NHS Changes

Heres some visuals from the BBC simplifying some of the changes made to the NHS:

Running of the NHS:

Who plans and buys treatments?

Who directs funding?

Overall structure:

Clinical observations

I always check patients' bedside observations before starting any oral trials/ before a swallow assessment, so i thought i'd revise the norms:

Observation	Normal range	Indications if abnormal
Temperature (degrees C)	36.5 – 37.2 Deg. C.	High – may indicate a fever/ pneumonia/ infection. Low - hypothermia
Pulse rate (beats per min)	60 – 100 beats per min	Fast – may indicate an infection or dehydration.
Respiration rate (breaths per min)	15 – 20 breaths per min	Above 25 – high may indicate an infection/ bleeding/ lung or heart disorder.
Systolic blood pressure (mmHG) – artery pressure when the heart contracts Diastolic BP – artery pressure when the heart is at rest	<120 mmHG  - Systolic <80   mmHG - diastolic	High BP – increased risk of stroke Low BP – risk of fainting
O2 Saturation (SPO2) – oxygen level in the blood	96 – 99 % on air	Low SPO2 (below 90) – can lead to respiratory failure

Twitter

Great video about using twitter professionally by Nicola Botting

http://www.youtube.com/watch?v=Ko2RoSbtF5U&feature=youtube_gdata&utm_source=twitterfeed&utm_medium=twitter

Dysphagia readings: Assessment

Huckerbee Ch4

·       No clear association between the site of lesion and dysphagia presentation.

·       Dysphagia occurs in a high proportion of stroke patients (30%?)

·       Clinical swallowing examination is therefore the first step in evaluating all stroke patients.

Patient History

·       Medical History form patient records – medical charts, : Stroke onset, characteristics and complications associated with stroke (e.g. intubation).

·       History of dysphagia – do they have this?

·       Patient interview – rehabilitation setting will warrant a lengthier interview than acute. Find out if swallowing has changed, if different on different consistencies. Initially open ended – may ask more closed questions if the patient has cognitive/comm. Diff.

·       Less than 50% of stroke patients are aware of dysphagia symptoms – limitations of interview.

Groher CH 7

Clinical examination of swallowing (CED) = description of problem, health history, clinical observations and a physical examination.

Warning signs (dysphagia likely):

1.     Confused mental state – may be difficulties with the eating process since requires planning + judgement e.g. speaking while eating, going too quickly, large bolus’.

2.     Dysarthria (slow, labored, slurred articulation, nasal emission, hoarse/breathy voice) = due to inherent weakness/ incoordination of muscles common to swallowing.

3.     Excessive drooling (sialorrhea) – due to motor/sensory impairments of swallowing mechanism.

4.     Frequent coughing episodes – sign of potential aspiration – i.e. pooling into the airway.(protective mechanism to prevent aspiration). – no cough reflex = sign that most foods may be unsafe unless the patient is dysphraxic + has no voluntary cough.

5.     Weightloss

6.     Complaints of pain/ obstruction – common complaint of those with neurologic condition resulting in muscle weakness/ incoordination + those with oesophageal motility disorders. Cricopharyngeal dysfunction – often point to the thyroid cartilage level. Pooling in valleculae/ pyriforms – may point to area adjacent to the larynx. Timing – if early – may be oropharyngeal – if later – oesophageal problem.

7.     History of pneumonia – may be associated with neuromuscular incoordination, weakness of the oropharyngeal swallowing mechanism or esophageal dysfunction.

Clinical observations

·       Mental status –

·       Physical examination:

·       Voice and speech – e.g. ability to sustain a vowel (quality,pitch, intensity) – Hyper-nasality suggests impaired palatopharyngeal function.

·       Weight – nutrition?

·       Muscles of facial expression

·       Muscles of mastication – masseter is the largest (inserts into the mandible), temporalis -  jaw up/ forward/back.

·       Pathologic reflexes e.g. brainstem reflexes – normally inhibited in adults e.g. the bite reflex – often elicited in those with severe neurologic lesions by touching the tongue, teeth or lips with a tongue blade.

·       Oral mucosa – moisture?

·       Dentition

·       Gag reflex – very variable – diminished reflex is  significant in patients with weakened pharyngeal musculature

·       Tongue – coordinated interaction between the tongue and the pharyngeal muscles propels the bolus. Look for atrophy, fasciculations or abnormal reflexes.

·       Sensation – chewing/saliva flow and swallowing = reflexes depending on sensation.

Swallow summary

1.     Bolus moved into the oropharynx by lip/tongue/cheek muscles

2.     Swallow reflex initiated

3.     Muscles suspending the larynx contract – larynx moves up so that the epiglottis can go down into the base of tongue (covering airway).

4.     Pharyngeal constrictors move the bolus towards the cricopharyngeal sphincter muscle. Which opens allowing the bolus to travel to the oesophagus.

Swallowing Assessment

·       Swallowing reflexes are subject to warm up and fatigue.

·       Aspiration is difficult to evaluate – listen for air mixing with liquid as a sign of aspiration. Change in face colour, gurgily breath signs, breathiness or loss of voice may indicate acute aspiration

·       Examine the oral cavity for residue.

·       Ice chips = safe + give sensory stimulus

Logemann chapter 5

Oral –motor control examination

·       Evaluation of the range rate and accuracy of movements of the lips, tongue, soft palate and pharyngeal walls during speech, reflexive activity and swallowing.

·       Swallowing apraxia – usually perform best when no swallowing instructions are given

·       Labial function - /i/ /u/ alternately, drooling/ anterior loss?

·       Tongue – touch mouth corners/ lips + then rapid tongue movement. Posterior tongue function (tongue base) – get patient to say /k/ + repeat /ka/ (DDK).

·       Soft palate – ask patient to produce a strong loud ‘ah’ and to sustain this for a few seconds.

·       Oral sensation  - use an oral sponge – ask the patient if everywhere feels the same

Laryngeal examination

·       Voice quality – gurgily voice = associated with aspiration, hoarsness – may indicate reduced laryngeal closure – cough reflex (although voluntary cough doesn’t mean the patient will have a reflexive cough).

·       Ability to change pitch – pharyngeal swallow + cough reflex may arise from the superior laryngeal nerve – therefore inability to change pitch implies reduced sensitivity around the larynx. Phonation time tasks – info on laryngeal control – e.g. /z/ prolong a /z/ as long as possible. Phonation time = also a test of respiration.

The Swallowing Examination

Observations during swallowing trial

·       Hand under the patients’ chin with fingers spread and in light contact: index finger behind mandible, middle finger on hyoid, little finger at the bottom of the thyroid cartilage.

·       Feel for: tongue movement, hyoid movement, and laryngeal movement. Compare the time between the initiation of tongue movement and the initiation of hyoid/ laryngeal movement.

·       Can’t assess what is occurring physiologically.

·       Ask patient to say ‘ah’ after swallowing – listen to vocal quality. (however consider silent aspiration, potentially 50%).

·       Ask patient to pant + turn head to either side after swallowing – material dislodged from the pharyngeal recesses – and then say ‘ah’.

·       Use small amounts of material

·       If swallow strategies are not feasible – modify consistencies.

Enteral Feeding Script

……. Has not been alert enough or able to follow the instructions required for a full swallow examination. As she has been in hospital for over a month and has not been able to participate in assessment she is likely to need enteral (artificial) feeding in the long term. If ….. becomes more alert the speech and language therapist will assess her swallowing and start to develop a therapy program.

There are two main types of enteral feeding, Naso-gastric feeding and PEG (percutaneous endoscopic gastrostomy) feeding.

Advantages and disadvantages

Naso-gastric feeding           NG-tubes are typically used for under 30 days.	PEG Feeding           A feeding tube is placed through the abdominal wall directly into the stomach. Mild anaesthetic can be used and the procedure is non-surgical.
Advantages          NG –tube placement is a quick    procedure.          No surgery is required.          NG- tubes can be removed easily.	Advantages             Patients are less likely to pull out a PEG than an NG-tube.             PEG’s can be kept for feeding in the long term.
Disadvantages  Patients may find the NG-tube uncomfortable. Patients may pull out the NG- tube as ….. has done. Regular re-insertion of the NG-tube can be traumatic for patients. Risk of aspiration (liquid/solids going into the patients lungs) if the tube is displaced. Regular x-ray’s may be required to check placement of the tube. Patients are therefore not normally discharged into the community or into nursing homes with NG-tubes.  NG-tube feeding can cause diarrhea, vomiting and cramping.	Disadvantages             If the patient is not medically stable or is unwell they will not be safe to undergo the PEG procedure. -

We have recommended PEG feeding because: 1. …. Has removed her NG-tubes multiple times and has been unable to receive nutrition/ medication when the tube is not in place. 2. No constraints e.g. the mittens, need to be used so the patient is free to use her left hand in therapy/ to communicate and 3. The PEG can be used in the long term.

Locked in syndrome

1. Think of a recent therapy session or event.

I assessed a patient who had locked in syndrome (quadriplegic, with bilateral vocal fold palsy. Some movement in his right index finger and thumb. All due to multiple brainstem and cerebellar infarcts). I called his previous hospital for a handover and contacted therapists at the specialist AAC centre in Putney for advice on his access to communication.

2. Describe the session/experience

The patient had been extensively assessed throughout his time in hospital, so I made sure to get a detailed handover. I have little experience using AAC so I contacted specialists in Putney. They advised that I look at the following: a) Consistent yes/no response, b) cognition, c) What movements can he do consistently, d) comprehension, e) cranial nerves. They also advised that I keep a diary for the patient so that his family and staff can record his behaviours and note down what he does in his day, for use in SLT e.g. did you… how was physio … It was advised that I create clear communication guidelines for the patient and assess for a baseline. The therapists recommended using an AEIOU alphabet chart.

During my session I 1) asked the patient 1-2 stage instructions, 2) explained my role and the information I had on him 3) Trialled use of the alphabet chart. The patient was consistent with head nodding/ shaking for a yes/ no response. It was effortful for both of us to use the alphabet chart. I followed advice from Putney and modelled spelling out items using the alphabet chart. The patient engaged with this.

3. What did this session make you feel?

I felt exhausted from concentrating on the patients communication attempts (mouthing, breathy speech, jerky body movements, head nodding/shaking, alphabet chart use). I felt that by keeping assessment functional e.g. giving instructions relating to an oro-motor exam and asking about pain/ comfort the patient stayed engaged in my session. It was reported that he quickly became disengaged in communication sessions due to the effort fullness of communication.

4. What would you want to change, and why?

I would ideally have talked to the patient’s family to ask them for some yes/no questions that are engaging for the patient. I would also have done a joint session with the OT around what movements may be harnessed for AAC use.

5. What has this session has taught you?

Look for a consistent yes/ no responses, think about low tech accessible forms of AAC, continue to empathise with patients and explain the goals of my assessments in order to motivate them for assessment.

6. What do you need to learn or find out before the next event?

More information about AAC and communication with locked- in patients.

Putney advice

·      Use errorless learning when teaching AAC use e.g. with the AEIOU alphabet chart. E.g. we are going to spell tree…

·      Patients normally pick up alphabet chart use if they have no cognitive impairments – it may be a sign of impairment if they have ++ difficulties.

·      Have joint sessions with OT’s re – big mac or switch use.

·      Start with a nurse call – big mac = good prep for Phigh tech AAC since switch use is a pre-requisite for eye gaze etc..

·      Make sure Yes/ no is reliable + staff consistently ask for the same response.

·      Using a diary is a good way to engage with family members/ find material for communication sessions.

·      What commands can they follow?

·      Establish a clear baseline.

A	B	C	D
E	F	G	H
I	J	K	L	M	N
O	P	Q	R	S	T
U	V	W	X	Y	Z

Guidelines for using the AEIOU alphabet board

Purpose

To help John communicate information that he is unable to convey using mouthing, body language, eye pointing and head nodding/ shaking. The alphabet is split into rows so that communication partners don’t need to read out the whole alphabet. The letters are in alphabetical order making communication quicker and thereby reducing the burden on Johns’ sight.

How to use the alphabet board

1.    Ask John to think of the first letter of the word he wishes to spell and to look at the row this letter is in.

2.    Confirm the row as either A, E, I, O or U, looking for a head nod on the correct row.

3.    Ask John to nod when you say the correct letter, and then proceed to read out the letters in the row.

4.    Write down the letters John chooses and confirm his responses.

Communication method	YES	NO
Head	Nod	Shake
Thumb/ finger	Moves up/out	Moves down/in
	Eyes looks up Eyes Look to one side  Look to a YES card	Eyes looks down Look to the other side Look to a NO card
Blinks	One long blink	Two short blinks
Eyebrows	Raised	Lowered
Switch	Pressed once	Pressed twice

Aim for the most natural method, the clearest and the easiest to perform. + that everyone uses the same method. If the patient is well supported and comfortable they are more likely to be able to make a consistent response.