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Abstrak :
Latar Belakang: Disfagia adalah gangguan fungsi menelan yang disebabkan oleh gangguan neurologik, non-neurologik, ataupun campuran. Disfagia dapat menyebabkan berbagai komplikasi yang membahayakan kehidupan jika tidak ditangani dengan baik. Profil pasien disfagia baik di Indonesia maupun di negeri lain tidak terdata dengan baik sehingga diperlukan lebih banyak penelitian dalam hal ini guna meningkatkan kualitas dan efisiensi rehabilitasi disfagia di masa yang mendatang. Metode: Penelitian deskriptif retrospektif ini dilakukan di RSCM dengan mendata profil 52 pasien disfagia yang datang ke poli rehabilitasi medik RSCM dari Januari sampai dengan Juni 2023 yang terpilih menggunakan teknik consecutive sampling. Usia, jenis kelamin, fase disfagia, etiologi disfagia, dan derajat disfagia dari subjek terpilih dikumpulkan melalui akses rekam medis masing-masing pasien. Hasil: Subjek berumur 58–67 tahun paling prevalen dengan perbandingan keseluruhan jenis kelamin subjek laki-laki terhadap perempuan sebesar 1.08:1. Seluruh subjek didiagnosis dysphagia orofaringeal dan 84,6% kasus disebabkan oleh etiologi neurologik. Derajat disfagia beragam di antara subjek dengan skor penetration-aspiration scale (PAS) 8 paling prevalen (32,7%). Kesimpulan: Penelitian ini telah mendata profil usia, jenis kelamin, fase disfagia, etiologi disfagia, dan derajat disfagia dari 52 pasien disfagia yang terpilih. Data yang telah terkumpul dan disajikan direkomendasikan untuk dipakai dan dianalisis lebih lanjut oleh penelitian lain di masa mendatang. ......Background: Dysphagia is defined as the dysfunction in swallowing which is caused by neurologic, non-neurologic, and other mixed etiologies. Dysphagia can lead to multiple life-threatening complications if proper intervention isn’t given. Profiles of patients with dysphagia aren’t well documented in Indonesia nor in other countries. This calls for more researches to study this topic to increase the quality and efficiency of dysphagia rehabilitation in the future. Methods: A retrospective descriptive study was done at RSCM by collecting the data of 52 patients with dysphagia that visited RSCM’s medical rehabilitation ward from January to June of 2023 chosen with the consecutive sampling technique. Age, gender, dysphagia phase, dysphagia etiology, and dysphagia degree of selected subjects was collected by accessing the their medical records. Results: Subjects aged 58–67 years old were the most prevalent with an overall comparable man to woman ratio of 1.08:1. All subjects were diagnosed with oropharyngeal dysphagia mostly caused by neurologic etiologies (84,6%). Dysphagia degree amongst subjects showed a considerable variety with a penetration-aspiration scale (PAS) score of 8 being the most prevalent (32.7%). Conclusion: This research has documented the age, gender, dysphagia phase, dysphagia etiology, and dysphagia degree profiles of 52 selected dysphagic patients. The data presented is recommended to be used and analysed further in future studies.

Abstrak :
Gangguan menelan atau disfagia sering dijumpai pada pasien stroke, kanker kepala dan leher, serta lansia. Disfagia dapat meningkatkan risiko malnutrisi, aspirasi, dan kematian. Pasien disfagia juga rentan mengalami ansietas atau depresi yang berdampak pada penurunan kualitas hidup. Dysphagia Handicap Index (DHI) merupakan instrumen swaisi yang dirancang khusus untuk menilai kualitas hidup pasien disfagia. Instrumen DHI terdiri dari 25 pertanyaan yang meliputi penilaian domain fisik, fungsional, dan emosional, serta telah diterjemahkan dan divalidasi dalam berbagai bahasa. Penelitian ini bertujuan untuk menguji validitas dan reliabilitas DHI versi Bahasa Indonesia. Kuesioner DHI diterjemahkan ke dalam Bahasa Indonesia melalui proses forward translation dan backward translation, serta cognitive debriefing. Hasil terjemahan balik juga didiskusikan dan disetujui oleh penulis utama DHI. Kuesioner DHI versi Bahasa Indonesia (DHI-INA) final kemudian diujikan kepada 46 subjek dengan berbagai etiologi disfagia. Sebanyak 20 subjek kemudian melakukan pengisian ulang satu minggu setelah pengisian pertama. DHI-INA menunjukkan korelasi yang kuat antara masing-masing domain dan skor total [fisik (r = 0,93); fungsional (r = 0,97); emosional (r = 0,93); dan keparahan (r = 0,84)]. Konsistensi internal DHI-INA juga menunjukkan nilai yang baik (Cronbach's = 0,87), begitu pula uji tes-retest untuk skor total (ICC = 0,94). Tingkat keterbacaan DHI-INA setara dengan kelas 7 berdasarkan formula grafik Fry. Kuesioner DHI-INA merupakan kuesioner yang valid dan reliabel untuk menilai kualitas hidup pasien disfagia. ......Swallowing problem or dysphagia often found in stroke patients, head and neck cancer, and elderly. Dysphagia increases the risk of malnutrition, aspiration, and death. Patient with dysphagia also prone to have anxiety or depression which has an impact on decreasing quality of life. The Dysphagia Handicap Index (DHI) is a self-administered instrument specially designed to assess the quality of life of dysphagic patients. The DHI instrument consists of 25 questions covering physical, functional, and emotional aspects and has been translated and validated into various languages. This study aims to test the validity and reliability of the Indonesian version of DHI. The DHI questionnaire was translated into Indonesian through a forward and backward translation process, and cognitive debriefing. The backward translation results were discussed and approved by the lead author of DHI. The final Indonesian version of the DHI Questionnaire (DHI-INA) was then tested on 46 subjects with various etiologies of dysphagia. A total of 20 subjects were then refilled one week after the first administration. DHI-INA showed strong correlation between each domain and total score [physical (r = 0.93); functional (r = 0.97); emotional (r = 0.93); and severity (r = 0.84)]. The internal consistency of DHI-INA was also good (Cronbach's a = 0.87), as well as test–retest reliability for the total scores (ICC = 0.94). The readability level of DHI-INA is 7th grade using the Fry graph formula. The DHI-INA questionnaire is a valid and reliable questionnaire to assess the quality of life of dysphagia patients.

Abstrak :
Kemampuan makan dan menelan pada anak bersifat dinamis sejalan dengan proses tumbuh kembang anak. Struktur anatomi mengalami pertumbuhan yang selanjutnya berdampak pada kematangan fungsi menelan. Gangguan pada proses menelan menyebabkan disfagia. Tesis ini membahas mengenai gambaran proses menelan pada anak dengan kecurigaan disfagia, dengan menggunakan pemeriksaan menelan dengan endoskopi serat optik lentur, serta menilai karakteristik percontoh berdasarkan usia, masa kehamilan, pengasuh, gejala, komplikasi serta kelainan medis. Penelitian ini adalah penelitian potong lintang dengan desain deskriptif pada 54 subyek yang diambil secara berurutan. Hasil dari penelitian ini didapatkan prevalensi disfagia pada anak dengan kecurigaan kesulitan makan sebesar 63 . Gejala disfagia pada anak le; 6 bulan yang paling sering adalah apnea saat menyusu 7/34 . Sedangkan pada anak > 6 bulan adalah postur tubuh terganggu 10/34 , mengeces berlebih 6/34 , dan batuk saat makan 8/34 . Kelainan medis yang mendasari adalah kelainan struktural 25/34 , kelainan jantung / paru / laring 24/34 , dan kelainan neurologis 23/34 . Komplikasi yang terjadi adalah PRGE 12/34 , gagal tumbuh 10/34 , dan pneumonia aspirasi 3/34 . Pada pemeriksaan FEES didapatkan standing secretion 22/34 dan pergerakan lidah terganggu 20/34 adalah tanda yang sering ditemukan pada anak disfagia; dan residu sering terjadi pada konsistensi tim kasar 44,7 , penetrasi pada konsistensi air 44,2 , serta aspirasi pada konsistensi susu 34,8 .Kata kunci: aspirasi, disfagia, pemeriksaan menelan dengan endoskopi serat optik lentur, penetrasi, residu, sekret yang terkumpul di hipofaring.

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Eating and swallowing ability in Children had dynamic characteristic and closely related with growth process in themselves. The anatomical structure underwent growth process, therefore had impact in the maturity of swallowing ability. Disruption of swallowing process may caused dysphagia. This study use Flexible Endoscopic Evaluation of Swallowing FEES and also assessed the characteristics of the subjects based on age, gestation age, caregivers, symptom, complication, and medical disorder. This study is a descriptive cross sectional design involving 54 subjects with consecutive sampling. The result of this study are prevalence of dysphagia is 63 in children with dysphagia suspicion. Dysphagia symptom in children 6 months, apnea while bottle breast feeding 7 34 . Meanwhile, in children 6 months, postural impairment 10 34 , drooling 6 34 , and cough while eating 8 34 . Underlying disease are structural anomaly 5 34 , cardiopulmonary larynx disorder 24 34 and neurological disorder 23 43 . The complication are GERD 12 34 , failure to thrive 10 34 , and aspiration pneumonia 3 34 . In FESS examination, standing secretion 22 34 and impaired tongue movement 20 34 are sign for dysphagia, and residue is more common in gastric rice consistency 44,7 while penetration in thin liquid 44,2 and aspirations is more common in thick liquid 34,8.

Abstrak :
Disfagia adalah kondisi medis yang berkaitan dengan kesulitan menelan. Pasien dengan disfagia tidak bisa minum cairan normal dikarenakan cairan biasa dapat masuk ke paru paru dan menyebabkan pneumonia aspirasi. Penggunaan cairan kental adalah pengobatan yang paling umum. Di bawah pedoman Australia cairan kental dibagi menjadi tiga tingkatan tingkat 150 agak tebal tingkat 400 cukup tebal dan tingkat 900 sangat tebal. Cairan mengental tersedia dalam dua bentuk sias dikonsumsi pre thickened minuman atau sebagai bubuk pengental yang dapat ditambahkan ke dalam minuman apapun hand thickened. Masalah utama dengan cairan kental adalah inkonsistensi dalam viskositas mereka antara cairan dan jenis pengental yang berbeda Juga pedoman untuk pengukuran viskositas fluida menebal sangat subjektif. Oleh karena itu tujuan pengukuran rheologi dilakukan untuk menentukan viskositas air dan susu pre thickened air dan susu menebal menggunakan bubuk pengental membandingkan viskositas thickened water dan thickened milk baik dalam bentuk pre thickened dan hand thickened Selain itu perbandingan viskositas antara bentuk juga diselidiki. Reologi dari seluruh sampel dianalisis menggunakan Rheoscope. Ditemukan bahwa thickened milk memiliki viskositas lebih tinggi dari pada thickened water yang menunjukkan bahwa kandungan cairan memiliki efek pada viskositas. Selanjutnya cairan pre thickened ditemukan memiliki viskositas lebih tinggi dari hand thickened. ......Dysphagia is a medical condition related to difficulties with swallowing. Patients with dysphagia cannot drink normal fluids because thin fluids could enters their lungs and cause aspiration pneumonia. Use of thickened fluids are the most common treatment for dysphagia. Under Australian guidelines thickened fluids are divided into three levels level 150 mildly thick level 400 moderately thick and level 900 extremely thick. Thickened fluids are available in two forms ready to serve pre thickened drinks or as powder thickener that can be added into any drink hand thickened. The main issue with thickened fluids is the inconsistency in their viscosity between different fluids and type of thickener. Also the guidelines for measurement of thickened fluid viscosity is very subjective. Therefore objective rheological measurement is performed to determine the viscosity of pre thickened water and milk and water and milk thickened using powder thickener compare the viscosity of thickened water and thickened milk in both pre thickened and hand thickened forms Moreover the comparison of viscosity between forms was also investigated. Rheology of all samples were analysed using Rheoscope. It was found that thickened milk had a higher viscosity than thickened water which indicates that the content of a fluid have an effect on viscosity. Furthermore pre thickened fluids were found to have a higher viscosity than hand thickened fluids.

Abstrak :
ABSTRAK
Latar Belakang: Disfagia fase faring ditemukan pada sebagian besar pasien karsinoma nasofaring (KNF) pasca-kemoradiasi. Manuver Mendelsohn bertujuan untuk meningkatkan durasi elevasi kompleks hyolaringeal, telah digunakan dalam penatalaksanaan disfagia dengan berbagai penyebab. Penelitian ini menilai pengaruh latihan manuver Mendelsohn pada penderita KNF pasca-kemoradiasi dengan disfagia fase faring. Metode: Desain kuasi eksperimen dengan penilaian sebelum dan sesudah latihan menelan dengan manuver Mendelsoh selama 6 minggu. Penelitian dilakukan pada 20 pasien KNF yang memenuhi kriteria penelitian. Sampel didapat secara konsekutif. Penilaian dilakukan dengan flexible endoscopic swallowing study (FEES) terhadap standing secretion, residu, penetrasi, dan aspirasi menggunakan konsistensi pure, thick liquid dan thin liquid. Hasil: Terdapat perbedaan bermakan pada penilaian standing secretion (p=0,034). Penilaian terhadap residu mendapatkan perbedaan bermakna pada pemberian pure dan thick liquid (p=0,021 dan p=0,008), sedangkan pada pemberian thin liquid tidak didapatkan perbedaan bermakna (p=0,129). Penilaian terhadap penetrasi mendapatkan perbedaan bermakna pada pemberian pure dan thick liquid (p=0,034 dan p=0,008), pada pemberian thin liquid tidak didapatkan perbedaan bermakna (p=0,059). Penilaian terhadap aspirasi tidak mendapatkan perbedaan bermakna pada pemberian ketiga konsistensi (p=>0,05). Kesimpulan: Latihan menelan dengan manuver Mendelsohn selama 6 minggu memeperbaiki standing secretion, residu pada pemberian pure dan thick liquid, penetrasi pada pemberian pure dan thick liquid. Latihan ini tidak memperbaiki aspirasi secara bermakna pada pemberian ketiga konsistensi.

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ABSTRACT
Background: Dysphagia is commonly seen in patients with nasopharingeal carcinoma (NPC) post chemoradiation. The Mendelsohn maneuver which promotes a prolonged voluntary of hyolaryngeal elevation at the peak of swallowing process has been used to treat various causes of pharyngeal dysphagia. The aim of the study was to see of the influence of swallowing exercise with Mendelsohn manuever in post-chemoradiation NPC patients with pharyngeal phase dysphagia. Methods: A quasi experimental with pre and post-test assessment at before and after six weeks exercise of Mendelsohn manuever. The study was conducted on 20 NPC patients who met the study criteria. Flexible endoscopic of swallowing study (FEES) was used to asess standing secretion, residue, penetration, and aspiration by giving 3 consistency of food/fluid (pure, thick liquid and thin liquid). Results: There was a significant difference in standing secretion assesment (p=0,034). Significant differences were found in residue assesment of pure and thick liquid, although no significant difference was found in thin liquid (p=0,129). There were also significant differences in penetration assesment of pure and thick liquid (p=0.034 and p = 0.008), but no significant difference in thin liquid ( p = 0.059 ). The study did not find significant differences in assesment of aspiration in all kind of consistencies (p > 0.05). Conclusion: Six weeks swallowing exercise with Mendelsohn manuever can reduce severity of standing secretion, residue and penetration of pure and thick liquid. However the exercise improve aspiration status but did not reach significant difference at all consistencies. ;Background: Dysphagia is commonly seen in patients with nasopharingeal carcinoma (NPC) post chemoradiation. The Mendelsohn maneuver which promotes a prolonged voluntary of hyolaryngeal elevation at the peak of swallowing process has been used to treat various causes of pharyngeal dysphagia. The aim of the study was to see of the influence of swallowing exercise with Mendelsohn manuever in post-chemoradiation NPC patients with pharyngeal phase dysphagia. Methods: A quasi experimental with pre and post-test assessment at before and after six weeks exercise of Mendelsohn manuever. The study was conducted on 20 NPC patients who met the study criteria. Flexible endoscopic of swallowing study (FEES) was used to asess standing secretion, residue, penetration, and aspiration by giving 3 consistency of food/fluid (pure, thick liquid and thin liquid). Results: There was a significant difference in standing secretion assesment (p=0,034). Significant differences were found in residue assesment of pure and thick liquid, although no significant difference was found in thin liquid (p=0,129). There were also significant differences in penetration assesment of pure and thick liquid (p=0.034 and p = 0.008), but no significant difference in thin liquid ( p = 0.059 ). The study did not find significant differences in assesment of aspiration in all kind of consistencies (p > 0.05). Conclusion: Six weeks swallowing exercise with Mendelsohn manuever can reduce severity of standing secretion, residue and penetration of pure and thick liquid. However the exercise improve aspiration status but did not reach significant difference at all consistencies.

Abstrak :
Pasien dengan disfagia rentan mengalami komplikasi seperti pneumonia aspirasi hingga kematian. Oleh karena itu diperlukan alat skrining untuk mendiagnosis disfagia secara cepat. GUSS merupakan alat skrining dengan validitas dan reliabilitas yang baik dalam menilai disfagia, namun belum dilakukan uji diagnostik di Indonesia. Subjek penelitian terdiri dari pasien disfagia neurogenik yang kemudian menjalani pemeriksaan GUSS-INA dengan modifikasi bahan uji, dilanjutkan dengan pemeriksaan baku emas FEES. Selanjutnya, dilakukan uji diagnostik untuk melihat sensitivitas dan spesifisitas GUSS-INA sebagai metode skrining disfagia. Rerata pasien disfagia neurogenik di RSCM berusia 56 tahun dengan jumlah proporsi laki – laki lebih besar dengan penyebab tersering adalah stroke, dengan komorbid hipertensi (56.5%), dengan komplikasi pneumonia 21.7%. Sebagian besar mengalami disfagia kronik, seluruh pasien mengalami keluhan subjektif disfagia dengan 3 gejala tersering adalah batuk, tersedak, dan sulit menelan terutama konsistensi padat. Lebih dari separuh pasien membutuhkan selang makan. Rerata status gizi pasien menunjukan indeks masa tubuh 24.92, dengan rerata penurunan BB 2 kg. Berdasarkan pemeriksaan pencitraan pasien stroke, lokasi tersering berada supratentorial, dengan derajat stroke sedang. Rerata nilai GUSS 14 (disfagia sedang) pada seluruh subjek, 28.3% mengalami aspirasi. Hasil Uji diagnostik GUSS-INA sebagai alat skrining deteksi disfagia memiliki nilai Sensitivitas 84%, Spesifisitas 78%, NDP 94%, NDN 54% dan AUC 0.86. Modalitas GUSS-INA dapat dijadikan alat skrining disfagia yang cukup baik. ......Patient with dysphagia has the tendency to undergo serious complications such as aspiration pneumonia that can cause increased mortality. Screening tool to effectively diagnose dysphagia in patient with difficulty swallowing is needed. GUSS is a screening tool with good validity and reliability; however, no diagnostic test has been done in Indonesia. This study samples consisted of neurogenic dysphagia patients which underwent GUSS-INA with test material modification assessment followed by FEES as gold standard examination. Diagnostic test was then done to analyze sensitivity and specificity of GUSS-INA as dysphagia screening tool. The average age of neurologenic dysphagia patients in Cipto Mangunkusumo Hospital was 56 years with higher male proportion, most common etiology was stroke, with most common morbidity being hypertension (56,5%). History of pneumonia was found in 21.7% patients.Majority of patients have chronic dysphagia, all patients had subjective dysphagia complaint with three most common symptoms being cough, choking, and difficulty swallowing especially of solid texture. More than half of the patients needed feeding tube. The average of BMI was 24.93, with average weight loss of 2 kg. Based on radiology results on post-stroke cases, the most common lesion was supratentorial, with moderate stroke score. Average GUSS score is 14 (moderate dysphagia) from all subjects and in 18.3% patients aspiration in found. Diagnostic test result of GUSS-INA as screening tool for neurogenic dysphagia had 84% sensitivity, 78% specificity, 94% PPV, 54% NPV, and AUC of 0.86. GUSS-INA could be used as a screening tool for dysphagia.

Abstrak :
This book provides a comprehensive and up-to-date description of the diagnosis and management of dysphagia, with particular reference to oral and pharyngeal dysfunction. All aspects of dysphagia are covered, from anatomy and physiology to patient care. Alongside descriptions of a variety of disease entities, signs and symptoms, and treatment approaches, many other relevant topics are addressed, including endoscopic and manometric aspects, malnutrition and dehydration, the psychiatric burden, and features specific to pediatric and geriatric patients. The authors are without exception renowned experts in their field. This book will be of value to all specialists involved in the evaluation and treatment of dysphagia, including ENT surgeons, thoracic surgeons, speech and language pathologists, phoniatricians, gastroenterologists, neurologists, and radiologists.

Abstrak :
Latar Belakang: Disfagia adalah kesulitan dalam memulai atau menyelesaikan proses menelan. Disfagia dapat dibedakan menjadi disfagia orofaring dan disfagia esofagus. Sebagian besar pasien dengan keluhan disfagia mengeluhkan atau mengalami kesulitan menelan terutama pada fase orofaring. Disfagia orofaring dapat disebabkan oleh kelainan neurologis dan kelainan struktur yang terlibat dalam proses menelan. Tujuan: Penelitian ini dilakukan untuk mengetahui perbedaan kejadian temuan FEES pada disfagia neurogenik dan mekanik. Metode: Penelitian observasional pada 10 kasus disfagia neurogenik dan 40 kasus disfagia mekanik kemudian dilakukan pemeriksaan FEES untuk melihat regurgitasi, leakage, residu, penetrasi, dan aspirasi setelah diberikan 6 jenis bolus makanan yang berbeda mulai dari air, susu, bubur saring, bubur tepung, bubur biasa 5 ml, dan seperempat biskuit. Hasil: Terdapat perbedaan bermakna antara disfagia neurogenik dengan disfagia mekanik dalam hal kejadian residu air (p=0,001; RP=16,000; IK 95%: 2,830-90,465), penetrasi (p=0,006; RP=9,333; IK 95%: 1,721-50,614). Penetrasi air (p=0,020; RP=6,000; IK 95%: 1,365–26,451), aspirasi (p=0,018; RP=7,000; IK 95%: 1,480-33,109), aspirasi air (p=0,018; RP=7,000; IK 95%: 1,480-33,109). Tidak didapat perbedaan yang bermakna dalam hal regurgitasi; leakage; residu susu, bubur saring, bubur tepung, dan biskuit; penetrasi susu, bubur biasa, bubur tepung, dan biskuit; serta aspirasi susu, bubur biasa, bubur tepung, dan biskuit. Kesimpulan: Terdapat perbedaan bermakna antara disfagia neurogenik dengan mekanik dalam hal kejadian residu air, penetrasi air, aspirasi, dan aspirasi air. Tidak didapat perbedaan yang bermakna dalam hal regurgitasi, leakage, residu, penetrasi, dan aspirasi pada konsistensi yang lain.

Abstrak :
Disfagia adalah gangguan menelan dimana makanan dan cairan tidak dapat masuk kedalam sistem pencernaan bawah yang merupakan salah satu dampak dari stroke iskemik. Latihan menelan terstruktur merupakan salah satu intervensi untuk meningkatkan kekuatan otot lidah, rahang dan mengembalikan fungsi menelan. Tujuannya yaitu menganalisis penerapan intervensi latihan menelan terstruktur pada pasien stroke yang mengalami disfagia. Metodenya dengan menerapkan latihan menelan terstruktur pada pasien stroke iskemik yang mengalami disfagia, dilakukan selama 7 hari berturut-turut, sebanyak 5 kali dalam sehari, selama 15 menit setiap latihan, dan 8 hitungan setiap gerakan. Hasil evaluasi hari ke 7 reflek menelan pasien sudah ada, pasien dapat menjulurkan lidahnya, dan wajah pasien simetris. Hasil dari keefektifan latihan menelan terstruktur ini dapat dijadikan sumber informasi perawat dalam melakukan tindakan keperawatan mandiri untuk mengatasi masalah gangguan menelan pada pasien stroke iskemik. ...... Dysphagia is a swallowing disorder that causes food and fluids cannot enter the lower digestive system, which is one of the effects of ischemic stroke. Structured swallowing exercise is one of intervention to strengthen tongue muscle, jaw, and restore the swallowing function. The purpose of this paper is to analyze the application of structured swallowing excercise in stroke patient with dysphagia. This study used case study method wich applied structured swallowing exercises in ischemic stroke patient who underwent dysphagia, is conducted for 7 consecutive days in 5 times a day, for 15 minutes each exercise, and 8 counts for each movement. The results of the 7 th day evaluation, the patients swallowing reflex is present; the patient can stick out his tongue; and the facial grimace is symmetric. The results of the effectiveness of structured swallowing exercise can be an information for nurses in implementing independent nursing intervention to solve the problem of swallowing disorders in ischemic stroke patient.