Our hospital recently became Stroke Certified. My initial reaction was sheer joy. How many evaluations would that create for me!?!?!?!
My new reaction is HOW many more evaluations do I have to do on patients that did not really have a stroke!?!?!?!
In working on Stroke Certification, nursing staff was educated on administration and interpretation of the 3 Ounce Water Swallow Challenge. Having the nursing staff give the patients 3 ounces of water to swallow was one of the easiest ways to incorporate screening in their assessment. It is also backed by research.
I continue to evaluate ALL stroke patients, per our protocol.
I assess them at bedside with trial consistencies. Cranial nerves are examined through an oral mech exam.
If you have access to ASHA SIG 13 Perspectives, there is an excellent Food for Thought regarding Cranial Nerves by Dr. Giselle Carnaby.
The most important part of a cranial nerve exam is to understand the nerve functions so that you can assess dysfunction during your oral mech examination.
By understanding normal you will be able identify abnormal.
My nursing staff, so far, has responded well to the 3 ounce swallow assessment and we will continue it in our facility.
So, people may wonder what other screening tools are available for dysphagia.
Remember, when looking at these screenings, you want to examine validity and reliability. Some research terms:
Accuracy: The amount the test result reflects the true clinical state. If disease is present, a truly accurate test will always give a positive result, whilst if disease is not present, the test will always give a negative result. This is not the case for all tests.
Sensitivity: Sensitivity is the measure used to report how effective a test is in identifying individuals with a disease. The higher the sensitivity/the proportion of positive results the better.
Specificity: The measure used to report how effective a test is in identifying individuals without the disease. The higher the specificity/proportion of negative test results the better.
Reliability: Reliability is the degree of consistency of what a test measures i.e. the extent to which a test or any measuring procedure provides the same result on repeated trials. Within the study, reliability is concerned with the consistency of the measurement tool when employed by nurses compared against its use by the SLTR for determining the presence or absence of dysphagia and the appropriateness of referring acute stroke patients to the SLT.
Validity: The extent to which a test accurately measures what it is supposed to measure. Within the research programme, validity is concerned with the measurement tool’s success at detecting the presence or absence of signs of dysphagia and the appropriateness of decisions to refer patients for full clinical dysphagia assessment when used by nurses in a given context with the acute stroke population as measured against the ‘Gold standard (the SLTR’s bedside assessment of swallowing) measure outcomes.
(Information from the Thesis The Design and Evaluation of a Valid Dysphagia Screening Tool for Acute Stroke Patients)
Clinical Assessment of Swallowing and Prediction of Dysphagia Severity
(Information taken from the above link)
Using the following:
Clinical predictors of aspiration risk. Predictor Operational Definition
Dysphonia Voice disturbance in parameters of vocal quality, pitch, or intensity.
Dysphoria Speech disorder resulting from disturbances in muscular control that affect respiration, articulation, phonation, resonance, or prosody.
Abnormal Gag Reflex Absent or weakened velar or pharyngeal wall contraction, unilaterally or bilaterally, in response to tactile stimulation of posterior pharyngeal wall.
Abnormal Volitional Cough Weak, verbalized, or absent response upon command to cough.
Cough After Swallow Cough immediately after or within 1 min of ingestion of calibrated volumes of water (5, 10, and 20 mL in duplicate).
Voice Change After Swallow Alteration in vocal quality after ingestion of calibrated volumes of water.
Score Classification Description
1 Normal No airway invasion.
2 Mild Bolus enters airway with clearing.
3 Moderate Bolus enters airway without clearing.
4 Moderate Bolus contacts vocal cords with airway clearing.
5 Moderate Bolus contacts vocal cords without airway clearing.
6 Severe Bolus enters trachea and is cleared into larynx or out of airway.
7 Severe Bolus enters trachea and is not cleared despite patient attempts.
8 Severe Bolus enters trachea and patient does not attempt to clear.
Normal-Mild Range from no laryngeal penetration to evidence of laryngeal penetration.
Moderate Two or less aspiration episodes of one consistency.
Severe More than two aspiration episodes of one consistency or aspiration of more than one consistency
50 ml water swallow test and/or pulse oximetry
Pharyngeal Sensation Assessment, Oromotor Assessment, and 50-ml Water Test
30-ml water swallowing test
Swallowing Provocation Test
Standardized Swallowing Assessment (SSA)
Timed Test of Swallowing and Questionnaire
Oxygen Saturation Monitoring
50ml Drinking Test
Resources for screening of swallowing ability and stroke.
The following is a link to a review of different dysphagia screening tools. Screening Tools
The following is an interesting article for dysphagia s/p stroke. Dysphagia and Aspiration Post Stroke
Slides regarding dysphagia screenings
The importance of looking at screenings and deciding which is best for you is the responsibility of individual SLPs. Understanding what to look for in a screen is important.
Do I recommend a diet based on a screening?