The Cardiovascular
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Barnes-Jewish Hospital stroke dysphagia screen

Bedside screen for aspiration risk after acute stroke.

Barnes-Jewish Hospital stroke dysphagia screen
GCS <13 (unable to participate)
Facial, tongue or palatal asymmetry/weakness
Any sign on the 3-ounce water swallow test
Cough, throat-clearing or voice change during/after drinking, or inability to complete.
ResultPassed screen

Low aspiration risk; an oral diet may be started per clinical judgement.

When to use

  • Nurse-administered aspiration screen before oral intake in acute stroke.

Formula

Fail if GCS <13, or any facial/tongue/palatal asymmetry, or any sign on a 3-ounce water swallow test. Otherwise pass.

Pearls and pitfalls

  • Preliminary items are checked first; any positive stops the screen and the patient fails without the water test.

References

  1. Edmiaston J, Connor LT, Loehr L, Nassief A. Am J Crit Care. 2010;19(4):357-64.