DYSPHAGIA AFTER

STROKE
ROHMAN AZZAM, SPd, S.Kep, M.Kep, Ns,
Sp.Kep.M.B.
 Objectives
Student will be able to:
Understanding standardized terminology
Defined dysphagia appropriatly
Find the facts about incidence of dysphagia
Understanding swalowing mechanism
Identiciation neural regulation of swallowing
Dampak dysphagia
Mengidentifikasi fokus perawatan ps dysphagia
Mengenali tanda dan gejala dysphagia
Manajemen nutrisi dan mencegah pneumonia aspirasi
Nursing care plan for dhysphagia
 Terms
1. Aspiration: removal of substance by suction;
breathing of fluids or foods into the trachea and
lungs
2. Bolus: a feeding administered into the stomach
in large amounts and at designated intervals
3. Duodenum: the first part of the small intestine,
which arises from the pylorus of the stomach
and extends to the jejunum
4. Enteral nutrition: nutritional formula feedings
introduced through a tube directly into the
gastrointestinal tract
5. Gastrostomy: surgical creation of an opening
into the stomach for the purpose of
 Terms
6. Nasoduodenal tube: tube inserted through the nose into the
proximal portion of the small intestine (ie, duodenum)
7. Nasoenteric tube: tube inserted through the nose into the
stomach and beyond the pylorus into the small intestine
8. Nasogastric (NG) tube: tube inserted through the nose into
the stomach
9. Nasojejunal tube: tube inserted through the nose into the
second portion of the small intestine (ie, jejunum)
10.Orogastric tube: tube inserted through the mouth into the
stomach.
11.Parenteral nutrition (PN): method of supplying nutrients to
the body by an intravenous route
12.Percutaneous endoscopic gastrostomy (PEG): a feeding
tube inserted endoscopically into the stomach
 Definition
Difficulty swallowing (dysphagia) means it
takes more time and effort to move food or
liquid from your mouth to your stomach.
Dysphagia may also be associated with pain.
In some cases, swallowing may be impossible.
Dysphagia is a condition in which disruption of
the swallowing process interferes with a
patients ability to eat. It can result in
aspiration pneumonia, malnutrition,
dehydration, weight loss, and airway
obstruction.
(Paik, 2014; Mayo Clinic Staff, 2014)
 Incidence Rate
The incidence rates: 29-67% in acute
stroke.
Separuh pasien sadar yg masuk ke rs
dg stroke akut tidak dapat menelan
secara aman

(Martino et al. 2005 dalam Teasell, Foley, Martino, Richardson, Bhogal, & Speechley,
2013; Warlow et al, 2008).
 Normal Swallowing (1)
Swallowing has four sequential
coordinated phases:
1. Oral preparatory phase,
2. Oral propulsive phase,
3. Pharyngeal phase
4. Esophageal phase.
 3 Phases of swallowing
Dysphagia can be secondary to
defects in any of the 3 phases of
swallowing, which are as follows:
Oral phase:
the oral preparatory phase, and
the oral transit phase
Pharyngeal phase
Esophageal phase
 Normal Swallowing (2)
1.Oral Preparatory Phase.
. Food in the oral cavity is
manipulated and masticated in
preparation for swallowing.
. The back of the tongue controls the
position of the food, preventing it
from falling into the pharynx.
 Normal Swallowing (3)
2. Oral Propulsive Phase.
During the oral propulsive, the tongue
transfers the bolus of food to the
pharynx, triggering the pharyngeal
swallow.
 Normal Swallowing (4)
3. Pharyngeal Phase.
During the pharyngeal phase, complex and
coordinated movements of the tongue and
pharyngeal structures propel the bolus
from the pharynx into the esophagus.
The closing of the vocal cords and the
backward movement of the epiglottis
prevents food or liquid from entering the
trachea.
 Normal Swallowing (5)
4. Esophageal Phase.

During the esophageal phase of

swallowing, coordinated contractions
of the esophageal muscle move the
bolus through the esophagus towards
the stomach.
Neural Regulation of Swallowing (1)

Swallowing is initiated by sensory impulses

transmitted as a result of stimulation of receptors on
the fauces (tenggorokan), tonsils, soft palate, base
of the tongue, and posterior pharyngeal wall.
Sensory impulses reach the brainstem primarily
through the 7th, 9th, and 10 cranial nerves, while
the efferent (motor) function is mediated through
the 9th, 10th, 12th cranial nerves.
Cricopharyngeal sphincter opening is reflexive,
relaxation occurring at the time when the bolus
reaches the posterior pharyngal wall prior to
reaching this sphincter.
 Neural Regulation of Swallowing (2)
Cranial Nerves CN IX -- Glossopharyngeal
CN V -- Trigeminal contains both sensory and
motor fibers
contains both
important for taste to posterior
sensory and motor tongue, sensory and motor
fibers that innervate functions of the pharynx
the face
CN X -- Vagus
important in chewing
contains both sensory and
CN VII -- Facial motor fibers
contains both important for taste to
sensory and motor oropharynx, and sensation and
fibers motor function to larynx and
laryngopharynx.
important for
important for airway protection
sensation of
oropharynx & taste CN XII -- Hypoglossal
to anterior 2/3 of contains motor fibers that
primarily innervate the tongue
 Dampak Dysphagia
Berisiko tersedak, drooling, aspirasi,
atau regurgitasi.
Berisiko kekurangan nutrisi

Smeltzer, Bare, Hinkle, & Cheever. (2010). Brunner & Suddarths textbook of med-Surg nursing. (12th ed.).
Lippincott: Williams & Wilkins.
 Fokus Keperawatan
Mempertahankan
keamanan/keselamatan pasien
melalui pencegahan aspirasi
Memastikan status nutrisi adekuat

Smeltzer, Bare, Hinkle, & Cheever. (2010). Brunner & Suddarths textbook of med-Surg nursing. (12th ed.).
Lippincott: Williams & Wilkins.
 Signs & Symptoms (1)
Oral or pharyngeal dysphagia:
Coughing or choking with swallowing
Difficulty initiating swallowing
Food sticking in the throat
Sialorrhea/ngeces/air liur berlebihan
Unexplained weight loss
Change in dietary habits
Recurrent pneumonia
Change in voice or speech (wet voice)
Nasal regurgitation
 Signs & Symptoms (2)
Esophageal dysphagia:
Sensation of food sticking in the chest or
throat
Change in dietary habits
Recurrent pneumonia[1]
Symptoms of gastroesophageal reflux
disease (GERD), including: heartburn,
belching (sendawa), sour regurgitation,
and water brash
 Pemeriksaan Saraf Kranial IX
(Glosofaringeus) dan X (Vagus)
Cara pemeriksaan
Berikan minum sedikit air, lalu obs
kemampuan menelan.
Observasi kesimetrisan peningkatan
soft palate dan uvula saat pasien
mengatakan ah
Kaji reflek muntah (gag) dg menyentuh
bagian belakang tenggorokan
menggunakan spatula lidah
Kaji kemampuan pasien untuk
Kemungkinan temuan
abnormal
Dysphagia (kesulitan menelan)
adalah masalah yang sering
ditemukan. Hal ini terjadi
akbiat gangguan aliran darah
ke arteri vertebrabasiler dan
bagian posteroinferior,
anteroinferior, atau arteri
serebral superior.
Kehilangan reflek menelan
unilateral terjadi pada lesi
yang mengenai saraf kranial
IX dan X.
 Assisting With Nutrition
Dispagia pada stroke akibat terganggunya fungsi
mulut, lidah, palatum, larynx, pharynx, atau bagian
atas esopagus.
Obs pasien thd:
Batuk paroksisme (tiba-tiba),
Pergerakan makanan keluar mulut
Terkumpul makanan ke salah satu sisi mulut
Makanan tertahan lama di mulut
Pengeluaran makanan melalui hidung
Kesulitan menelan meningkatkan risiko:
Pneumonia aspirasi
Dehidrasi
Malnutrisi.
 Assisting With Nutrition
Evaluasi kemampuan menelan.
Jika fungsi menelan sebagian terganggu, maka:
Pikirkan alternatif teknik menelan
Sarankan menelan bolus makanan lebih kecil
Makan makanan yang lebih mudah ditelan
Mulailah diet cair, tingkatkan bertahap sesuai kemajuan
ke makanan cair kental
Posisikan pasien tegak, lebih baik lagi jika di kursi, bukan
di tempat tidur
Instruksikan sedikit fleksi ke arah dada untuk cegah
aspirasi, jangan ekstensi kepala/leher.
Jika tidak dapat menerima intake via oral, maka dapat
dipasang gastrointestinal feeding tube.
 Assisting With Nutrition
Selang nasogastric (hingga gaster) atau nasoenteral (di
duodenum) untuk menurunkan risiko aspirasi.
Tanggung jawab keperawatan:
1. Elevasikan tempat tidur bagian kepala sedikitnya 30o untuk
mencegah aspirasi
2. Periksa posisi selang sebelum memberikan makan
3. Pastikan cuff tracheostomy (jika terpasang) dalam keadaaan
mengembang
4. Berikan makan perlahan.
5. Aspirasi selang secara periodik untuk memastikan makanan
telah melawati saluran gastrointestinal. Makanan yang
tertahan/tersisa akan meningkatkan risiko aspirasi.
Untuk poemberian makan jangka panjang, lebih baik
menggunakan gastorstomy tube.
 Tips Keamanan Saat Pasien
Makan
1. Pastikan posisi pasien duduk tegak.
2. Pastikan leher pasien sedikit fleksi.
3. Makanan saring atau lunak.
4. Berikan/trmpatkan makanan di sisi mulut yang sehat.
5. Mintalah pasien menelan satu makanan pada satu
waktu.
6. Bila selesai makan, periksalah mulut akan
kemungkinan adanya makanan terselip terutama di
sisi mulut yang sakit.
7. Selalu siagakan peralatan suction disisi tempat tidur
untuk antisipasi terjadinya sumbatan jalan napas atau
aspirasi
Le Mone & Burke (2000). Med-Surg nursing: Critical thinking in client care. (2nd ed.). Toronto: Prentice
Hall Canada Inc.
 Treatment (2)
Dietary treatment:
Dietary modification is the key component in the general
treatment program of dysphagia.
Diets for patients with dysphagia include the following:
Dysphagia diet 1: Thin liquids (eg, fruit juice, coffee, tea)
Dysphagia diet 2: Nectar-thick liquids (eg, cream soup, tomato juice)
Dysphagia diet 3: Honey-thick liquids (ie, liquids that are thickened to a honey consistency)

Dysphagia diet 4: Pudding-thick liquids/foods (eg, mashed bananas, cooked cereals, purees)

Dysphagia diet 5: Mechanical soft foods (eg, meat loaf, baked beans, casseroles)
Dysphagia diet 6: Chewy foods (eg, pizza, cheese, bagels)
Dysphagia diet 7: Foods that fall apart (eg, bread, rice, muffins)
Dysphagia diet 8: Mixed textures
 Treatment (3)
Because fluid intake is restricted in most
patients with dysphagia, these individuals
are at risk of dehydration. Therefore, the
patient's hydration status must be
closely monitored.
 Treatment (4)
Exercise and facilitation techniques
The following types of exercise can be
recommended to patients with dysphagia:
Indirect (eg, exercises to strengthen
swallowing muscles)
Direct (eg, exercises to be performed while
swallowing)
 Treatment (5)
Facilitation techniques used in the
treatment of dysphagia include the
following:
Somatosensory stimulation: In the form
of an electrical current applied to the
pharynx
Deep pharyngeal neuromuscular
stimulation (DPNS)
Tactile-thermal stimulation (TTS)
 Treatment (6)
Compensatory techniques
Maintaining oral feeding often requires
compensatory techniques to reduce aspiration or
improve pharyngeal clearance. These include the
following:
Use of the chin-tuck position (sedikit fleksi)
Rotation of the head to the affected side
Tilting of the head to the strong side
Lying on one's side or back during swallowing
Supraglottic swallow
Bolus-clearing maneuvers
 Treatment (7)
Enteral feeding:
Nasogastric tube (NGT) feeing
Oroesophageal tube feeding
Percutaneous endoscopic gastrostomy
(PEG)
 Treatment (8)
Surgery for chronic aspiration
Medialization:
This helps to restore glottic closure and subglottic pressure
during the swallow
Laryngeal suspension:
The larynx is in a relatively protected position under the
tongue base
Laryngeal closure:
This may be performed to close the glottis off, in this way
protecting the airway at the expense of phonation
Laryngotracheal separation-diversion:
This procedure may be done to separate the airway from the
alimentary tract
 Treatment (1)
Medications:
Botulinum toxin type A (BoNT-A)
Diltiazem
Glucagon
Cystine-depleting therapy with
cysteamine
Nitrates
Diagnosa Keperawatan
 Resiko terjadi aspirasi berhubungan
dengan ketidakmampuan menelan
akibat kerusakan saraf kontrol fasial
Hasil yang
diharapkan :
Pasien dapat menelan Intervensi :
makanan dan 1. Berikan posisi tubuh
minuman tanpa terjadi tegak/duduk/setengah duduk
aspirasi/tidak tersedak. pada saat makan atau minum
2. Hindari posisi kepala over
ekstensi pada saat pasien
mencoba makan atau minum
3. Berikan makanan yang lunak
yang dapat diatur oleh lidah
untuk didorong masuk/ditelan
4. Hindari memberi air dalam jumlah
yang banyak sekaligus untuk
diteguk
 Resiko tinggi nutrisi kurang dari
kebutuhan tubuh b.d intake tidak
adekuat
Hasil yang Intervensi :
diharapkan :
Asupan nutrisi yang 1. Anjurkan pasien makan perlahan,
adekuat kunyah seksama.
2. Pemberian makanan sedikit tapi
sering
3. Sajikan makanan dengan cara yang
menarik
4. Hindari makan makanan atau minum
yang mengandung zat iritan seperti
alkohol
5. Timbang berat badan tiap hari dan
catat pertambahannya
6. Observasi asupan nutrien pasien dan
kaji hal-hal yang
menghambat/mempersulit proses
menelan
 Sekian

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