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Title of the Module:
Date of Publication: 5/6/09
Nursing Dysphagia Screen
Stroke Education
Content Expert(s): Candace Goss, Cindy Ruble, Sue Witer
Test Author(s): Candace Goss, Cindy Ruble, Sue Witer
Module Designer: Candace Goss, Cindy Ruble, Sue Witer
Editor: Candace Goss, Cindy Ruble, Sue Witer
Final Reviewer(s): Candace Goss, Cindy Ruble, Sue Witer
Educator Review: Josh Lady
Contact Person/Phone Number: Sue Witer, 839-3883 or ext. 1-3883
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GUIDELINES
American Stroke Association
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All stroke patients will remain NPO until a dysphagia
(swallow) assessment is completed
NPO is defined as no food, fluids or medications
All stroke patients with a diagnosis of TIA, CVA or
ICH will be screened for dysphagia prior to any oral
intake including food, fluids or medications
A dysphagia assessment can be completed by the
Registered Nurse (RN) and/or the Speech Language
Pathologist (SLP)
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What is Dysphagia?
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A dysfunction of feeding and swallowing
that can result from a variety of causes including
 Patient Intubated/Extubated
 Head and Neck Cancers
 Dementia
 Neuromuscular Disorders
 Neurological Disorders
 Stroke
 Degenerative Diseases
 Traumatic Injuries
 Tumors
www.scottcamazine.com
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Anatomy
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Nares
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Tongue
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Esophagus
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Trachea
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Valleculae
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Pyriform Sinus
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Modified Barium Swallow Image
Epiglottis
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Inverts to cover airway during
swallowing to prevent aspiration
of food and fluids
Valleculae
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Anatomical structure described
as a depression or crevice where
pooling of food and fluids can
occur with dysphagia
Trachea
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Anatomical pathway for air
into the lungs
Esophagus
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Anatomical pathway for food
and fluids into the stomach
BOLD ARROWS IDENTIFY AREAS OF ASPIRATION
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Dysphagia Definitions
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Aspiration
Penetration of food/liquids below the level
of the vocal cords
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Silent Aspiration
Penetration below the level
of true vocal cords without
outward signs of difficulty (~16%)
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Clinical Swallow Evaluation (CSE)
A swallow evaluation that is performed
at the patient’s bedside by SLP
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Modified Barium Swallow (MBS)
A swallow evaluation performed
in the radiology department by SLP
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Stroke Facts
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Dysphagia is clinically present in 42-67%
of stroke patients in the first 3 days
50% of stroke patients with dysphagia
experience aspiration
33% of patients with dysphagia develop
pneumonia requiring medical treatment
There is a 3-fold increase in risk of death
when diagnosed with pneumonia after
stroke
35% of post-stroke deaths are caused by
aspiration pneumonia
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WHO DOES WHAT?
RN Screen versus SLP Evaluation
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The Nursing Dysphagia Screen performed by the RN is NOT
the same as the Clinical Swallow Evaluation performed by the Speech
Language Pathologist (SLP)
COMPLETED BY RN
Nursing Dysphagia Screen
 The nursing screen does not require a physician’s order and is performed
on ALL stroke patients and any patient that exhibits swallowing difficulty
COMPLETED BY SLP
Clinical Swallow Evaluation (CSE)
Modified Barium Swallow (MBS)
 Both the CSE and the MBS require a physician’s order
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“IT’S TIME FOR YOUR DYSPHAGIA SCREEN”
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LET’S GET STARTED
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The Nursing Dysphagia Screen is completed by
the RN and consists of three parts…
Part 1 – Aspiration Risk Screen
Part 2 – Swallow and Medication Screen
Part 3 – Screen Results
The RN is to STOP the screen at any time during
the assessment if the patient is at risk of
aspiration
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Part 1 – Aspiration Risk Screen
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If ANY of the following signs are observed, STOP the screen
and mark as FAILED
Assessment of patient’s aspiration risk
 Unable to stay awake/alert, ↓ LOC or nonresponsive
 Unable to follow commands upon request
 Drooling of oral secretions
 Aphonia (inability to produce speech sounds)
 Facial droop/asymmetry, garbled or slurred speech
 Intubated
 Decreased or loss of sensation of pin prick/touch to face
 Tongue deviates from midline or with slow or no
movement
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Part 2 – Swallow and Medication Screen
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Assessment directions
1.
2.
3.
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HOB ↑ 90° (high-Fowler’s position)
Support the hemiplegic/stroke affected side
with a pillow as needed
Insure patient is wearing dentures if applicable
Assess the patient’s risk of aspiration at each
step in the following order
1.
2.
3.
Give sips of water from a teaspoon
Give sips of water from a paper cup (nurse to
control sip size) – No Straws
Give ½ teaspoon of applesauce
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Part 2 – Swallow and Medication Screen
Assessment
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Holds food in mouth without initiating swallow or spits out food
Food/fluids coming out of mouth
Pocketing of flood/fluids in mouth, cheeks
Suctioning required during swallow screen
Food or liquid coming out of nares (nostrils)
Patient complains of food “getting stuck” in throat and/or
swallowing difficulties
Eyes reddening and/or tearing with swallow attempts
Wet, gurgling sounds
Choking, persistent coughing with food/fluids
Labored breathing or rales
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Part 3 – Screen Results
Patient Passed the Screen
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RN to document that the patient has Passed the screen
and implement the following interventions…
 RN to notify physician that patient Passed screen
and request a diet order
 If physician’s diet order is written and patient has
Passed screen, then food, fluids and medications
can be initiated
 RN to implement the following aspiration precautions…
- No Straws
- HOB ↑ 30° (at rest)
- HOB ↑ 90° (with meals and meds)
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Part 3 – Screen Results
Patient Failed the Screen
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RN to document that the patient has Failed the screen
The nurse will implement the following aspiration
precautions…
- Keep patient NPO
- Keep HOB ↑ 30 degrees
- Bedside suction
- Provision of oral care
- Document in Kardex: Patient is NPO and on
aspiration precautions
RN to notify physician of Failed screen and request a
SLP Consult for a Clinical Swallow Evaluation (CSE) and
Treatment
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Important Points to Remember
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A physician’s order is not required to initiate the Nursing Dysphagia
Screen
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RN must complete the Nursing Dysphagia Screen on ALL stroke patients
prior to any oral intake (no food, fluids or medications)
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RN can initiate the Nursing Dysphagia Screen on any patient exhibiting
swallowing difficulties including the following…
 Parkinson’s
 Dementia
 Head and Neck Cancer
 Tracheostomy
 Progressive Neurological Disorders (e.g., Multiple Sclerosis)
 Debility
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Terms
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Nares: the nostrils or the nasal passages
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Tongue: the movable organ in the floor of the mouth functioning in taking
and swallowing of food, speaking and tasting
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Esophagus: muscular passage connecting the mouth or pharynx with the
stomach for food and fluids
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Trachea: anatomical pathway for air into the lungs
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Valleculae: anatomical structure described as a depression or crevice
where pooling of food and fluids can occur with dysphagia
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Pyriform Sinus: a common place where food can become trapped and
may give the sensation of food being stuck in the throat
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