Reflective log - counselling

Reflective Log 20.04.13 – Counselling

1. Think of a recent therapy session or event.

I had a session with a young patient (48 years old) who had just heard the news that she had primary progressive multiple sclerosis as well as having had a basal ganglia stroke.

2. Describe the session/experience

I had a plan of activities to do with the patient and had heard that the day before they had been informed of their new diagnosis. I did not change my session plan. The patient was very tearful and wanted to talk about her new diagnosis rather than have a normal session.

3. What did this session make you feel?

I felt concerned that the patient was so upset and I felt out of control, as if nothing I could say would make her feel better. I made sure I did not patronise the patient or sympathise with them. I made attempts to empathise with the patient but felt that these were clumsy. The patient cried for a while and then talked about her future and asked me questions about her diagnosis.

4. What has this session has taught you?

 - I should consider a patients mood before making a session plan.

 - I can change my session plans if needed and I am able to consider the clients feelings.

5. What are you going to do before your next session?

- re-familiarise myself with information form a counselling training day I went on.

Standards of care

I've been looking over the standards of care we are required to achieve by our commissioners, heres the key points:

Standards of care for a stroke unit

Current NHS London staffing standards for SLT = 0.081 SLT per stroke bed (HfL SU Standard 13)

24 stroke beds = 1.95 SLTs

Service standards

·   All newly admitted patients to be seen by SLT within 72 hours of admission to SU (NICE Stroke Quality Standard 2010, Standard #5)

• All referrals for swallow ax seen within 24 hours (preferably) and not longer than 72 hours (RCP Clinical Guidelines for Stroke 2008, CQ3 – within 2 working days for high risk ax)

• Attend both MDMs every week (HfL SU standard 17)

·   Set goals within 5 days of admission to stroke unit (NICE Stroke Quality Standard 2010, Standard #5).

• All patients with communication difficulties to be seen for 45 mins of therapy per day, unless unable to tolerate (NICE Stroke Quality Standard 2010, Standard #7). Our practice uses communication, breakfast, newspaper, stroke education and counselling group to help us meet this target (an SLT or SLTA attends all of these groups).

Royal College of Physicians Clinical Guidelines for Stroke 2008

• All patients with any impairment at 24 hours should receive a full multidisciplinary assessment using an agreed procedure or protocol within five working days, and this should be documented in the notes.

Dysphagia:

If the admission screen indicates problems with swallowing, the person should have a specialist assessment of swallowing, preferably within 24 hours of admission and not more than 72 hours afterwards.

• Until a safe swallowing method has been established, all patients with identified swallowing difficulties should:
• receive hydration (and nutrition after 24–48 hours) by alternative means
• be given their medication by the most appropriate route and in an appropriate form
• have a comprehensive assessment of their swallowing function undertaken by a speech and language therapist or other appropriately trained professional with specialism in dysphagia
• be considered for nasogastric tube feeding
• have written guidance for all staff/carers to use when feeding or providing liquid.
• Patients with difficulties in swallowing should be assessed by a speech and language therapist or other appropriately trained professional with specialism in dysphagia for active management of oral feeding by:
• sensory modification, such as altering taste and temperature of foods or carbonation of fluids
• texture modification of solids and/or liquids.
• Every patient who requires food or fluid of a modified consistency should:
• be referred to a dietician or multidisciplinary nutrition team
• have texture of modified food or liquids described using national agreed descriptors
• have both fluid balance and nutrition monitored.
• Patients with difficulties in self-feeding should be assessed and provided with the appropriate equipment to enable them to feed independently and safely.
• Gastrostomy feeding should be considered for patients who:
• need but are unable to tolerate nasogastric tube feeding within the first four weeks
• are unable to swallow adequate amounts of food and fluid orally at four weeks
• are at long-term high risk of malnutrition.
• Instrumental direct investigation of oropharyngeal swallowing mechanisms (eg by videofluoroscopy or flexible endoscopic evaluation of swallowing) should only be undertaken:
• in conjunction with a speech and language therapist with specialism in dysphagia
• if needed to direct an active treatment/rehabilitation technique for their swallowing difficulties, or
• to investigate the nature and causes of aspiration.
• Any patient unable to swallow food safely at one week after stroke should be considered for an oropharyngeal swallowing rehabilitation programme designed and monitored by a speech and language therapist with specialism in dysphagia. This should include one or more of:
• compensatory strategies such as postural changes (eg chin tuck) or different swallowing manoeuvres (eg supraglottic swallow)
• restorative strategies to improve oropharyngeal motor function (eg Shaker head lifting exercises)
• Any patient discharged from specialist care services with continuing problems with swallowing food or liquid safely should:
• be trained, or have carers trained, in the identification and management of swallowing difficulties
• receive planned follow-up and reassessment of the swallowing difficulty.

Aphasia:

• Any patient found to have aphasia on screening or suspected to have it on clinical grounds should have a full formal assessment of language and communication by a speech and language therapist.
• When a patient has been found to have aphasia, a speech and language therapist should:
• explain the nature of the impairment to the patient, family and treating team
• establish the most appropriate method of communication and then inform (and if necessary train) the family and treating team
• re-assess the nature and severity of the loss at appropriate intervals.
• Any patient with aphasia persisting for more than two weeks should:
• be given treatment aimed at reducing identified specific language impairments while continuing to progress towards goals
• be considered for early intensive (2–8 hours/week) speech and language therapy if they can tolerate it
• be assessed for alternative means of communication (eg gesture, drawing, writing, use of communication aids) and taught how to use any that are effective.
• While a patient has difficulties with communication:
• all people interacting regularly with a person who has aphasia should be taught the most effective communication techniques for that person.
• their mood should be assessed using whatever method seems most appropriate (eg direct questioning using adapted techniques, behavioural observation).
• Any patient with aphasia persisting at six months should
• be considered for and if appropriate referred for a further episode of specific treatment (in a group setting or one-to-one)
• have their need and the need of their family for social support and stimulation assessed formally, and met if possible (eg by referral to voluntary sector groups)

Dysarthria:

• Any patient whose speech is unclear or unintelligible so that communication is limited or unreliable should be assessed by a speech and language therapist to determine the nature and cause of the speech impairment.
• Any person who has dysarthria following stroke sufficiently severe to limit communication should:
• be taught techniques to improve the clarity of their speech
• be assessed for compensatory alternative and augmentative communication techniques (eg letter board, communication aids) if speech remains unintelligible.
• The communication partners (eg family, staff) of a person with severe dysarthria should be taught how to assist the person in their communication. (RCP 2008)

Dyspraxia:

o   Any patient who has marked difficulty articulating words should be formally assessed for apraxia of speech and treated to maximise intelligibility.

• Any patient with severe communication difficulties but reasonable cognition and language function should be assessed for and provided with appropriate alternative or augmentative communication aids.

Artefacts group

1. Find and bring in interesting objects ( e.g. crystals.....) with different colours shapes etc.

2. Show them to patients in an aphasia group.

3. Encourage communication about the objects.

We had some researchers looking at improving quality of life by bringing in interesting items for patients to look at. I observed some of the sessions and having interesting objects really took the pressure out of communication. The patients were able to use facial expression, gestures and speech to comment on how the objects made them feel/ what they thought of them.

Bilingual Aphasia Tests

Here is a resource for bilingual aphasia tests in over 50 languages, many with English translations and language pair specific tests so that you can compare language proficiency in different languages.

http://www.mcgill.ca/linguistics/research/bat/#langtests

Facial Tapping

Facial Tapping – with physiotherapy lupetape

I've contacted clinical experts in facial tapping to research how i would use it with a patient who has a dense right sided lower motor neuron facial weakness. Here are the two main ways tapping is used:

1.       Facilitator Tapping – tape acts like a sling to actively lift the face up. Keeps muscles in a shortened more aligned position to make them easier to activate. E.g. lifting up the mouth corner/ assist with lip closure. Could use when completing facial exercises.

2.       Inhibitor tapping – Can be used therapeutically. If the affected side is underactive and the unaffected side overactive e.g. if the nasolabial fold is pulled towards the unaffected side. Tape applied in a downward direction in the line of the labionasal fold and anchored with tape on the chin. Used with reminders to relax the unaffected side and downward stretches. Often at NHNN advice is given to the patient to support the weaker side of the mouth with the palm of hand when talking e.g. with arm on a desk.

I've also found that completing facial exercises with facial tapping using a mirror allows the patient to get extra feedback on the muscles they are activating. The tape will crinkle when a muscle is activated under it, hereby showing even small amounts of muscle activation.

Computer Therapy

I've just been researching the computer resources we have on the stroke unit. So far i haven't used computers therapeutically, this is about to change!!

Computer resources

·         Grid-2 = used to assess if patients can access AAC e.g. typing/ symbol use etc.

·         Speech sounds on cue = used  for aphraxia of speech – drills with pictures

·         REACT-2 = sections on: 1. Auditory processing (clicking on correct word out of choice), 2. Visual processing (e.g. reading/ matching symbols and shapes), 3. Semantics(grouping items etc.), 4. Memory and sequencing (remembering items and the sequence of presentation), 5. Life skills (e.g. pragmatics matching emotions to video’s, telling the time, money, recipe’s.

·         Computer use – for emails/ typing/ Ghanaian newspaper access/ scanning

Personalised Cuing Therapy

(Olsen et al 2012) Aphasiology

Cues: Initial phoneme cues, associated words, Rhyming sounds/words, sentence completion, written word, gestures.

Personalised cuing
= a semantic cuing method, since cues are generated using the patients personal semantic information about a target word.

E.g. Football = your team is Arsenal, you coached a team in Hackney Fields

- Ties in past experience and gives the word a semantic context.

Treatment

1. Generate personalised cues for a word.
2. Show a picture of the target word, giving the personalised cue and ask the patient to name it. Multiple personalised cues can be used including sentence completion e.g. In hacney FIelds you coach.......

Theory

• In this way the word becomes associated with personal semantic information and later retrieval is facilitated.
• Cognitive analysis of a word/ item will support retrieval of the word.
• Semantic encoding is more effective than phonological encoding.

Results of the study

• Personalised cuing therapy improved naming accuracy and improved naming in naturalistic settings.

My Experiences of Using Personalised Cuing Therapy

I used personalised cuing therapy for a patient who had a large LMCA and a severe expressive and mild receptive aphasia. I chose this therapy because the patient was very resistant to using any form of AAC including total communication strategies. I interviewed the patient's son in order to get very personalised information on words which would be functional for the patient at home e.g. 'Dinner Club' - place where the patient went every week to meet friends and have food. The patient engaged with this form of therapy and improved his naming of functional words. His family also stated that they appreciated being involved in his therapy.

Oesophageal Cancer Patient

Here are some of the factors i considered when assessing the swallowing of a patient on the Liverpool Care Pathway who had oesophageal cancer and a posterior cerebral artery infarct.

1. What type of foods they were eating before they were admitted to the unit (they haven't had any oral intake recently).
2. How they are managing their oral secretions. If not managing secretions they are unlikely to be able to manage oral intake.
3. Their respiratory rate - when a patient is near death they may have periods of shallow and then deep breathing/ or chain-stoke breating. This may in turn make it difficult for them to coordinate their swallow- breath cycle.
4. The clients preferences i.e. whether they wish to take oral intake and risk manage.

Assessment

• Asking the patient to voluntarily cough.
• Swallow trial on yogurt and water - thin fluids and softer food are likely to be easier for a patient with oesophageal cancer to swallow. Water rather than tea is less likely to cause an infection when aspirated.
• Palpation of the patient's larynx, hyoid and base of tongue while they swallowed - to feel for hyolaryngeal excursion.
• Asking the patient to say 'ahh' post swallow to listen for voice quality changes.
• Asking the patient to open their mouth for me to see if there was any residue post swallow e.g. due to pharyngeal and tongue muscle weakness since the patient was malnourished.

Hyoscin Hydrobromide

I've been working with a patient on the Liverpool Care Pathway and was involved in a discussion about whether to prescribe Hyoscine. Hyoscine hydrobromide is prescribed to reduce respiratory secretions. his in turn reduces the amount of suctioning a palliative care patient will need and therefore reduces their distress. Hyoscine Hydrobromide is most effectively administered subcutaneously.

To PEG or Not to PEG

To PEG or not to PEG

Cervo, FA. Bryan and L. Farber, S. (2006) A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics, volume 61, number 6.

Introduction

·      Review article looking at the evidence for PEG placement for patients with advanced dementia.

·      For patients with severe dementia deciding whether to use or withhold artificial nutrition/ hydration is difficult.

·      Eating is typically the last activity of daily living to become impaired.

·      Difficulties eating are associated with the final phase of dementia.

·      Percutaneous endoscopic gastrostomy (PEG) tube placement is now a relatively simple procedure requiring local anaesthetic.

·      The American Gastroenterological Association (AGA) allows for PEG tubes when: 1. The patient cannot/ will not eat. 2. The gut is functional. 3. The patient can tolerate placement of the device.

Review of the evidence for PEG tube placement

Health domain	Evidence
Nutrition	·      Increasing weight loss and pressure ulcer development were associated with longer term tube feeding. ·      Studies have shown that nutritional markers did not significantly improve after PEG tube placement.
Skin integrity	·      Incontinent dementia patients who are tube fed are more likely to be restrained, increasing the risk of pressure ulcer formation.
Aspiration Pneumonia	·      Aspiration occurs in up to 50% of patients with feeding tubes. ·      PEG tube placement may increase the risk of GI reflux. ·      A history of previous aspiration is a poor prognostic indicator for tube feeding. ·      Aspiration of oral secretions is not prevented by insertion of a PEG tube.
Quality of life	·      Elderly patients often have an impaired thirst mechanism and may not be distressed by dehydration. ·      Dehydration decreases the production of bodily fluids such as urine and oral secretions, which reduces the need for suctioning/ toileting. ·      Patients with feeding tubes are more likely to be restrained with mittens to prevent them pulling out the tubes. This causes distress.
Functional status and survival	·      Severe dementia is a terminal illness not reversed by feeding tube placement.

The Decision Making Process

·      Advance directives – should reflect the patient’s specific wishes regarding artificial nutrition/ hydration. In there absence decisions are made based on what a surrogate believes the patient would choose if they had capacity.

·      Ethical considerations – the clinical benefit of PEG tube feeding is unclear, therefore decisions should be made based on the patients/families values and preferences.

·      Cultural background and religious beliefs should be considered.

Key Learning Outcomes

·      There is no clear evidence (randomised controlled trials) proving that PEG tube placement will improve the quality of life, or functional status of patients with advanced dementia.

·      Decisions need to be made with the patients’ family/ surrogate considering the patients cultural background, religious beliefs and personal views.

Don't eat too fast

Just made a poster for a patient with comprehension difficulties who refuses to comply with eating/ drinking recommendations. We ended up doing a videofluoroscopy to be sure what was happening with their swallow and have evidence to back up our risk management plan (no way he was going to comply with thickened fluids). The VF showed that when the patient ate slowly and took small sips/mouthfuls he didn't aspirate.

Heres the skeleton of the poster:

I need to eat slowly.
And take small mouthfuls/sips.
So that I don’t need:
And so that I don’t get a lung infection.

Home Visit

I recently had a home visit with a patient, here are the key aspects of communication/ swallowing that i was looking to assess/ provide support for:

1. Swallowing Safety - I prepared a poster with eating/ drinking guidelines for the patient (go slow, small sips/mouthfuls and no thickener/ chest infections) and a laminated information poster on what foods are soft/ easier to eat. The social worker/ the patients family organised mealtime supervision.
2. Emergency Communication - With the OT I ensured that the patient had a pendant alarm they could use in an emergency.
3. Information for carers - I created a carer information pack on the patients communication difficulties, including information about their stroke and the best way to communicate with them.
4. Comprehension - I checked if the patient was able to show me around their house/ understand questions/ instructions given by the OT.

Gest

Just been reading about the GesT project at City University. GesT is an gesture based communication program for people with aphasia. The program involves patients putting on a fluorescent glove and practicing specific hand gestures on a compuer program.

Level 1: Gesture practice
Level 2: Gestures in a virtual world
Level 3: Gestures in context


Initial results have been promising and further studies are planned for 2013.


Learning Outcomes for my clinical practice

1. Dysphraxia - can impact a patient's ability to use gestures,
2. Symbolic Thinking - needed for gesture production (hold a representation in your brain) e.g. assess by picture to object matching etc.

http://www.soi.city.ac.uk/great/

Dehydration

Dehydration

Dehydration can be indicative of dysphagia and can contribute to dysphagia. Dehydration may also cause renal failure Here are some clinical signs doctors look for when assessing for dehydration:

• Pinch the skin on the back of a patient's hand - if it doesn't retract - sign of dehydration.
• Look into the patients mouth - is is dry?
• Are the patients eyes dry?
• Is the patients heart rate high?
• Does the patient have low blood pressure?