Transcript Dysphagia Screen

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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
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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
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2.
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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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