Subjective Assessment

Subjective Assessment Number: Type:

Assessment (narrative summary):

Part I: Hyopharyngeal/Laryngeal Anatomy and Movement

Symmetrical at rest:

Base of Tongue Yes No
Pharynx Yes No
Larynx Yes No

Edema:

Pharynx Yes No
Larynx Yes No

Movement of Velopharynx,Tongue, Pharynx:

Laryngeal Activity:

**Secretions (status of standing secretions in hypopharynx):**

Moist
Pooling in valleculae/pyriforms
Pooling in laryngeal vestibule
Pooling in laryngeal vestibule resulting in aspiration of secretions

Other:

E-stim Tx Plan following Subjective Assessment Number:

P.O. Intake:

Initiate/Continue NPO status
Initiate/Continue Water Protocol
Initiate Tx Feedings with ST only
Diet
Liquids
Continue e-stim
Monitor temps and pulm status
Crush meds in applesauce
Repeat FEES in days
Repeat FEES not necessary unless there is a change in status
Educate pt and family

The following Swallowing Guidelines are recommended, patient should:

Assist and monitor as needed
PMSV/trach plugged with meals
Alternate liquids and solids
Place food to the right
Place food to the:
- Left
- Right Center
Do not use straw
Sit at 90 degrees for meal and 45 min after
Use a chin tuck
Check for pocketing/residue
Crush meds
Take small bites
Take small sips
Head turn/tilt to
- Left
- Right
Swallow each bite/sip __times
Cough or throat clear occasionally during mea

Estim Placement Recommendations:
Primary Position: mA: Frequency:

Facial Position: mA:

Data entered by:

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