SWALLOW SCREENING TOOL - UPDATED DRAFT FOR DUAL CAMPUS USE 2016

A. tPA
Has the patient received tPA within the past 24 hours? Exemption per YES NO
physician order
If you answered YES, maintain NPO status and repeat the screen once patient is 24 hrs s/p tPA administration. If answered NO,
continue to next question. If selected physician exemption, move onto next question.

B. PATIENT STATUS:
Is the patient able to sit upright/remain in a seated position (>30 degrees) for testing? YES NO
Is the patient able to remain alert for testing (not lethargic or comatose)? YES NO
If you answer NO to any of these questions, discontinue screen. Pt is to maintain NPO status and repeat screen daily until all
answers are YES. If you answer YES to all of these questions, continue to next section.

C. EXCLUSION CRITERIA:
Is the patient eating a modified diet (thickened liquids) due to pre-existing dysphagia? YES NO
Does the patient receive enteral feeds via stomach or nose? YES NO
Does the patient have a tracheostomy? YES NO
Has the patient been extubated within the past 24 hours (excluding intubation for < 24 hours)? YES NO
If you answer YES to any of these questions, discontinue screen. Pt is to maintain NPO status and consult Speech Pathology.
If you answer NO to all of these questions, continue to section D.

D. PRE-FEEDING OBSERVATIONS:
Can the patient follow simple commands? YES NO
(open/close mouth/lips, stick out their tongue and move side-to-side, pucker lips)
Is the patient able to cough or clear his or her throat sharply? YES NO
Can the patient swallow his or her own saliva? YES NO
If you answer NO to any of these questions, discontinue screen. Pt is to maintain NPO status and consult Speech Pathology.
If you answer YES to all of these questions, then continue to Section E.

E. FEEDING OBSERVATIONS: Sit the patient upright at 80-90 degrees (or as high a tolerated >30 degrees).
Complete 3 Ounce Water Swallow Challenge. Ask the patient to drink the entire 3 ounces of water WITHOUT STOPPING.
Patient swallows without difficulty Coughing Wet sounding
Voice Difficulty Breathing Choking
Unable to complete 3 ounces sequentially without stopping
If you select ANY choice beside patient swallows without difficulty, discontinue screen. Pt is to maintain NPO status and
consult Speech Pathology.

RESULTS:
PASS: Patient completed 3 ounces of water without stopping. NO coughing, wet sounding voice, difficulty breathing, or
choking was observed. Auto response should state: Patient may be cleared for oral intake. Call MD to place orders for
appropriate diet.
FAIL: IF coughing, wet sounding voice, difficulty breathing, choking selected on 3 ounce water swallow, AND/OR the
patient was unable to drink the entire 3 ounces WITHOUT STOPPING, keep the patient NPO , STOP the screening and
consult Speech Dept. Auto response should state Keep the patient NPO. An Auto-consult for speech pathology has
been placed. Orders will be addressed within 24 hours.
Patient NPO: [ ] Yes [ ] No Order given for Speech Consult: [ ] Yes [ ] No

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