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UWH Stroke Dysphagia Screen

UWH Stroke Dysphagia Screen - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Name: Nicole Bennett
Email: NBennett@uwhealth.org
Last reviewed: 12/18/15

UWH Stroke Dysphagia Screen
Exclusion Criteria: post-extubation patients, post t-PA pts, non-stroke patients
Date________________ Time _____________
Screen Completed By: ___________________________________________
Patient Assessment and History
Level of consciousness Is patient scoring above 0?
(LOC question on the abbreviated UWNIHSS)
Yes No
Does patient have a history of swallowing problems? (May include
foods sticking when swallowing, coughing/choking when eating,
difficulty managing saliva or drooling.)

Yes No
Is patient drooling, having difficulty managing secretions, or
exhibiting wet voice quality?
Yes No
Have the patient repeat this sentence:
“They heard him speak on the radio last night”
Is the patient’s voice weak or abnormal in any way?

Yes No
Does the patient demonstrate slurred speech (dysarthria) ?

Yes No



Swallow Test
Patient should be sitting upright for this test.
5 mL volume of water via medicine cup.
Direct the patient to take the water from the cup and swallow as
they normally would.
ξ Does the patient demonstrate cough, throat clear, or
wet/gurgly voice quality after swallowing?



Yes No
90 mL volume of water via straw
Direct the patient to take the water through the straw without
stopping until the water is all consumed.
ξ Does the patient demonstrate cough, throat clear, or
wet/gurgly voice quality after swallowing?

Yes No


For YES to any of these questions, STOP dysphagia screen and consult swallow service.
If all answers are NO, proceed to swallow test.
IF


For YES to any of these questions, STOP dysphagia screen and consult swallow service.
If all answers are NO, then call the resident for a general diet (low fat, low cholesterol)
Document results in progress note (.dysphagiaPASS or .dysphagiaFAIL)


IF

Feedback:

Please place in manager’s mailbox.

Place pt sticker here