GUSS is an assessment technique to check?

Appeared in: SCTIMST Staff Nurse - 2016

Explanation

GUSS is an acronym for the Gugging Swallowing Screen.
It is a validated, multistep bedside screening tool used to identify the presence of dysphagia (difficulty swallowing) and the risk of aspiration.
The tool was specifically developed and is widely used for patients who have had a stroke, as they are at high risk for swallowing problems.
Dysphagia screening tools like GUSS are crucial for preventing complications such as aspiration pneumonia, malnutrition, and dehydration.

Option A: Skin integrity is not assessed by GUSS. GUSS is for swallowing.
Option C: Neurological status, specifically the level of consciousness, is not assessed by GUSS.
Option D: While GUSS is often used in stroke patients, it assesses a complication of stroke (dysphagia), not the overall severity of the stroke itself.

Clinical Relevance

Nursing practice connection: Use the key finding related to Use of standardized assessment tools in nursing to guide bedside assessment, documentation, and the next nursing action.
Early identification of dysphagia using a validated tool like GUSS is a critical nursing responsibility to prevent life-threatening aspiration pneumonia.
A positive dysphagia screen is a trigger for immediate nursing action, including making the patient NPO (nothing by mouth) and initiating a referral to a Speech-Language Pathologist (SLP).
What if? If a stroke patient is alert and has a strong cough but coughs after sipping water, the GUSS screen would still be positive. The nurse's action would be to stop the screening, keep the patient NPO, and report the finding, as even a single sign of aspiration risk requires intervention.

How to Approach the Question

First, identify the core of the question, which is to define the purpose of the 'GUSS' assessment.
This is a factual recall question. Your knowledge of common nursing assessment tools and acronyms is being tested.
Mentally try to expand the acronym 'GUSS' to 'Gugging Swallowing Screen'. The word 'Swallowing' is the key.
Evaluate the options based on this keyword. 'Dysphagia' is the medical term for difficulty swallowing, making it the direct match.
Eliminate the other options by recalling the correct tools for them: Braden Scale for skin, GCS for consciousness/neuro status, and NIHSS for stroke severity.

Concept Tested & Keywords

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 193-195

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 86-88

E6 Nursing Fundamentals Taylor p. 412-414

Practise the full SCTIMST Staff Nurse - 2016

Attempt every question from this paper in a timed mock, then review the full solution for each one.