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