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needs addressed in the first 72 hours of admission to the hospital because nutrition is important for recovery and healing. Safety Alert=• The first oral feeding should be approached carefully because the gag reflex may be impaired due to dysphagia.Speech therapists (if available) should perform a swallowing evaluation before patients are started on oral intake. The majority of patients experience dysphagia after a stroke. Before initiating feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. The speech therapist or occupational therapist is usually responsible for designing this program. However, you may be called on to develop the program in some clinical settings.To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated) and give the patient a small amount of crushed ice or ice water to swallow. If the gag reflex is present and 43
the patient is able to swallow safely, you may proceed with feeding.After careful assessment of swallowing, chewing, gag reflex, and pocketing, oral feedings can be initiated. Mouth care before feeding helps stimulate sensory awareness and salivation and can facilitate swallowing. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes afterward.The speech therapist may recommend various dietary items. Foods should be easy to swallow and provideenough texture, temperature (warm or cold), and flavor to stimulate a swallow reflex. Crushed ice can be used as a stimulant. Instruct the patient to swallow and then swallow again. Pureed foods are not usually the best choice because they are often bland and too smooth. Thin liquids are often difficult to swallow and may promote coughing. Thin liquids can be thickened with a commercially available thickening agent(e.g., Thick-It). Avoid milk products because they tend to increase the viscosity of mucus and increase salivation.Place food on the unaffected side of the mouth. Feedings must be followed by scrupulous oral hygiene because food may collect on the affected side of the mouth. During the acute and rehabilitation phase of the stroke, a dietitian can assist in determining the appropriate daily caloric intake based on the patient's size, weight, and activity level. If the patient is unable to take in an adequate oral diet and dysphagia persists, a percutaneous endoscopic gastrostomy (PEG) tube may be used for nutritional support. Most commercially prepared formulas provide about 1 cal/mL. Communication.During the acute stage of stroke, your role in meeting the patient's psychologic needs is primarily supportive. Speech, comprehension, and language deficits are the most difficult problems for the patient and caregiver. Assess the patient for both the ability to speak and the ability to understand. The patient's response to simple questions can guide you in structuring explanations and instructions. If the patient