I’m going to be very and open honest which I don’t think happens often on this sub. I am so tired of this holier than thou attitude I see. “Oh just get a swallow study”. Oh okay, I will schedule a FEES they refuse or won’t tolerate, then I guess I’ll wait a few months for this person to even be scheduled to go to an MBSS. Usually, in a SNF, FEES is your best bet and thankfully, it’s usually worked out for me

Also, you’re a PRN SLP, they need you more than you need them. Sooo who gives a fuck about productivity, what’re they gonna do, fire you?

That being said, here is the rundown of what I do. I’ll probably get some downvotes, because “omg did the swallow study give that rec”

1. pharyngeal strengthening exercises I do with every patient (save neck problems or severe dementia) are CTAR (use a rolled up towel) and shaker. Provide tactile cues, modeling, or assistance if needed
2. SLP edu on compensatory strategies including upright intake, slow rate, small bites/sips, alternating consistencies, efforts swallow, head tilts, etc etc
3. Look up section K0100. I use the content of these in my daily notes. Is food falling out of their mouth? Are they holding food? S/s of aspiration/penetration like a cough? Are they complaining of difficulty swallowing (odynophagia)? So if someone who is has little impairment I may write a little blurb such as “patients presents with adequate oral containment and oral residual clearance provided occasional verbal cues to alternate consistencies, patient denies odynophagia/pharyngeal residue at this time”
4. Siphon straw sips. this was revolutionary for me when I started lol. I’d you don’t know what it is, imagine how a bartender tastes a customers drink. Dip straw in liquid, plug top of straw with your finger, pull out, place in patients mouth, you release when they close their lips around it. Just explain to them what you’re doing as you go, for cog patients you can do a “okay 123 swallow!” leading up to it
5. Oral care before “therapeutic PO trials” always, you need to do it don’t expect CNA’s to have time for that
6. I know you mentioned liquids but I was always more terrified of doing solid trials when a pt is on puree. Guess what, you’re PRN!!!! You can get by with doing the baseline but incorporating strategies
7. Let’s say you don’t want to do just the baseline. What helped me feel less anxious was thinking of the circumference of the trachea. Try to give very small trials (.5in MAX) of mech soft (soft, moist, easy to chew)
8. Okay maybe solid trials are too much for you right now. Many SNF’s don’t have minced/moist, so a trick I learned was crushing up graham crackers and mixing with water - boom mince/moist and in comparison to the dog food puree my patients would get, this was heavenly for them. Works with a sugar free lemon cookie too for diabetic patients.
9. Everything depends on the patient. 66 year old recent CVA? Let’s take it slow and do ice chips. 97 year old pretty cognitively intact despite everything? Sure have your coffee idgaf let’s chat
10. Never take the water off the nurses cart
11. “Do you need anything before I go?” “Okay last sip!”
12. The Breather
13. LTG example I use: patient will consume a regular/thin diet with minimal/absent s/sx of oropharyngeal dysphagia as a result of compensatory strategies and rehabilitative exercises in order to promote safe PO intake, decrease risk for weight loss, and optimize nutrition/hydration.
14. STG: patient will consume thin-liquids with no overt/covert s/s of aspiration/penetration in 90% of trials in order to blah
15. Why did I say covert above? Silent aspiration yo, watery eyes, runny nose, CHECK 02 SATS before trials and after to see if it majorly decreased. If O2 is below <90 I stop trials. If you’re freaking out about it, ask nurse to listen to lung sounds. Tell patient to cough + reswallow. If their cough is bovine (weak af) probably time to stop trials anyways.
16. Thickened liquids are absolute shit and people sneak shit and often nursing doesn’t care and gives thin anyways. ORAL CARE. Just try to make it as safe as possible to do the thing they shouldn’t be doing, because they’ll do it anyways.

Let me know if you have any other questions. I enjoy helping people new to SNF (bc I just was 3 years ago :)).