Dysphagia: a screening tool for stroke patients.
Abstract: The Examine Ability to Swallow (EATS) dysphagia screening protocol for stroke patients is time and cost effective and may prevent adverse complications. This assessment tool consists of a kit containing specific instructions and test foods, as well as a screening form. If dysphagia is detected, nothing more is allowed by mouth, and an evaluation is automatically requested with a speech pathologist. A negative result permits the patient to safely begin oral nutrition and hydration.
Subject: Deglutition disorders (Diagnosis)
Stroke patients (Health aspects)
Authors: Wood, Paulette
Emick-Herring, Brenda
Pub Date: 10/01/1997
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 1997 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Oct, 1997 Source Volume: v29 Source Issue: n5
Accession Number: 20112551
Full Text: Introduction

Dysphagia has been documented in 25-500/0 of individuals following stroke. Delayed swallow reflex, laryngeal incompetence (poor elevation of the larynx and incomplete vocal cord adduction for example) and pharyngeal residue (food particles that persist in the vallecular sinus or stick to the wall of the pharynx) following deglutition, are frequent sequela following stroke. Stroke patients with swallowing impairments arc at unnecessary jeopardy for aspiration silent or apparent) and malnutrition. Both complications then also place the person at high-risk for skin breakdown, muscle weakness and fatigue. As this occurs, the patient's quality of life diminishes and health care costs increase. This article describes a dysphagia screening tool that can be used by nurses specifically for early detection of dysphagia in stroke patients.

A New Screening Tool For Early Detection of Dysphagia

In developing clinical pathways for stroke, every effort needs to be made to optimize functional performance outcomes while reducing the length of hospitalization. Too often newly admitted stroke patients cannot manage their saliva, struggle to swallow medications, are unable to swallow sufficient fluids for adequate hydration and risk inadequate nutritional intake secondary to oral or pharyngeal phase dysphagia. Unfortunately, it may take several episodic struggles to alert the nurse or the physician that dysphagia exists and that referral to a speech-language pathologist for dysphagia evaluation is indicated. (Dysphagia simply means chewing, sucking, or swallowing problems). The reader is directed to Table 1 for general signs and symptoms of dysphagia.

Table 1. General Signs and Symptoms of Dysphagia



Undiagnosed and unremediated dysphagia is risky and often results in medical complications, prolonged hospital stays[1] and increased mortality rates. Levine stated, "Stroke is the most common disabling neurological disease of adulthood and typically is the most common cause of neurogenic dysphagia" (p 4).[2] After surveying its membership, the American Speech-Language-hearing Association revealed that an estimated 75% of the dysphagic patients being treated by speech-language pathologists were dysphagic due to neurogenic causes and 52% were stroke patients.[3] Such information clearly suggests that early detection of dysphagia should be a high priority of healthcare professionals.

Proactive Team Approach

The dysphagia team at Iowa Methodist Medical Center assumes each stroke patient admitted to the 783 bed medical facility is at risk for dysphagia. A screening program was developed, tested and implemented for the purpose of enhancing early detection and treatment of dysphagia.

The patient's nurse conducts a screening evaluation for swallowing competency within the first twenty-four hours of the stroke patient's hospital admission. The nurse uses professional judgement to determine when the patient is ready for the screening evaluation. Oral medications, foods, and liquids are held until the patient's swallowing competency has been established. This is done in an effort to prevent adverse effects in an already fragile patient population.

The screening program was originally coordinated by a speech-language pathologist specializing in dysphagia management. The speech pathologist along with other members of the team, including an occupational therapist, clinical dietitian and neuroscience nurse constructed and refined the dysphagia screening protocol that is currently in place. The screening consists of in Examine Ability to Swallow (EATS) box (Figs 1,2) which includes a standard nursing assessment tool. The written tool guides the nurse's assessment, provides an avenue for documentation of findings and activates a dysphagia evaluation when needed. Table 2 delineates the contents of the box and Table 3 describes the process for implementation.

Table 2. Examine Ability to Swallow (EATS) Box

Items in EATS box include the following:

* One Italian Ice (meltable, tart flavor, colored bolus easily absorbed by the lungs)

* A 6-oz can of cranberry juice (cold, thin liquid, strong flavor, bold color)

* A 6-oz can of apricot nectar (cold, thick liquid, strong flavor)

* One jar baby fat peaches (cold pureed bolus, strong flavor)

* One package graham crackers (bolus requiring mastication)

* Two small cups, two spoons, one napkin

* One card of procedural instructions (Table 3)

Table 3. Procedural Instructions

Elevate the head of the patient's bed to least 70 degrees. Support the hemiplegic side with a pillow. Present bites/sips in these order (stop if the patient struggles at any step):

1. Give 1/2 teaspoon Italian Ice, placing at midline of tongue.

2. Give 1 teaspoon Italian Ice, placing at midline of tongue.

3. Give 1 teaspoon peaches. Repeat a second teaspoon.

4. Pour apricot into a cup, filling at least 1/2 full. Give patient the cup and allow the second sip to be an uncontrolled size.

5. If the thick liquid was successful, repeat the procedure above using the cranberry juice.

6. Give the patient a graham cracker and ask to take a bite, chew and swallow. If successful, offer the rest of the craker.

Record Results on the Nutrition and Swallowing Screen and forward copies to appropriate departments.

Initially the speech-language pathologist and clinical dietitian trained each shift of nurses in the medical center who would be caring for new stroke admissions. They specifically explained how the program was developed and demonstrated how to safety do the EATS screening evaluation and the documentation process inherent to the protocol.

Current Nursing Protocols

Prior to conducting a dysphagia screening, the nurse secures the EATS "Nutrition and Swallowing Screen" report form (Fig 3) from the nursing station, and takes an EATS box from the refrigerator on the nursing unit. The nurse also obtains an Italian ice, the meltable bolus for EATS which is stored in the freezing compartment of the refrigerator.

The nurse readies the patient for the dysphagia screen by elevating the head of the patient's bed to at least 70 [degrees] supporting the hemiplegic side with a pillow. As the dysphagia screening examination is conducted (Table 3), the nurse records the patient's responses on the EATS "Nutrition and Swallowing Screen" report. Depending upon the condition of the patient, this screen takes the nurse 15-30 minutes to complete.

If the patient demonstrates one or more behaviors symptomatic of swallowing dysfunction, the screening examination is considered positive. A positive screening report is considered a physician's standing order for a dysphagia evaluation. One copy of the "Nutrition and Swallowing Screen" is sent to the speech department immediately after the evaluation and actually becomes the necessary paperwork for the referral process. Another copy is sent to the food and nutrition service while the third copy remains in the chart. Thus three members of the dysphagia team (nurse, speech pathologist and dietitian) have knowledge of the swallowing status of every stroke patient within twenty-four hours of admission. If the screening is positive, the nurse also places a blue armband on the patient. This visually signifies the patient is dysphagic and should not be given food or fluids without appropriate professional evaluation. Within twenty-four hours, including weekends, the speech-language pathologist completes the dysphagia evaluation and has a recommended treatment plan in place.

Conversely if the patient exhibits no behaviors symptomatic of swallowing dysfunction, the screening examination is considered negative. Oral intake can then be initiated by the nursing staff. If the patient demonstrated significant pocketing of food, a pureed diet is ordered with thick and thin liquids. The dietitian will coordinate with the primary nurse to upgrade the patient's diet as appropriate. If no pocketing was observed, a mechanical soft diet, thin and thick liquids is initiated.

Summary

Initiating safe oral nutrition and hydration immediately following stroke had become a critical concern for health care professionals at our facility. The Examine Ability to Swallow (EATS) dysphagia screening protocol, administered by nurses, was developed to solve this clinical dilemma. The dysphagia screening process for the acute stroke patient has successfully met the facilities' needs and more importantly has increased patients' satisfaction. No formal data were collected. This proactive approach is beneficial to the patient's physiological status as a means of preventing adverse complications, which impacts the recovery time frame for the patient. In addition it promotes the emotional well being of patients, and is economically prudent. This is an asset in today's healthcare environment.

References

[1.] Bernstein LH, Shaw-Stiffel TA, Schorow M Brouillette R: Financial implications of malnutrition, Clin Lab Med 1993; 13:491-507.

[2.] Levine RL: Neurologic approach to dysphagia. Division 13 Newsletter of the American Speech-Language Association 1993; 2(3):4.

[2.] Robbins JA: Guest editor. Division 13 Newsletter of the American Speech-Language-hearing Association 1993; 2(3):l

Bibliography

1. Emick-Herring B, Wood P: A team approach to neurologically based swallowing disorders, Rebab Nurs 1990; 15(3):126-132.

2. Garon BR, Engle M, Ormiston C: Silent aspiration: Results of 1,000 videofluoroscopic swallow evaluations. J Neuro Rehab 1996; 10: 121-126.

3. Gilbride J, Spector S: Nutritional considerations for the stroke patient with dysphagia. Topics in Stroke Rehabilitation 1996; 3(3):51-68.

4. Groher ME: Dysphagia Diagnosis and Management, 2nd ed. Butterworth-Heinemann, 1992.

5. Roueche, JR: Page 7 in: Dysphagia: An Assessment and Management Program For 7-be Adult Sister Kenny Institute, 1990.

6. Homer J, Massey W: Silent aspiration following stroke. Neurology 1988; 38:317-319.

7. Logemann JA: Noninvasive approaches to deglutive aspiration. Dysphagia 1993; 8:331-333.

8. Martin-Harris B, Cherney L: Treating swallowing disorders following stroke. Topics in Stroke Rehabilitation 1996; 3(3):1740.

9. Ritky DC, Kumar R, Scremin O: Clinical outcomes of dysphagia in elderly patients with cerebrovascular accident. J Neuro Rebab 1996; 10:217-222.

10. Steefel JS: Dysphagia Rehabilitation For Neurologically Impaired Adults. Charles C Thomas, 1981.
Symptom                                  Suspected Impairment

Abnormal voice quality                   Laryngeal incompetence
Food or liquid spilling from the mouth   Incomplete lip closure
                                         Impaired oral sensation
                                         Decreased cognition
Food or liquid held in mouth             Absent tongue pumping
                                         Decreased cognition
Food residue in the mouth after          Inefficient gathering
  the swallow                              by tongue
Coughing or choking on food/medication   Delayed swallow reflex
                                         Pharyngeal residue
                                         Laryngeal incompetence
Globus sensation                         Pharyngeal residue
                                         Disrupted pharyngeal
                                           peristalsis
Bad taste/metallic taste in mouth        Pharyngeal residue
                                         Gastrointestinal reflux
Painful swallow                          Pharyngeal/
                                           esophageal lesion
                                         Stricture
                                         Gastrointestinal reflux
Tracheal expectoration/need for          Poor epiglomatic inversion
  suctioning                             Laryngeal incompetence
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