Charts for Feeding, Swallowing and Aspiration

People with developmental disabilities encounter similar health problems as the general population. There are however, some conditions of higher prevalence related to the etiology and consequences of having a disability. Conditions like seizures, aspiration pneumonia, eating and nutritional disorders; osteoporosis and sensory problems are some of them.

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• Identifying Individuals at Risk for Aspiration & What To Do About It
• Screening Chart for Swallowing, Feeding, and Aspiration
• Aspiration Risk Factors & Decision Tree
• Additional Web links on Aspiration

SCREENING CHART for SWALLOWING, FEEDING, AND ASPIRATION

Observation Date:

Identification/Demographics:

Name: DOB//SS#//

Address:

Phone: ( ) Fax ( ) ___________________________________

Case Manager: Agency

PCP

Medical/Nursing Information:

Medical Diagnosis:

1                                                                      4

2                                                                      5

3                                                                      6

Hx of Aspiration Y/N

If Dysphagia is a dx, was there a swallowing study? Y/N Date:

Results of swallowing study/Upper GI:

 

Hospitalizations (Dx & Dates):

Allergies (medications,foods, Latex):

Medication List:

l.

Vitamins? Y/N Whole Pills_______ Crushed _______ Liquid _______

Other pertinent medications

Review of Systems and Pertinent Medical Hx:

Hx of constipation? Y/N Is there a bowel program? Y/N History of weight loss? Y/N

Describe:

Hx of wheezing? Y/N Are there oxygen requirements? Y/N ____________liters/min

Hx of cough? Y/N Choking? Y/N Hx of fevers? Y/N Hx of rumination? Y/N

Level of Alertness: (circle) alert/aware/lethargic/semi-conscious/unresponsive(comatose)

Head control Muscle tone qualities

Is there scoliosis? Y/N Describe severity and location (lumbar,thoracic)

Oral Hygiene plan Dentures

Nutrition/Dietary Information:

RWR Current Weight Height (or arm span)

Special Dietary Needs(i.e. caloric needs,food consistency,special formula,etc

If formula is given through tube: rate of feedings___________________ frequency_______________

Speech & Language Pathologist/Occupational Therapist Observation:

Adaptive Equipment Needs (special spoon,cup):____________________________________________

Is the equipment available? Y/N

Is there a mealtime program in place? Y/N Is it being followed? Y/N

Describe how the person is assisted with feedings and time involved in feeding: __________________

Has there been staff training in mealtime implementation? Y/N Residential staff and/or Day

Program staff Dates:

Who attended (position titles,roles)

Oral Feedings?____________ Tube Feedings?_____________Hx of GE-reflux__________________

Precautions in place (i.e. position,food consistency, medications)

Position while eating or being fed: seating upright________in bed______right or left side?_________

Drooling? Y/N Is there lip closure? Y/N is there a bite reflex? Y/N

Is there gagging? Y/N, coughing? Y/N, during Y/N, or after swallowing? Y/N

Does the agency have access to a Speech and Language Pathologist? (preferably with experience regarding eating and people with disabilities) Y/N

Does the agency have access to a Nutritionist? Y/N

Physical Therapist Observation:

Positioning in which person eat: ___________________Description of posture: _______________

Wheelchair? Y/N Description of wheelchair___________________________________________

Other equipment for positioning used during meals:______________________________________

If tube feedings are being used:

Check all that apply and indicate angle of trunk elevation in each setting.

Assessment by Individual Discipline:

Speech & Language:

Occupational Therapy/Physical Therapy:

Nursing/Medical:

Team’s perception of individual’s enjoyment and notion for eating:

The following recommendations are based on brief observations done by this team. On specific cases, it may be indicated to have a more comprehensive review by individual discipline(s).

Team Recommendations:

l.

2.

3.

4.

5.

Adaptive equipment:

Follow Up:

Dates:

__________________________ ________________________ __________

S&L OT/PT Nursing

8/5/98

• Aspiration Risk Factors & Decision Tree:

Name: ______________________________________________________

Address:____________________________________________________

Phone #:____________________________________________________

Case Manager:______________________________________________

Medical Diagnosis List:

l._________________ 2.______________ 3._______________

4.________________ 5.______________ 6._______________

Does the person have a highly suggestive history of associated risk factors?

  
Additional Information on Aspiration:

Medscape Respiratory Care Reference
Article:  Aspiration Pneumonia:  Current Concepts and Approaches to Management
Author:  Hugh Cassiere, MD Winthrop University Hospital
http://www.medscape.com ..
http://list.dysphagia.com/dysphagia/1999-August/msg00009.html