dukes dysphagia eval
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8/7/2019 Dukes Dysphagia Eval
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 1
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:_______________________________
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 2
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:_________________________________________________________ ______________________________________________________________ ______________________________________________________________
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 3
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*>
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 4
____ 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@&
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 5
____ 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^&<*>
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 6
____ 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
o Marinol
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 7
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)
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 8
___ 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
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 9
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_______
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 10
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)
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 11
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 sidedeviation
(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)
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 12
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
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 13
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)
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 14
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)
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 15
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______
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 16
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 downµ foods Present_____ Absent______
Increased hiccupping Present_____ Absent______
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 17
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 ½were 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 _____
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 18
Bedside Swallow AssessmentOral Mech Exam (If trached, remember to deflate cuff!!! )___ Pa ssy Muir Val ve Oral Phase:
Lips:
Lip ope ning _________________________
Lip clo sure __________________________
Drool ing ___________________________
De viat io n/Droo p_____________________
Lab ial Ga niometer ________
/i/ /u/_____________________________
/pupupu/____________________________
Secretions:
Able to co ntrol ______________________
Teeth:
De nture s__________________________
Natural ____________________________
Co ndit io n___________________________
Tongue:
Protru sio n__________________________
Retract io n__________________________
Ele vat io n:___________________________
De pre ssio n:_________________________
Lateral izat io n:_______________________
Lingual groo ve :_______________________
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 19
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____________________________
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 20
(Suggestions for food )¼ cu p pureed fruit ¼ cu p ground me at ¼ cu p regu lar me at
¼ cu p mi xed veget ables ¼ cu p ri ce or nood les 1 s li ce white bre ad 1 pine apple ring 1 sug ar coo kie 1 c. cheerios 1 c. mi lk1 c. gr ape jui ce ¼ c food t hi ckener
Marg arine _________________ _________________ _________________ _________________ _________________
O2 s ats before testing :________
T e mp Before T esting :______ Liquids
Thin Nectar Honey
___Ant .Spi llage ___Ant .Spi llage ___Ant .Spi llage
___Or al Phase T i me ___Or al Phase T i me ___Or al Phase T i me
___De cre ased Lar .Ele . ___De cre ased Lar .Ele . ___De cre ased Lar .Ele .
___Coug hing ___Coug hing ___Coug hing
___Wet Vo cal Qu alit y ___Wet Vo cal Qu alit y ___Wet Vo cal Qu alit y
___Ot her _______ ___Ot her _______ ___Ot her _______
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 21
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____________
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 22
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 EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L. Wallace, MA, CCC-SLP 765-475-2160 Page 23
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
Sour ce: Cher ney LR, Cantier i CA, Pannell II: Clinical Evalu ation of Dysphagia.
Rockville, MD, Aspen Pub lisher s, 1986.
Functional Oral Intake Scale (FOIS)
C rary MA, C ranaby Mann GD, Groher ME
Tube De pen den t (Le ve ls 1-3)
1. No oral intake2. 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.
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Bedside Swallow EvaluationDukes Memorial Hospital Speech Language Pathology Department
Tiffani L Wallace MA CCC SLP 765 475 2160 Page 24
Sources
Carl, L., & Johnson, P. (2005). Drug s and dy sphagi a: How medic ati ons c an affect e ati ng and swallowi ng . Au sti n, TX: Pro-Ed .
DPNS Manu al. Avai lable t hroug h t he Speec h T e am Inc . Aut hor: Karle ne
Stef anokos.
Logem ann, J. A. (1998). Evalu ati on and t re atme nt of swallowi ng di sorde rs. Au sti n,
TX: Pro-Ed .
Sc hott DM, Kai se r K, Yac ono CL, Bray -Hooke r A. Bolu s Manipu lati on Task t o
Me asu re Efficie ncy . (2008). Vol. 18, Issue 41, Page 5, Ad vance Mag azi ne .
Suite r, DM, Lede r, SB. 3 Ou nce s i s All You Need . Pe rspecti ve s on Swallowi ng and Swallowi ng Di sorde rs (Dy sp hagi a) 2009 18: 111-116.
The Sou rce f or Dy sp hagi a. Li nguiSy stem s. Aut hor: Nancy Swige rt .
Wi jti ng , Yoric k. Vit alStim Manu al. (2003). www .vit alstim .c om
www .asha.org
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