Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Department of Speech Language Pathology

Dysphagia Case History

Chart Review

Physician’s order? Yes___ No___

Admitting Diagnosis:_____________________________________________

Previous dx and/or tx:

______________________________________________________________
______________________________________________________________

Functional problems as reported by

nsg/staff:______________________________________________________
______________________________________________________________

Patient complaints:
______________________________________________________________
______________________________________________________________

Advance directive: yes___ no___ Feeding tube yes___ no___

GI/Barium/Neuro/Dietary Evals:
______________________________________________________________
______________________________________________________________

Surgery: _______________________________________________________

Radiation Treatment: _____________________________________________

Reason for referral: ______________________________________________

Reflux: Yes___ No___

Temperature spikes? Yes___ No___

When:_______________________________

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 1

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Drooling: Yes___ No___

Weight loss: Yes___ No___ How much _________________________

Level of alertness: non-responsive lethargic alert

Cognitive Status: ________________________________________________

Sensory impairments: Hearing: Yes__ No__, Vision: Yes__ No__,

Smell: Yes__ No__

Premorbid Status:
______________________________________________________________
______________________________________________________________

Pneumonia: Yes___ No___ When: _________________________

Lung sounds: __________________________________________________

Chest x-ray: __________________________________________________

Diet

Current diet: ___________________________________________________

Recent changes in diet:

______________________________________________________________
______________________________________________________________

Dietary Restrictions: _____________________________________________

Pulmonary Status

O2: Trach ______ Mask_____ N.C._____ Amount_____ Passy Muir Valve_____

Intubation: Yes___ No___ When: ____ How long: _________________

Notes:_________________________________________________________
______________________________________________________________
______________________________________________________________

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 2

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Medications Affecting Swallowing

*=Dry Mouth ? =Weight Loss >=Speech Difficulties

@=Nausea **=Dysphagia ~=Laryngitis/sore throat

#=Lethargy ^=Trouble Breathing +=Tongue Pumping

$=Dehydration &=Confusion !=Decreased Peristalsis in the Esoph/Larynx

%=Loss of Appetite <=Weakness

____ Adrenaline% ____ Calan!

____ Akineton*> ____ Carbamazepine>#@&

____ Albuterol% ____ Carbidopa-Levodopa@&>

____ Aldomet^*@ ____ Cardizem~

____ Alprazolam&<> ____ Catapres*#%^&<

____ Aluminum Salts (Antacid) >**# ____ Cerespan*#%^&<

____ Amantadine@&> ____ Chlorazepate&<>

____ Amitriptyline^&<*> ____ Chlordiazepoxide&<>

____ Antidepressants ____ Chlorpromazine*^+

____ Antipsychotics ____ Chlorpropamide&

____ Apresoline*#%^&< ____ Chlorthalidone*@#$

____ Aricept?% ____ Cimetidine&

____ Arlidin*#%^&< ____ Clofibrate#

____ Artane*> ____ Clonazepam&<>

____ Ativan&<> ____ Clonidine*#%^&<

____ Atromid-S# ____ Codeine>**#

____ Atropine*> ____ Compazine*^+

____ Axid& ____ Corgard*#%^&<

____ Belladonna*> ____ CorticoSteroids**

____ Benzocaine/Phenol/Benzyl Alcoho>**# ____ Coumadin #@

____ Benztropine*> ____ Coyentin*>

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 3

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

____ Beta Blockers ____ Crystodigin@&

____ Biperiden*> ____ Dalmane&<>

____ Brethine% ____ D-Amphetamine%?*

____ Butabarbital&<#>^ ____ Deltason**

____ Butisol&<#>^ ____ Demerol*

____ Depakene>#@& ____ Folic Acid Deficiency>**#

____ Depekote>#@& ____ Fosomax **

____ Dexedrine%?* ____ Furosemide*@#$

____ Dextromethorphan>**# ____ Gemfibrozil#

____ Diabeta& ____ Glipizide &

____ Diabinese& ____ Glucotrol &

____ Diazepam&<> ____ Glyburide&

____ Digitoxin@& ____ Halcion&<>

____ Digoxin@& ____ Haldol*^+

____ Dilantin>#@& ____ Haloperidol*^+

____ Diltiazem~ ____ Heparin#@

____ Diphenhydramine>**# ____ Hydralazine*#%^&<

____ Dipyridamole~ ____ Hydrochlorothiazide*@#$

____ Divalproex Sodium>#@& ____ Hydrodiuril*@#$

____ Doxepin^&<*> ____ Hygroton *@#$

____ Dyazide*@#$ ____ Imipramine^&<*>

____ Effexor? ____ Inderal*#%^&<

____ Elavil^&<*> ____ Iron**

____ Eldepryl* ____ Isoproterenal%

____ Elixophyllin % ____ Isoptin!

____ Epinepherine ____ Isuprel%

____ Equanil> ____ Klonopin&<>

____ Ethotoin >#@& ____ Lanoxin@&

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 4

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

____ Famotidine& ____ Larodopa@&>

____ Flexeril* ____ Lasix*@#$

____ Fluoxetine^&<*> ____ Levadopa (L-Dopa) @&>

____ Fluphenazine*^+ ____ Librium&<>

____ Flurazepam&<> ____ Lomotil?

____ Lopid# ____ Orinase&

____ Lopressor*#%^&< ____ Papaverine*#%^&<

____ Lorazepam&<> ____ Pavabid*#%^&<

____ Lovastatin# ____ Peganone >#@&

____ Macrobid** ____ Pentoxifylline~

____ Magnesium Salts (Antacid) >**# ____ Pepcid&

____ Mellaril*^+ ____ Persantine~

____ Mephenytoin>#@& ____ Phenytoin>#@&

____ Meprobamate> ____ Pilacor XR!

____ Mesantoin ____ Potassium**

____ Methyldopa^*@ ____ Powdered Opium Paregoric/Morphine>**#

____ Methylphenidate%?* ____ Prazocin*#%^&<

____ Metoprolol*#%^&< ____ Primidone>#@&

____ Mevacor# ____ Procainamide>

____ Mexiletine> ____ Procan SR>

____ Mexitil> ____ Procardia ~

____ Micronase& ____ Prochlorperazine*^+

____ Miltown> ____ Prolixin*^+

____ Minipres*#%^&< ____ Pronestyl >

____ Mysoline>#@& ____ Propranolol*#%^&<

____ Nadolol*#%^&< ____ Protonix $

____ Nembutal&<#>^ ____ Proventil%

____ Nitroglycerin ____ Prozac^&<*>

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 5

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

____ Nizatidine& ____ Quinaglute>

____ Norpramin^&<*> ____ Quinidex>

____ Nortriptyline^&<*> ____ Quinidine>

____ NSAIDS (Non Steroid Anti Inflammatory)** ____ Ranitidine&

____ Nylidrin *#%^&< ____ Restoril&<>

____ Ritalin%?* ____ Tofranil^&<*>

____ Secobarbital&<#>^ ____ Tolazmide&

____ Seconal&<#>^ ____ Tolbutamide&

____ Selegeline* ____ Tolinase &

____ Seroquil>**# ____ Tranxene &<>

____ Sinequan^&<*> ____ Trental~

____ Sinemet@&> ____ Triamterene*@#$

____ Slophyllin% ____ Triazolam&<>

____ Sodium Warfarin#@ ____ Trifluoperazine*^+

____ Stelazine*^+ ____ Trihexphenidyl*>

____ Symmetrel@&> ____ Valium&<>

____ Synthroid/Levoxyl$? ____ Valproic Acid>#@&

____ Temazepam&<> ____ Tagamet&

____ Terbutaline% ____ Ventolin%

____ Theo-24% ____ Tegretol>#@&

____ Theo-Dur% ____ Verapamil!

____ Theophylline% ____ Verslan!

____ Thioridazine*^+ ____ Xanax&<>

____ Thorazine*^+ ____ Zantac&

____ Zoloft?%

 Appetite Stimulants:
o Eldertonic Elixer
o Periactin
o Megace

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 6

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

o Marinol

Lab Values
 White Blood Count (WBC) ~

___High ( Increased could be infection)

____Low (Decreased could get infection)

____Normal

 Monocytes~

____High (Increased=bacterial infection)

____Low

____ Normal

 Red Blood Cell Count (RBC)~

____ High (Increased= dehydration, severe diarrhea)

___ Low

____ Normal

 Hemoglobin (HGB)~

____High( Increased=dehydration)

____ Low

____ Normal

 Hematocrit (HCT)~

____High (Increased=dehydration)

____Low (Decreased= excessive fluids, overhydration, malnutrition)

____ Normal

 Blood Urea Nitrogen (BUN)~

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 7

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

____High (Increased=dehydration, GI bleed)

___ Low (Decreased=low protein, overhydration)

____ Normal

 Creatinine~

____High (Increased=starvation)

____ Low (Decreased very rare)

____ Normal

 Albumine~

____High (Increased=dehydration)

____Low (Decreased= malnutrition, overhydration)

___ Normal

 Potassium(K)~

____High (Increased=dehydration)

____ Low (Decreased= malnutrition

____ Normal

 Sodium (NA)~

____High (Increased=dehydration or inadequate fluid intake)

____ Low (Decreased= starvation, overhydration)

____ Normal

 Chloride~

____High( Increased dehydration)

____ Low (Decreased=severe vomiting/diarrhea, pneumonia)

____ Normal

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 8

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Dehydration Indicators
 Dry mucous membranes Yes ____ No_____

 Loss of skin turgor Yes ____ No_____

 Intense thirst Yes ____ No_____

 Flushed skin Yes ____ No_____

 Oliguria (decreased urine in relation Yes ____ No_____

to fluid intake)

 Possible increased temp Yes ____ No_____

 Dark, clear yellow urine output Yes ____ No_____

Pharyngeal Reflexes
 Apneic reflex Present _____ Absent_______

 Palatal trigger reflex Present _____ Absent_______

 Glottal effort closure reflex Present _____ Absent_______

 Laryngeal elevation reflex Present _____ Absent_______

 Aryepiglottic/laryngeal ventricle Present _____ Absent_______

reflex

 Tongue base retraction reflex Present _____ Absent_______

 Peristalsis reflex Present _____ Absent_______

 Cricopharyngeal/esophageal reflex Present _____ Absent_______

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 9

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Cranial Nerves Asseessment

CN V Trigeminal (Motor)

Open mouth ____ WNL ____ Deviation to left ____Deviation to right

(Dev to r indicates r lateral pterygoid, dev to l indicates l lateral pterygoid)

Open mouth with resistance ____WNL ____weakness

(weakness indicates decreased pterygoids)

Move jaw laterally ____WNL ____L only ____R only

(inability to L indicates R pterygoid paralysis, inability to R indicates L pterygoid

paralysis, decreased range indicates R/L paralysis)

Palpate master muscle ____WNL ____atrophy ____weakness

Clench teeth ____WNL ____weak L side ____weak R side

(atrophy weakness=LMN lesion, weak on right with teeth

clenched=weakness/atrophy of R masseter muscle, weak on left with teeth
clenched=weakness/atrophy of L masseter muscle)

Say /pu pu pu/ (15-20x in 3 five second trials) ____WNL ____deviation

CN V Trigeminal (Sensory)

Bilateral sensation on the forehead using tissue or cotton tipped applicator ____WNL
____Decreased right side ____ decreased left side

(Loss of sensation suggests damage to ophthalmic branch of trigeminal nerve)

Bilateral sensation of the cheeks using tissue or cotton tipped applicator ____WNL
____decreased right side ____ decreased left side

(loss of sensation suggests damage to the maxillary branch the trigeminal nerve)

Bilateral sensation of the jaw using tissue or cotton tipped applicator ____WNL
____decreased right side ____ decreased left side

(loss of sensation suggests damage to the sensory component of the mandibular

branch the trigeminal nerve)

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 10

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

CN VII Facial

Survey face ____WNL ____eye droop ____ tremors, contortions, tics ____lip corner
droop ____drooling ____assymetry ____mask-like face

(Above suggests ipsilateral lesion. Mask-like indicates bilateral lesion)

CN VII Facial (Motor)

Wrinkle forehead or look up at ceiling without moving head ____WNL ____ right side
deviation ____left side deviation

(R/L side paralysis indicates damage to frontalis muscle)

Close eyes as tightly as possible ____WNL ____ right side deviation ____left side
deviation

(inability to R/L indicates R/L orbicularis occuli muscle paralysis)

Pucker lips ____WNL ____droop to right ____ droop to left

(drooping to R/L indicates R/L orbicularis oris muscle)

Smile, pull back corners of lips strongly ____WNL ____deviation to right side
____deviation to left side

(Paralysis to R/L suggests damage to R/L buccinator muscle)

Show teeth and pull down hard with corners of the mouth ____WNL ____right side
deviation ____left side deviation

(Weakness to R/L side suggests damage to R/L platysma muscle)

Say /pu pu pu/ (15-20x in 3 five second trials) with bite block in place____WNL
____deviation

(inability suggests damage to facial nerve)

Repeat without bite block ____same as above ____better ____worse

(same indicates no damage, better indicates CNV damage, worse indicates CN VII
damage)

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 11

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

CN VII Facial (Sensory)

Test taste for sweet, sour, salty on anterior 2/3 of tongue ____WNL ____absent sweet
____absent salty ____absent sour

(inability to taste indicates damage to sensory pathway of CN VII)

Test stapedial reflex with impedance testing ____WNL ____Deviation

(No reflex indicates damage to sensory pathway of CN VII)

CN IX and X Glossopharyngeal and Vagus

Observe soft palate at rest ____WNL ____lower on right arch ____ lower on left arch

(R/L deviation indicates R/L paralysis)

CN IX and X Glossopharyngeal and Vagus (Motor)

Have pt. say ah and examine soft palate ____WNL ____ no elevation R ____no elevation L
____deviation of uvula to R ____deviation of uvula to L

(No elevation on R/L indicates R/L paralysis. Deviation of uvula to R/L side
indicates paralysis on opposite side)

Have pt. blow tissue (bubbles or cotton) ____WNL ____nasal emission

(nasal emission indicates damage to CN IX and/or CN X)

Have pt. produce velars, sibilants and plosives (words and sentences) ____WNL ____nasal
emission

(nasal emission indicates damage to CN IX and/or CN X)

CN IX and X Glossopharyngeal and Vagus (Sensory)

Test taste of salty, sweet, sour to posterior 1/3 of tongue ____WNL ____ absent sweet
____absent salty ____absent sour

(inability to taste indicates damage to sensory pathway of CN IX)

CN X Vagus Laryngeal Function Test

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 12

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Phonate and prolong “ahhh” ____Less than 20 seconds in 3 trials ____ 20 or more seconds
in 3 trials

(hoarse/breathy vocal quality may suggest vocal cord paralysis d/t CN X damage)

Cough ____WNL ____hoarse ____breathy

(hoarse/breathy cough may suggest damage to both the superior and recurrent
laryngeal nerves)

Match several pitches ____WNL ____monopitch

(monopitch may suggest damage to recurrent laryngeal branch of CN X)

CN XI Spinal Accessory (Motor)

Maintain turned head position against resistance ____WNL ____weakness to L

____weakness to R

(Inability to R/L indicates opposite side sternocleidomastoid damage)

Push head forward against resistance ____WNL ____ unable

(inability suggests damage to sternocleidomastoid)

Shrug shoulders ____WNL ____ unable

(inability suggests damage to trapezius)

CN XII Hypoglossal (Motor)

Examine tongue at rest ____WNL ____atrophy R ____atrophy L ____fasciculations

____median raphe concave R ____median raphe concave L

(atrophy or fasciculations indicate damage, concave indicates paralysis)

Protrude tongue ____ WNL ____deviation R ____deviation L ____unable to protrude

past lips

(Deviation to R/L indicates R/L genioglossus paralysis/ipsilaterial LMN lesion.

Inability to protrude past lips suggests bilateral lesion)

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 13

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Open mouth while SLP has finger on mandible ____WNL ____unable to draw tongue base
up or back ____unable to retract and depress

(Inability for tongue back/up suggests styloglossus damage. Inability for

retract/depress suggests hypoglossus damage.)

Move tongue side to side ____WNL ____inability to move R ____ inability to move L

(inability to R/L indicates R/L lesion)

Push tongue depressor against tongue while pt. offers resistance to assess protrusion and
lateralization ____WNL ____weakness

(weakness suggests contralateral paralysis d/t UMN lesion and/or ipsilateral

paralysis d/t LMN lesion)

Manipulate tongue with tongue depressor through range of lateralization and elevation.
____WNL

____decreased tone (flaccidity) ____ increased tone (spasticity)

(Flaccidity suggests LMN lesion, Spasticity suggests UMN lesion)

Say /ta ta ta/ and /ka ka ka/ (15-20 productions in 3 5 second trials ____WNL
____uneven rate ____sound substitutions/distortions

(abnormal suggests damage to CN XII)

Repeat with bite blocks block ____same as above ____better ____worse

(same indicates no damage, better indicates CNV damage, worse indicates CN XII
damage)

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 14

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Indicators of Dysphagia (Patient Complaints)

Pain or burning sensation Present_____ Absent______

Early satiety Present_____ Absent______

Coughing during or right after eating or drinking Present_____ Absent______

Wet or gurgly sounding voice during or after eating or Present_____ Absent______

drinking.

Extra effort or time needed to chew or swallow Present_____ Absent______

Food or liquid leaking from the mouth or getting Present_____ Absent______

stuck in the mouth.

Recurring pneumonia or chest congestion after eating Present_____ Absent______

Weight loss or dehydration from not being able to eat Present_____ Absent______
enough.

Drooling Present_____ Absent______

Pocketing food Present_____ Absent______

Reflux/backflow (coughing at night, bad taste in mouth Present_____ Absent______

shortly after eating and burning in chest/pharynx)

Difficulty with bolus management Present_____ Absent______

Difficulty with chewing food Present_____ Absent______

Hx increased respiratory infections or pneumonia Present_____ Absent______

(watch left lower lobe)

Complaint of food sticking in throat Present_____ Absent______

Spiking high grade temperature or constantly Present_____ Absent______

running a low grade temperature.

Increased respirations with oral intake Present_____ Absent______

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 15

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Throat clearing during meals Present_____ Absent______

Pain during swallow Present_____ Absent______

Leaking food through nose while eating Present_____ Absent______

Repetitive swallows Present_____ Absent______

Tongue thrust Present_____ Absent______

Slurred speech Present_____ Absent______

Mealtime resistance Present_____ Absent______

Taking longer than 2-10 seconds to swallow Present_____ Absent______

Weakness, poor motivation Present_____ Absent______

Poor chewing ability which may lead to choking on food Present_____ Absent______

Facial grimaces or reddening of the face Present_____ Absent______

Impulsive eating behaviors Present_____ Absent______

Hoarse or recurrent sore throat. Present_____ Absent______

Necessity to “wash down” foods Present_____ Absent______

Increased hiccupping Present_____ Absent______

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 16

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Three Ounce Water Test

 Debra M. Suiter and Steven B. Leder (2008)
 Individuals are required to drink 3 oz of water without interruption
o Those who stop, cough, choke or show a wet-hoarse vocal quality
during the test or for 1 min after are considered to have fail.
 Leder performed FEES on patients with passing criteria of 6 boluses, 5 ml
each (3 puree and 3 thin liquid) after FEES, pt. given 3 oz water test.
o 98% who passed the water test did not aspirate on FEES.
o However failure of 3 oz water test does not mean p.o. diet is unsafe.
70.6% who failed could tolerate some type of diet and more than ½
were able to tolerate thin.
o If fail 3 oz water, move to instrumental assessment.
 Only 1.5% of patients who passed water test exhibited trace aspiration of
FEES.
 Leder feels silent aspiration is only with small volumes.
 Cathy Lazarus-MBS
o Administered 3 oz thin barium.
o 40 patients, 10 aspirated, of the 10, 7 were silent aspirators, of the
10, no aspiration with cup sips.

3 Ounce Water Test: Pass ____ Fail _____

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 17

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Bedside Swallow Assessment

Oral Mech Exam (If trached, remember to deflate cuff!!!)
___Passy Muir Valve
Oral Phase:

Lips:

Lip opening _________________________

Lip closure__________________________

Drooling ___________________________

Deviation/Droop_____________________

Labial Ganiometer ________

/i/ /u/_____________________________

/pupupu/____________________________

Secretions:

Able to control______________________

Teeth:

Dentures__________________________

Natural____________________________

Condition___________________________

Tongue:

Protrusion__________________________

Retraction__________________________

Elevation:___________________________

Depression:_________________________

Lateralization:_______________________

Lingual groove:_______________________

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 18

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Deviations/Abnormalities_______________

/tututu/____________________________
/kukuku/___________________________

Jaw:

Rotary chewing motion__________________

Able to maintain closure_________________

Gag Reflex:

Present Absent

Velar function:

Say /ahh/ Symmetrical_____ Assymetrical_______

Palatal Reflex:

Touch a cold laryngeal mirror to the juncture of the hard and soft
palate, soft palate should move up and back, but pharyngeal wall should
not move or use a needleless syringe to squirt water against the
palate.

____________________________________________________

Pharyngeal Phase:

Swallow reflex? Yes _____ No______

Palpation of Hyoid Elevation:____________________________________

Palpation of Hyoid Protraction:__________________________________

Palpation of Thyrohyoid Approximation____________________________

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 19

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

(Suggestions for food)

¼ cup pureed fruit
¼ cup ground meat
¼ cup regular meat
¼ cup mixed vegetables
¼ cup rice or noodles
1 slice white bread
1 pineapple ring
1 sugar cookie
1 c. cheerios
1 c. milk
1 c. grape juice
¼ c food thickener
Margarine
_________________
_________________
_________________
_________________
_________________

O2 sats before testing:________

Temp Before Testing:______

Liquids

Thin Nectar Honey

___Ant.Spillage ___Ant.Spillage ___Ant.Spillage

___Oral Phase Time ___Oral Phase Time ___Oral Phase Time

___Decreased Lar.Ele. ___Decreased Lar.Ele. ___Decreased Lar.Ele.

___Coughing ___Coughing ___Coughing

___Wet Vocal Quality ___Wet Vocal Quality ___Wet Vocal Quality

___Other _______ ___Other _______ ___Other _______

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 20

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Pureed Soft Solid

___Anterior Spillage ___Anterior Spillage ___Anterior Spillage

___Bolus Formation Diff. ___Bolus Formation Diff. ___Bolus Formation Diff.

___Abnormal Mastication ___Abnormal Mastication ___Abnormal Mastication

___Del Oral Phase ___Del Oral Phase ___Del Oral Phase

___Del Swallow Initiation ___Del Swallow Initiation ___Del Swallow Initiation

___Decreased Lar. Elevation ___Decreased Lar. Elevation ___Decreased Lar. Elevation

___Coughing ___Coughing ___Coughing

___Wet Vocal Quality ___Wet Vocal Quality ___Wet Vocal Quality

___Sensation Globus ___Sensation Globus ___Sensation Globus

___Other _________ ___Other _________ ___Other _________

O2 sats during testing:________

Notes:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

O2 sats after testing:_________

Temp After Testing:________

%age of intake____________

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 21

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Functional Severity Levels for Oral Intake

1. Profound
 All nourishment via alternative feeding method
 Pre-feeding stimulation only
 No trial oral intake
2. Severe
 All nourishment via alternative feeding method
 Nothing by mouth
 Trial oral intake by speech language pathologist
3. Moderately Severe
 Alternative feeding method as primary source of nourishment
 Limited, inconsistent success with oral intake
 Patient requires constant supervision
 Some team involvement, but only speech language pathologist
introduces new items or techniques
4. Moderate
 Alternative feeding may be withdrawn on a trial basis
 Fairly reliable oral feeding with prescribed diet of specific
items
 Patient requires close supervision
 Nursing staff most involved, following instructions of slp
 SLP working on addition of new item to diet
5. Mild to Moderate
 Farily reliable oral feeding with defined level of food
consistency
 Patient may have difficulty with clear liquids or solids
 Patient requires supervision, for which nursing staff take
primary responsibility
6. Mild
 Patient receives diet with some food restrictions
 Patient may requires some special techniques or procedures to
achieve successful oral intake

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 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

 Patient does not require close supervision

7. Minimal
 Patient receives a regular diet with no restrictions
 No supervision required
 Occasional episodes of coughing with liquids or solids
8. Normal
 Independent oral intake of all consistencies of food
 Safe and efficient swallowing competency

Source: Cherney LR, Cantieri CA, Pannell II: Clinical Evaluation of Dysphagia.
Rockville, MD, Aspen Publishers, 1986.

Functional Oral Intake Scale (FOIS)

Crary MA, Cranaby Mann GD, Groher ME

Tube Dependent (Levels 1-3)

1. No oral intake
2. Tube dependent with minimal/inconsistent oral intake
3. Tube supplements with consistent oral intake

Total Oral Intake (Levels 4-7)

4. Total oral intake of a single consistency.

5. Total oral intake of multiple consistencies requiring special preparation.
6. Total oral intake with no special preparation, but must avoid specific
foods or liquid items.
7. Total oral intake with no restrictions.

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 23

 Bedside Swallow Evaluation…Dukes Memorial Hospital Speech Language Pathology Department

Sources

Carl, L., & Johnson, P. (2005). Drugs and dysphagia: How medications can affect
eating and swallowing. Austin, TX: Pro-Ed.

DPNS Manual. Available through the Speech Team Inc. Author: Karlene
Stefanokos.

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders. Austin,

TX: Pro-Ed.

Schott DM, Kaiser K, Yacono CL, Bray-Hooker A. Bolus Manipulation Task to

Measure Efficiency. (2008). Vol. 18, Issue 41, Page 5, Advance Magazine.

Suiter, DM, Leder, SB. 3 Ounces is All You Need. Perspectives on Swallowing and
Swallowing Disorders (Dysphagia) 2009 18: 111-116.

The Source for Dysphagia. LinguiSystems. Author: Nancy Swigert.

Wijting, Yorick. VitalStim Manual. (2003). www.vitalstim.com

www.asha.org

Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 24