Patients With Post Stroke Dysphagia Health And Social Care Essay

This chapter deals with discussion, summary and conclusions drawn. It clarifies the limitations of the study, the implications and recommendations given for different areas in Nursing practice, Education, administration and research.

DISCUSSION

The present study was designed to assess the effectiveness of Selected Nursing Interventions among patients with Post Stroke Dysphagia at KMCH, Coimbatore-14. The researcher carried out the study among 30 patients and adopted pre-experimental research design with single group pre test post test design. The researcher used non probability purposive sampling technique to select the 30 subjects. The researcher conducted this study to assess the effectiveness of Shaker Exercise and Hyoid Lift Maneuver on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia.

DEMOGRAPHIC DESCRIPTION OF SUBJECTS

The demographic variables included in the study were Age, Sex, Education and Habits.

The mean Age of the subjects was 60. Half of the subjects were in the Age group 50-70 years. Almost equal numbers of subjects were in the 30-50 and above 70 years Age groups and it was about 23 and 27 percent respectively.

Regarding the Sex, nearly equal numbers of subjects were in the male and female Sex group and it showed 53 and 47 percent respectively.

On the basis of their Educational Status, 67 percent of the subjects were studied up to secondary Education. About 33.33 percent of the subjects completed any one of the graduate degree course.

In accordance with their Personal Habits, 53.33 percent had no bad Habits like Smoking and Alcoholism. Ten percent of subjects had the habit of Tobacco use. Seven percent of subjects were consuming Alcohol. Thirty percent of the subjects had the habit of both Tobacco and Alcohol consumption.

CLINICAL DESCRIPTION OF SUBJECTS

The clinical variables include Type of Stroke and Co-morbid Illness.

In consistent with the Type of Stroke, 10 percent of the subjects had Stroke due to the problem in anterior circulation, 40 percent of the subjects had Stroke due to problem in middle circulation and 50 percent of the subjects had Stroke due to problem in the posterior circulation. With reference to the Co-morbid Illness, 13.33 percent of the subjects had No Co-morbid Illness. About 10 and 40 percent of the subjects had the complaints of Diabetes Mellitus and Hypertension respectively. Remaining 36.67 percent of the subjects had both Hypertension and Diabetes Mellitus.

The major findings of the study were discussed according to the objectives:

The first objective was to assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia.

In the pre test assessment of the Swallowing Performance using GUSS Score indicates 23.33% of the subjects had Mild Dysphagia, 40% of the subjects had Moderate Dysphagia and 36.67% of the subjects had Severe Dysphagia. The post-test assessment of Swallowing Performance explains that 16.67% of the subjects were improved to the No Dysphagia stage with good Swallowing and Feeding Performance. About 26.67% of the subjects had Mild Dysphagia and 23.33% of the subjects had Moderate Dysphagia. Remaining 33.33% of the subjects had severe Dysphagia with various improvements in the Swallowing Performance.

The pre test and post test Feeding Performance Score using FOIS describes equal number of subjects in the Tube Dependent (36.67%) and Total Oral Intake category (63.33%). Despite the result revealed an equal number of subjects in the pre and post test assessment, the subjects had an improvement in the Feeding Performance during the post test assessment from no oral intake level to tube supplement with consistent oral intake level in the Tube Dependent category. Likewise, subjects showed an improvement from the intake of single consistency to the total intake with no restriction in the Total Oral Intake category.

The present study was supported by Trapl et al., who conducted study in 2002 and described that out of 30 patients, 30 to 50% had Severe Dysphagia and showed significantly higher risk of aspiration with liquids compared with semisolid textures (p=0.001). Therefore they confirmed the subsequent sequence of GUSS.

The second objective was to determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.

With reference to the Swallowing Performance based on the GUSS Score, the mean pre-test SwallowingS among subjects was 12.50 and the mean post-test Swallowing Score was 13.87 based on the GUSS tool. Paired ‘t’ test was used to compute the mean difference. The ‘t’ value for this mean difference between pre and post test Swallowing Score was 6.150. The ‘t’ value obtained at .001 level of significance and at 29 degrees of freedom. Hence there is a significant difference exist between the mean pre and post test Swallowing Scores. It further implies that the Swallowing Score in the post test was higher than the pre test Swallowing Score. This improvement was due to the Selected Nursing Interventions such as Swallowing Exercises and Positioning while Swallowing. So the Swallowing Exercises such as Shaker Exercise and Hyoid Lift Maneuver found to be effective in improving the Swallowing Performance in Stroke patients. The final result concluded that 22 subjects (73.3%) expressed improvement after the treatment. Remaining 8 subjects (26.7%) had no changes in their Swallowing Performance after the therapy.

The median of pre-test Feeding Score among subjects was 5 and the median of post-test Feeding Score was 6.5. Sign test was computed to find out the difference between the pre and post test median Scores of Feeding. The sign test Score showed the p value 0.000 which was significant at .001 level. It showed that, a significant difference present between the pre and post test Feeding Scores. It further implies that the Feeding Score in post test was higher than the pre test Feeding Score. This improvement in the Feeding Performance was due to the Selected Nursing Interventions. So the Swallowing Exercises were effective in improving the Feeding Performance in Stroke patients having Dysphagia. Median test was used to compare the effect between the pre test and post test group instead of mean as because the FOIS was a 7 point likert scale. As the variables did not follow the normality and the highest Score was 7, parametric test was not applicable. Hence non parametric sign test was adopted which is equivalent to paired ‘t’ test to find out the effectiveness.

The result of the present study was substantiated with a study conducted by Mepani et al., in 2005 on augmentation of deglutitive thyrohyoid muscle shortening by the Shaker Exercise. The study involved the effect of 6 weeks shaker exercise in 11 dysphagic patients; six patients were randomized to control group and 5 patients to the Shaker Exercise group. After the therapy the change in thyrohyoid distance among Shaker Exercise group was significantly greater compared to the control group (p=0.034), this subsequently improve the swallowing function of the patients.

Association of the Swallowing and Feeding Performance with selected Demographic and Clinical variables among patients with Post Stroke Dysphagia

The Fisher exact test was used to associate the selected Demographic and Clinical variables with the Swallowing and Feeding Performance of the patients with Post Stroke Dysphagia.

The calculated p values for the association between the Swallowing Performance of Post Stroke patients with the selected Demographic and Clinical variables such as Sex, Habits, Type of Stroke and Co-morbid Illness were not significant and hence there exist no association between them.

The calculated p values for the association between the Feeding Performance of Post Stroke patients with selected Demographic and Clinical variables such as Sex, Habits, Type of Stroke and history of Co-morbid Illness were not significant and hence there is no association between them.

SUMMARY

The aim of the present study was to assess the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia, for which the following objectives were formulated;

To assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia.

To determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.

To associate the Swallowing and Feeding Performance with selected Demographic and Clinical variables.

The study was based on Ernesteine Wiedenbach’s helping art of clinical nursing theory (1970). The research design applied for the study was pre experimental single group pre test-post test design. Study was conducted in KMCH. 30 samples were selected by non probability purposive sampling technique. The tool used for data collection consists of Demographic and Clinical variables, Gugging Swallowing Screen (GUSS) and Functional Oral Intake Scale (FOIS) to assess the Swallowing and Feeding Performance in Post Stroke Dysphagic patients. The data were collected for a period of 6 weeks. Descriptive and inferential statistics were used in statistical analysis, to assess the effectiveness of Selected Nursing Interventions among patients with Post Stroke Dysphagia. Fisher exact test was used to find out the association between the selected Demographic and Clinical variables with the Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.

Major findings of the study

On the basis of Gugging Swallowing Screening (GUSS), the investigator observed the degrees of improvement in Swallowing difficulty after the therapy among patients with Post Stroke Dysphagia. About 16.67% of the subjects had No Dysphagia, 26.67% had Mild Dysphagia, 23.33% had Moderate Dysphagia, and 33.33% had Severe Dysphagia.

In accordance with the Functional Oral Intake Scale (FOIS), 36.67% of the subjects were in Tube Dependent category and 63.33% were in Total Oral Intake category with sustained improvement in the Feeding Performance.

The mean pre test score of the Swallowing Performance using Gugging Swallowing Screening (GUSS) tool was 12.50. The mean post test Score of the Swallowing Performance using GUSS evaluation tool was 13.87.

There was a significant difference between the mean pre-test and post-test Swallowing Performance Score. The ‘t’ value obtained was 6.150 which is significant at 0.001 level and at 29 degrees of freedom.

The final result explained that, 22 subjects (73.3%) expressed Swallowing improvement after the treatment. Remaining eight subjects (26.7%) had no changes in their Swallowing Performance after the therapy.

Median test was used to compare the Feeding Performance Score of the pre and post test groups. The median pre test Feeding Performance of the patients with Post Stroke Dysphagia was 5 with a range of 1 to 6 and that of post median test was 6.5 with a range of 1 to 7.

The non parametric sign test was used to find out the effectiveness of the therapy on Feeding Performance. The obtained p value was 0.000 at 0.01 level of significance. This revealed a significant improvement in the Feeding Performance of Post Stroke Dysphagic patients.

The final result revealed that 24 respondents (80%) showed an improvement in their Feeding Performance after the therapy and was assessed by FOIS scoring. But remaining six respondents (20%) showed no changes in the Feeding Performance when assessed by FOIS.

There was no significant association exist between the Swallowing and Feeding Performance of the Post Stroke Dysphagic patients with the selected Demographic and Clinical variables.

CONCLUSION

The study was tested and accepted the hypothesis that there is a significant difference in Swallowing and Feeding Performance before and after the implementation of Selected Nursing Interventions in Post Stroke patients with Dysphagia.

The result concluded that the study group had better outcome than the others. There was a significant improvement in the Swallowing and Feeding Performance of the Post Stroke Dysphagic patients after the Exercise and Positioning therapy. The participants had reduced the risk of aspiration and aspiration related complications after the therapy. Hence, Selected Nursing Interventions such as Swallowing Exercises like Shaker exercise and Hyoid Lift Maneuver and positioning during Swallowing can be recommended for the patients with Post Stroke Dysphagia.

IMPLICATIONS

The present study has its own implications in nursing practice, nursing education, nursing administration and nursing research.

Nursing practice:

Dysphagia is one of the major complications among Post Stroke patients. This study implies the effectiveness of Selected Nursing Interventions in the improvement of Swallowing and Feeding Performance among the Post Stroke Dysphagic patients.

This study creates awareness among the nursing personnel about the importance of the various complications after the Stroke and its various evidence based management.

The present study shows that the exercise intervention for the Post Stroke Dysphagic patients can prevent the risk of aspiration and aspiration pneumonia.

The result shows that, Selected Nursing Intervention for the Post Stroke patients can reduce the risk of malnourishment.

Nurses can gain skill for providing Swallowing Exercises in the Post Stroke Dysphagic patients to improve their quality of life.

Nursing Education:

The nurse educator can create awareness among the health care professionals about the complicated effects of Stroke and its various evidence based management.

The nurse educator can arrange in-service Education programs to update their knowledge regarding the new techniques and modalities to manage the Post Stroke Dysphagia.

The nurse educator can teach the students about the present study findings and its implication in patients with Post Stroke Dysphagia. This will help to improve the knowledge of the students on Swallowing Exercises.

The nurse educator can motivate the nursing personnel and students to use this Swallowing Exercises and positioning in the improvement of Swallowing and Feeding Performance and in the reduction of aspiration risk in Post Stroke Dysphagic patients.

Nursing administration:

Nurse administrator should aware of the problem experienced by the clients after the Stroke.

Nurse administrator can provide continuing education or short term courses in the clinical area for preparing the nurses with competence in managing the after effects of Stroke especially Dysphagia.

Nurse administrator can plan and organize seminars, workshops and conferences about “Selected Nursing Interventions for the improvements of Swallowing and Feeding Performance among patients with Post Stroke Dysphagia.

Nurse administrator can formulate protocol to incorporate the study findings in nursing intervention.

Nursing research:

This study provides a basis for further studies.

The findings of the study can be a foundation for conducting the study on large sample to strongly support the efficacy.

The implications of the study can be used as a motivation for nurses to conduct research in India, where the health care system is advancing.

This study helps to update the knowledge and proper utilization of resources in the field of nursing practice.

LIMITATIONS OF THE STUDY

The study was limited to small sample size of 30 subjects.

The study was limited to a single setting.

The study was conducted using a single group.

RECOMMENDATIONS

A similar study can be conducted with large number of subjects to generalize the research findings.

A study can be conducted at different settings.

Similar study can be undertaken using different Swallowing and lingual exercises.

This study can be conducted with experimental and quasi experimental design.

A comparative study can be conducted between different types of Swallowing Exercises in Post Stroke Dysphagic patients.

A similar study can be done to assess the effectiveness of Swallowing Exercises among patients with Dysphagia who are receiving head and neck radiation for cancer.

ABSTRACT

The present study entitled “Effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia at KMCH, Coimbatore-14. This study was undertaken during the year 2012-2013, in partial fulfillment of requirement for the degree of Master of Science in Nursing at KMCH College of Nursing, Coimbatore, which is affiliated to the Tamilnadu Dr. M.G.R. Medical University, Chennai.

Objectives: 1.To assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia. 2. To determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia. 3. To associate the Swallowing and Feeding Performance with selected Demographic and Clinical variables. Research Design: Pre experimental design with single group pre test-post test design. Setting: Neuro inpatient and outpatient department of Kovai Medical Center and Hospital, Coimbatore. Samples: All Post Stroke Dysphagic patients. Sample Size: The sample size was 30. Sampling Technique: Non probability purposive sampling. Conceptual framework: Ernestine Widenbach’s Helping Art of Clinical Nursing Theory (1970) was adopted. Intervention: Selected Nursing Interventions such as Swallowing Exercises and Positioning during the swallowing were incorporated. The clients were instructed to do the Shaker Exercise and Hyoid Lift Manoeuvre 3 to 6 times a day for a period of 6 weeks. The subjects were instructed to elevate or down the chin and tilt the head towards stronger side while Swallowing. Outcome Measures: Swallowing and Feeding Performance was assessed by Gugging Swallowing Screen (GUSS) and Functional Oral Intake Scale (FOIS) respectively. Results: The mean difference between pre and post test Swallowing Score was 6.150 and which was significant at 0.001 level. The p value obtained for Feeding Score was 0.000 at 0.001 level of significance. The result showed a significant improvement in the Swallowing and Feeding Performance. Conclusion: This study proved that the implementation of Selected Nursing Interventions rather than the other conventional treatment will improve Swallowing and Feeding Performance among Post Stroke patients with Dysphagia. Hence the Swallowing Exercises and Positioning can be recommended in clinical practice to improve the Swallowing and Feeding Performance in Post Stroke Dysphagic patients.