Practice Recommendations: Dysphagia

Recommendation	Level of Evidence
6.0 Nurses should maintain all clients with stroke NPO (including oral medications) until a swallowing screen is administered and interpreted, within 24 hours of the client being awake and alert.	IIa
6.1 Nurses in all practice settings, who have appropriate training, should administer and interpret a dysphagia screen within 24 hours of the stroke client becoming awake and alert. This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. This screening should include: Assessment of the client's alertness and ability to participate; Direct observation of signs of oropharyngeal swallowing difficulties (choking, coughing, wet voice); Assessment of tongue protrusion; Assessment of pharyngeal sensation; Administration of a 50 ml water test; and Assessment of voice quality. In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.	IIa

Recommendation

Level of Evidence

6.0 Nurses should maintain all clients with stroke NPO (including oral medications) until a swallowing screen is administered and interpreted, within 24 hours of the client being awake and alert.

IIa

6.1 Nurses in all practice settings, who have appropriate training, should administer and interpret a dysphagia screen within 24 hours of the stroke client becoming awake and alert. This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. This screening should include:

Assessment of the client's alertness and ability to participate;
Direct observation of signs of oropharyngeal swallowing difficulties (choking, coughing, wet voice);
Assessment of tongue protrusion;
Assessment of pharyngeal sensation;
Administration of a 50 ml water test; and
Assessment of voice quality.

In situations where impairments are identified, clients should be referred to a trained healthcare professional for further assessment and management.

IIa

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