INTRODUCTION

When approaching people with impaired swallowing, it is important that the multidisciplinary team is aware of its consequences and knows how to identify its clinical signs¹. Thus, an early assessment of the swallowing function is as or greater importance as the assessment of the person's state of consciousness and the nursing team must be prepared to quickly identify these persons, facilitating the diagnosis and treatment of the alteration in question².

The intervention of the nurse, namely the rehabilitation nurse, is essential for persons with impaired swallowing, accompanying them in the rehabilitation process since its beginning and constantly.

The person's perception is equally fundamental in the nursing diagnosis “compromised swallowing”. In this sense, the Eat Assessement Tool (EAT-10) is an instrument that can be applied to persons with impaired swallowing, regardless of their diagnosis, as it allows measuring the degree of swallowing change felt by them³.

It is a Likert-type questionnaire where the person reports the intensity of the perceived change, assigning a score to each of the ten statements, from which a score can be obtained that can vary between 0 for no problem and 4 that corresponds to big problem. A final score greater or equal to three points indicates the presence or risk of impaired swallowing³.

A study indicates that 48% of people with aspirations detected by videofluoroscopy did not present cough after aspiration of swallowed content, attesting to a high incidence of silent aspirations⁴. Considering this problem, the Volume-Viscosity Swallow Test (V-VST) is an easy-to-apply clinical exploration method that uses pulse oximetry as a complementary procedure for the rapid identification of these persons without recourse to invasive methods such as videofluoroscopy or videoendoscopy⁴.

This method allows the rapid detection of clinical signs of change in the efficiency and safety of swallowing through the administration of three types of consistencies: nectar, liquid and pudding, respecting a flowchart with different degrees of difficulty⁴. Changes in efficacy include: ineffective lip closure, presence of oral or pharyngeal residues, and multiple swallows per bolus administered. Signs of change in safety include: change in voice quality, cough or decrease in pulse oximetry greater or equal to 3%⁴.

With the data obtained in the application of the V-VST method, it is possible to categorize the functional limitations in oral feeding⁴. In this sense, the Functional Oral Intake Scale (FOIS), with its 7 items, is an assessment instrument that allows this approach. A person positioned at level 7 does not present any type of limitation, on the other hand, a person positioned at level 1 is not able to swallow any food orally⁵.

In turn, in levels from 1 to 3 of this instrument, are those who need a nasogastric tube to maintain an adequate food or water intake. Levels 4 to 7 are intended for those who are capable of oral ingestion without the need for any alternative route⁵.

The EAT-10 and the FOIS are two easy-to-apply instruments⁵, they are validated for the Portuguese population^(3;5) and are a valuable asset for the assessment of those with impaired swallowing, guiding their respective rehabilitation⁵.

with regards to treatment of swallowing disorders, it is important to accurately identify the affected structures and the type of deficit in swallowing. If muscle weakness is identified, the person should be guided to perform a series of exercises focused on re-educating specific areas of the base of the tongue or the lateral walls of the pharynx. In the case of the presence of neurological deficit that leads to changes in the swallowing reflex or if the muscle deficit is insurpassed, then the person should be guided to implement compensatory strategies to improve swallowing safety⁶.

After identifying the change in swallowing, it is essential to outline the planning of nursing care, aiming at the functional re-education of swallowing which, given its complexity, requires specific skills in the field of intervention⁷.

The rehabilitation process of compromised swallowing encompasses skills training and muscle strength components, which aim to ensure safe oral intake and combat swallowing alterations⁸.

In parallel, it is also essential to implement other rehabilitation nursing care, such as techniques to improve the ventilatory pattern and ventilatory mechanics, seeking to ensure the permeability of the airways, promote strengthening of the respiratory muscles and reduce the risk of aspiration⁷.

The prevention of the consequences of immobility should include nursing interventions focused on promoting self-care using adaptive strategies⁹. It is common to observe changes in mobility in people with impaired swallowing, such change cannot be neglected in the planning and implementation of a rehabilitation nursing program. Thus, nursing interventions, in this context, should promote self-control and self-care for these persons.

Introducing rehabilitation as a process that aims at the person's functional recovery, reintegration into the family, community and society, a holistic approach to the person being cared for is necessary¹⁰. When approaching the person with compromised swallowing, these premises must always be constant.

Rehabilitation Nursing can play a key role in approaching the person with this disorder. This specialty, with another area of ​​Nursing, must be supported by a framework that guides the practice. In the present approach, Dorothea Orem's Self-Care Deficit Nursing theory fits perfectly.

The aforementioned nursing theory proposes five areas of activities for practice, which are: the maintenance of a therapeutic relationship; determining how the person can be helped through nursing care; the response to the person's needs in relation to the nurse's contact and assistance; the prescription, provision and regulation of direct help to the person and significant companions; the coordination and integration of nursing care in the person's daily life; other health care or the necessary social and education services¹¹. The five areas mentioned are well present throughout the case presented.

The present study focused on the implementation of a functional re-education program, consisting of rehabilitation nursing interventions with a person with compromised swallowing of neurological etiology. Thus, strategies were developed duly based on the Nursing Process and on the Documentary Standard of Specialized Care of the Rehabilitation Nursing Specialty¹². Likewise, the use of appropriate assessment instruments allowed the elaboration of diagnostic criteria that helped to define more accurate rehabilitation nursing diagnoses in this context and sought to guide the process of evaluating the results of that same program.

In this sense, the general objective of this study was to identify the gains sensitive to rehabilitation nursing care with the implementation of a swallowing optimization program in a person with impaired swallowing. The specific objectives aimed to identify swallowing changes using three instruments: assessment of swallowing changes; define the main rehabilitation nursing diagnoses in the context of compromised swallowing; evaluate the impact of implementing a swallowing optimization program in a person with impaired swallowing, in improving rehabilitation nursing diagnoses.

MATERIAL AND METHODS

In Nursing, the approach through the case study allows the researcher to study a complex phenomenon of life in an intensive and profound way, using multiple sources of evidence¹³.

Case studies can generate hypotheses for future clinical studies, as well as guidance for the individualization and personalization of care provision. The CAse REport (CARE) guidelines were used as they provide the necessary structure to satisfy the accuracy, integrity and transparency in the scientific approach to case studies¹⁴.

CARE's guidelines are part of a 13-item checklist (title, keywords, abstract, introduction, person information, clinical findings, schedule, diagnostic evaluation, therapeutic intervention, clinical follow-up and results, discussion, person perspective, term of informed consent) and is specially structured to correspond to the main components of a case study and to apprehend the relevant clinical information¹⁴.

Likewise, in the structuring of this study, the six stages of the development of the case study defined by Yin and Stake were fulfilled, namely: Definition of the problem; Case definition; Theoretical foundation; Preparation of the study protocol; Data collection; Analysis and interpretation of results¹³.

This study describes the case of a person with compromised swallowing and presents a longitudinal character, which allows to demonstrate the functional swallowing reeducation program developed with this person and showing the results achieved.

It was carried out during the month of November 2017, from admission to a unit in the department of medicine of a Hospital Center of the Regional Health Administration of Lisboa e Vale do Tejo, until the functional swallowing was recovery. It is a unique case and a holistic approach.

The person involved in the study signed the free and informed consent form for health acts/interventions under the terms of standard No. 015/2013 of the Directorate-General for Health.

The study was approved by the Ethics Committee for Health and authorized by the Board of Directors of the Hospital Center.

It is noteworthy that all ethical aspects connected with research carried out with human beings were respected. Thus, was sought to comply with the indications expressed in the Declaration of Helsinki, in the Convention on Human Rights and Biomedicine, in the guidelines of the Council for International Organizations of Medical Sciences and in the Guide to Good Clinical Practices.

The person was designated by a letter (A), safeguarding data confidentiality and anonymity.

The use of specific instruments for the assessment of swallowing commitment required the request for authorization from national researchers who had adapted these same instruments to European Portuguese.

This study shows the results of a participant who was part of a large project whose inclusion criteria for the participants were: a Glasgow Comas Scale score greater or equal to 11 points (maximum score on the items “eye opening” and “best motor response”) , in order to include people with speech deficits; EAT-10 score greater or equal to 3 points (suggesting the perception of commitment in swallowing³); FOIS higher than level 1 and lower than level 7 (allowing the inclusion of persons with oral intake, but with commitment in the ingestion of certain consistencies⁵).

A statistical analysis of all EAT-10 questionnaires applied to the person throughout the study was performed, using the IBM-SPSS (Statistical Package for the Social Sciences) version 22.0 software, facilitating a subsequent descriptive analysis.

CASE PRESENTATION

RESULTS

As mentioned above, Mr. A was part of a larger project, having started the swallowing functional reeducation program at the beginning of the project selection period.

After signing the informed consent, he completed a total of 10 sessions, with 4 assessments being carried out in total, respecting the interval of 3 sessions, and remained in the program until functional recovery from swallowing.

Decreased levels of awareness, the presence of fatigue and neurological alterations can compromise the person’s response and the maintenance of sufficient alertness to favor their participation in therapeutic sessions²². Thus, before any intervention, the level of consciousness was always assessed through the application of the Glasgow Comas Scale.

As mentioned above, it could be observed that Mr. A always remained alert and collaborative, with 15 points on that scale, both in the initial assessment and in the remaining assessments.

This was followed by the step of assessing the perception of swallowing changes, using the EAT-10 questionnaire. The questionnaire was always completed by Mr. A, only requiring guidance to filling it out on the day of the initial assessment.

In the analysis of the responses obtained in the EAT-10 questionnaires, it can be seen that the most frequently perceived problems resided at “swallowing liquids requires a greater effort” and “I cough when I eat”, being reported in all evaluations carried out. This fact suggested that these are the most disturbing problems for Mr. A throughout the swallowing functional reeducation program (Graph 1).

In the statistical analysis of the EAT-10 questionnaires, it was also verified that, although it was not reported in all evaluations, the difficulty in swallowing pills was also a relevant problem reported by Mr. A (Table 1).

In the first evaluation, the perception of the change in swallowing was evident, with a very high final score (13 points). However, at the end of the swallowing functional reeducation program, the score obtained was less than 3 points (2 points) (Table 2), suggesting a total remission of symptoms of impaired swallowing^3,5.

Regarding the clinical exploration of swallowing, through the application of the V-VST method, it was found that, in the seventh session, Mr. A was already tolerating liquid bolus, maintaining signs of alteration in the safety of swallowing in high volumes (20ml). Supervised fluid intake was recommended in medium volumes (10 ml) (Table 3).

In the tenth session, Mr. A was already ingesting high volumes of liquid (20 ml) without showing signs of compromising the safety or effectiveness of swallowing. It was found that Mr. A completed the swallowing functional reeducation program without presenting oxygen desaturation, a situation that was frequent at the beginning (Table 3).

The data obtained from the application of the V-VST clinical exploration method guided the selection of the most appropriate exercises and techniques.

In the initial session, program 1 was selected and program 2 was selected in the remaining sessions that Mr. A had a greater number of alterations in the pharyngeal phase, which justified the selection of program 2 more frequently.

Specialized rehabilitation nursing care inherent to the person with impaired swallowing was ensured, directed at the changes presented by Mr. A, aiming to achieve maximum functionality and autonomy.

Thus, regarding the diagnosis “compromised swallowing”, there was a progression of Mr. A's autonomy in the degree of commitment throughout the program. Within the scope of “Knowledge” and “Learning Skills” dimensions, the changes in exercise program and swallowing techniques, from program 1 to program 2, contributed to the existence of some gaps in the transition phase. However, these gaps were being filled (Table 4).

The high adherence to the proposed swallowing exercises and techniques is highlighted.

Mr. A demonstrated increased capacity in the exercises and techniques that were performed more frequently throughout the swallowing functional reeducation program, with greater difficulty in performing the Masako maneuver (because it is a difficult technique to perform). The thermal stimulation technique was initially performed by the nurse. However, at the end of the program, Mr. A has already demonstrated the capacity to carry it out.

There was a greater lack of knowledge about the super-supraglottic swallowing technique. Although the Masako maneuver is the technique where the person showed greater difficulty in execution, this was not verified with the knowledge about it. Mr. A demonstrated more consistent knowledge of the therapeutic exercises given since the beginning of the program.

The family caregiver (wife) was not always present in all sessions, but correctly apprehended the activities and techniques addressed throughout the program. Like Mr. A, he demonstrated consistent knowledge of the techniques that were most frequently performed throughout the program. Both Mr. A and the family caregiver gradually acquired knowledge about the adapted consistency technique (use of thickener).

Taking into account the change in swallowing, the “risk of compromise in nutritional intake” was evident ¹⁶. At the end of the program, when Mr. A already had the functional capacity to ingest meals with two or more consistencies, this risk was no longer present. The BMI was monitored weekly and, as mentioned above, no changes were detected throughout the program.

In the analysis of the data obtained, it was found that Mr. A presented functional improvement in swallowing, as evidenced by the progression in the FOIS level. It should be noted that Mr. A completely reversed the swallowing changes, reaching level 7 on the FOIS scale (Table 5).

DISCUSSION

The approach presented and the results achieved demonstrate that specialized rehabilitation nursing care can play an important role in early intervention on people with impaired swallowing and on their functional re-education.

Nurses are the professionals who spend more time with the person, being responsible for ensuring their autonomy and safety². It is recommended that, for an effective approach to persons with impaired swallowing, the need to face this reality as a priority for multidisciplinary action should be considered^2,23.

Conducting studies in this area is essential to establish the effectiveness of rehabilitation in persons with specific swallowing disorders, to define the appropriate treatment to maximize costs and produce positive results⁸. In order to achieve this objective, this case included the assessment of swallowing through the application of valid, reliable, responsive and efficient assessment instruments²⁴ and the implementation of a swallowing optimization program based on the detected changes. This set of interventions aimed at the functional recovery of the studied person's swallowing.

In selecting the most appropriate set of exercises and swallowing techniques, the use of the EAT-10 and V-VST instruments was essential to characterize the observed alterations^3,4.

The presence of swallowing changes can lead to feelings of depression and anxiety during meals³. The application of the EAT-10 tool made possible to measure the degree of severity of symptoms, monitor the effectiveness of the established program^3,5 and detect the most frequently perceived problems that most disturbed the person approached. There was a significant reduction in reported symptoms.

The combination of the EAT-10 tool with the V-VST clinical exploration method presents great precision with regard to the detection of swallowing alterations⁴. The results presented with the application of these instruments evoke the need for clinical screening and skill training by someone with skills in swallowing assessment, capable of determining the presence, severity and mechanism of alteration^7,23.

The V-VST allowed the detectition of changes in the safety and effectiveness of swallowing and provided the necessary data to demonstrate that, at the end of the program, the studied person was already tolerating high volumes of fluids, which suggests the effectiveness of the planned interventions.

According to the clinical manifestations observed, it was essential to adjust the muscle strengthening exercises, compensatory postures and techniques that facilitate swallowing¹⁹ throughout this approach. Such adjustment allowed the individualization of the swallowing functional reeducation program.

The functional re-education of swallowing in a person with a stroke should include therapeutic measures focused on increasing oral sensitivity, oral motor exercises and compensatory maneuvers in order to prevent aspiration²⁵. Such aspects were always addressed in the two proposed rehabilitation programs.

Positive reinforcement was essential and necessary to achieve the goals outlined for the functional re-education program²⁶ of swallowing. In the case analyzed, the person demonstrated, in general, to have knowledge and ability to perform exercises and swallowing techniques, with positive reinforcement being the key to such success.

The person's difficulty in performing certain therapeutic exercises, mainly in the scope of compensatory techniques of swallowing, was related to the presence of motor and sensory deficits that made it impossible for them to be independent in their performance.

In order to implement self-care and self-control, a structured approach to rehabilitation nursing care is needed, involving family and informal caregivers in the proposed interventions ²⁷. Thus, the participation of the informal caregiver in the person's rehabilitation process proved to be essential, reinforcing their role in the continuity and reinforcement of the care provided.

Aiming to promote the re-adaptation processes and promote the capacity for self-care ²⁸, the importance of planning rehabilitation nursing care based on nursing diagnoses in accordance with the observed changes is highlighted.

The effectiveness of the care method advocated by Dorothea Orem depends, to a large extent, on the nurse's creativity, appreciation, knowledge about and respect for the person. An environment favorable to development is also an environment favorable to learning.²⁹ The approach explained in this study is based on Dorothea Orem's theory of self-care deficit, which focuses on the role of Nursing in learning and developing the skills of the person being cared for.

The clinical reasoning that the nurse makes culminates in a diagnosis and involves making decisions based on the identification of the person's clinical conditions (diagnostic criteria), in this sense, the greater the accuracy of a diagnosis, the more accurate the clinical decision process should be ³⁰. The use of instruments that allowed the assessment of swallowing alterations contributed to the definition of diagnostic criteria for rehabilitation nursing.

On the other hand, these instruments helped to assess the progress of the person's state with the intervention of the Rehabilitation Nurse and, together with the implemented interventions, contributed to the functional re-education of swallowing, this purpose being attested by the progression in the FOIS scale.

The study of this case allowed us to reflect on the relevance of the systematic assessment of swallowing and reinforce the idea that the nutritional risk of a person with a stroke requires continuous monitoring and effort ³¹.

From the results of the implementation of this program, some limitations stand out. It would be essential, in future research, to extend the time available for the implementation of different therapeutic activities, allowing for more consistent results. Likewise, the fact that only one person's case is addressed makes it impossible to make inferences about the results obtained.

There are not many publications by nurses in the area of ​​functional re-education of swallowing. In this way, this exhibition can give visibility to the interventions of rehabilitation nurses on the person with this change. Thus, the need to carry out more studies on this theme becomes emergent, namely experimental or quasi-experimental studies.

The case presented may contribute to a properly systematized specialized nursing practice, enabling the dissemination of knowledge about the intervention of the rehabilitation nurse with the person with impaired swallowing, with a view of strengthening the teaching and practice of this specialty.

FINAL THOUGHTS

This case study highlighted the effectiveness of rehabilitation nursing interventions in the context of promoting the safety and functionality of persons with impaired swallowing, which is a possible approach to take into account in persons with alterations of this nature.

Throughout the implemented program, it was essential to detect the person's ability to eat and hydrate safely and effectively, this was possible through constant monitoring of awareness using the Glasgow Coma Scale.

The assessment of the risk of changes in swallowing was possible using the EAT-10 questionnaire, which allowed for the identification of symptoms of impaired swallowing and its degree of severity.

The clinical signs identified with the application of the clinical exploration method (V-VST) were fundamental for the selection of the appropriate set of exercises.

The assessment instruments (FOIS, EAT-10 and V-VST) in addition to helping to define the stated rehabilitation nursing diagnoses, made the diagnostic criteria more objective, facilitating the implementation of diagnostic action statements and interventions for nursing appropriate to the person's clinical situation and the observed dysfunction, and allowed a holistic and personalized approach.

The evolution of the person approached was visible through the results obtained in the application of the assessment instruments and the positive progression in the degree of commitment in the stated nursing diagnoses. Nursing interventions proved to be effective in reversing swallowing changes and contributed to improve the autonomy and independence of the studied person.

Throughout the program, the risk of compromise in nutritional intake was evident, but no large fluctuations in BMI values ​​that could prove such compromise were observed.