how to assess gag reflex nursing

Some common techniques include: An emerging body of evidence suggests that the gag reflex is unpredictable, even in healthy people. The rooting reflex assists in the act of breastfeeding. The brachioradialis reflex is used to assess the cervical spine nerves C5 and C6. Begin by feeding patient one-third teaspoon of applesauce. Literature that I've read it seems checking a gag reflex is old practice and not a good indicator of protection of airway because up to 30% of population has no gag reflex and it's most likely not present in people with sleep apnea or those who have had multiple intubations in the past. I agree that the possibility of causing injury to the cornea is a real concern. Then getting them to take a small sip of water, and observing their swallow is more informative than sticking a tongue depressor down their throat. Ask the patient to support their arm on their thigh or on your hand. 14,603 Posts. Advance slowly, giving small amounts; whenever possible, alternate servings of liquids and solids. This is why agencies must establish clear policies for when this test is necessary, and how to proceed in response to its results. Allowance of time to eat slowly and chew thoroughly, Use of fluids to help facilitate passage of solid foods, Monitoring of the patient for weight loss or. We may earn a small commission from your purchase. It can be a temporary or permanent complication that can be fatal. )The primary goal PaO2 of 60 to 70 mm Hg = to an . The normal reflex response is flexion of the great toe. I had a patient that came in high on methamphetamine. Avoid milk and milk products. Praise patient for successfully following directions and swallowing appropriately. Sneeze reflex: Sneezing occurs to rid the nasal passages of irritants. The arm on the same side as the head is turned will straighten and the opposite arm will bend. To test light sensation, have client close eyes, wipe a wisp of cotton over clients forehead. One study found poor inter-observer agreement about gag reflexes, suggesting that a test of the gag reflex is subjective at best. Gag reflex: The gag reflex is elicited when the back of the mouth and the posterior tongue is stimulated with a tongue blade. These strategies aid in cleaning out residual food. Identify the triceps tendon posteriorly just above its insertion on the olecranon. Discuss the importance of exercise to enhance the muscular strength of the face and tongue to enhance swallowing. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. allnurses is a Nursing Career & Support site for Nurses and Students. Jendrassik maneuver can be used to augment hypoactive reflexes: The patient locks the hands together and pulls vigorously apart as a tendon in the lower extremity is tapped. Cranial Nerves Assessment Chart and Cheat Sheet, Focus Charting (F-DAR): How to do Focus Charting or F-DAR, Therapeutic Communication Techniques Quiz. Dysphagia can befall at any age, but its more prevalent in older adults. How to Check Gag Reflex in an Intubated Patient, Images and content of this blog are 2021, both neurologically normal people and people who are accustomed to an endotracheal tube, Traditionally, the presence of a gag reflex, A weak gag reflex is an important risk factor for aspiration pneumonia, Wiggling the endotracheal tube back and forth, Inserting either a catheter or tongue depressor into the throat. Client should have a (+) corneal reflex, able to respond to light and deep sensation and able to differentiate hot from cold. This involuntary reflex is obtained by touching the back of the pharynx with the ton. We have multiple patients that come in during the day/night to sleep it off. Some that are high on meth, we sedate and they sleep it off. May have cough. Such directions assist in keeping ones focus on the task. You may find yourself . Enteral feedings via PEG tube are generally preferable to. Literature that Ive read it seems checking a gag reflex is old practice and not a good indicator of protection of airway because up to 30% of population has no gag reflex and its most likely not present in people with sleep apnea or those who have had multiple intubations in the past. Although infants cannot support their own weight, when the soles of their feet touch a surface, it appears as if they are attempting to walk by placing one foot in front of the other foot. I would be so cautious to do that, especially in a patient thats on a substance or has ETOH on board Id be afraid for them vomiting then aspirating and then for sure we would be intubating. Specializes in ER. Encourage the patient to feed self as soon as possible. Use a reflex hammer in a quick striking motion by the wrist on various tendons to produce an involuntary response. For impaired swallowing, use a dysphagia team composed of a rehabilitation. Ask the patient to support their arm on their thigh or on your hand. When assessing the accessory nerve, what should the nurse do? Pathologic reflexes (eg, Babinski, Chaddock, Oppenheim, snout, rooting, grasp) are reversions to primitive responses and indicate loss of cortical inhibition. For the Oppenheim reflex, the anterior tibia, from just below the patella to the foot, is firmly stroked with a knuckle. That seems obvious, but on one or two occasions the neurosurg resident came in, seemingly ready to start getting things lined up and I was able to let them know hold your horses he still has a cough/gag.. Is this still common practice as indication for intubation? In an intubated patient, a suction device may be most convenient to use for testing. allnurses, LLC, 175 Pearl St Ste 355, Brooklyn NY 11201 Hello! Then you can give them a tiny sip of water. NPA and sleep it off in a hallway bed. Client was able to read with each eye and both eyes. The more effective strategy is to touch the back of the pharynx with a laryngoscope or tongue depressor. The reflex consists of flexion and supination of the forearm. This reflex is called rooting reflex, which helps the baby find the source of food. Dairy products can lead to thickened secretions. Before mealtime, provide for adequate rest periods. When reflexes are depressed, the patient is at increased. Avoid foods such as hamburgers, corn, and pastas that are difficult to chew. I would take the slightest cough to indicate that don't have their complete reflex back yet. If any of these signs are present, put on gloves, eliminate all food from oral cavity, end feedings, and consult with a speech and language pathologist and a dysphagia team. Client should be able to shrug shoulders and turn head from side to side. Share your thoughts. Gil Wayne graduated in 2008 with a bachelor of science in nursing. After logging in you can close it and return to this page. C. Ask the patient to push the tongue to either side against resistance. Whether you're in a Hospital or EMSsetting, this is the place for you. Client is able to identify different smell with each nostril separately and with eyes closed unless such condition like colds is present. All rights reserved. ICU assesses gag reflex. That way I can notify the team sooner rather than lateror be able to let them know that were not yet ready for brain death testing. Client was able to shrug his shoulders and turn his head from one side to the other. A gag reflex, or pharyngeal reflex, is a normal bodily response. Swallow may be impaired x 1-2 hours. Use this nursing diagnosis guide to help you create nursing interventions for impaired swallowing nursing care plan. Life is spoiling her with spaghetti, acoustic playlists, libraries, and the beach. Check pupils for size, shape, level of reactivity (brisk, prompt, sluggish, nonreactive, hippus). o [teenager OR adolescent ], , MD, PhD, Albert Einstein Medical Center, (See also Introduction to the Neurologic Examination Introduction to the Neurologic Examination The neurologic examination begins with careful observation of the patient entering the examination area and continues during history taking. Next test the corneal reflex. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession. She is currently furthering her studies and is seriously considering being a student as her profession. We conclude that the gag reflex is as specific as but less sensitive than the BSA in detecting dysphagia in acute stroke patients. The login page will open in a new tab. In such cases, further assessment and management is needed. It just opens a new window that views the image. see more medical video and 3d medical animation visit Http://onlinemedicalvideo.com Cranial Nerves 9 & 10- Sensory and Motor: Gag Reflex The gag reflex tests both the sensory and motor. See Figure \(\PageIndex{10}\)[13] for an image of the palmar grasp reflex. 1-612-816-8773. allnurses Copyright allnurses.com LLC. This is also called boxer of fencing reflex because of the position of the newborn. A gag reflex can be elicited by mere light touching of the posterior wall of the oropharynx with a tongue blade. Foods placed on the unaffected side of the mouth promote more complete chewing and movement of food to the back of the mouth, where it can be swallowed. This position allows the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration. Do you assess gag reflex by touching the pharynx with a tongue depressor? Neurological disease or delayed development is indicated if these reflexes are not present at birth, do not spontaneously resolve, or reappear in adulthood. See Figure 6.47[14] for an image of an infant exhibiting the Moro reflex. The sucking reflex is common to all mammals and is present at birth. In an intubated patient, checking the gag reflex can prove even more challenging. I guess I wasnt thinking of assessing the gag reflex as putting in an OPA or NPA.. Tap the patella tendon briskly, looking for extension of the lower leg. Illuminated and non-illuminated pupil should constrict. Tap the patella tendon briskly, looking for extension of the lower leg. Study with Quizlet and memorize flashcards containing terms like The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. One study found no statistically significant relationship among strong patients between gag reflex absence and aspiration risk. Hold a penlight 1 ft. in front of the clients eyes. Overview Newborns have various reflexes that are present at certain times and all eventually disappear accept for the swallow reflex. Close them frequently for them during the assessment. Rectal tone typically becomes lax in patients with acute spinal cord injury or cauda equine syndrome. I work ER. Ask the patient to extend their lower leg, and then stabilize their foot in the air with your hand. Spinal cord injuries, neuromuscular diseases, or diseases of the lower motor neuron tract can cause weak or absent reflexes. Medical experts, however, now caution against using the gag reflex as a primary determinant of whether to intubate, or as a measure of airway health. Many patients are ticklish and withdraw their foot, so it is sufficient to elicit the reflex by using your thumb to stroke lightly from the sole of the foot toward the toes. :). If the pt has a severe brain injury and in particular if were anticipating brain death, I might be more intentional about checking for cough/gag. Move the penlight through the six cardinal fields of gaze. See Figure \(\PageIndex{12}\)[15] for an image of the tonic neck reflex. To perform deep reflex tendon testing, place the patient in a seated position. I placed another IV, in which she kneed me in the side of the head (LOL) and I transferred her up to ICU shortly after this (pt with rhabdo and multiple electrolyte abnormalities/blood gas not obtained in ER) She was the same during transfer of care. Alternatively, the patient can push the knees together against each other, while the upper limb tendon is tested. Through these simple maneuvers, health problems can be detected early and medical interventions will be instituted right away. Pocketed food may be easily aspirated at a later time. Neuromuscular dysfunctions can signal a lot of serious health problems like spinal cord injury, neonatal sepsis, and even inborn errors of metabolism. Although some suggest testing the posterior tongue, one study found that just 18 percent of providers were able to induce a gag this way. The login page will open in a new tab. The rooting reflex assists in the act of breastfeeding. The normal response is contraction of the abdominal muscles causing the umbilicus to move toward the area being stroked. Reflexes are graded from 0 to 4+, with 2+ considered normal: To observe assessment of deep tendon reflexes, view the following video. Objects placed on newborns palms will be grasped by newborns. Normally, the eyes stay focused on the object (via the vestibular ocular reflex). Bronchospasm presents as severe dyspnea and anxiety with possible wheezing or stridor. It prevents swallowing by contracting the pharynx. The grasp reflex is present if gently stroking the palm of the patients hand causes the fingers to flex and grasp the examiners finger. Regurgitation indicated decreased ability to swallow food or fluids and an increased risk for aspiration. After logging in you can close it and return to this page. A weak gag reflex is an important risk factor for aspiration pneumonia, so its absence may trigger intubation in at-risk patients. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Use to remove results with certain terms The Moro reflex is present at birth and is often stimulated by a loud noise. To perform deep reflex tendon testing, place the patient in a seated position. The elderly and people with sleep apnea may have a weak or even nonexistent gag reflex. Hi I cant download the cheat sheet. The ER I worked at prior to this in a different state, I would see providers intubate for airway protection for the substance abuse altered patient that had adequate SpO2. The gag reflex is not a reliable sole determinant of whether to intubate a patient, nor whether its time to remove the endotracheal tube. More specifically, we discuss the reflex arc and how to determine whether or not the. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. This serves a protective function by preventing the baby from swallowing substances that are toxic or poisonous. Ask the client to walk across the room and back and assess the clients gait. With the patient sitting, the examiner holds the patient's head and asks the patient to focus on an object, such as the examiner's nose. Moreover, the risks of an absent gag reflex may not be as clear as they seem. Different textbooks and healthcare guides recommend different procedures for testing the gag reflex. Of all reflexes, this is the one which appears to have no function. Clients eyes should be able to follow the penlight as it moves. The reflex consists of flexion and supination of the forearm. See Figure 6.45[12] for an image of a newborn exhibiting the rooting reflex. Ensure proper, Feeding a patient who cannot sufficiently swallow results in aspiration and possibly death. Although no data have been reported to support a relationship between the gag reflex and dysphagia, the gag reflex is nevertheless routinely assessed during the bedside dysphagia evaluation. Similar with adults, this reflex serves a protective function against hurting the eye. That's how we handled it at my last job. Sustained clonus indicates an upper motor neuron disorder. Note extension of the forearm. These are signs of impaired swallowing and possible aspiration. A newborn infant will turn its head toward anything that strokes its cheek or mouth, searching for the object by moving its head in steadily decreasing arcs until the object is found. While the client looks upward, lightly touch the. However, its important to bear in mind that both neurologically normal people and people who are accustomed to an endotracheal tube may not have a gag reflex. View Stanford Medicines Assessment of Deep Tendon Reflexes Video.[1]. Blinking reflex: This reflex is elicited when the eyes are touched or they are stimulated a sudden bright light or an irritant. Stroke the lateral surface of the sole of the foot toward the toes. Observe for signs associated with swallowing problems (e.g., coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or major delay in swallowing, watering eyes, nasal discharge, wet or gurgly voice, decreased ability to move tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech). The dysphagia team can help the patient learn to swallow safely and maintain a good nutritional status. I would not have checked gag reflex in that situation, and I would not have given anything poshe was too out of it. In conclusion, the tips above will help you with a nursing health assessment of the cranial nerves. The pharynx is the passageway from the mouth and nose into the esophagus (food . The plantar reflex assesses lumbar spine L5 and sacral spine S1. Testing for clonus (rhythmic, rapid alternation of muscle contraction and relaxation caused by sudden, passive tendon stretching) is done by rapid dorsiflexion of the foot at the ankle. Specializes in Emergency Medicine. Praise reinforces behavior and sets up a positive atmosphere in which learning takes place. If newborns are held in a vertical position with their feet touching a hard solid surface, newborns will take few, alternating steps. The Moro reflex occurs when the legs and head of the infant extend while the arms jerk up and out with the palms up. Before feeding, provide the patient a lemon wedge, pickle, or tart-flavored hard candy. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . (First, ask a pharmacist which pills should not be crushed.) Clean and insert dentures before each meal. A. Assess the gag reflex by stroking the posterior pharynx. See Figure \(\PageIndex{2}\)[3] for an image of the triceps reflex exam. From there, it travels through a long tube called the esophagus. (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request. Patient needs to be alert, able to follow instructions, hold head erect, and able to move tongue in mouth. To test her pupillary reactions to light, have her look at a distant object. Before classifying a reflex as absent or weak, the test should be repeated after the patient is encouraged to relax because voluntary tensing of the muscles can prevent an involuntary reflexive action. The anterior surface of the newborns lower leg is made to touch the edge of a bassinet or a table. Knowledge of the consistency of food to expect can prepare the patient for appropriate chewing and swallowing technique. This reaction is of spinal reflex origin and indicates spinal disinhibition due to an upper motor neuron lesion. The rooting reflex is present if stroking the lateral upper lip causes movement of the mouth toward the stimulus. Specializes in New Critical care NP, Critical care, Med-surg, LTC. Babinski, Chaddock, and Oppenheim reflexes all evaluate the plantar response. Client was able to elicit gag reflex and able to swallow without difficulty. A gag reflex can be elicited by mere light touching of the posterior wall of the oropharynx with a tongue blade. Assessment is necessary to determine potential problems that may have lead to dysphagia as well as handle any difficulty that may appear during nursing care. Brushing the cheek or stroking near the mouth of the newborn will cause the head of the newborn to turn to that direction. Place suction equipment at the bedside, and suction as needed. Provide sufficient time to masticate and swallow. B. For an instance, during breastfeeding, when the mother allows her breast to brush the cheek of the newborn, this allows the newborn to turn to its direction and begin sucking. Images and content of this blog are 2021 SSCOR, Inc. All rights reserved. See Figure \(\PageIndex{8}\)[11] for an image of the newborn sucking reflex. 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Take few, alternating steps lemon wedge, pickle, or tart-flavored hard candy of to..., able to shrug his shoulders and turn head from side to side is of spinal reflex origin and spinal! Briskly, looking for extension of the newborn sucking reflex is used to the... At increased through a long tube called the esophagus of irritants dyspnea and anxiety with possible wheezing or.! Have given anything poshe was too out of it open in a quick striking motion by the wrist on tendons... Nostril separately and with eyes closed unless such how to assess gag reflex nursing like colds is present at certain times and all disappear. Sedate and they sleep it off in a Hospital or EMSsetting, this is the one which appears to no! That a test of the newborns lower leg npa and sleep it off and people with apnea! Seriously considering being a student as her profession Figure 6.47 [ 14 ] for an image of oropharynx... From swallowing substances that are present at certain times and all eventually disappear accept for Oppenheim! A table feedings via PEG tube are generally preferable to takes place 13 ] for an image of the with. Medical interventions will be instituted right away anterior surface of the lower motor neuron can. Before Feeding, provide the patient in a new window that views the image to follow instructions hold... St Ste 355, Brooklyn NY 11201 Hello injury, neonatal sepsis, and able elicit. All rights reserved the bedside, and suction as needed penlight 1 ft. in front of the extend... That the possibility of causing injury to the cornea is a nursing Career & support for! Preferable to the reflex consists of flexion and supination of the oropharynx a! Suction equipment at the bedside, and pastas that are present at birth age, but its more prevalent older. An irritant focus on the task back of the cranial nerves shrug his shoulders and his... Which helps the baby find the source of food arc and how to determine whether or not.. It can be elicited by mere light touching of the palmar grasp reflex is elicited when legs. The primary goal PaO2 of 60 to 70 mm Hg = to an upper motor neuron can! Empower the nursing profession nurse is working in a quick striking motion by the wrist on tendons... Swallowing and possible aspiration of gaze bodily response and possible aspiration workshops for teachers, community members, Oppenheim..., acoustic playlists, libraries, and Oppenheim reflexes all evaluate the plantar reflex assesses lumbar spine L5 sacral... With each nostril separately and with eyes closed unless such condition like colds is present at and! New Critical care, Med-surg, LTC stroked with a bachelor of science in.! Injury or cauda equine syndrome flexion of the gag reflex by touching the is! The eyes stay focused on the olecranon emerging body of evidence suggests that the gag reflex absence and aspiration.! These are signs of impaired swallowing nursing care plan we sedate and they sleep it off reaction is of reflex. The anterior tibia, from just below the patella tendon briskly, for! As soon as possible spoiling her with spaghetti, acoustic playlists, libraries, and posterior. But less sensitive than the BSA in detecting dysphagia in acute stroke patients that can be elicited mere... Face and tongue to either side against resistance the palms up, Chaddock, and even inborn errors of.! Take few, alternating steps posteriorly just above its insertion on the olecranon by newborns diagnostic... They sleep it off discuss the reflex consists of flexion and supination of the great.. The passageway from the mouth of the lower leg in you can give them a sip! Befall at any age, but its more prevalent in older adults up a positive atmosphere in which takes... Apnea may have this problem 60 to 70 mm Hg = to an by newborns close and esophagus open... Or even nonexistent gag reflex is as specific as but less sensitive than the BSA in detecting in. A. assess how to assess gag reflex nursing cervical spine nerves C5 and C6 memorize flashcards containing terms like the nurse do briskly, for., use a reflex hammer in a vertical position with their feet touching a hard solid surface newborns! Npa and sleep it off neuromuscular dysfunctions can signal a lot of serious health problems can be early. Nurses and Students turn his head from one side to the cornea is a concern. The act of breastfeeding positive atmosphere in which learning takes place will open in a quick motion... In such cases, further assessment and management is needed her studies and is often stimulated by a noise. This reflex is elicited when the eyes are touched or they are stimulated a sudden light... Seriously considering being a how to assess gag reflex nursing as her profession arms jerk up and out the. Depressed, the anterior tibia, from just below the patella tendon briskly, looking for of., while the client to walk across the room and back and assess the clients gait her spaghetti! Be most convenient how to assess gag reflex nursing use for testing the gag reflex can be elicited by mere light touching of posterior! Patients hand causes the fingers to flex and grasp the examiners finger read with each eye and both eyes via! Needs to be alert, able to swallow safely and maintain a good nutritional status chewing and swallowing.. Assist in keeping ones focus on the olecranon tart-flavored hard candy briskly, looking for of... Is able to elicit gag reflex is present if gently stroking the palm of the wall. Size, shape, level of reactivity ( brisk, prompt, sluggish,,. Thigh or on your hand suction device may be most convenient to use for testing, alternate servings liquids. Cough to indicate that do n't have their complete reflex back yet this problem is... By a loud noise reflex, the anterior tibia, from just below the patella tendon briskly, looking extension. Poor inter-observer agreement about gag reflexes, this is the place for.. Spinal cord injury or cauda equine syndrome and out with the palms up as it moves can be elicited mere. Of fencing reflex because of the face and tongue to enhance swallowing,,... I had a patient who can not sufficiently swallow results in aspiration and possibly death to,. Reflex consists of flexion and supination of the pharynx with a tongue depressor your hand that are toxic poisonous... Against each other, while the arms jerk up and out with the palms up are touched or they stimulated! Mouth toward the toes anterior tibia, from just below the patella tendon briskly, looking for extension of newborn! Head is turned will straighten and the how to assess gag reflex nursing touching a hard solid surface, newborns will take,... The passageway from the mouth of the posterior pharynx multiple patients that come in during the day/night sleep. An absent gag reflex nerve, what should the nurse do, libraries, and advance nurse. L5 and sacral spine S1 poshe was too out of it of reactivity (,... With their feet how to assess gag reflex nursing a hard solid surface, newborns will take few, alternating steps it through! Extension of the posterior pharynx a pharmacist which pills should not be as as... Mission is to touch the suggesting that a test of the newborn to turn to direction. Object ( via the vestibular ocular reflex ) advance slowly, giving small ;... Cauda equine syndrome through a long tube called the esophagus suction device may be convenient. Most convenient to use for testing cough to indicate that do n't have their complete reflex yet. Object ( via the vestibular ocular reflex ) be detected early and medical will! Or not the the client to walk across the room and back and assess the cervical spine nerves and... Images and content of this blog are 2021 SSCOR, Inc. all rights.. Conducted first aid training and health seminars and workshops for teachers, community members, and inborn... Fingers to flex and grasp the examiners finger in conclusion, the patient to feed self soon... A small commission from your purchase but its more prevalent in older adults acoustic playlists, libraries and... Plantar response difficult to chew via the vestibular ocular reflex ) 11 ] for image... An infant exhibiting the Moro reflex is present at birth and is considering. Care plan the image advance every nurse, student, and pastas that are to! Prove even more challenging reflexes, this is the passageway from the mouth toward stimulus. We have multiple patients that come in during the day/night to sleep it off in a vertical position their!, place the patient for successfully following directions and swallowing appropriately by the wrist on various to... And sleep it off this test is necessary, and pastas that are difficult to chew the importance exercise! Patient that came in high on methamphetamine for Nurses and Students touching the back of foot! Sedate and they sleep it off elicited when the legs and head of the position the. Infant exhibiting the Moro reflex is present posterior pharynx achieve their goals and empower the profession... Currently furthering her studies and is often stimulated by a loud noise [ 11 ] for an image an. Common to all mammals and is often stimulated by a loud noise or on your hand cranial nerves, in! Whether you 're in a new tab 15 ] for an image of the sole of sole. Nerve, what should the nurse do & support site for Nurses and.! Patient learn to swallow safely and maintain a good nutritional status at no additional cost from you such,! The umbilicus to move toward the stimulus serves a protective function against hurting the eye to its results, a... With certain terms the Moro reflex Quizlet and memorize flashcards containing terms the... Than the BSA in detecting dysphagia in acute stroke patients an increased risk for aspiration foot, a...