EXAMPLE SWALLOW SCREEN

SIGN
Scottish Intercollegiate Guidelines Network
Part of NHS Quality Improvement Scotland
Can the patient be sat up and remain NO Keep nil by mouth and maintain oral hygiene.
awake and alert for at least 15 minutes ? Consider artificial nutritional support.
Consult dietitian as appropriate.
YES

Is the mouth clean? NO Implement oral hygiene immediately.

YES

Sit patient up and give a teaspoon

of water x3. Place fingers on midline
above and below the larynx and feel the Management of patients with stroke:
swallow. Observe each teaspoon. identification and management of

Are any of these signs present? YES Keep nil by mouth and refer to Speech and
119 dysphagia
- Absent swallow Language Therapist.
Quick Reference Guide
- Cough
- Delayed cough
- Altered voice quality

(ask the patient to say “Aah”)

NO

Observe the patient continuously drink a

glass of water.

Are any of these signs present?

- Absent swallow YES Keep nil by mouth and refer to Speech and
- Cough Language Therapist.
- Delayed cough
- Altered voice quality

(ask the patient to say “Aah”)

NO

Start feeding (soft options) with caution.

Continue to observe for coughing or June 2010

development of a chest infection and
refer to Speech and Language Therapy as
necessary.
COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE
ONLINE AT WWW.SIGN.AC.UK
 EVALUATING SWALLOWING AND NUTRITION NUTRITIONAL SCREENING NUTRITIONAL INTERVENTIONS
AFTER STROKE
D Assessment of nutritional risk should be carried out within C Following nutritional screening, those identified
the first 48 hours with regular re-assessment thereafter during as undernourished, and those at risk of becoming
Dysphagia affects a large proportion of stroke patients. Swallowing the patient’s recovery and be recorded prior to any discharge. undernourished, should be referred to a dietitian and
difficulties can result in aspiration and reduced oral intake, leading to considered for prescription of oral nutritional supplements as
the potentially serious complications of pneumonia, undernutrition and D Assessment of a patient’s nutritional risk should include part of their overall nutritional care plan.
dehydration. an assessment of their ability to eat independently and a
periodic record of their food consumption.  Patients with dysphagia who are unable to meet their
C All stroke patients should be screened for dysphagia before nutritional requirements orally should be considered for initial
being given food or drink. D Ongoing monitoring of nutritional status should include a NG feeding as soon as possible, within one week of onset.
combination of the following parameters:
This decision should be made by the multidisciplinary team in
ASPIRATION PNEUMONIA ƒƒ biochemical measures (ie low pre-albumin, impaired consultation with the patient and their carers/family.
glucose metabolism)
B The water swallow test should be used as part of the ƒƒ swallowing status D Patients in the early recovery phase should be reviewed
screening for aspiration risk in stroke patients. weekly by the multidisciplinary team to ascertain if longer
ƒƒ unintentional weight loss
ƒƒ eating assessment and dependence term (>4 weeks) feeding is required.
C Clinical history taking should take into account
comorbidities and other risk factors (eg smoking, respiratory ƒƒ nutritional intake. B Feeding via percutaneous endoscopic gastrostomy (PEG) is
disease) to identify increased risk of developing aspiration the recommended feeding route for long term (>4 weeks)
pneumonia. D Nutritional screening should cover; body mass index (BMI), enteral feeding. Patients requiring long term tube feeding
ability to eat, appetite, physical condition, mental condition.
should be reviewed regularly.
SWALLOW SCREENING
ASSESSMENT D Patient’s and carer’s perceptions and expectations of PEG
D Patients with dysphagia should be monitored daily in the B ƒƒ A
 standardised clinical bedside assessment (CBA) should feeding should be taken into account and the benefits, risks
first week to identify rapid recovery. Observations should be and burden of care fully explained before initiating feeding.
be used by a professional skilled in the management of
recorded as part of the care plan.
dysphagia
ROLE OF REGULAR REVIEW
 Patients not fit for assessment should be screened daily to avoid ƒƒ T
 he CBA developed and tested by Logemann, or a similar
delay in referral for full clinical assessment. tool, is recommended. D Patients with persistent dysphagia should be reviewed
regularly, at a frequency related to their individual
D A typical swallow screening procedure should include: C The modified barium swallow (MBS) test and fibreoptic swallowing function and dietary intake, by a professional
endoscopic evaluation (FEES) of swallow are both valid skilled in the management of dysphagia.
ƒƒ initial observations of the patient’s consciousness level
methods for assessing dysphagia. The clinician should
ƒƒ observations of the degree of postural control consider which is the most appropriate for different patients ORAL HYGIENE
If the patient is able to actively cooperate and is able to be in different settings.
D Good oral hygiene should be maintained in patients with
supported in an upright position the procedure should also D Hospital and community pharmacists or medicines dysphagia, particularly in those with PEG or NG tubes, in
include: information centres should be consulted on the most order to promote oral health and patient comfort.
ƒƒ observations of oral hygiene appropriate method of administering medication.
 An appropriate oral care protocol should be used for every
ƒƒ observations of control of oral secretions DYSPHAGIA THERAPY patient with dysphagia, including those who use dentures.
ƒƒ if appropriate, a water swallow test.
D All patients who have dysphagia for more than one week CARING FOR PATIENTS WITH DYSPHAGIA
 Patients on nil by mouth or modified diet should continue to should be assessed to determine their suitability for a
D Staff, carers and patients should be trained in feeding
receive clinically essential medication by an appropriate route rehabilitative swallowing therapy programme. Consideration
techniques. This training should include:
as advised by a pharmacist. should be given to:
ƒƒ modifications of positioning and diet
ƒƒ the nature of the underlying swallowing impairment
DIET MODIFICATION ƒƒ food placement
ƒƒ p
 atient suitability in terms of motivation and cognitive
D ƒƒ Advice on diet modification and compensatory techniques status. ƒƒ management of behavioural and environmental factors
(postures and manoeuvres) should be given following full ƒƒ delivery of oral care
swallowing assessment B  atients with dysphagia should have an oropharyngeal
P
swallowing rehabilitation programme that includes ƒƒ management of choking.
ƒƒ T
 exture modified food should be attractively presented restorative exercises in addition to compensatory techniques
and appetising. Patients should have a choice of dishes. and diet modification.
 ƒƒ Texture modified meals may be fortified to enable This Quick Reference Guide provides a summary of the main recommendations in SIGN 119 Management of patients with stroke: Identification and
patients to meet nutritional requirements management of dysphagia.
ƒƒ F
 ood and fluid intake should be monitored and, if
Recommendations are graded A B C D to indicate the strength of the supporting evidence. Good practice points   are provided where the guideline
indicated, a referral made to the dietitian.
development group wishes to highlight specific aspects of accepted clinical practice. Details of the evidence supporting these recommendations can be
found in the full guideline, available on the SIGN website: www.sign.ac.uk