rio de Janeiro.

The hospital has approximately 12 wards, with the Medical Clinic Infirmary being chosen as the setting for this study due to concentrating the largest number of pathologies that cause dysphagia. As an inclusion criterion, first year and second year residents were selected who worked directly in the care of dysphagic patients, in the selected unit, and who agreed to participate in both meetings; those who had not yet been assigned to this unit were excluded. The researcher, in a previous moment, met with the group residents, presented the project to them, distributed the Free and Informed Consent Forms and scheduled the dates of the meetings with those who agreed to participate in the study.

We used a Problem-Based Learning approach, which involves seven steps: Reading the problem; identification and clarification of unknown terms; identification of the proposed problems; formulation of hypotheses; summary of hypotheses; formulation of learning objectives; individual study of the learning objectives and re-consideration of the problem in the face of new knowledge acquired⁽⁷⁾.

Data collection took place during two 2-hour meetings, which were mediated by the researcher who looked at aspects of speech-language therapy intervention in order to support the care for dysphagic patients by nursing. The data were obtained through participant observation and records in a field diary, from meetings with residents participating in the research, conducted and based on the stages of PBL, and detailed in Figure 1.

Figure 1
Data collection scheme, developed by the researchers

In the first meeting, the methodology to be applied was explained following which the 17 residents were divided into 4 groups. The groups received the problem situation in writing, which included the description of the problems and other elements relevant to patients with oropharyngeal dysphagia seen by nurses. The residents were given 20 minutes to reflect and identify the problems.

After reading the problem situation, possible unknown terms and concepts were clarified and, thus, the main aspects of nursing care were identified, and the diagnostic hypotheses were raised. Among the main problems mentioned by the residents, the following stand out: communication between nurse-team-disabled patient; lack of adequate guidance for the patient and family; transfer of responsibilities; incomplete nursing assessment and diagnosis. Possible causes were identified: deficient nursing intervention; difficulty in multidisciplinary performance; and lack of commitment by health professionals.

At the end of the 1st meeting, based on the listed questions, a problematic question was created with the aim of provoking questions, stimulating critical-reflective thinking and serving as a stimulus for the collection of relevant information for the identification of the problems of patients with oropharyngeal dysphagia and nursing care.

Based on the problematic question they asked (What is nursing care for patients with oropharyngeal dysphagia?), the participants were taken through an active investigation process to seek the necessary information to answer the research question. They were encouraged to search through books and articles.

In the dispersion phase, residents had fifteen days to search, individually or in groups, for data and information to answer the learning question and conduct the discussion later in a group. At the 2nd meeting, the information and knowledge acquired about the nursing care found in the problem situation and beyond was presented.

The researcher was always attentive to all statements and speculations, correcting possible errors and clarifying remaining doubts, and started the discussion regarding the main aspects of nursing care for dysphagic patients.

In each of the meetings, the researcher mediated the group’s discussions projecting the selected problems, the possible causes and the main nursing care for the dysphagic patient on a data show and writing on the flipchart to ensure the engagement of all participants. Concomitantly and after the meetings, records were made in a field diary, resulting from the participant observation of the researcher.

The data were worked according to content analysis, following the three steps provided: pre-analysis, exploration of the material, treatment of the data obtained/interpretation. In this way, the research material resulting from the field diary records was gathered and organized from the floating reading. Subsequently, the data were coded from the recording units and, subsequently, categorized, classifying the elements according to their similarities, with subsequent regrouping, according to common characteristics⁽⁸⁾.

RESULTS

The analysis of the data allowed the identification of guiding factors for the main aspects of nursing care in hospitalized dysphagic patients, that permeated the entire research process.

Thus, three thematic categories were defined in order to understand the content of the residents’ statements, which are: The nursing process for the patient with oropharyngeal dysphagia; Management of patient care with oropharyngeal dysphagia; and Communication between nurse-team-patient.

Thus, the discussion of these categories allowed the elaboration of a Nursing care Protocol for hospitalized patients with oropharyngeal dysphagia. The protocol aims to guide nursing care, as described in Chart 1.

Chart 1
Nursing care protocol for hospitalized patients with oropharyngeal dysphagia

Assessment of oropharyngeal dysphagia
Action	Description
Anamnesis and physical examination	Obtain information such as: age, physical condition, medical history, neurological diagnosis, state of awareness, respiratory condition, eating habits, presence of xerostomia/sialorrhea, duration of the meal and vocal or speech disorders.
Assessment of acceptance of diet and medication	Investigate difficulties with swallowing food and medications.
Assessment of nutrition/hydration status	Analyze the amount of food and liquids ingested/day and the need for help with eating and/or drinking.
Observation of aspiration signs and symptoms	Observe coughing/choking, shortness of breath during feeding, fever etc.
Therapeutic planning for the patient with oropharyngeal dysphagia
Action	Description
Monitoring of the patient with oropharyngeal dysphagia	Observe and record the patient's swallowing process, due to the ease of continuous monitoring.
Reevaluation of the ability/inability to swallow, according to clinical evolution	It has the purpose of generating adequate monitoring, analyzing the occurrence of complications or improvements.
Preparation for discharge	Instruct the patient/caregiver/family about measures to adapt to dysphagia.
Adaptation measures for oropharyngeal dysphagia
Action	Description
Postural adjustment of the patient	Maintain a safe position: If the patient is seated, keep them in an upright position and, if they are restricted to the bed, keep the headboard at a 45 ° Fowler position, in order to avoid aspiration of food.
Assist the use of food thickener, oral hygiene.	Observe the use of the thickener in all prescribed consistencies, maintain strict mouth hygiene, privileging the hydration of the mucous membranes.
Care for the rate and speed of food supply.	Guide the placement of small amounts of food in the mouth and only introduce food when you are sure that the previous mouthful has been swallowed.
Indication of alternative feeding route	Indicate the alternative route for feeding after careful clinical evaluation, along with complementary exams. In situations where the dysphagia is total and/or permanent, the indication of a nasogastric tube or percutaneous gastrostomy tube may be necessary.
Nurse/patient/team communication
Action	Description
Communication to the team about the identification of patients with dysphagia and its evolution	Encourage/facilitate multidisciplinary interaction, emphasizing the quality of care for dysphagic patients.
Guide the patient and his caregivers about measures to adapt to dysphagia; train patients and their caregivers on safe feeding and swallowing techniques	Promote integration between nurse/patient, enabling the family to provide adequate care to the dysphagic patient.

DISCUSSION

The discussion of the results refers to the delimited thematic categories and the notes of the Nursing Care Protocol for hospitalized patients with oropharyngeal dysphagia detailed in Chart 1.

The nursing process in the patient with oropharyngeal dysphagia

The Nursing Process is a methodological tool divided into 5 stages (nursing data collection, nursing diagnosis, nursing planning, nursing intervention and assessment), used to make nursing care systematic, with the aim of guiding care by nursing professionals, to improve the quality of care provided⁽⁹⁾.In this manner, nurses can identify patients at risk of dysphagia already during the data collection phase, in which the presence of swallowing disorders can be identified and nursing diagnosis of swallowing difficulties or nutritional imbalances can be made, based, for example, on the North American Nursing Diagnosis Association (NANDA) Classification of Nursing nutrients to satisfy metabolic needs^(10,11). Affected patients can also be identified through screening tools. There are many non-invasive instruments validated for the identification of dysphagia, among them, the GUSS scale (Gugging Swallowing Screen), which is one of the validated instruments and was created to be simple to use at the patient’s bedside, and can be performed by any health care professional⁽¹²⁾.

Thus, data collection and screening instruments provide assistance to guide appropriate interventions, in addition to providing data that are often not collected by the rest of the team, since nursing is mostly with patients. Issues pertinent to the need for nutrition/hydration are also emphasized, where the nurse’s focus should be on investigating difficulty swallowing, the amount of fluids ingested/day and the need for help with eating and/or drinking⁽¹³⁾.

Nursing care management

In the nurse’s work process, care management takes place in two complementary dimensions: the managerial dimension, whose object is work organization and nursing human resources, and the assistance dimension, with its intervention object focused on patient care needs⁽¹⁴⁾.

The assistance dimension is characterized by the implementation of nursing care measures and its purpose is to provide comprehensive care to patients. Therapeutic planning and measures of adaptation to dysphagia stand out in the care dimension.

Therapeutic planning is defined by a set of therapeutic alternatives, defined from the evaluation, with a multidisciplinary and interdisciplinary approach, which aims to obtain greater adherence by the patient and those responsible for treatment⁽¹⁵⁾. Nurses are able to monitor the patient with oropharyngeal dysphagia in their daily practice, as they are closer to the patients and, thus, provide a quicker and safer response to this symptom. This proximity also allows the monitoring of the ability/inability to swallow, according to the clinical evolution and the preparation for hospital discharge.

In measures of adaptation to dysphagia, it is up to the nurse to observe a series of interventions to be carried out in order to improve the independence of the patient with swallowing disorders, in the basic nursing care of eating and drinking properly, such as: patient positioning and postural alignment in order to avoid aspiration of liquid/solid foods; good oral hygiene (which allows for better assessment and management of swallowing) and care for the rate and speed of food supply.

Thus, in care management, in addition to direct actions with the patient, there should be nurse plan assistance, development of care projects with and for patients, and promotion of interaction with other professionals.

Nurse-team-patient communication

The safety of inpatients is a major concern and communication is a determinant of quality and safety in the provision of care. Therefore, in order to be effective in care, it is necessary to have prepared and trained professionals to build a structured relationship through the quality of the information exchanged, reducing risks and failures for the patient, promoting quality of health care without causing harm⁽¹⁶⁾.

Communication between professionals, managers and patients is a key element. It is an essential element in care, in its various forms, has a function of humanizing significance and, for this, the team needs to be willing and involved to establish this relationship and understand that it is essential to recognize the patient as a subject of care and not as a passive object⁽¹⁷⁾.

The communication between the nurse and the dysphagic patient and the family takes place through guidance regarding therapeutic approaches and progress reports. The patient and their family must be informed about changes in the diet, the risks of resorting to “unsafe” foods even when the patient requests them, the use of compensation devices when necessary, the feeding process and emergency measures when choking occurs.

Effective communication between the multidisciplinary team also results in greater productivity, improved teamwork and decision-making. The nurse, in caring for hospitalized patients, must communicate the identification of patients with dysphagia and their subsequent evolution to the team⁽¹⁸⁾.

Thus, communication is a necessary skill for health care professionals, who must be attentive to informational content and also to the results of this communicative process, because when the team works effectively, practicing clear and precise communication, this will reflect positively on care processes and, consequently, on the quality of services and patient safety⁽¹⁷⁾.

CONCLUSION

In view of the results, it was concluded that the study represents a contribution to and progress in the field of nursing education in the care of hospitalized dysphagic patients.

This allowed the creation of a nursing care protocol for hospitalized patients with DOF and it is hoped that it can provide assistance for the performance of these professionals, thus improving the quality of care and safety of the service provided to hospitalized patients.

Thus, it is believed that this research promotes greater discussion about nursing care in patients hospitalized with oropharyngeal dysphagia, in addition to motivating a debate in other services and units and stimulating multidisciplinary work between nurses and other health care professionals, contributing to the training of qualified staff and excellent care for these patients.

It is suggested that other studies be developed to assess the impact of implementing the care protocol and the challenges of multiprofessional action.

• Study conducted at Programa de Mestrado Profissional em Ensino na Saúde - MPES - Universidade Federal Fluminense - UFF - Niterói (RJ), Brasil.
• Financial support: Nothing to declare.

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Publication Dates

• Publication in this collection
  15 June 2020
• Date of issue
  2020

History

• Received
  08 June 2018
• Accepted
  10 July 2019