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ALLINA PROFESSIONAL NURSING

Evidence-based Practice Protocol: Nursing Swallow Screen Protocol Effective October 1, 2010
Nursing Swallow Screen Protocol
Inclusion Population:
• All patients with signs and or symptoms of a stroke, including those with mild symptoms prior to their first oral intake
(including medications).
• Ongoing assessment is critical during the first several days post-stroke due to the potential that the patient’s
neurological status may change. Continue to monitor the patient’s oral intake and the potential development of signs of
aspiration. Reassess the patient’s ability to safely swallow if their neurological status deteriorates.
• The Nursing Swallow Screen Protocol may also be used to screen for impaired swallowing in high risk populations
other than stroke (e.g. degenerative neurologic disease, head and neck cancer/surgery).

Exclusion Population:
• Patients who have a known previous history of dysphagia, aspiration, or a brain stem stroke.
• Patients for whom the nurse has concern about the ability to protect his/her airway.

Personnel: RN

Objective: The Nurse will rapidly and accurately identify potential stroke patients at risk for aspiration using the Three (3)
Ounce Water Swallow Screen. This sensitive screening tool is used to identify patients at risk for clinically significant
aspiration who need referral for more definitive swallow evaluation.

NOTE: The 3 oz. water swallow screen is not a comprehensive dysphagia evaluation and does not replace a formal speech
therapy consult.

Step INSTRUCTIONS DETAILS
Step ASSESS IF THE SWALLOW SCREEN PROTOCOL IS If patient meets exclusion criteria in Step 1,
1: INDICATED: STOP and:
Assess if the swallow screen protocol is indicated by Keep the patient NPO and do not proceed
reviewing the inclusion and exclusion population noted with the swallow screen.
above.
Document “UTA” (unable to assess) in the
If the swallow screen protocol is not indicated, “Swallow Screen - 3 oz. water test” row in
follow the steps to the right. the swallow screen group on the flowsheet.

If the swallow screen is indicated, proceed to step 2. If not already addressed, contact the
provider for a formal dysphagia evaluation
and orders for strict NPO for all food, fluids
and medications (seek order for alternate
routes if indicated).
Step ORAL CARE
2:
If possible, swab the patient’s teeth, tongue and gums with
an antiseptic oral rinse prior to swallow screen.

Step ORAL ASSESSMENT If the patient exhibits impairment in any of the
3: Step 3 assessments, STOP and:
Assess for any impairment of the following:
Gag/swallow reflex Keep the patient NPO and do not proceed
Tongue/mouth movement with the swallow screen.
Control of secretions
Document “Impaired” in the “Pre Screen
o Inspect oral cavity for pooling of oral
Assessment” row and “UTA” (unable to
secretions (retained food is also a sign of
assess) in the “Swallow Screen - 3 oz. water
impaired swallow).
test” row in the swallow screen group of the
If patient exhibits impairment of any of the above flowsheet.
assessments, follow the steps to the right.
If not already addressed, contact the
If patient exhibits no impairments of any of the provider for a formal dysphagia evaluation
above assessments, proceed to Step 4. and orders for strict NPO for all food, fluids
and medications (seek order for alternate
routes if indicated).
May 6, 2010, 2010 Page 1 of 2
Document Owner: Stroke Core Measure System-Wide Team Posting Date 09/27/2010

Retrieved 05/29/09 from http://stroke.3 oz. 49: 1259. medications. water test” row in Observe for signs of aspiration (impaired swallowing) the swallow screen group of the flowsheet. Summers. Be Sitting in an upright position Document “Impaired” in the “Pre Screen Be able to follow simple commands Assessment” row and “UTA” (unable to Not display facial droop assess) in the “Swallow Screen . an order for a formal dysphagia evaluation. If patient exhibits impairment of any of the above assessments. Document “Intact” in the “Pre Screen Assessment” row and “Impaired” in the The patient should NOT use a straw “Swallow Screen . K. including sips and ice chips A continuous drink is drinking from the cup without interruption or sipping. proceed to Step 5. routes for medications. Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke patient.ALLINA PROFESSIONAL NURSING Evidence-based Practice Protocol: Nursing Swallow Screen Protocol Effective October 1. REFERENCES DePippo. Stroke published online May 28. Step DOCUMENTATION OF INTACT SWALLOWING 6: If the patient does NOT display signs of swallow impairment: Document “Intact” in the “Pre Screen Assessment” and “Swallow Screen . 2010. (1992). fluids and medications (seek order for alternate routes if indicated). Validation of the 3-oz Water Swallow Test for Aspiration following stroke. STOP and: Patients who undergo the swallow screening must: Keep the patient NPO and do not proceed Be Alert with the swallow screen. If not already addressed. including: Document findings of the psychomotor and Coughing during or for one minute after drink level of consciousness assessment as part of Wet or hoarse vocal quality after drink the usual neurologic assessment on the flowsheet. 2010 Step INSTRUCTIONS DETAILS Step PSYCHOMOTOR AND LEVEL OF CONSCIOUSNESS If the patient exhibits impairment in any of the 4: ASSESSMENT: Step 4 assessments. follow the steps to the right. If the patient does not exhibit impaired swallowing. (2009). Leonard.L. D.. contact the provider for a formal dysphagia evaluation and orders for strict NPO for all food. Step THREE OUNCE WATER SWALLOW TEST If the patient displays impaired swallowing: 5: Make or keep strict NPO for all Have the patient drink three ounces of water (90 ml or the amount in three medicine cups) in one continuous drink. Ounce Water Test. proceed to Step 6. food and fluids. the Three flowsheet. Document findings of the psychomotor and level of consciousness assessment as part of If patient exhibits no impairments of any of the the usual neurologic assessment on the above assessments. Implement oral meds and food/fluids as ordered.. inform of the results Repeated clearing of the throat of the swallow screen and obtain alternate.3 oz. 2010 Page 2 of 2 Document Owner: Stroke Core Measure System-Wide Team Posting Date 09/27/2010 .org May 6. et al. 2009. A. Anticipate the steps to the right.3 oz. Inability to control liquids or secretions in mouth Contact the physician. If the patient displays impaired swallowing follow non-oral. water test” rows in the swallow screen group of the flowsheet.ahajournals. Archives of Neurology. Document findings of the psychomotor and level of consciousness assessment as part of the usual neurologic assessment on the flowsheet. water Have understandable speech test” row in the swallow screen group of the flowsheet.