With the aging of the population and more intense focus on factors that increase hospital costs, nurses are playing a larger role in the identification and management of patients with dysphagia. A recent study found patients with dysphagia stay in the hospital 40 percent longer than those with intact swallowing, and they typically have poorer clinical outcomes (Altman, K.W., et al., 2010, Archives of Otolaryngology-Head & Neck Surgery)
Patricia Ratliff, MSN, RN, CNRN, education specialist for the neuroscience service line at Florida Hospital Orlando, explained the importance of immediate screening for dysphagia. "We know 50 percent of people with strokes have dysphagia and up to 30 percent are at risk for silent aspiration," she said. "We have a nursing swallow screen as part of our evidence-based Brain Attack Order Set. The nurse takes a spoon and applesauce or pudding into the room, gives the patient a tablespoon of the food, watches the mechanical swallowing process, and ensures the patient isn't pocketing food or aspirating."
At the University of Virginia Medical Center in Charlottesville, Heather Turner, BSN, RN, stroke program coordinator, and her colleagues have taken a proactive approach to dysphagia. The first step was the development of an RN Swallow Screen that compares patient status against a list of factors associated with dysphagia, as well as risk factors for dysphagia. These include a decreased level of consciousness, cognitive deficits, inability to sit upright, facial weakness or drooping, shortness of breath, slurred speech, weak or wet cough, hoarseness, a wet or gurgling sounding voice, and drooling. "The nurses who do these swallow screens receive training from the speech-language pathologists on our Stroke Quality Support Team," said Turner. "They assess the patient for any of those characteristics and stop the evaluation if they are present. Patients with any of those features are referred to a speech pathologist for a formal swallow evaluation."
If the patient doesn't have any of the characteristics, the nurse proceeds to do a 3-ounce water swallow screening. "The patient is given 90 mL of water in a cup and asked to swallow it without interruption," Turner explained. "If the patient coughs while swallowing or in the minute afterward, or if the nurse notices the patient has a wet or hoarse voice, the patient has failed part two of the RN Swallow Screen. The patient stays NPO until the speech pathologist does the evaluation and orders the appropriate diet."
Karen Moriarty-Poole, MSN, RN, PCCN, critical care clinical specialist and stroke coordinator at Washington Hospital Center, Washington, DC, described the education and quality improvement processes that surround dysphagia management. "We have on online educational module written by one of our speech-language pathologists," she explained. "After passing the online test, each nurse meets one-on-one with the speech language pathologist to demonstrate the proper procedure for doing a 3-ounce water swallow screen."
Moriarty-Poole and her speech colleagues observe RNs doing swallow screening on an ongoing basis to ensure inter-rater reliability. "Our RNs are getting the same results 90 percent of the time or better, which we're very pleased with," she said. "We're now thinking of expanding our swallow screens beyond the stroke population. We may want to look at doing them for patients who have been intubated for a short period of time, screening them after extubation and before we feed them or administer oral medications."
Sonia Sandhaus, MS, RN-BC, CRNP, director of the Hospital Elder Life Program (HELP) at Moses Taylor Hospital, Scranton, PA, introduced an educational poster about dysphagia identification and management at the annual nursing competency fair years ago. "An interdisciplinary team consisting of our hospital's speech pathologist, a university-based nurse researcher and myself came up with 10 pre-test questions to assess nurses' knowledge, and then we did a post-test at 3 months and again at 6 months," she said. "The educational intervention was effective in increasing their knowledge and they maintained that knowledge over time."
Dysphagia screening is now part of the nursing admission process for every patient at Moses Taylor Hospital, and Ratliff and her colleagues are currently conducting a pilot study at the suggestion of one of the speech-language pathologists. "We're placing a pulse oximeter on the patient's finger and watching the oxygen saturation as he swallows," she said. "If the O2 saturation drops more than 2 percent, that change identifies a patient at risk for silent aspiration."
Nursing Care Plan
Dysphagia management is integrated into the nursing care plan at Washington Hospital Center. Stroke patients who don't pass the swallow screen are evaluated by a speech-language pathologist, who then collaborates with a nutritionist to identify the right diet for the patient. Moriariy-Poole asks nursing staff to verify the patient receives the right diet. Thickened liquids or pureed foods, for example, may be better tolerated than thin liquids. "I've been teaching the nurses to observe the patient during the first meal, no matter what the swallow screening shows," she said. "We want to expand this idea to all patients as well."
Ratliff described other nursing interventions to improve safety for patients who don't pass the nursing swallow screen. "We immediately make the patient NPO, contact the physician for a speech-therapy evaluation and IV fluid orders, and explain the situation to the patient and family," she said. "We let them know the patient is at risk for aspiration, and that we're making these changes for the patient's safety until he can safely take nutrition by mouth."
Nursing judgment is crucial to avoid aspiration in high-risk patients. "If the nurse notices a gurgling voice, wet cough or other characteristics of dysphagia, she'll take the tray away and notify the speech pathologist," said Turner. "Likewise, if the nurse is feeding the patient and believes it's time to advance his diet, she can ask the speech pathologist to come back and re-evaluate him."
Sandy Keefe is a frequent contributor to ADVANCE.