BEDSIDE SWALLOW SCREEN FOR DYSPHAGIA
BEDSIDE SWALLOW SCREEN
FOR DYSPHAGIA
Laura Cowen Ph.D. CCC-SLP
Speech Language Pathologist
Alanna Kearns RN, BSN, PN
Stroke Program Coordinator
July 2015
•
The nurse will be able to identify which patient population
requires a swallow screen before eating, drinking, or taking
anything by mouth.
•
The nurse will be able to explain the rationale for having oral
suction immediately available when doing a bedside swallow
screen.
•
The nurse will be able to explain the difference between a
swallow screen and a swallow evaluation.
•
The nurse will be able to recognize if the patient has passed the
first section of the swallow screen.
•
The nurse will be able to explain how to safely administer a
bedside swallow screen.
Objectives
2
3
•
All TIA and Stroke patients
must have a swallow screen
to identify dysphagia before
receiving any oral intake for
the first time including
liquids, food and
medications.
•
An MD order is not required
to perform the Swallow
Screen for Dysphagia.
The Joint Commission & SBMC’s Requirement
•
Use the
Swallow Screen for
Dysphagia
form in Cerner,
found in Ad Hoc and click the
green checkmark to save.
•
There should be a swallow
screen performed on every
TIA/stroke patient.
4
•
Performed by RN
•
Done automatically
prior to any oral intake
•
Brief
•
Utilizes only water
•
Basic observation
•
Performed Speech Therapist
•
Done only with MD order
•
Can take 30-60 minutes
•
Utilizes full trial feed with
multiple textures
•
Includes full oral and
pharyngeal assessment
Swallow Screen vs. Bedside Swallow Evaluation
Swallow Screen
Bedside Swallow Evaluation
5
•
“Swallow evaluation”
•
“Swallow assessment”
•
“Bedside”
•
“Dysphagia evaluation”
•
“Video swallow”
•
“Swallow study”
•
“Videofluoroscopic Swallow
study”
•
“Barium swallow with video”
Procedures Performed by a Speech Therapist)
Bedside Swallow Evaluation
(BSE)
Modified Barium Swallow Study
(MBSS)
6
•
All Acute Ischemic Strokes (AIS)
•
All Hemorrhagic Strokes
•
All Transient Ischemic Attacks (TIA)
Criteria for a Swallow Screen for Dysphagia
7
•
Recently extubated patients
•
Head trauma patients
•
Any patient with recent neurological changes
•
Patients with neurodegenerative diseases
•
Patients with dementia
•
Recent cervical surgery patients
•
Patients that you feel are having swallowing difficulties
Other patients appropriate for swallow screen
8
•
Note
: Only Registered Nurses who have completed this training
may perform a Swallow Screen for Dysphagia
•
Only Nurses will perform this screening.
•
Have oral suction immediately available
•
See that the mouth is moist and clean. If not, provide oral care
prior to doing the Swallow Screen for Dysphagia
•
Explain procedure to patient
•
Provide privacy
•
Provide patient teaching
•
Document patient’s response to Swallow Screen for Dysphagia
•
Save your work
“To Do” List
9
RN Swallow
Screen
•
Chart this as a “
Screen
”
not an “Evaluation”
•
Note that any
boxes checked in the top
area is an automatic
“Fail”
•
Keep the pt NPO
•
Nothing oral at all
•
A Swallow Evaluation by
a Dysphagia Specialist will
be automatically ordered
if the patient fails this
screen
10
•
Current Status, Observations
–
Patient or family may give data
•
Can patient stay awake/follow simple commands?
•
History of recurrent or aspiration pneumonia?
•
Wet sounding voice?
•
Absent, weak or wet cough?
•
Difficulty managing secretions?
(drooling or frequent suctioning)
•
Facial droop or slurred speech?
•
Feeding tube?
•
Difficulty swallowing when eating or drinking?
“The Swallow Screen”
11
•
All stroke and TIA patients that have orders for
“NPO
except
medications”
will be kept
NPO
•
Until successfully passing a swallow screen
•
And having this documented in the electronic medical record
NPO
except
medications
12
•
Did the water dribble or drool from patient’s mouth?
•
Did the patient swallow multiple times?
•
Did the patient cough immediately or within one minute after
swallowing?
•
Did the patient’s vocal quality become wet or gurgly?
Swallow Screen (continued)
1
st
Oral Trial – 1 tablespoon water (15 ml)
2
nd
Oral Trial – 2-3 sips of water from cup (NO straws) (90 ml)
13
•
Patient unable to remain alert/awake without repeated
stimulation
•
Inability to follow simple oral commands
–
Open mouth, stick out tongue, smile
•
Patient with existing feeding tube
•
Patient with respiratory difficulty, weak or absent cough, or
recent history of aspiration pneumonia
•
Patient unable to sit upright at a 90 degree angle
•
Drooling with or without coughing
•
No voice
Swallow Screen Contraindications or Instant “Fail”
14
•
If ANY of the answers to the questions on the first part of the
screen is anything other than “None”, the patient automatically
FAILS the screen and needs to be kept NPO
•
A
“ST BEDSIDE SWALLOW EVALUATION”
will be ordered in
Cerner.
Results of the Screen
15
1.
Observe patient for any frequent coughing, throat clearing,
choking, breathlessness, or wet/gurgly voice after drinking or
eating.
2.
Observe patient for oral pocketing of food and leakage of food
or liquid from mouth.
3.
Monitor aspiration indicators such as worsening lung sounds,
elevated temperature and decreasing oxygen saturation.
If patient passes SCREEN and begins an oral diet…
16
4.
Observe for worsening neurological condition and repeat
SCREEN if worsening occurs.
5.
Request a Nutrition Consult for inadequate hydration or
nutritional intake.
6.
Any concerns about swallowing, consult Physician about
getting a “Bedside Swallow Evaluation by Speech Therapy”.
If patient passes SCREEN and begins an oral diet…
17
Remember:
NO “NPO except Medications”!
Always check the swallowing!
Swallow Screen: STK 7
Thank You
In this guide, learn about the bedside swallow screen for dysphagia, its importance in identifying swallowing difficulties, differences from a swallow evaluation, and procedures involved. Understand why all TIA and stroke patients need a swallow screen, the criteria for screening, and other patients who may require evaluation. Explore the roles of nurses, speech therapists, and the Joint Commission's requirements.
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Presentation Transcript
BEDSIDE SWALLOW SCREEN FOR DYSPHAGIA Laura Cowen Ph.D. CCC-SLP Speech Language Pathologist Alanna Kearns RN, BSN, PN Stroke Program Coordinator July 2015
Objectives The nurse will be able to identify which patient population requires a swallow screen before eating, drinking, or taking anything by mouth. The nurse will be able to explain the rationale for having oral suction immediately available when doing a bedside swallow screen. The nurse will be able to explain the difference between a swallow screen and a swallow evaluation. The nurse will be able to recognize if the patient has passed the first section of the swallow screen. The nurse will be able to explain how to safely administer a bedside swallow screen. 2
The Joint Commission & SBMCs Requirement All TIA and Stroke patients must have a swallow screen to identify dysphagia before receiving any oral intake for the first time including liquids, food and medications. Use the Swallow Screen for Dysphagia form in Cerner, found in Ad Hoc and click the green checkmark to save. There should be a swallow screen performed on every TIA/stroke patient. An MD order is not required to perform the Swallow Screen for Dysphagia. 3
Swallow Screen vs. Bedside Swallow Evaluation Swallow Screen Bedside Swallow Evaluation Performed Speech Therapist Done only with MD order Performed by RN Done automatically prior to any oral intake Brief Utilizes only water Can take 30-60 minutes Utilizes full trial feed with multiple textures Includes full oral and pharyngeal assessment Basic observation 4
Procedures Performed by a Speech Therapist) Bedside Swallow Evaluation (BSE) Modified Barium Swallow Study (MBSS) Swallow evaluation Video swallow Swallow assessment Swallow study Bedside Videofluoroscopic Swallow study Dysphagia evaluation Barium swallow with video 5
Criteria for a Swallow Screen for Dysphagia All Acute Ischemic Strokes (AIS) All Hemorrhagic Strokes All Transient Ischemic Attacks (TIA) 6
Other patients appropriate for swallow screen Recently extubated patients Head trauma patients Any patient with recent neurological changes Patients with neurodegenerative diseases Patients with dementia Recent cervical surgery patients Patients that you feel are having swallowing difficulties 7
To Do List Note: Only Registered Nurses who have completed this training may perform a Swallow Screen for Dysphagia Only Nurses will perform this screening. Have oral suction immediately available See that the mouth is moist and clean. If not, provide oral care prior to doing the Swallow Screen for Dysphagia Explain procedure to patient Provide privacy Provide patient teaching Document patient s response to Swallow Screen for Dysphagia Save your work 8
RN Swallow Screen Chart this as a Screen not an Evaluation Note that any boxes checked in the top area is an automatic Fail Keep the pt NPO Nothing oral at all A Swallow Evaluation by a Dysphagia Specialist will be automatically ordered if the patient fails this screen 9
The Swallow Screen Current Status, Observations Patient or family may give data Can patient stay awake/follow simple commands? History of recurrent or aspiration pneumonia? Wet sounding voice? Absent, weak or wet cough? Difficulty managing secretions? (drooling or frequent suctioning) Facial droop or slurred speech? Feeding tube? Difficulty swallowing when eating or drinking? 10
NPO except medications All stroke and TIA patients that have orders for NPO except medications will be kept NPO Until successfully passing a swallow screen And having this documented in the electronic medical record 11
Swallow Screen (continued) 1st Oral Trial 1 tablespoon water (15 ml) 2nd Oral Trial 2-3 sips of water from cup (NO straws) (90 ml) Did the water dribble or drool from patient s mouth? Did the patient swallow multiple times? Did the patient cough immediately or within one minute after swallowing? Did the patient s vocal quality become wet or gurgly? 12
Swallow Screen Contraindications or Instant Fail Patient unable to remain alert/awake without repeated stimulation Inability to follow simple oral commands Open mouth, stick out tongue, smile Patient with existing feeding tube Patient with respiratory difficulty, weak or absent cough, or recent history of aspiration pneumonia Patient unable to sit upright at a 90 degree angle Drooling with or without coughing No voice 13
Results of the Screen If ANY of the answers to the questions on the first part of the screen is anything other than None , the patient automatically FAILS the screen and needs to be kept NPO A ST BEDSIDE SWALLOW EVALUATION will be ordered in Cerner. 14
If patient passes SCREEN and begins an oral diet 1. Observe patient for any frequent coughing, throat clearing, choking, breathlessness, or wet/gurgly voice after drinking or eating. 2. Observe patient for oral pocketing of food and leakage of food or liquid from mouth. 3. Monitor aspiration indicators such as worsening lung sounds, elevated temperature and decreasing oxygen saturation. 15
If patient passes SCREEN and begins an oral diet 4. Observe for worsening neurological condition and repeat SCREEN if worsening occurs. 5. Request a Nutrition Consult for inadequate hydration or nutritional intake. 6. Any concerns about swallowing, consult Physician about getting a Bedside Swallow Evaluation by Speech Therapy . 16
Swallow Screen: STK 7 Remember: NO NPO except Medications ! Always check the swallowing! 17
