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1. Begin the module 123 Title of the Module: Nursing Dysphagia Screen Stroke Education Date of Publication: 5/6/09 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

2. GUIDELINESAmerican Stroke Association • 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)

3. What is Dysphagia? • 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

4. Anatomy • Nares • Tongue • Esophagus • Trachea • Valleculae • Pyriform Sinus

5. Modified Barium Swallow Image Epiglottis • Inverts to cover airway during swallowing to prevent aspiration of food and fluids Valleculae • Anatomical structure described as a depression or crevice where pooling of food and fluids can occur with dysphagia Trachea • Anatomical pathway for air into the lungs Esophagus • Anatomical pathway for food and fluids into the stomach BOLD ARROWS IDENTIFY AREAS OF ASPIRATION

6. Dysphagia Definitions • Aspiration Penetration of food/liquids below the level of the vocal cords • Silent Aspiration Penetration below the level of true vocal cords without outward signs of difficulty (~16%) • Clinical Swallow Evaluation (CSE) A swallow evaluation that is performed at the patient’s bedside by SLP • Modified Barium Swallow (MBS) A swallow evaluation performed in the radiology department by SLP

7. Stroke Facts • 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

8. WHO DOES WHAT?RN Screen versus SLP Evaluation • 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

9. “IT’S TIME FOR YOUR DYSPHAGIA SCREEN”

11. LET’S GET STARTED • 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

12. Part 1 – Aspiration Risk Screen • If ANYof 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

13. Part 2 – Swallow and Medication Screen • Assessment directions • 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 • 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

14. Part 2 – Swallow and Medication ScreenAssessment • 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

15. Part 3 – Screen ResultsPatient Passed the Screen • 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)

16. Part 3 – Screen ResultsPatient Failed the Screen • 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 Failedscreen and request a SLP Consult for a Clinical Swallow Evaluation (CSE) and Treatment

17. Important Points to Remember • A physician’s order is not required to initiate the Nursing Dysphagia Screen • RN must complete the Nursing Dysphagia Screen on ALL stroke patients prior to any oral intake (no food, fluids or medications) • RN can initiate the Nursing Dysphagia Screenon any patient exhibiting swallowing difficulties including the following… • Parkinson’s • Dementia • Head and Neck Cancer • Tracheostomy • Progressive Neurological Disorders (e.g., Multiple Sclerosis) • Debility

18. You’ve now completed this NetLearning module • Please click on “take test” • Upon successful completion of a short test, this module will be added to your NetLearning transcripts

19. Terms • Nares: the nostrils or the nasal passages • Tongue: the movable organ in the floor of the mouth functioning in taking and swallowing of food, speaking and tasting • Esophagus: muscular passage connecting the mouth or pharynx with the stomach for food and fluids • Trachea: anatomical pathway for air into the lungs • Valleculae: anatomical structure described as a depression or crevice where pooling of food and fluids can occur with dysphagia • Pyriform Sinus: a common place where food can become trapped and may give the sensation of food being stuck in the throat Return to Previous Slide