Cheyne-Stokes Breathing

Recently one of the consultant doctors mentioned Cheyne Stokes breathing. Breathing pattern characterised by: - periods of shallow, deep breathing  and apnoea. e.g. Apneoa followed by respiration of increasing depth and frequency. - symptomatic of congestive heart failure it is a negative symptom increased liklihood of death and difficulty sleeping at night.

Cervical Auscultation

Purpose

• Evaluating the pharyngeal swallow non invasively.
• A stethoscope is used to listen to the breathing/ swallow sounds heard at the laryngopharynx level.
• Can be done on all patients including COPD/ Tracheostomy patients.

Procedure (Stroud, 1999)

1. Tap the Stethoscope to test. Use the concave bell to hear breathing sounds and the flat diaphragm to hear swallow sounds. 
2. Place on the lateral junction between the cricoid cartilage and the trachea. Listen for normal breathing sounds to get a baseline (hollow/tubular sounding) and listen to a dry saliva swallow to get a swallow baseline.
3. Give the patient the trial fluid/solid. Listen to the swallow-breath pattern. Inhalation, Exhalation, Apnea, 2 swallow clicks (VF closure), Expiratory burst. Listen to both sides to check for asymmetrical pooling. A disordered swallow may sound less clear/ bubbly if aspiration occurred. 

Normal Swallow (Zenner et al 1995)

• Swallow occurs promptly after oral transit.
• Apneic period occurs during the swallow.
• Exhalation at the end.

Disordered Swallow

Listen for:

• Premature spillage of the bolus before the pharyngeal swallow is triggered.
• 2 clicks of VF closing - are they absent?
• Exhalation - absent?
• A clearing swallow may be heard,
• Pooling/penetration - e.g. gurgling/ wet breath sounds.

Impaired pharyngeal Swallow

• Tracheal Aspiration = suspected when flushing fluid sound is heard prior to the pharyngeal swallow, or when wet breath sounds/stridor/coughing/throat clearing/voice distortion is heard.
• Dysphagia - different respiratory pattern, more variable, swallow apnea is less consistent, inspiration at the end of the swallow.

 

Family Meeting

Here are some recommendations for myself after feeding back SLT information during a family meeting.

**1**

Keep up to date ICF/ mini ICF forms with information about patients and infomration about their goals and areas targeted by their goals. This will allow me to explain better the patients goals and the priorities for them.

**2**

Greet patients family members and explain my role to them before the family meeting, so as to be less imposing.

**3**

Read the patients MDM notes before the meeting in order to be up to date with their progress/ status.

First Week

I've just finished my first week as a fully qualified SLT!!! After a few days of induction i was onto the stroke unit to see my first patient and get familiar with the way the unit is run. The main difference from my student placements is that you need to think much quicker. I've needed to really organise my thoughts, e.g. what i'm looking for in a patient and why. 

Here are my personal recommendations after reflecting on my performance feeding back to the team about an initial communication assessment:

1. I need to give concrete examples of the language/communication used by the client and examples of what context they were used in e.g. when asked to describe a picture ...... was unable to ..... and was able to convey some meaning through gesture.

2. I need to become fluent at giving jargon free descriptions of my medical diagnoses e.g. Expressive and receptive aphasia.

3. I need to support the patient during the family meeting to a) Understand what we are talking about and b) Contribute to decisions about their care.

Communicating with someone who has a Brain Injury

Here is a poster i developed in a cognitive communication group with patients who have brain injuries. Each communication trait highlighted was suggested by a patient.

Family Members Rehabilitation Goals

Just read an interesting article in the september-october 2012 IJLCD (p511-521) on the rehabilitation goals of family members. The researchers found 7 categories of goals, all of which fit within 3 family member roles; Caregiver, Family member with a relationship to the client and Family member with their own rehabilitation needs.

1. To be included in rehabilitation (caregiver)
- Directions on how to reinforce communication skills/ assist the client.
- e.g. observing sessions, interviewed to provide personal info on the client i.e. interests/cultural info, keeping family members who work in the week in the loop.

2. To be provided with hope and positivity (caregiver/ client)
-especially in the early stages of rehab - give encouragement and motivation e.g. most recovery occurs within the first 6-12 months but it will continue afterwards.

3. To be able to communicate and maintain their relationship with the person with aphasia (Family member role)
- e.g. train family members in key communication skills, work with the family + the client e.g. Aphasia Couples Therapy or work with the clients family in parallel to work with the client.

4. To be given information (caregiver/client)
- variety of formats (video's, written, verbal, pictures) - using 'layman's terms'
- information about stroke/ aphasia/ rehabilitation process/ support services and charities.

5. To be given support (all)
- e.g. to be put in contact with the counsellor, social worker or family support groups with peers.

6. To look after their own mental, emotional and physical wellbeing (all)
- e.g respite care.

7. To be able to cope with new responsibilities
- e.g. new roles, financial responsibilities.

Skills 2

According to Karen Bunning there are a totem of  8 key clinical skills:

1. Engagement
 - making sure your client can maintain their attention and aknowledging their       engagement.

2. Modification
- Adapting communication to allow the client to understand, ascribing meaning to the clients responses and checking the clients interpretation.

3. Facilitation
- Encouraging contribution, modelling and requesting a specific response e.g. presenting a picture to elicit a response and assisting contribution.

4. Feedback
- Checking contribution, differential (quality) feedback, evaluative feedback e.g. that was difficult, and summative feedback.

5. Personal Maintenance
- Noticing the clients emotional/behavioural state/ physical needs.

7. Context maintenance
- organising the equipment/ the environment.

8. Transaction
- giving information/ getting information from the client/carer / providing instructions and rationales/ note taking

Skills

To be a good SLT you need skills
http://www.youtube.com/watch?v=8KgtGs1ny0k

How to get a job in 30 days

Nice title but it took longer than that. Everyone’s been saying that the job outlook in the NHS is bleak but a fair number of SLT students got jobs within or even before the first month of graduating. I was not one of them.

I had been an SLT assistant previously so was reluctant to apply for assistant posts. I was also fairly certain that I wanted to work with adults and looking at my CV I would not interview me for a paediatric job so I only applied to adult posts. It took around 2 months for me to hone down my personal statement into something that would get me shortlisted. Job applications aren’t kept open very long but it was definitely worth re-writing each personal statement to make it more specific to the job and make it clear why that job is the best for you. The NHS website saved all of your data (schools, qualifications…) and makes job hunting quite easy. During this time I worked a little part time and did some voluntary work within the field I was interested in. Many people got SLT assistant agency work or research assistant jobs while looking for work.

I had one failed interview before managing to get a job and feel that this prepared me for my successful interview. A friend who got a job months sooner than me had 5 unsuccessful interviews before bagging her perfect job. Second time around I revised as if for an exam, looking at topical issues for NQP’s such as prioritisation and caseload management. The most useful thing I did was to order my experiences so that I could use them to evidence the skills mentioned in the job specification. Although it was disheartening not getting shortlisted for jobs this process enabled me to reflect on what my key skills were and to develop a personal statement that would get shortlisted. I had set a time period of 3.5 months (before my birthday) to get a job, after which I would have licence to panic and make a plan B. Although I was pushing 3.5 months I felt more in control and relaxed.

Prioritising a SALT caseload

The Royal College of Speech and Language Therapists provides guidance on prioritisation in their book on best practice; Communicating Quality 3 (RCSLT 2006). Prioritisation is a highly relevant topic in the NHS environment at present due to the streamlining of services and the demand for efficacy.

CQ3 states that:

1.     ‘a prioritisation policy should be formulated which defines a range of criteria upon which the decision to fulfil a duty of care will be made on a case by case basis’.

2.     ‘ The key factor in relation to prioritising an individual for therapeutic care is the judgement about the level of clinical risk’.

Recommended Prioritisation Criteria:

1.  Risk

·   Immediate health risks if the individual is not seen e.g. risk of penetration.

·   The risk of secondary complications if the individual is not seen e.g. aspiration pneumonia.

2    2.Timing

·   Optimal time for intervention to achieve maximum potential, e.g. there is evidence for improved health outcomes for people with long term neurological conditions  when they are seen early on in their pathway by a specialist.

·   Medical urgency e.g. rapidly deteriorating condition.

3   3. Wellbeing

·   Anxiety/distress/concern expressed by the individual, caregiver or family.

·   Effect of difficulties on the individuals communicative/ swallowing function in the current environment.

·   Effect of difficulties on participation in everyday activities/ quality of life.

4   4. Predicted outcome in current context

·   Individual/carers ability to engage with therapy.

·   Availability of SLT resources/ skilled support to help the individual maintain gains.

·   The individuals potential for change.

·   Response to previous SLT.

Ward Rounds

I've just read a joint report by the Royal College of Nursing and the Royal College of Physicians called: Ward rounds in Medicine: Principles for Best Practice (Published in October 2012). Here is my summary of the most important learning outcomes:

Medical Ward Rounds

1.     Opportunity for the multi-disciplinary team to come together to review the patients’ condition and develop a plan for care while facilitating the full engagement of the patient/carer in making decisions about their care.

2.     Opportunity for information sharing and joint learning.

Barriers/Challenges

1.     Communication - multiple teams may be responsible for a patients’ care, frequent staffing changes e.g. rotations, and frequent patient transfer between wards/teams may all have a detrimental effect on communication within the team.

2.     Ward rounds may be inadequately prioritized.

3.     The patient may need support (e.g. from a nurse/SLT) to articulate their views.

Recommendations for ward rounds

1.     A senior nurse should be present at every bedside patient review and nursing staff should be informed of all key decisions.

2.     Individual roles/responsibilities should be allocated at the start of ward round to engage all MDT members. Preparation for ward round should include a re-round briefing and the identification of staffing issues/ adverse factors relating to the patients.

3.     Patients should be encouraged to prepare in advance for ward rounds and patients/carers/relatives should be provided with a ‘summary sheet’ detailing information discussed in ward round.

4.     All members of the ward round team should be introduced to the patient.

5.     Board rounds – can facilitate MDT input and planning for discharge.