The First Affiliated Hospital of Shantou University Medical College吞咽障碍筛查和护理陈思洽1The First Affiliated Hospital of Shantou University Medical College目录目录吞咽及吞咽障碍概述吞咽及吞咽障碍概述吞咽障碍筛查吞咽障碍筛查喂食注意事项喂食注意事项0102032The First Affiliated Hospital of Shantou University Medical College正常吞咽及吞咽过程吞咽：吞咽：食物经咀嚼后形成的食团，由口腔经咽和食管入胃的整个过程吞咽过程：吞咽过程：口腔阶段咽腔阶段食道阶段3The First Affiliated Hospital of Shantou University Medical College口腔阶段u通过舌后上举将食行送入咽。舌骨肌和二腹肌完成张口运动，食物进入口腔。咀嚼肌咀嚼食物成团块。通过舌后上举将食行送入咽4The First Affiliated Hospital of Shantou University Medical College咽腔阶段食物进入咽，诱发吞咽反射会厌掩盖气管，防止食物进入气管软腭与鼻咽壁接触把鼻和口腔分隔防止倒流5The First Affiliated Hospital of Shantou University Medical College食道阶段腭咽闭合，咽缩肌群收缩蠕动使食物团通过咽腔。环咽括约肌松驰，食团进入食道，蠕动至胃6The First Affiliated Hospital of Shantou University Medical College什么是吞咽障碍？什么是吞咽障碍？吞咽障碍吞咽障碍由于下颌、双唇、舌、软腭、咽喉、食道括约肌或食道功能受损，不能安全有效地将食物由口送到胃内取得足够的营养和水分，由此产生的进食困难7The First Affiliated Hospital of Shantou University Medical College吞咽障碍的不良后果吞咽障碍的不良后果饮水呛咳饮水呛咳吞咽时吞咽时/后咳嗽后咳嗽口鼻返流口鼻返流食物残留食物残留/异物感异物感进食后突发呼吸困难进食后突发呼吸困难体重下降体重下降脱水、电解质紊乱脱水、电解质紊乱营养不良营养不良抵抗力下降抵抗力下降发热发热/吸入性肺炎吸入性肺炎近期影响近期影响长期影响长期影响8The First Affiliated Hospital of Shantou University Medical College 医生医生 决策决策 者者护士护士筛查评估者筛查评估者家属家属 鼓励患者鼓励患者治疗师治疗师评估患者评估患者者者患患者者吞咽障碍的团队及角色9The First Affiliated Hospital of Shantou University Medical College吞咽障碍筛查对象吞咽障碍筛查对象脑血管病（脑梗塞、脑出血、球麻痹）多发性硬化、运动神经元病帕金森病、老年痴呆重症肌无力营养不良鼻咽癌放疗术后年龄65岁老年患者10The First Affiliated Hospital of Shantou University Medical College气管切开或气气管切开或气管插管管插管意识不清醒或意识不清醒或不合作者不合作者现存吸入性现存吸入性肺炎肺炎呼吸困难的患呼吸困难的患者者筛查的禁忌症筛查的禁忌症11The First Affiliated Hospital of Shantou University Medical College 反复唾液吞咽试验反复唾液吞咽试验洼田饮水试验洼田饮水试验V_VSTV_VST测试测试评估方评估方法法床边饮水、吞糊试验床边饮水、吞糊试验吞咽障碍筛查方法12The First Affiliated Hospital of Shantou University Medical College方法：方法：患者取坐位，若患患者取坐位，若患者卧床则采用放松体位，者卧床则采用放松体位，检查者将手指放在患者的检查者将手指放在患者的喉结及舌骨喉结及舌骨处，让其尽量处，让其尽量快速反复吞咽，快速反复吞咽，口腔干燥口腔干燥时可在舌面注时可在舌面注1ml1ml水，水，观观察在察在3030秒内秒内患者吞咽次数患者吞咽次数和活动度和活动度3.2.1反复唾液吞咽测试（反复唾液吞咽测试（RSSTRSST）13The First Affiliated Hospital of Shantou University Medical College反复唾液吞咽测试结果反复唾液吞咽测试结果结果判断结果判断高龄患者高龄患者（8080岁以上）岁以上）中年患者中年患者（50-8050-80岁）岁）喉上下活喉上下活动动正常正常30s330s3次次5 5次次2cm2cm异常异常30s330s3次次55次次2cm2cm14The First Affiliated Hospital of Shantou University Medical College吞咽功能障碍筛查床边饮水测试床边饮水测试糊测试糊测试15The First Affiliated Hospital of Shantou University Medical College筛查时机 入院时入院时留置胃管期间，视病情留置胃管期间，视病情1 1次次/QW/QW拔胃管前拔胃管前病情变化随时测评病情变化随时测评16The First Affiliated Hospital of Shantou University Medical College筛查的用具筛查的用具量杯5ml注射器指脉氧监测仪17The First Affiliated Hospital of Shantou University Medical College筛查用品筛查用品小毛巾凝固粉18The First Affiliated Hospital of Shantou University Medical College3.2.2改良饮水试验方法改良饮水试验方法010204035 5ml水试饮水试饮观察所需时间分观察所需时间分几次喝完、和呛几次喝完、和呛咳情况咳情况，结果判断结果判断30ml水洼田水洼田饮水试验饮水试验02通过通过通过通过不通过不通过每次加每次加1ml至至10ml每次减每次减1ml至至3ml目的：确定饮水安全一口量目的：确定饮水安全一口量试验出现清喉试验出现清喉咙、咳嗽，声咙、咳嗽，声嘶、吞咽延迟嘶、吞咽延迟等，血氧饱和等，血氧饱和度下降度下降2-4%2-4%，未通过未通过注意事项注意事项19The First Affiliated Hospital of Shantou University Medical College洼田饮水试验洼田饮水试验分级分级表现表现1 1级（优：正常吞咽功能）级（优：正常吞咽功能）5 5秒钟内顺利地秒钟内顺利地1 1次将水咽下次将水咽下2 2级（良：级（良：可疑吞咽功能障碍可疑吞咽功能障碍）分分2 2次以上，能不呛咳地咽下次以上，能不呛咳地咽下3 3级（中：轻度吞咽功能障碍）级（中：轻度吞咽功能障碍）能能1 1次咽下，但有呛咳次咽下，但有呛咳4 4级（可：中度吞咽功能障碍）级（可：中度吞咽功能障碍）分分2 2次以上咽下，但有呛咳次以上咽下，但有呛咳5 5级（差：轻度吞咽功能障碍）级（差：轻度吞咽功能障碍）频繁呛咳，不能全部咽下频繁呛咳，不能全部咽下级、级留置胃管；级行吞糊试验患者端坐，喝下患者端坐，喝下30毫升温开水，观察所需时间和呛咳情况毫升温开水，观察所需时间和呛咳情况20The First Affiliated Hospital of Shantou University Medical College糊测试方法方法：病人取直立坐位病人取直立坐位/ /抬高抬高床头床头30-6030-60。向病人解释测试目的，向病人解释测试目的，取得病人的配合。取得病人的配合。准备一杯准备一杯100ml100ml的温开的温开水，加水，加3g3g凝固粉凝固粉调成调成糊糊状（特稠），每次状（特稠），每次5ml5ml喂病人。喂病人。观察患者血氧饱和度的观察患者血氧饱和度的变化及有无误吸、吞咽变化及有无误吸、吞咽困难的症状。困难的症状。21The First Affiliated Hospital of Shantou University Medical College结果吞咽困难症状吞咽困难症状是是否否糊从口角流出糊从口角流出/溢出溢出有呛咳有呛咳/咳嗽咳嗽 吞咽后出现声音浑浊吞咽后出现声音浑浊 诉吞咽困难、乏力诉吞咽困难、乏力/延迟延迟 出现鼻返流出现鼻返流 糊残留口腔糊残留口腔 测试后呼吸不适测试后呼吸不适 SPO2降低降低4 22The First Affiliated Hospital of Shantou University Medical CollegeV_VST测试23The First Affiliated Hospital of Shantou University Medical College 进食姿势v坐或半坐卧位v头前倾30度v杜绝头后仰v偏瘫侧肩部以枕垫起；v喂食者位于患者健侧24The First Affiliated Hospital of Shantou University Medical College一口量一口量即最适于吞咽的每次摄食入口量过多，食物将从口中漏出或引起咽部残留导致误咽过少，则会因刺激强度不够，难以诱发吞咽反射尽量不要用吸管喝水，因不好掌握安全一口量 一口量进食一口量进食25The First Affiliated Hospital of Shantou University Medical College进食进食速度速度调整合适的进食速度，前一口吞咽完成后再进食下一口，避免两次食物重叠入口的现象，以防误吸耐力不足，可采取少量多餐26The First Affiliated Hospital of Shantou University Medical College把食物放在把食物放在健侧舌中后部或健侧颊部健侧舌中后部或健侧颊部，这样有利，这样有利于食物的吞咽。于食物的吞咽。适合部分或全部舌、颊、口、面部有感觉障碍的适合部分或全部舌、颊、口、面部有感觉障碍的患者；患者；适合所有面舌肌肉力量弱的患者。适合所有面舌肌肉力量弱的患者。放入口中位置放入口中位置27The First Affiliated Hospital of Shantou University Medical College禁止不经医护禁止不经医护同意私自喂食同意私自喂食喂食物时尽量采喂食物时尽量采用坐立与下颌内用坐立与下颌内收位收位患者未咽干净患者未咽干净前勿喂下一口前勿喂下一口进餐后清洁口腔进餐后清洁口腔 保持坐立位保持坐立位20-30分钟分钟家属及患者注意事项家属及患者注意事项当出现呛咳时要立即当出现呛咳时要立即停止喂咽停止喂咽注意注意28The First Affiliated Hospital of Shantou University Medical College29The First Affiliated Hospital of Shantou University Medical College谢谢聆听30若有不当之处，请指正，谢谢！31