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Development and Utilization of Assessment and Intervention Checklist for Post-stroke Dysphagia

Eun Ha Lee1, Ja Yun Choi2
Korean Journal of Adult Nursing 2013;25(2):113-124.
Published online: April 18, 2013

1Chonnam National University Hospital, Gwangju

2College of Nursing, Chonnam National University․CRINS, Gwangju, Korea

Corresponding author: Choi, Ja Yun College of Nursing, Chonnam National University, 5 Hak-dong, Dong-gu, Gwangju 501-746, Korea. Tel: +82-62-220-4343, Fax: +82-62-225-3307, E-mail: choijy@chonnam.ac.kr
• Received: November 19, 2012   • Accepted: April 10, 2013

© 2013 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    Purposes of this study were to develop a reliable and valid checklist to assess and manage post-stroke dysphagia and to identify its utilization.
  • Methods
    The first step was to develop checklist through systematic literatures reviews, to test the content validity from 11 clinical experts, and to test the construct validity and the internal consistency from 97 patients with post-stroke dysphagia. The second step was to identify clinical use of the checklist from the same 97 patients.
  • Results
    A total of 18 items compromised the assessment checklist and 64 items for intervention checklist. Internal consistencies of assessment checklist and intervention checklist were .84 and .98, respectively. In both checklists, level of utilization of general appearance was the highest, while that of early signs of aspiration was the lowest. The utilization levels of two checklists were significantly higher among patients who were less than 60 years old, and had liquid diet, facial paralysis, and previous history of aspiration pneumonia.
  • Conclusion
    We found that the checklists were reliable and valid. Further study is needed to develop specific strategies to improve nurses' use of assessment and intervention checklists for post-stroke dysphagia.
  • Key Words: Deglutition disorders; Checklist; Risk assessment; Early intervention; Stroke
Table 1.
Pilot Test for Internal Reliability of Checklist for Post-stroke Dysphagia (N=20)
Variables Assessment Intervention
No of items Cronbach's ⍺ No of items Cronbach's ⍺
Total 19 .85 70 .98
  Awake and alert mental status 1 - 4 .23
  Sitting position for at least 15 minutes 1 - 5 .71
  Head control 1 - 3 .68
  Spontaneous cough 1 - 2 .92
  Lip open 1 - 6 .92
  Lip closing 1 - 3 .88
  Facial symmetry 1 - 4 .73
  Tongue movement 1 - 3 .88
  Jaw movement 1 - 6 .95
  Oral stasis 1 - 4 .90
  Swallow reflex 1 - 3 .92
  Wet voice 1 - 6 .95
  Shortness of breath after swallowing 1 - 3 .90
  Coughing during swallowing 1 - 4 .85
  Nasal regurgitation 1 - 2 .96
  Spontaneous cough after aspiration 1 - 2 .95
  Coughing after swallowing 1 - 5 .95
  Vomiting or regurgitation 1 - 3 .87
  Unpleasant breathing odor 1 - 2 .94

No=number.

Table 2.
Factor Analysis of Assessment Checklist for Post-stroke Dysphagia (N=97
No Components/Factor Factor loading Eigen value Explained variance (%) Accumulative variance (%)
  General appearance (3)   1.79 9.96 59.10
2   Sitting position for at least 15 minutes .84      
1   Awake and alert mental status .65
3   Head control .44
  Preparation of oropharynx (5)   2.48 13.80 38.42
10   Oral stasis .68      
11   Swallow reflex .64
18   Vomiting or regurgitation .56
6   Lip closing .53
5   Lip open .48
  Preparation of swallowing (2)   1.46 8.10 67.20
7   Facial symmetry .84      
14   Coughing during swallowing .58
  Swallowing condition (2)   1.93 10.72 49.14
4   Spontaneous cough .82      
8   Tongue movement .81
  Early symptoms of aspiration (6)   4.43 24.62 24.62
13   Shortness of breath after swallowing .86      
16   Spontaneous cough after aspiration .82
15   Nasal regurgitation .75
19   Unpleasant breathing odor .74
17   Coughing after swallowing .74
12   Wet voice .73

No=number.

Table 3.
Internal Consistency of Checklist for Post-stroke Dysphagia (N=97
Variables Assessment Intervention
No of items Cronbach's ⍺ No of items Cronbach's ⍺
Total 18 .84 64 .98
General appearance 3 .42 12 .78
  Sitting position for at least 15 minutes 1   5 .71
  Awake and alert mental status 1 4 .75
  Head control 1 3 .72
Preparation of oropharynx 5 .76 19 .96
  Oral stasis 1   4 .90
  Swallow reflex 1 3 .92
  Vomiting or regurgitation 1 3 .87
  Lip closing 1 3 .88
  Lip open 1 6 .92
Preparation of swallowing 2 .55 8 .84
  Facial symmetry 1   4 .73
  Coughing during swallowing 1 4 .85
Swallowing condition 2 .71 5 .92
  Spontaneous cough 1   2 .92
  Tongue movement 1 3 .89
Early symptoms of aspiration 6 .89 20 .99
  Shortness of breath after swallowing 1   3 .90
  Spontaneous cough after aspiration 1 2 .95
  Nasal regurgitation 1 2 .96
  Unpleasant breathing odor 1 2 .98
  Coughing after swallowing 1 5 .96
  Wet voice 1 6 .95

No=number.

Table 4.
Utilization of Checklists for Post-stroke Dysphagia (N=97)
Variables Assessment Intervention
M±SD M±SD
Total 0.42±0.21 0.36±0.31
General appearance 0.90±0.20 0.67±0.21
  Sitting position for at least 15 minutes 0.88±0.33 0.55±0.26
  Awake and alert mental status 0.98±0.14 0.80±0.21
  Head control 0.86±0.35 0.65±0.36
Preparation of oropharynx 0.37±0.34 0.33±0.37
  Oral stasis 0.41±0.49 0.39±0.43
  Swallow reflex 0.34±0.48 0.35±0.44
  Vomiting or regurgitation 0.28±0.45 0.29±0.40
  Lip closing 0.33±0.47 0.30±0.41
  Lip open 0.47±0.50 0.34±0.40
Preparation of swallowing 0.69±0.38 0.44±0.33
  Facial symmetry 0.74±0.44 0.35±0.35
  Coughing during swallowing 0.63±0.49 0.54±0.41
Swallowing 0.34±0.41 0.31±0.40
  Spontaneous cough 0.43±0.50 0.37±0.47
  Tongue movement 0.25±0.43 0.25±0.39
Early symptoms of aspiration 0.16±0.29 0.22±0.37
  Shortness of breath after swallowing 0.14±0.35 0.19±0.36
  Spontaneous cough after aspiration 0.12±0.33 0.22±0.41
  Nasal regurgitation 0.10±0.31 0.24±0.42
  Unpleasant breathing odor 0.12±0.33 0.22±0.40
  Coughing after swallowing 0.21±0.41 0.22±0.37
  Wet voice 0.24±0.43 0.25±0.39
Table 5.
Utilization of Two Checklists for Post-stroke Dysphagia according to General Characteristics (N=97)
Characteristics Categories n (%) Assessment Intervention
M±SD t or F p M±SD t or F p
Age (year) ≤59a 22 (22.7) 0.54±0.28 5.62 .005 0.47±0.33 1.65 .199
60~69b 28 (28.8) 0.40±0.21   a＞c 0.35±0.29    
≥70c 47 (48.5) 0.36±0.16   0.32±0.30
Gender Male 58 (59.8) 0.41±0.21 0.14 .890 0.36±0.30 -0.06 .956
Female 39 (40.2) 0.41±0.22     0.37±0.32    
Diet Regular dieta 54 (55.7) 0.39±0.16 9.84 c ＜.001 0.33±0.26 3.11 .030
Soft dietb 15 (15.5) 0.32±0.11   c＞a, b, d 0.28±0.27    
Liquid dietc 11 (11.3) 0.70±0.28   0.61±0.33
Water feedingd 17 (17.5) 0.37±0.26   0.38±0.40
Stroke site Left cerebrum 47 (48.4) 0.40±0.23 1.05 .373 0.36±0.31 1.83 .148
Right cerebrum 12 (22.7) 0.44±0.21     0.41±0.33    
Brain stem 15 (15.5) 0.35±0.14 0.22±0.12
Other 13 (13.4) 0.48±0.23 0.47±0.35
Paralysis site Right 50 (51.5) 0.40±0.21 0.39 .764 0.38±0.32 0.61 .608
Left 29 (29.9) 0.45±0.22     0.38±0.31    
Limbs 7 (7.3) 0.41±0.30 0.29±0.30
None 11 (11.3) 0.38±0.20 0.26±0.23
Facial palsy Yes 77 (79.4) 0.43±0.23 2.97 .004 0.37±0.31 0.61 .546
No 20 (20.6) 0.32±0.12     0.33±0.30    
History of aspiration pneumonia Yes 7 (7.2) 0.80±0.35 3.12 .020 0.72±0.38 3.32 .001
No 90 (92.8) 0.38±0.17     0.34±0.28    
Previous CVA Yes 10 (10.3) 0.42±0.24 0.15 .881 0.26±0.20 -1.11 .272
No 87 (89.7) 0.41±0.21     0.38±0.31    
Type of CVA† Large artery atherosclerosis 28 (28.9) 0.47±0.26 1.67 .194 0.44±0.34 1.15 .323
Cardioembolism 44 (45.4) 0.37±0.18     0.34±0.31    
Small artery occlusion 23 (23.6) 0.42±0.23 0.33±0.27
Stroke severity‡ Mild 68 (70.1) 0.41±0.18 0.35 .708 0.35±0.27 0.40 .679
Moderate 20 (20.6) 0.44±0.30     0.40±0.37    
Severe 9 (9.3) 0.37±0.26 0.42±0.42

CVA=cardiovascular attack.

†Excluded 2 undetermined cases;

‡Stroke severity was three levels as mild, moderate and severe, and range scores for three levels were 0 to 5, 6 to 13, and 14 and more than 14 in National Institutes of Health Stroke Scale (NIHSS), respectively.

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      Development and Utilization of Assessment and Intervention Checklist for Post-stroke Dysphagia
      Korean J Adult Nurs. 2013;25(2):113-124.   Published online April 30, 2013
      DOI: https://doi.org/10.7475/kjan.2013.25.1.113
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      Development and Utilization of Assessment and Intervention Checklist for Post-stroke Dysphagia
      Korean J Adult Nurs. 2013;25(2):113-124.   Published online April 30, 2013
      DOI: https://doi.org/10.7475/kjan.2013.25.1.113
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      Development and Utilization of Assessment and Intervention Checklist for Post-stroke Dysphagia
      Development and Utilization of Assessment and Intervention Checklist for Post-stroke Dysphagia

      Pilot Test for Internal Reliability of Checklist for Post-stroke Dysphagia (N=20)

      Variables Assessment Intervention
      No of items Cronbach's ⍺ No of items Cronbach's ⍺
      Total 19 .85 70 .98
        Awake and alert mental status 1 - 4 .23
        Sitting position for at least 15 minutes 1 - 5 .71
        Head control 1 - 3 .68
        Spontaneous cough 1 - 2 .92
        Lip open 1 - 6 .92
        Lip closing 1 - 3 .88
        Facial symmetry 1 - 4 .73
        Tongue movement 1 - 3 .88
        Jaw movement 1 - 6 .95
        Oral stasis 1 - 4 .90
        Swallow reflex 1 - 3 .92
        Wet voice 1 - 6 .95
        Shortness of breath after swallowing 1 - 3 .90
        Coughing during swallowing 1 - 4 .85
        Nasal regurgitation 1 - 2 .96
        Spontaneous cough after aspiration 1 - 2 .95
        Coughing after swallowing 1 - 5 .95
        Vomiting or regurgitation 1 - 3 .87
        Unpleasant breathing odor 1 - 2 .94

      No=number.

      Factor Analysis of Assessment Checklist for Post-stroke Dysphagia (N=97

      No Components/Factor Factor loading Eigen value Explained variance (%) Accumulative variance (%)
        General appearance (3)   1.79 9.96 59.10
      2   Sitting position for at least 15 minutes .84      
      1   Awake and alert mental status .65
      3   Head control .44
        Preparation of oropharynx (5)   2.48 13.80 38.42
      10   Oral stasis .68      
      11   Swallow reflex .64
      18   Vomiting or regurgitation .56
      6   Lip closing .53
      5   Lip open .48
        Preparation of swallowing (2)   1.46 8.10 67.20
      7   Facial symmetry .84      
      14   Coughing during swallowing .58
        Swallowing condition (2)   1.93 10.72 49.14
      4   Spontaneous cough .82      
      8   Tongue movement .81
        Early symptoms of aspiration (6)   4.43 24.62 24.62
      13   Shortness of breath after swallowing .86      
      16   Spontaneous cough after aspiration .82
      15   Nasal regurgitation .75
      19   Unpleasant breathing odor .74
      17   Coughing after swallowing .74
      12   Wet voice .73

      No=number.

      Internal Consistency of Checklist for Post-stroke Dysphagia (N=97

      Variables Assessment Intervention
      No of items Cronbach's ⍺ No of items Cronbach's ⍺
      Total 18 .84 64 .98
      General appearance 3 .42 12 .78
        Sitting position for at least 15 minutes 1   5 .71
        Awake and alert mental status 1 4 .75
        Head control 1 3 .72
      Preparation of oropharynx 5 .76 19 .96
        Oral stasis 1   4 .90
        Swallow reflex 1 3 .92
        Vomiting or regurgitation 1 3 .87
        Lip closing 1 3 .88
        Lip open 1 6 .92
      Preparation of swallowing 2 .55 8 .84
        Facial symmetry 1   4 .73
        Coughing during swallowing 1 4 .85
      Swallowing condition 2 .71 5 .92
        Spontaneous cough 1   2 .92
        Tongue movement 1 3 .89
      Early symptoms of aspiration 6 .89 20 .99
        Shortness of breath after swallowing 1   3 .90
        Spontaneous cough after aspiration 1 2 .95
        Nasal regurgitation 1 2 .96
        Unpleasant breathing odor 1 2 .98
        Coughing after swallowing 1 5 .96
        Wet voice 1 6 .95

      No=number.

      Utilization of Checklists for Post-stroke Dysphagia (N=97)

      Variables Assessment Intervention
      M±SD M±SD
      Total 0.42±0.21 0.36±0.31
      General appearance 0.90±0.20 0.67±0.21
        Sitting position for at least 15 minutes 0.88±0.33 0.55±0.26
        Awake and alert mental status 0.98±0.14 0.80±0.21
        Head control 0.86±0.35 0.65±0.36
      Preparation of oropharynx 0.37±0.34 0.33±0.37
        Oral stasis 0.41±0.49 0.39±0.43
        Swallow reflex 0.34±0.48 0.35±0.44
        Vomiting or regurgitation 0.28±0.45 0.29±0.40
        Lip closing 0.33±0.47 0.30±0.41
        Lip open 0.47±0.50 0.34±0.40
      Preparation of swallowing 0.69±0.38 0.44±0.33
        Facial symmetry 0.74±0.44 0.35±0.35
        Coughing during swallowing 0.63±0.49 0.54±0.41
      Swallowing 0.34±0.41 0.31±0.40
        Spontaneous cough 0.43±0.50 0.37±0.47
        Tongue movement 0.25±0.43 0.25±0.39
      Early symptoms of aspiration 0.16±0.29 0.22±0.37
        Shortness of breath after swallowing 0.14±0.35 0.19±0.36
        Spontaneous cough after aspiration 0.12±0.33 0.22±0.41
        Nasal regurgitation 0.10±0.31 0.24±0.42
        Unpleasant breathing odor 0.12±0.33 0.22±0.40
        Coughing after swallowing 0.21±0.41 0.22±0.37
        Wet voice 0.24±0.43 0.25±0.39

      Utilization of Two Checklists for Post-stroke Dysphagia according to General Characteristics (N=97)

      Characteristics Categories n (%) Assessment Intervention
      M±SD t or F p M±SD t or F p
      Age (year) ≤59a 22 (22.7) 0.54±0.28 5.62 .005 0.47±0.33 1.65 .199
      60~69b 28 (28.8) 0.40±0.21   a＞c 0.35±0.29    
      ≥70c 47 (48.5) 0.36±0.16   0.32±0.30
      Gender Male 58 (59.8) 0.41±0.21 0.14 .890 0.36±0.30 -0.06 .956
      Female 39 (40.2) 0.41±0.22     0.37±0.32    
      Diet Regular dieta 54 (55.7) 0.39±0.16 9.84 c ＜.001 0.33±0.26 3.11 .030
      Soft dietb 15 (15.5) 0.32±0.11   c＞a, b, d 0.28±0.27    
      Liquid dietc 11 (11.3) 0.70±0.28   0.61±0.33
      Water feedingd 17 (17.5) 0.37±0.26   0.38±0.40
      Stroke site Left cerebrum 47 (48.4) 0.40±0.23 1.05 .373 0.36±0.31 1.83 .148
      Right cerebrum 12 (22.7) 0.44±0.21     0.41±0.33    
      Brain stem 15 (15.5) 0.35±0.14 0.22±0.12
      Other 13 (13.4) 0.48±0.23 0.47±0.35
      Paralysis site Right 50 (51.5) 0.40±0.21 0.39 .764 0.38±0.32 0.61 .608
      Left 29 (29.9) 0.45±0.22     0.38±0.31    
      Limbs 7 (7.3) 0.41±0.30 0.29±0.30
      None 11 (11.3) 0.38±0.20 0.26±0.23
      Facial palsy Yes 77 (79.4) 0.43±0.23 2.97 .004 0.37±0.31 0.61 .546
      No 20 (20.6) 0.32±0.12     0.33±0.30    
      History of aspiration pneumonia Yes 7 (7.2) 0.80±0.35 3.12 .020 0.72±0.38 3.32 .001
      No 90 (92.8) 0.38±0.17     0.34±0.28    
      Previous CVA Yes 10 (10.3) 0.42±0.24 0.15 .881 0.26±0.20 -1.11 .272
      No 87 (89.7) 0.41±0.21     0.38±0.31    
      Type of CVA† Large artery atherosclerosis 28 (28.9) 0.47±0.26 1.67 .194 0.44±0.34 1.15 .323
      Cardioembolism 44 (45.4) 0.37±0.18     0.34±0.31    
      Small artery occlusion 23 (23.6) 0.42±0.23 0.33±0.27
      Stroke severity‡ Mild 68 (70.1) 0.41±0.18 0.35 .708 0.35±0.27 0.40 .679
      Moderate 20 (20.6) 0.44±0.30     0.40±0.37    
      Severe 9 (9.3) 0.37±0.26 0.42±0.42

      CVA=cardiovascular attack.

      †Excluded 2 undetermined cases;

      ‡Stroke severity was three levels as mild, moderate and severe, and range scores for three levels were 0 to 5, 6 to 13, and 14 and more than 14 in National Institutes of Health Stroke Scale (NIHSS), respectively.
      Table 1. Pilot Test for Internal Reliability of Checklist for Post-stroke Dysphagia (N=20)

      No=number.

      Table 2. Factor Analysis of Assessment Checklist for Post-stroke Dysphagia (N=97

      No=number.

      Table 3. Internal Consistency of Checklist for Post-stroke Dysphagia (N=97

      No=number.

      Table 4. Utilization of Checklists for Post-stroke Dysphagia (N=97)

      Table 5. Utilization of Two Checklists for Post-stroke Dysphagia according to General Characteristics (N=97)

      CVA=cardiovascular attack.

      Excluded 2 undetermined cases;

      Stroke severity was three levels as mild, moderate and severe, and range scores for three levels were 0 to 5, 6 to 13, and 14 and more than 14 in National Institutes of Health Stroke Scale (NIHSS), respectively.

      Table 1.

      Table 2.

      Table 3.

      Table 4.

      Table 5.

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