Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Dysphagia

6.0 Nurses should maintain all clients with stroke NPO (including oral medications) until a swallowing screen is administered and interpreted, within 24 hours of the client being awake and alert.

6.1 Nurses in all practice settings who have the appropriate training should screen within 24 hours of the client becoming awake and alert for risk of dysphagia using a standardized tool (such as, Gugging Swallowing Screen, Standardized Bedside Swallowing Assessment [SSA] or Toronto Bedside Swallowing Screening Test [TOR-BSST©]). This screen should also be completed with any changes in neurological or medical condition, or in swallowing status. In situations where impairments are identified, clients should be kept NPO and referred to a trained healthcare professional for further assessment and management.