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___ 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

Feeding tube yes___ no___

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Medications Affecting Swallowing
*=Dry Mouth @=Nausea #=Lethargy $=Dehydration %=Loss of Appetite ? =Weight Loss **=Dysphagia ^=Trouble Breathing &=Confusion <=Weakness >=Speech Difficulties ~=Laryngitis/sore throat +=Tongue Pumping !=Decreased Peristalsis in the Esoph/Larynx

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Adrenaline% Akineton*> Albuterol % Aldomet^*@ Alprazolam&<> Aluminum Salts (Antacid) >**# Amantadine@&> Amitriptyline^&<*> Antidepressants Antipsychotics Apresoline*#%^&< Aricept?% Arlidin*#%^&< Artane*> Ativan&<> Atromid-S# Atropine*> Axid& Belladonna*> Benzocaine/Phenol/Benzyl Alcoho>**# Benztropine*>

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Calan! Carbamazepine>#@& Carbidopa-Levodopa@&> Cardizem~ Catapres*#%^&< Cerespan*#%^&< Chlorazepate&<> Chlordiazepoxide&<> Chlorpromazine*^+ Chlorpropamide& Chlorthalidone*@#$ Cimetidine& Clofibrate# Clonazepam&<> Clonidine*#%^&< Codeine>**# Compazine*^+ Corgard*#%^&< CorticoSteroids** Coumadin #@ Coyentin*>

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Beta Blockers Biperiden*> Brethine% Butabarbital&<#>^ Butisol&<#>^ Depakene>#@& Depekote>#@& Dexedrine%?* Dextromethorphan>**# Diabeta& Diabinese& Diazepam&<> Digitoxin@& Digoxin@& Dilantin>#@& Diltiazem~ Diphenhydramine>**# Dipyridamole~ Divalproex Sodium>#@& Doxepin^&<*> Dyazide*@#$ Effexor? Elavil^&<*> Eldepryl* Elixophyllin % Epinepherine Equanil> Ethotoin >#@&

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Crystodigin@& Dalmane&<> D-Amphetamine%?* Deltason** Demerol* Folic Acid Deficiency>**# Fosomax ** Furosemide*@#$ Gemfibrozil# Glipizide & Glucotrol & Glyburide & Halcion&<> Haldol*^+ Haloperidol*^+ Heparin#@ Hydralazine*#%^&< Hydrochlorothiazide*@#$ Hydrodiuril*@#$ Hygroton *@#$ Imipramine^&<*> Inderal*#%^&< Iron** Isoproterenal% Isoptin! Isuprel% Klonopin&<> Lanoxin@&

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Famotidine& Flexeril* Fluoxetine^&<*> Fluphenazine*^+ Flurazepam&<> Lopid# Lopressor*#%^&< Lorazepam&<> Lovastatin# Macrobid** Magnesium Salts (Antacid) >**# Mellaril*^+ Mephenytoin>#@& Meprobamate> Mesantoin Methyldopa^*@ Methylphenidate%?* Metoprolol*#%^&< Mevacor# Mexiletine> Mexitil> Micronase& Miltown> Minipres*#%^&< Mysoline>#@& Nadolol*#%^&< Nembutal&<#>^ Nitroglycerin

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Larodopa@&> Lasix*@#$ Levadopa (L-Dopa) @&> Librium&<> Lomotil? Orinase& Papaverine*#%^&< Pavabid*#%^&< Peganone >#@& Pentoxifylline~ Pepcid& Persantine~ Phenytoin>#@& Pilacor XR! Potassium** Powdered Opium Paregoric/Morphine>**# Prazocin*#%^&< Primidone>#@& Procainamide> Procan SR> Procardia ~ Prochlorperazine*^+ Prolixin*^+ Pronestyl > Propranolol*#%^&< Protonix $ Proventil% Prozac^&<*>

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Nizatidine& Norpramin^&<*> Nortriptyline^&<*> NSAIDS (Non Steroid Anti Inflammatory)** Nylidrin *#%^&< Ritalin%?* Secobarbital&<#>^ Seconal&<#>^ Selegeline* Seroquil>**# Sinequan^&<*> Sinemet@&> Slophyllin% Sodium Warfarin#@ Stelazine*^+ Symmetrel@&> Synthroid/Levoxyl$? Temazepam&<> Terbutaline% Theo-24% Theo-Dur% Theophylline% Thioridazine*^+ Thorazine*^+

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

Quinaglute> Quinidex> Quinidine> Ranitidine& Restoril&<> Tofranil^&<*> Tolazmide& Tolbutamide& Tolinase & Tranxene &<> Trental~ Triamterene*@#$ Triazolam&<> Trifluoperazine*^+ Trihexphenidyl*> Valium&<> Valproic Acid>#@& Tagamet& Ventolin% Tegretol>#@& Verapamil! Verslan! Xanax&<> Zantac& Zoloft?% 

o o o o

Appetite Stimulants: Eldertonic Elixer Periactin Megace Marinol

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

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)~ ____High (Increased=dehydration, GI bleed)

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

___ 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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Dehydration Indicators 
Dry mucous membranes  Loss of skin turgor  Intense thirst  Flushed skin  Oliguria (decreased urine in relation to fluid intake)  Possible increased temp  Dark, clear yellow urine output Yes ____ No_____ Yes ____ No_____ Yes ____ No_____ Yes ____ No_____ Yes ____ No_____ Yes ____ No_____ Yes ____ No_____

Pharyngeal Reflexes 
Apneic reflex  Palatal trigger reflex  Glottal effort closure reflex  Laryngeal elevation reflex  Aryepiglottic/laryngeal ventricle reflex  Tongue base retraction reflex  Peristalsis reflex  Cricopharyngeal/esophageal reflex
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160

Present _____ Absent_______ Present _____ Absent_______ Present _____ Absent_______ Present _____ Absent_______ Present _____ Absent_______

Present _____ Absent_______ Present _____ Absent_______ Present _____ Absent_______
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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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Phonate and prolong ´ahhhµ ____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

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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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Indicators of Dysphagia (Patient Complaints)
Pain or burning sensation Early satiety Coughing during or right after eating or drinking Wet or gurgly sounding voice during or after eating or drinking. Extra effort or time needed to chew or swallow Food or liquid leaking from the mouth or getting stuck in the mouth. Recurring pneumonia or chest congestion after eating Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______

Present_____ Absent______ Present_____ Absent______

Present_____ Absent______

Weight loss or dehydration from not being able to eat Present_____ Absent______ enough. Drooling Pocketing food Present_____ Absent______ 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 Difficulty with chewing food Hx increased respiratory infections or pneumonia (watch left lower lobe) Complaint of food sticking in throat Spiking high grade temperature or constantly running a low grade temperature. Increased respirations with oral intake Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Present_____ Absent______ Present_____ Absent______ Present_____ Absent______

Present_____ Absent______ Present_____ Absent______

Present_____ Absent______ Page 15

Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Throat clearing during meals Pain during swallow Leaking food through nose while eating Repetitive swallows Tongue thrust Slurred speech Mealtime resistance Taking longer than 2-10 seconds to swallow Weakness, poor motivation

Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______

Poor chewing ability which may lead to choking on food Present_____ Absent______ Facial grimaces or reddening of the face Impulsive eating behaviors Hoarse or recurrent sore throat. Necessity to ´wash downµ foods Increased hiccupping Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______ Present_____ Absent______

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

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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

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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

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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
___Ant.Spillage ___Oral Phase Time ___Decreased Lar.Ele. ___Coughing ___Wet Vocal Quality ___Other _______

Nectar
___Ant.Spillage ___Oral Phase Time ___Decreased Lar.Ele. ___Coughing ___Wet Vocal Quality ___Other _______

Honey
___Ant.Spillage ___Oral Phase Time ___Decreased Lar.Ele. ___Coughing ___Wet Vocal Quality ___Other _______

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Pureed
___Anterior Spillage ___Bolus Formation Diff. ___Abnormal Mastication ___Del Oral Phase ___Del Swallow Initiation

Soft
___Anterior Spillage ___Bolus Formation Diff. ___Abnormal Mastication ___Del Oral Phase ___Del Swallow Initiation

Solid
___Anterior Spillage ___Bolus Formation Diff. ___Abnormal Mastication ___Del Oral Phase ___Del Swallow Initiation ___Decreased Lar. Elevation ___Coughing ___Wet Vocal Quality ___Sensation Globus ___Other _________

___Decreased Lar. Elevation ___Decreased Lar. Elevation ___Coughing ___Wet Vocal Quality ___Sensation Globus ___Other _________ ___Coughing ___Wet Vocal Quality ___Sensation Globus ___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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department

Functional Severity Levels for Oral Intake
1. Profound    2. Severe        4. Moderate         6. Mild   Patient receives diet with some food restrictions Patient may requires some special techniques or procedures to achieve successful oral intake 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 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 All nourishment via alternative feeding method Nothing by mouth Trial oral intake by speech language pathologist 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 All nourishment via alternative feeding method Pre-feeding stimulation only No trial oral intake

3. Moderately Severe

5. Mild to Moderate

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

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Bedside Swallow Evaluation Dukes Memorial Hospital Speech Language Pathology Department 

7. Minimal    8. Normal  

Patient does not require close supervision Patient receives a regular diet with no restrictions No supervision required Occasional episodes of coughing with liquids or solids 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

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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 Knowledge and Skills Needed by Speech Language Pathologists Providing Services to Individuals with Swallowing and/or Feeding Disorders ² www.asha.org Preferred Practice Patterns for the Profession of Speech-Language Pathology ² www.asha.org Frequently Asked Questions (FAQ) on Swallowing Screening: Special Emphasis on Patients With Acute Stroke ² www.asha.org Special Interest Division 13; Swallowing and Swallowing Disorders

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

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