الفهرس 
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Abstract
Post stroke dysphagia (PSD) isa complication that often occurs in critically ill patients with acute stroke and can causestroke associated pneumonia (SAP).SAP increases mortality, length of ICU stay and is associated with poor outcomes. Prevention of SAP is the one of the major obstacles facing the ICU team members particularly theCritical care nurses(CCNs).
Critical care nurses play an important role in diagnosis, management of PSD and prevention of SAP in critically ill patient with acute stroke. CCNs are responsible for early detecting signs and symptoms of PSD through early dysphagia screening(EDS). The provision of certain feeding strategies and effective oral care by CCNs also is important for prevention of SAP.
Aim of the study
The current study was conducted to determine the effect of early dysphagia screening, feeding strategies and oral care on occurrence of stroke associated pneumonia among critically ill patients with acute stroke.
Materials & Method
A quasi experimental research design was utilized to accomplish this study. This study was conducted in the General medical ICUs namely: the General ICU ”I” which has 15 beds, the General ICU ”II” which has 13 beds at Damanhur Medical National Institute, The General ICU at kafr El-dawar Hospital which has 12 beds and Stroke ICU of kafr El-dawar Hospital which has 5 beds.
A convenient sample of 60 adult patients newly admitted to the previously mentioned settings with the following inclusion criteria: patients who were diagnosed with acute stroke (ischemic or hemorrhagic stroke), had moderate or severe dysphagia, admitted within the first 24hr after symptom onset and had NIHSS grade more than 4. Patients who were mechanically ventilated, had pre –existing dysphagia, had pre –existing pneumonia were excluded from the study.
To accomplish the aim of the current study; four tools were used for data collection. Tool one: ”Early dysphagia screening tool” Gugging Swallowing Screen (GUSS). This tool was adopted fromTrapl et al. (2007).It was used by the researcher to identify alterations of the swallowing process and to characterize clinical signs that are suggestive of aspiration. It consists of two tests; test one (indirect swallowing test) and test two (direct swallowing screening test). Tool two: ”feeding strategies intervention tool”. This tool was adopted from Trapl et al. (2007), International Dysphagia Diet Standardisation Initiative [IDDSI] (2017). It was used to apply the suitable feeding strategies based on dysphagia severity. Tool three” oral care checklist tool”. This tool was adapted fromSheffler, (2014). It was used to perform oral care. Tool four” Assessment of stroke Associated Pneumonia”. This tool was adopted from the diagnostic criteria formulated by the Chinese Expert Consensus on Diagnosis and Treatment of Stroke Associated Pneumonia 2010, it was used to assess the occurrence of SAP.
The study design was accomplished as follow:
An official letter was obtained from the Faculty of nursing and was sent to hospital administrative authorities to conduct the study with explanation of the aim of the study. An official approval to carry out the study was obtained from the hospital administrative authorities to collect the necessary data from the selected settings.An informed consent was obtained from patients’ legal guardians. The Study tools were submitted to 5 jury of experts in the field of study to assess content validity. The necessary modifications were done accordingly.A pilot study was carried out on patients (10% of the sample) in order to assess feasibility of the study and applicability of the tools. The necessary modifications were done accordingly.
Data were collected over a period of 8 consecutive months (from January 2020 to September2020). Patients who met the inclusion criteria were randomly assigned into two equal groups, control and study, 30 patients in each.
For both groups: The socio-demographic and clinical characteristics were obtainedfrom the patient’s chart or family and recorded upon admission using tool one. All patients included in the study were assessed for pneumonia in admission by chest X-ray. Absence of pneumonia on admission was a necessary baseline in order to accurately determine the impact the intervention.
The Control groupwas subjected to early dysphagia screening using the GUSSthen routine care used in the study settings (feeding strategies, oral care)was observed for the seven consecutive days after admission and patients were assessed for occurrence of SAP for the seven consecutive days after admission.
The study group was screened using the GUSS (tool one) to assess severity of dysphagia. The researcher starts with indirect swallowing test (test one): Firstly, Vigilance was assessed. Secondly, Voluntary cough reflex was tested. Thirdly, Saliva swallowing was assessed.Then, Voice Change after the saliva swallow, involuntary cough and drooling was assessed. Only if total score of the indirect swallow test was 5 the researcher continued with direct swallowing test (test two).Then the researcher conducts direct swallowing test (test two), which consists of 3 sequentially performed swallowing trails. Firstly, semisolid swallowing test then liquid swallowing and finally solid swallowing trial.At the end of the subtest the researcher waits for a period of up to 3 minutes to determine whether coughing, drooling, voice change occur. If these signs occur, the test was stopped. Based on the level of dysphagia severity different feeding strategies were given according to the diet recommendations of the GUSS using tool two, Patients with moderate dysphagiawere given feeding via nasogastric tubeand given supplementary food (pureed, liquidized textures food). Patients with severe dysphagiaweregiven nothing per mouth and feeding was given via nasogastric tube. Oral care procedure was performed by the researcher using tool three. It was done twice daily by the researcher. The patients were assessed for seven consecutive days for the occurrence of stroke associated pneumonia by using tool four.
Results of the study
Most of studied patients in this study were females; ranged between 51 and 60 years old; had ischemic stroke; had severe stroke, were hypertensive, received antibiotics prophylaxis. Furthermore, there was no significant difference between the studied groups regarding demographic and clinical characteristics namely, sex, age, stroke type, stroke severity, past medical history, medications.
As regards duration between admission& dysphagia screening, it can be noted that more than two third of the study group (73.3%) were screened for dysphagia during the first four hours of admission. While, 40% of the control group of patients were screened between (15–19) hours of admission. There was a statistically significant difference between the two groups in this regard (p=<0.001).
Regarding dysphagia severity, 26.7% of the study group had moderate dysphagia compared to 30%of the control group. More than two third of the study and control group (73.3%, 70%) respectively had severe dysphagia with no significant difference between both groups (P=0.77) in this regard.
As regards feeding strategies, it can be noticed that all the studied patients with severe and moderate dysphagia in both groups took nasogastric tube feeding during the study. Theentire study group with moderate dysphagia were reassessed by initial part of GUSS before each meal during the study period compared to 0% of the control group with a significant difference between the two groups in this regard (p<0.001).
The study also reveals that 100% of the patients with moderate dysphagia in the study group took supplementary food (Puree, liquidized food) compared to 22.2% of the control group who took (only yogurt) with a statistically significant difference between the two groups (p =0.002).The study also shows that all the patients with moderate dysphagia in the study group took(thickened liquid, crushed pills mixed with puree food or given in NGT).While all the patients in the control group didn’t take thickened liquids, crushed pills mixed with puree food during the study period with a statistically significant difference between the two groups in these regards (p<0.001,<0.001) respectively. It can be also noticed that 100% of the study group took no liquid (Medications, water) compared to 77.8% of the control group with no statistically significant difference between the two groups (p= 0.47).
Regarding oral care, it shows that the entire study group were undergone all the steps of oral care. It can be noticed thatupright positioning, Inspection of mouth and brushing with 0.12% chlorhexidine were performed for 16.7 % of the control group. Concerningbrushing the teeth with toothpaste, suctioning as needed and rinsing the mouth, it was not performed for 100% of the control group. As regards using lips moisturizer, it was performed for only 3.3% of the control group. The table reveals a significant difference between the two groups (p <0.001) in all the steps of oral care.
Concerning occurrence of SAP, 13.3% of the study group developed SAP compared to 40% of the control group with a statistically significant difference between the two groups in relation to occurrence of SAP (p=0.02).
As regard the duration between admission, dysphagia screening and occurrence of stroke associated pneumonia. there was a statistically significant relation between early dysphagia screening (EDS) and prevention of SAP (p=0.003, 0.016) for the study and the control group respectively.
As regard therelationship between dysphagia severity and occurrence of stroke associated pneumonia. There was a statistically significant relation between dysphagia severity and occurrence of SAP (p=0.004) for the control group.
Conclusion
The current study aimed to determine the effect of early dysphagia screening, feeding strategies and oral care on occurrence of stroke associated pneumonia among critically ill patients with acute stroke. Based on the current study findings, it can be concluded that:
• Combination of EDS, feeding strategies and oral care practices significantly decrease SAP occurrence among critically ill patients with acute stroke.
Recommendations
• Screen critically ill patients with acute stroke for PSD by CCNs using GUSS as early as possible within the first 24 hours after admission.
• Encourage collaboration between CCNs, physicians/SLT and dietitian to provide the appropriate care for critically ill patients with PSD.
• Tailor the combination of EDS, feeding strategies and oral care practices based on the nature of critically ill patients with PSD illness, resources and available policies and procedures in the clinical settings.
• Develop educational programs and workshops to raise CCNs’ awareness regarding the importance of early dysphagia screening, different screening tools and how to apply dysphagia screening for critically ill patients with acute stroke and to teach them regarding feeding strategies and diet recommendation for patient with PSD.
• Include dysphagia screening and oral care tools as a part in nursing flowsheet.
• Undergraduate critical care nursing courses should be focused on the vital role of the CCNs in the acute PSC and preventing PSD complications including SAP.
• Replication of this study on large sample is needed for generalization of results.