Dysphagia screening tool for nurses. See full list on eatspeakthink.

Dysphagia screening tool for nurses We will discuss how a swallow screening tool for nursing is Jul 17, 2017 · Background and Purpose—Dysphagia is a common stroke symptom and leads to serious complications such as aspiration and pneumonia. Another bonus is Jul 10, 2020 · The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. 5 Sep 20, 2007 · Background and Purpose— Acute-onset dysphagia after stroke is frequently associated with an increased risk of aspiration pneumonia. It facilitates optimal nutritional support and can enhance overall patient health outcomes. 1. Dysphagia Dysphagia, or difficulty swallowing, can significantly impact quality of life and overall health. There’s strong evidence that early screening of at-risk patients decreases the incidence of pneumonia (Yang et al. Research has shown that implementing evidence-based clinical guidelines for dysphagia screening improves the management of dysphagia and ultimately improves patient outcomes. The Gugging Dec 12, 2008 · Background and Purpose— Dysphagia occurs in 55% of all acute stroke patients. A systematic review was undertaken to determine the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard. Dysphagia, 16 (1), pp. 2 ,4 The patient will benefit when a multidisciplinary team plans their care. The tool is suitable for a general acute and surgical inpatient population, in addition to stroke patients10. However, Jan 2, 2023 · Early recognition of dysphagia with bedside dysphagia screening can assist in preventing the complication of aspiration pneumonia. 97 and specificity of 0. This systematic review investigates the validity and reliability of screening tools that can be used by nurses to screen for dysphagia in patients with neurological disorders. The MR64B Dysphagia Screening Tool (Royal Brisbane Women's Hospital [RBWH]) is a quick and accurate nurse-administered tool for triaging dysphagia. RN assesses patient at first meal. 555-561. The two screening tools discussed are the Toronto Bedside Swallowing Screening Test and the 90-cc Water Swallow Test. . We compared NDST with gold-standard speech and language therapist The tools identified are different from each other, making their comparison impracticable. Methods—We trained the Aug 1, 2025 · EAT-10 stands for eating assessment tool-10, a validated dysphagia screening tool used to assess swallowing difficulties and their impact on a patient’s quality of life. 92 and 0. Although the Joint Commission no longer requires dysphagia screening rates be reported for stroke center certification, the Joint Commission encourages consistent monitoring for dys-phagia and use of evidence-based DSPs. Methods—The Medline, Embase, and Cochrane databases were Early detection of dysphagia is critical in stroke as it improves health care outcomes. A screen can also indicate if a patient needs support from a Jul 27, 2018 · The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and Validation of a Dysphagia Screening Tool for Patients With Stroke. Is there a Tongue Asymmetry/Weakness? Jun 1, 2016 · This review evaluated the validity and reliability of measurement tools for screening dysphagia in patients with neurological disorders to identify a feasible tool that can be used by nurses. The tool is a one-page, double-sided form. Dysphagia. If any of the following questions are answered with a YES, stop and refer to Speech Therapy for a comprehensive assessment. A diagnostic evaluation study was performed in North-East of England care homes. The specific aim of this study was to assess whether early detection for dysphagia with bedside screening administered to adult patients with stroke by a nondysphagia Nurses, when provided with education and the authority to implement NPO status under nurse-driven bedside swallow screening protocols, can significantly reduce the impact of aspiration in hospitalized patients. ” Mar 31, 2020 · Editor’s Note: This text is a transcript of the course, Back to Basics: Swallow Screening: How, when, and who, presented by Angela Mansolillo, MA, CCC-SLP, BCS-S. The sensitivity and specificity of the tool means that there are neither large numbers of inappropriate referrals to speech pathology or Feb 11, 2024 · Implementation of nurse-led dysphagia screening in intensive care may facilitate safe oral intake in patients and identify patients in need of specialised assessment. The use of formal dysphagia screening protocols has been associated with better dysphagia screening adherence and a lower pneumonia risk. The aim of this review was to map existing screening tools to assess and Background and Purpose—Dysphagia occurs in 55% of all acute stroke patients. Hospitals using mandatory and formal dysphagia screen-ing tools have lower rates of aspiration pneumonia than those who do not. Aug 11, 2012 · Perry L. Conclusion: Due to psychometric proprieties and dietary recommendations adjusted to dysphagia severity, of all available tools, GUSS is a suitable screening tool for nurses in clinical practice. Screening instruments in dysphagia are fairly heterogeneous and have been developed for different audiences with the main objective of identifying patients with swallowing disorders. In this sense, evaluation and assessment are important interventions for health professionals, although current tools and instruments are multiple and are dispersed in the literature. See full list on eatspeakthink. Nursing Dysphagia Screen *Adapted from the Yale, Massey Bedside Swallowing Screen and the Scottish Intercollegiate Guidelines Network Screen. The toronto bedside swallowing screening test (TOR-BSST) development and validation of a dysphagia screening tool for patients with stroke. Introduction A thorough dysphagia assessment can help with the early identification, management, prevention and mitigation of complications related to swallowing difficulties. The purpose of this umbrella review is to locate the most valid, reliable, and usable bedside screening tools that allow nurses to identify dysphagia in institutionalized patients. Electronic databases were searched for studies from 1992 to 2015 related to dysphagia screening measurements. In many hospitals, dysphagia screening is performed by speech–language therapists who are often not available on weekends/holidays, which results in delayed dysphagia assessment. Dysphagia can significantly increase the risk of complications, especially aspiration pneumonia, leading to increased risk of This review evaluated the validity and reliability of measurement tools for screening dysphagia in patients with neurological disorders to identify a feasible tool that can be used by nurses. The RN will complete the Nursing Dysphagia screen on all patients who have an order for Speech Therapy Bedside Assessment regardless of patient diagnosis Jan 24, 2025 · Consensus on the Screening, Assessment, and Nutritional Management of DysphagiaAbstract Dysphagia, characterized by impaired swallowing function, presents a substantial healthcare burden globally, affecting various populations and conditions. Administering a swallowing screening tool (SST) in the emergency department (ED) appears most logical as it is the first point of patient contact. To design and validate a swallowing screening tool to be used by health care professionals who are not Based on 68 completed screening episodes by independently competent nurses, a comparison with summative clinical judgement of swallow function revealed a sensitivity of 0. All adult acute patients are screened for dysphagia using the Royal Brisbane and Women's Hospital dysphagia screening tool. Methods— The TOR Mar 27, 2025 · Editorial Comment Dysphagia is common in adult intensive care patients and is an independent predictor of mortality. Complete prior to oral intake for all ischemic stroke, hemorrhagic stroke and TIA patients. Dysphagia Screening Tool Based on the Barnes Jewish Hospital Acute Stroke Dysphagia Screen ke or signs and symptoms of swallowing difficulties. There is growing body of evidence regarding the incidence of post-extubation dysphagia. Because most screening tools are complex and biased toward fluid swallowing, we developed a simple, stepwise bedside screen that allows a graded rating with separate evaluations for nonfluid and fluid nutrition starting with nonfluid textures. No valid and reliable postextubation dysphagia screening tools are available. Although this does not encompass the full range of swallow screening tools available to speech-language pathologists, conclusions may be relevant for clinicians looking to implement screening protocols or provide Although many dysphagia screening tools exist, none has high sensitivity and reliability or can be administered quickly with minimal training. Patients who receive prolonged endotracheal intubation (> 48 hours) are at risk for dysphagia. Mar 9, 2017 · Nurses, on the forefront of stroke care delivery, maintain a key role in early identification of patients with dysphagia. In adult patients with acute stroke, how effective is the Mar 11, 2011 · Frontline staff used the same methodology to revise a dysphagia screening tool to assess veterans for dysphagia, performed usability testing of the revised dysphagia screening tool, and subsequently adopted it into practice. It consists of ten self-reported questions that help quantify swallowing disorders and determine the need for further clinical evaluation. Competency training in dysphagia screening for healthcare practitioners can benefit individuals with neurological Prepared for OREG by: The Dysphagia Screening Tool Working Group Dysphagia Screening Tools: A Review, June 2008 2 Dysphagia Screening Tools: A Review Background Dysphagia is a significant consequence of stroke, occurring in approximately 50 to 55% of stroke survivors (Martino, Foley, Bhogal, Diamant, Speechley, and Teasell, 2005). rican Speech-Language-Hearing Association, of second multiple screening tools but limited data to create a standard protocol for nurse-led dysphagia screening leading to inconsistent screening, documentation, and screening techniques (Abu-Snieneh & Saleh, 2018; Patient Population, The Joint Com stered bedside The project was a six-month 2. III. Mar 20, 2023 · A detailed evaluation of dysphagia screening in acute stroke care, focusing on nursing interventions and patient outcomes. Swallowing screening team members are comprised of registered nurses, registered practical nurses, and allied health professionals who have undergone special training in dysphagia and have been trained to implement and interpret the TOR-BSST© swallowing screen to identify the presence or absence of dysphagia in stroke survivors. e. Screening for Dysphagia and Aspiration in Acute Stroke: A Systematic Review. The second part covers nurse's competency in terms of knowledge and skills of screening dysphagia among stroke patients. Early dysphagia screening can reduce these complications. Stroke, 40 (2), pp. Screening for dysphagia and aspiration in acute stroke: a systematic review. In this sense, the review identified specific disease-related tools and more general instruments, and it is an important contribution to more efficient dysphagia screening and prevention. To reinforce concepts and address visual learning modalities, PACU nurses were shown screenshots of the new tool and ran through the new swallow screening tool. Further research is needed to determine whether these six tools can be effectively applie … Feb 1, 2021 · To identify dysphagia screening tools used in residential care and to establish whether validated and used as per guidelines, their diagnostic accuracy and reliability and to identify the prevalence rate of dysphagia in this setting. Swallowing screens are also quicker, easier, and cheaper than a full speech therapy assessment. A screen often focuses on identifying overt signs of aspiration. 2001;10:474-481. , 2007). 4 A valid, reliable, and feasible swallow-screening tool is essential in today’s health-care environments, as the demands for better outcomes and cost-effective hospitalization are warranted. Although the Joint Commission no longer requires dysphagia screening rates be reported for stroke center certification, the Joint Commission encourages consistent monitoring for Aspiration Precautions for Patients Passing Swallow Screen: At meals, check for pocketing, difficulty chewing, and fatigue. Jan 1, 2025 · Implementation of nurse-led dysphagia screening in intensive care may facilitate safe oral intake in patients and identify patients in need of specialised assessment. The study aimed to promote nurses’ compliance with best practices for dysphagia screening in patients with stroke. (2001). Annual rates of aspiration pneumonia for ischemic stroke patients have ranged from 2% to 3% since 2007. In this lesson, you will learn how nurses perform screenings to identify patients at risk of dysphagia, or swallowing difficulty. Registered Nurse (RN) will complete a Bedside Nursing Dysphagia screening on all patients admitted with a diagnosis of stroke, TIA, stroke-like symptoms, neurological deficit, recurrent pneumonia and significant cognitive impairment. The purpose of this study was to validate a health system’s dysphagia (swallow) screening tool used since 2007 on all patients with suspected stroke symptoms. Bedside swallow screening tools for aspiration risk associated with dysphagia are available for use by healthcare professionals to quickly Results show that GUSS and SSA are reliable and sensitive tools for screening dysphagia which nurses can use in nursing homes. Each nurse was given verbal step-by-step instructions and followed along by reading the sheet provided by JoAnn DelMonte. Stroke, 40(2), 555-561. The initial development of a swallowing screening tool is the first step to promoting a nurse-led/-initiated bedside swallow screening tool that will enhance patient care and patient safety. , 2023). 7-18. For example, the Mann Assessment of Swallowing Ability (MASA) takes a comprehensive approach to accurately identify risk of dysphagia, aspiration, and pneumonia in a variety of patient populations (Okuni & Ebihara, 2022). Twenty-five to 30% of acute hospitalised individuals have dysphagia. Is there a Facial Asymmetry/Weakness? 3. Nurses should conduct swallowing assessments after extubation because of the high likelihood of aspiration pneumonia developing. The first part covers the literature on the training nurses in screening dysphagia among stroke patients and benefits of screening. 8 Ideally, such testing should be simple, validated and user-friendly for Background and Purpose—Acute-onset dysphagia after stroke is frequently associated with an increased risk of aspiration pneumonia. Is score on Glasgow Coma Scale LESS than 13? 2. The reliability and validity of a postextubation dysphagia screening tool that can help nurses determine an extubated patient's ability to swallow after prolonged endotracheal intubation were established. Early identification of dysphagia from screening can lead to earlier treatments and thereby reduce complications. Page one consists of the screening protocol, which is composed of three sections – two brief oral exams and one section on water swallowing. Acute Stroke Dysphagia Screen To be completed on all patients that present with signs/symptoms of stroke. A study published in the Scandinavian Journal of Caring Sciences concluded that most patients with dysphagia can be identified through systematic inter-views, observations, and test swallows, but that these need to be included in nursing care assessments. 4. Dec 12, 2008 · Background and Purpose— Dysphagia occurs in 55% of all acute stroke patients. Jul 1, 2020 · The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool for patients with acute stroke that is easy for nurses and therapists to use (Trapl et al. 7 Indeed, a single center trial reported that a bedside nurse-administered dysphagia screening lowered the odds of pneumonia by 57%. Objectives. The present article aims to present a comprehensive clinical consensus on dysphagia diagnosis, assessment, and management, derived from an expert group The nurse will identify potential stroke patients at risk for aspiration using the Dysphagia Screening Tool A physician’s order is not required to complete the dysphagia screening evaluation; however the physician may order the evaluation if one has not been completed. 12This makes it important to include the dysphagia screening tool on any documentation EAT-10: A Swallowing Screening Tool The Eating Assessment Tool 10 (EAT-10) is a list of 10 questions that can be completed in approximately 2 minutes. Aug 31, 2018 · The first part covers the literature on the training nurses in screening dysphagia among stroke patients and benefits of screening. Date of admission/event: Date of Screen: Time of Screen: Follow Algorithm and circle yes or no. 2001;10:463-473. Apr 18, 2025 · It’s a quick and simple screening tool that has recently received national media attention for its potential to support early detection of oropharyngeal dysphagia, a swallowing disorder that can affect people with neurological conditions, head or neck cancer, and other medical conditions. To establish content validity, analyze interrater reliability, and Clinical Practice Recommendations for Nursing Nurses, on the forefront of stroke care delivery, maintain a key role in early identification of patients with dysphagia. See below for instructive material used. Jul 10, 2019 · The tools identified are different from each other, making their comparison impracticable. Review question/ Objective The objective of this systematic review is to evaluate the effectiveness of two bedside screening tools used by nurses to assess for dysphagia among hospitalized adult patients with stroke. It is a stable and accurate dysphagia screening tool, which is quick and easy to use, taking less than 10 minutes to administer, score and document in the chart. Apr 13, 2023 · Therefore an easy-to-use, standardized bedside dysphagia screening tool, such as the GUSS-ICU, would allow ICU nurses to perform a systematic testing for dysphagia in the absence of dysphagia experts and/or instrumental swallowing evaluations. com This review evaluated the validity and reliability of measurement tools for screening dysphagia in patients with neurological disorders to identify a feasible tool that can be used by nurses. Aug 6, 2024 · Existing dysphagia screening tools exhibit varied efficacy across different patient populations; however, this study identifies MASA, GUSS, and V-VST as reliable and relatively accurate tools for dysphagia screening. A dysphagia diagnosis was defined as a diagnosis of oropharyngeal dysphagia on an assessment by an SLP using diagnostic swallow tools, the flexible endoscopic evaluation of swallowing (FEES) or video fluoroscopic swallow study (VFSS), or a clinical bedside exam (BSE). Jun 1, 2016 · This review evaluated the validity and reliability of measurement tools for screening dysphagia in patients with neurological disorders to identify a feasible tool that can be used by nurses. Screening swallowing function of patients with acute strokes. Nov 10, 2010 · Dysphagia has also been identified as a risk factor for airway obstruction, dehydration, and malnutrition. It is important to use a validated assessment tool that demonstrates good accuracy, clinical utility and cost-effectiveness. We designed and validated a new bedside dysphagia screening tool—the Toronto Bedside Swallowing Screening Test (TOR-BSST) for stroke survivors in acute and rehabilitative settings. Despite this, dysphagia remains an often overlooked medical condition. This tool is intended to be a resource for clinicians to use for self-assessment and for employers, supervisors, or preceptors to use as a tool for evaluating and documenting dysphagia knowledge and skill competencies. Fewer than thirty percent of surveyed ICU practitioners employ dysphagia protocols, while less than 20% of nurses undergo formal dysphagia training regarding the screening of patients for suspected PED (Freeman-Sanderson et al. May 5, 2017 · Use this simple assessment technique to detect dysphagia and reduce your patient’s risk for aspiration pneumonia. The purpose of a swallowing screen is to determine if dysphagia is likely and if a comprehensive swallowing assessment (and/or referral out) is needed. Jun 28, 2024 · The results highlight the gap in the unavailability of high-quality dysphagia screening tool in several emerged high-risk populations including elderly inpatients, or patients following endotracheal extubation. Read now! Dec 1, 2020 · Dysphagia occurs in up to 50% of patients with acute stroke symptoms, resulting in increased aspiration pneumonia rates and mortality. WHY DYSPHAGIA SCREEN? Dysphagia screening tool indicates likelihood of dysphagia Identifies patients who require attention from other members of the team such as SLP for full swallowing assessment Implementation of formal dysphagia screening protocol minimizes risks & procedures Regional Implementation of dysphagia screening tool- Mar 9, 2017 · Nurses, on the forefront of stroke care delivery, maintain a key role in early identification of patients with dysphagia. 2001;16 (1):7-18. *Screen ca be repeated at 24 hours for an assessment of change. The American Heart Association convened an evidence review committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke. Methods: Umbrella Review as suggested by the Joanna Briggs Institute. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses. These findings support the idea that systematic assessment for possible dysphagia in all intensive care patients is meaningful. Further research is needed to examine feasibility of screening with identified tools, and also, to establish effective and standardized protocols for these tools so they can … Post-Extubation Dysphagia Knowledge Prior to implementation of the algorithm, 43% of nurses reported that they regularly screened for dysphagia prior to initiating oral intake. Implementation should aim to provide nurses with competences in screening patients swallowing function and allow contextualisation without altering the properties of the instrument. Learning Objectives After this course, readers will be able to: Describe how to assess available screening tools for validity, sensitivity and specificity List 2-3 appropriate screening tools for your setting, client population Mar 1, 2018 · Background. Therefore, they need reliable and effective screening tools to detect dysphagia. To (1) develop a dysphagia screening tool to triage all patients at risk of aspiration/dysphagia on admission to acute hospital wards, (2) evaluate tool reliability, (3) evaluat Feb 2, 2012 · Background and Purpose—Screening for dysphagia is essential to the implementation of preventive therapies for patients with stroke. We found six high-quality, non-instrumental screening tools for detecting adult dysphagia cases in acute-care settings, including the Yale Swallow Protocol, Gugging Swallowing Screen, Toronto Bedside Swallowing Screening Test (both English and Portuguese versions), Sapienza Global Bedside Evaluation of Swallowing and Two-Step Thickened Water Test. 3 Screening tools should be evidence based and used within a formal protocol. Most of their screening methods were informal, involving a trial of water or ice chips and watching for any signs of difficulty (i. If change in the patien di YES NO Nurses and other clinicians can develop competencies in screening swallowing and assessing for safe oral intake in those with poststroke dysphagia. The questionnaire helps to measure to what extent you may experience swallowing difficulty and your risk of dysphagia. Keywords: Aspiration; Pneumonia; Swallow; Dysphagia; Stroke; Oral Intake; Intubated; Extubated Apr 14, 2022 · Conclusion: Due to psychometric proprieties and dietary recommendations adjusted to dysphagia severity, of all available tools, GUSS is a suitable screening tool for nurses in clinical practice. Although the Joint Commission no longer requires dysphagia screening rates be reported for stroke center certification, the Joint Commission encourages consistent monitoring for Clinical Practice Recommendations for Nursing Nurses, on the forefront of stroke care delivery, maintain a key role in early identification of patients with dysphagia. Perry L. Stroke, 40 (2), 555–561. Evaluation/Assessment Methods The design of the protocol is intended to be generic for different bedside screening techniques and therefore should accommodate the existing evaluation methods, such as clinical examinations and questionnaires. «LastName» , «FirstName» «PatientNumber» / «AdmitDate» «Gender» / «BirthDate» «PatientAddress1» / «AttendingDoctorName» «Room» / «MedicalRecordNumber» Swallowing screening procedures indicate the presence of clinical signs and symptoms that may be indicators of dysphagia, with a focus on identifying overt signs of aspiration. The nurse will identify potential stroke patients at risk for aspiration using the Dysphagia Screening Tool A physician’s order is not required to complete the dysphagia screening evaluation; however the physician may order the evaluation if one has not been completed. Jul 9, 2019 · The purpose of this systematic review was to identify dysphagia screening tools for acute stroke patients available for nurses validated against reference test. Perry, L. J Clin Nurs. Methods The Nurse Dysphagia Screening Tool (NDST) was developed via an iterative, participatory process. Methods—Four databases from 1985 through March 2011 were searched using the terms cerebrovascular Jan 24, 2018 · Introduction—Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. DYSPHAGIA SCREENING BEFORE THE PATIENT BEGINS EATING, DRINKING, OR RECEIVING ORAL MEDICATIONS IS EFFECTIVE TO IDENTIFY PATIENTS AT INCREASED RISK FOR ASPIRATION. 96. Moreover, the protocol design is devoted to a computer-aided dysphagia screening tool using wearable technology and machine learning techniques or As oropharyngeal dysphagia concerns important risks for the patient, a rigorous assessment must be performed. The screening for dysphagia is considered good practice in stroke care, yet is not routinely undertaken in the management of frail older adults. Methods— The TOR The Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) was previously developed as a simple bedside screen performed by nurses for sensitive detection of dysphagia and was previously validated against the speech pathologist’s clinical assessment for dysphagia. A thorough assessment of swallowing function is crucial in understanding its causes and determining appropriate interventions. , cough). Jun 5, 2021 · To address the uncertainty related to dysphagia screening benefit in patients with stroke, we conducted a systematic review of the literature that extends beyond RCT data and also includes high‐quality observational evidence. 5 Sep 20, 2007 · In this study, we present a bedside dysphagia screen for acute-stroke patients that is easy to use by stroke nurses and therapists. This new instrument allows a graded assessment of the patient’s swallowing abilities, measures the severity of dysphagia, and enables dietary recommendations. Patients who are not alert should be close monitored and screened when clinically appropriate. and Love, C. 9 for detection of dysphagia, with positive and negative predictive values of 0. The Gugging Clinical Swallow Evaluation vs Swallowing Screen? A swallowing screen is a quick tool for determining if someone needs a full swallow evaluation. Patients are triaged into categories of 'those requiring additional specialist intervention' and 'those who … Apr 2, 2022 · Oropharyngeal Dysphagia (OD) significantly decreases a patient’s quality of life and poses a high economic burden to institutions. Dysphagia is common after stroke and can lead to serious complications including pneumonia and mortality. May 11, 2009 · Aims and objectives. A short May 3, 2025 · Purpose To develop and test a screening tool enabling care-home staff to identify residents with high-risk swallowing problems (dysphagia). Feb 14, 2013 · Although this group did not use the decision K-T Matrix described previously, they considered many of the same items in choosing a dysphagia screening tool, including validity and reliability of existing screenings, ease of administration, administration time, safety for patient at risk, input from nurses, available resources, and whether or Feb 14, 2013 · Although this group did not use the decision K-T Matrix described previously, they considered many of the same items in choosing a dysphagia screening tool, including validity and reliability of existing screenings, ease of administration, administration time, safety for patient at risk, input from nurses, available resources, and whether or “Dysphagia screening may consist of a structured bedside swallow screen administered by nursing staff, bedside swallow evaluation by a speech-language pathologist, video fluoroscopic swallow evaluation, fiber optic endoscopic evaluation of swallowing, or other method approved by local institutional protocol. As people and the population age, the prevalence of swallowing problems (dysphagia) increases. The Yale Swallow Protocol is a swallowing screen that’s been validated by research for many patient populations and settings. vgiumpy ipzvsf gmvzc xwobk vmmek rkvy zdowh llee hgvv jhpqzf ysl wckogs mzkfighu fjsknd vbmu