狠狠撸

狠狠撸Share a Scribd company logo
2011/10/29
1
食勉②
‐随意運動の理解と
脳血管障害の診察‐
大石歯科医院(千葉県)大石善也
嚥下のメカニズム
ノドの構造は前に気管、後ろにチューブ状 いつもは気管のフタが開いており
の食道があり、気管のフタがあります いつでも呼吸ができるようになっている
そして、唾液や食物を食べるときには つまり呼吸と飲食物のルートがノドで交差
気管とフタが閉じて食道に流れる仕組み しており、このエリアの?????が問題となる
2011/10/29
2
誤嚥
? 誤嚥とは、誤って飲食物が気管に入ることで、そのために肺炎
になることを誤嚥性肺炎とよぶ
<複雑な要因が重なる>
① 環境 :覚醒?体位?動作?食事介助?薬剤?口腔乾燥?認知
② 咀嚼?嚥下:口唇閉鎖?咀嚼?舌圧?舌、頬の巧妙性?咽頭残留?
咽頭反射?喉頭挙上の不足&食形態の不一致
③ 呼吸?栄養:むせたときの咳の力や本来の呼吸状態、栄養
(免疫力)の低下
口腔機能体験(開口?舌の不動)の唾液嚥下
2011/10/29
3
なぜ高齢者には調理工夫が必要?
油脂を加える
ポテトサラダ
ねぎトロ
スイートポテト
トロミをつける
???????
????????
あんかけ料理
加熱
煮物
和え物
細かくきざまない
一口大
適度な水分
オムレツ
フレンチトースト
つなぎを入れる
肉団子
ハンバーグ
和え物
切り方
蛇腹切り
隠し包丁
繊維を断つ切り方
適切な食材の選択
嚥下
嚥下
咀嚼
口腔?嚥下
咀嚼 口腔機能
嚥下
咀嚼
口腔機能
嚥下
食塊
2011/10/29
4
どうしてもけんちん汁が食べたい!
80歳男性: 残存歯あり 既往歴なし
肺炎(-)ペースト介助?水で少しむせる
あなたならどうしますか?
介護高齢者2509人の日常生活における意識実態調査
食事への関心度が1番 (加藤ら1988)
脳血管障害と加齢(認知症)との関係
廃用 口や栄養の 咀嚼?嚥下 重症化 経口摂取
生活習慣 関連筋の廃用 合併症 の低下
認知 初期 中期 重度 末期 PEG検討
AD 短期記銘力低下 介護の山場 失禁?歩行障害 寝たきり 嚥下障害 多臓器不全
食形態低下 ペースト食
食形態低下 PEG検討
嚥下評価
1回目脳卒中 2回目脳卒中
???????病
神経筋疾患
が加わる
2011/10/29
5
錐体路系疾患
?随意運動(自分の意志によって行われる
運動)を支配する神経の主要経路
?大脳皮質の運動野に始まり、延髄を通る
ときに大部分の神経線維が交差して錐体
とよぶ高まりをつくり、反対側の脊髄に入り
全身に伝えられる
脳血管障害
運動麻痺:片麻痺など
巧緻運動の障害
半側空間失認(左)
中枢性
弛緩性?
痙性麻痺
失行
失認
失語
2011/10/29
6
高次脳機能
? 局在性が明確な脳機能
(右利きの99%、左利きの70-80%が左が優位半球)
優位半球:言語?計算?概念
劣位半球:図形?空間?音楽
? 失語:運動性?感覚性?全?交差失語
? 失認:視覚性?身体?半側空間失認
? 失行:肢節運動?観念運動性?開眼?拮抗性失行
着衣?構成失行
背景疾患の軌道予測と
嚥下機能の推移
① 脳血管障害後遺症のように発症(イベント)から、その状
態が固定しており、新たな血管イベントの再発により機
能低下するタイプ
② 神経難病など変性疾患により、疾患の進行に伴って嚥
下障害が生じてくるタイプ (PDの短期変動にも注意)
③ ADように徐々に機能低下するが、末期に嚥下機能が急
速に減弱するタイプ
2011/10/29
7
2011/10/29
8
嚥下のコントロールと反射の異常
● 要介護者では無症候性脳梗塞を高率に認め、その多くが基底核のラクナ梗塞である。
基底核に梗塞を生じると、ドパミン代謝が障害されサブスタンスPの産生量が低下
迷走神経や舌咽神経のサブスタンスPが低下し、嚥下反射と咳反射が低下する。
薬剤の関係
<嚥下に関与する薬剤>
? ???????(??????) :大脳基底核でのドパミン合成促進にて???????P
が増加し、嚥下反射が改善
? ????????(?????) : ACE阻害剤(降圧剤)は???????Pの分解を抑制
し 嚥下反射を改善
? ????????(??????):脳梗塞(心原性脳塞栓症を除く)の抗血小板薬
肺炎の累積発症率を長期に抑制
<口腔ケアの効果>
? 嚥下反射(潜時)が口腔ケア開始前に比べて改善、サブスタンスP濃度
にも有意な上昇
<ドパミン抑制作用>
? 要介護者は、睡眠剤や鎮静剤の使用頻度が高く、これらの薬剤はドパミン
抑制作用もあることから誤嚥リスクが高まる
2011/10/29
9
身体診察: ① ADL初回
? 視診: 座位体幹失調?歩行?????????????????
? 握手: ?????????(指示の入り)や麻痺、そして握力
(栄養?筋力)を確認(信頼感?協力度もわかる)
? 麻痺: グー?チョキ?パーを指示し、グー?パー可能なら
手でスプーンを握れる。チョキ可能なら箸や
ボタン着脱などの動作も可能
? 上肢: バンザイをしてもらい可動域を確認(顔まで可能
なら整容や虫などを対処できるなど、本人の生活
状況や衣類の着脱が把握できる)
身体診察: ② ADLその他
? 鼻指鼻??? :小脳疾患の場合、指を鼻(耳)を往復させて運動
調節機能を確認
? バレー徴候 :軽度でも陽性なら片麻痺があり平衡障害疑い
※ バレー徴候:一側性の軽い麻痺を診る検査で、両腕の手のひらを
上にして前方に水平に挙上し、 閉眼して20-30秒
そのままにすると麻痺側の上肢は回内してだんだん
下に落ちる
? 座位困難 :両側麻痺が多く嚥下や神経因性膀胱の合併を疑う
? 半側空間麻痺:正中線から見た半側、注視した空間の半側の
視覚、聴覚、触覚などの感覚刺激を無視
? 舌下神経麻痺:静止状態で口を開けさせて、舌の弾力を触診
舌を外に出させ麻痺のある側への偏位を確認
2011/10/29
10
身体診察: 栄養
? 体重変化 : 体重が1番大切
減少率(-2kg/月、-3kg/3か月、-5kg/6か月)
? BMI [kg/m2]: 体重 kg /身長 m2(標準 BMI:22)
? 血液検査 :アルブミン(2.8μ/dl↓)
総リンパ球数(1200>800>)
? 脱水: 水分量の聞き取りや皮膚の乾燥度や脇下の湿度
? 上腕: 筋肉(ゴリゴリ)や、皮下脂肪(ボヨボヨ)を診査
? 下肢: 浮腫(足の甲がぷっくりし、靴下のあとがつく)
浮腫は必ず触診が必要
身体診察: 呼吸
? SP02計測
? 体温測定: 平均値(5-10回)を必ず計測
? 頸部聴診: 咽頭残留の確認
<意思疎通あり>
良 :咳?唾液嚥下にてクリア
不良:自覚なし?咽頭麻痺疑い
<意思疎通なし>
不良:常に残留あり?誤嚥?麻痺の疑い
? 胸部聴診(同時に上腕の筋肉?脂肪触診)
?エアーの入りと複雑音の聴取

More Related Content

Featured (20)

2024 Trend Updates: What Really Works In SEO & Content Marketing
2024 Trend Updates: What Really Works In SEO & Content Marketing2024 Trend Updates: What Really Works In SEO & Content Marketing
2024 Trend Updates: What Really Works In SEO & Content Marketing
Search Engine Journal
?
Storytelling For The Web: Integrate Storytelling in your Design Process
Storytelling For The Web: Integrate Storytelling in your Design ProcessStorytelling For The Web: Integrate Storytelling in your Design Process
Storytelling For The Web: Integrate Storytelling in your Design Process
Chiara Aliotta
?
Artificial Intelligence, Data and Competition – SCHREPEL – June 2024 OECD dis...
Artificial Intelligence, Data and Competition – SCHREPEL – June 2024 OECD dis...Artificial Intelligence, Data and Competition – SCHREPEL – June 2024 OECD dis...
Artificial Intelligence, Data and Competition – SCHREPEL – June 2024 OECD dis...
OECD Directorate for Financial and Enterprise Affairs
?
How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...
How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...
How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...
SocialHRCamp
?
2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot
Marius Sescu
?
Everything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPTEverything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPT
Expeed Software
?
Product Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage EngineeringsProduct Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage Engineerings
Pixeldarts
?
How Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental HealthHow Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental Health
ThinkNow
?
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdfAI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
marketingartwork
?
Skeleton Culture Code
Skeleton Culture CodeSkeleton Culture Code
Skeleton Culture Code
Skeleton Technologies
?
PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024
Neil Kimberley
?
Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)
contently
?
How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
Albert Qian
?
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
Kurio // The Social Media Age(ncy)
?
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
Search Engine Journal
?
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
SpeakerHub
?
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
Clark Boyd
?
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
Tessa Mero
?
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Lily Ray
?
How to have difficult conversations
How to have difficult conversations How to have difficult conversations
How to have difficult conversations
Rajiv Jayarajah, MAppComm, ACC
?
2024 Trend Updates: What Really Works In SEO & Content Marketing
2024 Trend Updates: What Really Works In SEO & Content Marketing2024 Trend Updates: What Really Works In SEO & Content Marketing
2024 Trend Updates: What Really Works In SEO & Content Marketing
Search Engine Journal
?
Storytelling For The Web: Integrate Storytelling in your Design Process
Storytelling For The Web: Integrate Storytelling in your Design ProcessStorytelling For The Web: Integrate Storytelling in your Design Process
Storytelling For The Web: Integrate Storytelling in your Design Process
Chiara Aliotta
?
How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...
How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...
How to Leverage AI to Boost Employee Wellness - Lydia Di Francesco - SocialHR...
SocialHRCamp
?
2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot2024 State of Marketing Report – by Hubspot
2024 State of Marketing Report – by Hubspot
Marius Sescu
?
Everything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPTEverything You Need To Know About ChatGPT
Everything You Need To Know About ChatGPT
Expeed Software
?
Product Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage EngineeringsProduct Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage Engineerings
Pixeldarts
?
How Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental HealthHow Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental Health
ThinkNow
?
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdfAI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
marketingartwork
?
PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024
Neil Kimberley
?
Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)
contently
?
How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
Albert Qian
?
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
Search Engine Journal
?
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
SpeakerHub
?
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
Clark Boyd
?
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
Tessa Mero
?
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Lily Ray
?

随意运动の理解と脳血管障害の诊察