Dysphagic patients and ice chips

  1. During clinical today, we had a patient who was NPO and on a thicked diet. She was practically begging us to bring her some water. We explained the risks of thin fluids and instead brought her some gelled oj and water. We thought maybe we could give some ice chips which would at least help her dry mouth and refreshen it a bit, but then thought the ice would melt and possible cause her to aspirate. What do you guys do in your practice for dysphagic patients who really want hydration, but can't stand the thickend fluids. Shes not on an IV either. By the way, my friend and I tasted some gelled water and it was pretty horrible
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    About Aniroc

    Joined: Dec '04; Posts: 55; Likes: 34
    Medical Surgical Nurse; from CA
    Specialty: 4 year(s) of experience in Orthopedics

    13 Comments

  3. by   glopop11
    I would think frequent oral care would help....maybe q2h?
  4. by   stidget99
    Quote from Aniroc
    During clinical today, we had a patient who was NPO and on a thicked diet. She was practically begging us to bring her some water. We explained the risks of thin fluids and instead brought her some gelled oj and water. We thought maybe we could give some ice chips which would at least help her dry mouth and refreshen it a bit, but then thought the ice would melt and possible cause her to aspirate. What do you guys do in your practice for dysphagic patients who really want hydration, but can't stand the thickend fluids. Shes not on an IV either. By the way, my friend and I tasted some gelled water and it was pretty horrible
    Frequent oral care is a great start. When I have a pt in that situation, I try to provide thickened liquids other than water. If, for some reason the pt cannot have his/her choice of liquids, I alway use ice cold water w/ Thicket in it. Only prepare small amts at a time. There's also the option of providing other forms of liquids that might satisfy your pt's thirst(i.e. jello, ice cream).
  5. by   Genista
    Aniroc-
    If you have OT at your hospital, they are a great resource. They do swallow evals at my hospital, and are well educated about swallowing disorders.I have learned so much from them, as some liquids that you think are safe may actually be a danger. You do have to be careful, as jello and ice chips are actually considered thin liquids...once they melt in the mouth. It may not be safe to give thin liquids to your patient. They might be silently aspirating on it! There's a reason why they are recommended to have thickened liquids.

    Always find out what kind of liquids the patient can have, and what precautions need to be taken (i.e. straws versus no straws, HOB at 90 degrees etc). Where I work, OT posts a big sign over the bed reminding of precautions for dysphagia patients after the swallow eval is done (it is also posted in the Kardex). You can usually use those oral swabs (Toothettes) lightly moistened with supervision for dry mouth when in doubt. NPO means Nothing by Mouth! in my book- no jello, ice chips etc. If Doc writes for NPO except ice chips, that's different. I do oral care with the toothettes for NPO patients. But why was your patient NPO? Was it pending a swallow eval or for a procedure? I know it is hard for patients to be NPO, but think of safety first.
    Last edit by Genista on Mar 1, '05
  6. by   talaxandra
    I feel sorry for my stroke patients with dysphagia - all the thickened fluids are sweet, which is not necessarily refreshing or even thirst-quenching.
    We perform frequent mouth care, but sometimes (especially for patients on Os or mouth-breathers) that doesn't necessarily do the trick either. And I don't know about where you work, but I've tried sucking on a mouth swab and the cotton tastes disgusting, like chemicals.
    We have an ice-maker which makes ice cubes that melt into 15 - 20ml of water. For all my patients on ice only I melt them down by adding boiling water to a cup of cubes, agitating the cup and then pouring off the water, which melts the cubes down to 5 - 10ml or so, much more comfortably mouth sized.
    For patients who are horribly thirsty, oriented, and who have an impaired but not absent gag, I (very rarely) give them a sliver of ice about half the size again of a melted cube - the ice melts on the tongue and is absorbed by the oral mucosa, the volume is less than the amount of saliva most patients on a diet generate in a few minutes, and the coldness of the ice abates thirst faster than a larger volume of thickened fluid does.
  7. by   UM Review RN
    OK, try this:


    Mouth breathe for a few hours until your entire mouth is cracked and dry. Now insert a lemon glycerin swab or mouthwash-impregnated toothette.


    It tastes horrible! Not only that, but it's irritating to cracked mucosa.

    Instead, try this:

    Take a couple of 4X4 gauze squares and wrap them around a tongue depressor with silk tape. Glove. Now dip the end in water and squeeze out all the excess moisture. Place it on the patient's tongue long enough to soften up the crud. Dip and squeeze a few times and get the mucosa clean and moist. Not only can you do good oral care this way, frequently patients will suck on the water-soaked gauze more readily than the flavored types.

    One poor post-stroke LOM tube feeder I had was so happy with this routine he went from barely responsive to holding my hand and saying, "Yes, yes."
  8. by   GLORIAmunchkin72
    I, too, use toothettes to hydrate my mouthbreathers, but I definitely would not use mouthwash. If they do not have an NPO order I dip it frequently in a cool glass of water. And they desperately such on the toothettes. I would only do that with WATER because it is easily reabsorbed by the body God forbid they aspirate.
    Quote from Angie O'Plasty, RN
    OK, try this:


    Mouth breathe for a few hours until your entire mouth is cracked and dry. Now insert a lemon glycerin swab or mouthwash-impregnated toothette.


    It tastes horrible! Not only that, but it's irritating to cracked mucosa.

    Instead, try this:

    Take a couple of 4X4 gauze squares and wrap them around a tongue depressor with silk tape. Glove. Now dip the end in water and squeeze out all the excess moisture. Place it on the patient's tongue long enough to soften up the crud. Dip and squeeze a few times and get the mucosa clean and moist. Not only can you do good oral care this way, frequently patients will suck on the water-soaked gauze more readily than the flavored types.

    One poor post-stroke LOM tube feeder I had was so happy with this routine he went from barely responsive to holding my hand and saying, "Yes, yes."
  9. by   Aniroc
    Quote from talaxandra
    For patients who are horribly thirsty, oriented, and who have an impaired but not absent gag, I (very rarely) give them a sliver of ice about half the size again of a melted cube - the ice melts on the tongue and is absorbed by the oral mucosa, the volume is less than the amount of saliva most patients on a diet generate in a few minutes, and the coldness of the ice abates thirst faster than a larger volume of thickened fluid does.
    See, my patient was A&O - at the time, and was practically begging for water - to hydrate. We swabbed with the toothetes, but that wasn't good enough. She was being investigated for a CVA, but the CT was negative, and the speech pathologist did a swallowing assessment suggesting the thickend fluids because at one point had a decreased LOC.

    We gave her some of the gelled stuff, but its certainily not refreshing? Later, another student and I tasted it, and we were definately not impressed.
  10. by   GLORIAmunchkin72
    We had this one resident who didn't do very well on thickened liquids. We all helplessly watch her go down the tubes from dehydration. It was, of course, unacceptable. The daughter, thank God, stepped in and gave consent for her to have unthickened water in her room. She went from wilted flower to singing tunes. What to do, what to do.
    Quote from Aniroc
    See, my patient was A&O - at the time, and was practically begging for water - to hydrate. We swabbed with the toothetes, but that wasn't good enough. She was being investigated for a CVA, but the CT was negative, and the speech pathologist did a swallowing assessment suggesting the thickend fluids because at one point had a decreased LOC.

    We gave her some of the gelled stuff, but its certainily not refreshing? Later, another student and I tasted it, and we were definately not impressed.
  11. by   UM Review RN
    Quote from Aniroc
    We gave her some of the gelled stuff, but its certainily not refreshing? Later, another student and I tasted it, and we were definately not impressed.
    This stuff, on the other hand, is actually pretty good for alert people. There's just a hint of lemon in it to give it a bit of flavor:
    http://www.brucemedical.com/pretwat484oz.html
  12. by   CoffeeRTC
    Quote from Angie O'Plasty, RN
    This stuff, on the other hand, is actually pretty good for alert people. There's just a hint of lemon in it to give it a bit of flavor:
    http://www.brucemedical.com/pretwat484oz.html
    That is a good product..

    We deal with this alot in LTC for many reasons we have people on various consistancies from nectar, honey to pudding thick.
    Speech does the eval and will treat dyspagia. OT might work with adaptive equiptment. Ice Chips, ice cream, jello, sherbert regular soups and soaking wet oral sponges are not appropriate if they have a swallowing disorder and aspiration risk. I've see pts aspirate on all of these. All liquids must be thickened to be safe.
    Good and frequent oral care is a MUST. There are artifical saliva products (some flavored) that can be used.
    Most residents prefere the thickened juices over just water...cold is better. Just remember ice cubes will melt and thin the liquids.
    When pts/ families absolutly refuse to take the thickened liquids..they are educated on risks/ benifits and will sign a refusal of care.
  13. by   leslie :-D
    when i worked in the hospice unit, pts always came back from the hospital on aspiration precautions, always.
    then they would have a speech/swallow eval and 9 times out of 10 they were fine.
    so when i receive a patient who is ordered no thin liquids, i get a speech eval done.
    i also let sev'l of them suck on a cold washcloth and they're fine. i'll rinse the washcloth out and add more cold water until their thirst is satisfied.

    plus thick-it tastes like garbage, no matter what you add it to.

    leslie
  14. by   azzurra29
    Sorry for sounding terribly naiive, but what is the danger behind what is considered "thin liquids" like water as opposed to thickened liquids for NPO patients?

    I feel kind of bad because in clinical the other day a patient who was NPO and on a trach wanted some water--I shouldn't have but I left him have a few sips of water on his lips-- I felt pretty bad afterward because it was so obvious he was NPO and yet I wasn't thinking straight--that was a horrible day for me..

    Any danger in a few minimal sips of water to the lips like that?

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