Reflective log 29.05.13 – Chest infection

1. Think of a recent therapy session or event.

Nursing staff had reported that a patient was coughing when drinking. The patient had sounded chesty the day before but I had not seen any signs of aspiration. The patient was asthmatic and had not previously tolerated an NG-tube.

2. Describe the session/experience

I observed the patient at lunch. They were able to manage a puree meal and a yogurt without signs of aspiration but coughed post swallow on water. Their eyes watered when they swallowed the water and they needed three swallows to clear a single sip. Previously they had needed two swallows and had not coughed/ no eye watering.

I trialled a thickened grade 1 fresubin drink – there were no signs of aspiration. I therefore put the patient on syrup fluids and recommended that fluids be stopped if they were having difficulties since they were regularly getting sub-cut fluids. As the patient did not tolerate NG-feeding and managed to eat puree consistencies safely I left them on a puree diet. The doctor decided to give the patient antibiotics for her chest infection. The chest infection may have caused her swallow to deteriorate.

3. What did this session make you feel?

I felt that I had little choice about whether to allow the patient to continue eating/ drinking. However my supervisor advised that if the patients swallowing was very unsafe or their chest infection progressed they may be less alert and may be able to tolerate NG-feeding.

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

I would want to monitor stable dysphagia patients and proactively ask the nurses about their swallowing since they see the patients throughout the day.

5. What has this session has taught you?

- Asthmatic patients may get chest infections not related to aspiration.

- To continually monitor dysphagia patients and communicate with the nursing staff.

A day in the life of a dietician

Recently for one of my dysphagia competencies i spent the day shadowing a dietician on the stroke and elderly care units. Here's what i found out.......

A Day in the life of a Dietician

Examples of joint working

1. Weaning a patient from PEG feeding to Oral feeding. ·   If the patient is able to manage at least 3 days of good oral intake(>50% of required daily intake) the dieticians may agree to reduce their PEG feed in order to stimulate appetite. ·   A PEG may be used simply for fluids/hydration needs. 1.    Supplements ·   E.g. for a patient who will not tolerate an NG-feed and is not eating enough of a puree diet (with fluids often the doctor will prescribe sub-cut fluids). ·   E.g. supplements which are the right consistency for a patient to swallow. ·   On the stroke unit all patients on a puree diet are referred to the dieticians.

Interpreting Dieticians Clinical Notes

A.     Assessment – e.g. weight etc.

B.     Bloods (e.g. electrolytes, raised CRP/WBC = inflammatory/ infection marker)

C.     Clinical e.g. prescriptions

D.    Dietary – observation chart

E.     Estimated requirements

F.     Family

G.     Goals

H.    Aims/ plan

Body Mass Index

BMI = weight (kg)/ height (m2) <18.5 = underweight (probable poor protein energy status 20 – 25 = desirable weight 25- 30  = overweight

Estimating Nutritional requirements

1.     Calculate the approximate basal metabolic rate (BMR) 2.     Determine the patients metabolic state e.g. higher if metabolically stressed due to infection/ surgery etc… (increased energy requirements due to disease processes). 3.     Add an activity factor i.e. bed bound immobile/ bed bound mobile (sitting)/ mobile on the ward. 4.     Determine the goals of treatment e.g. maintenance/ weight gain.

Re-feeding syndrome

Definition: - a group of clinical symptoms/signs that can occur when nutrition is reintroduced to a malnourished individual. ·   Over-rapid/ unbalanced provision of oral, enteral or parenteral nutrition can lead to biochemical abnormalities (elecrolyte disturbances).

Electrolytes	Respiratory symptoms	Neuro-muscular symptoms
Low Phosphorus (P)	Acute ventilatory failure	Lethargy Weakness/paralysis Confusion Coma Diaphragm weakness
Low Potassium (K)	Respiratory depression	Paralysis Weakness Muscle breakdown
Low Magnesium (Mg)	Respiratory depression	Ataxia Confusion Muscle tremors Tetany
Fluid/glucose	Respiratory depression/ Pulmonary oedema	Coma

Feedback from the dieticians

1.    Refer patients to the dieticians more regularly if you feel they are at risk of malnutrition/ re-feeding syndrome.

2.    Find out patients’ food/drink preferences.

3.    Tea is a diuretic, so if encouraging fluids due to dehydration encourage other drinks as well.

4.    Information to hand over to dieticians: a) Consistencies the patient can manage b) Prognosis for their swallowing function.

5.    Fill out food and fluid charts and encourage the nursing team to as well. Include if the patient has refused food so that the dieticians know that someone hasn’t forgotten to record the data.

6.    SLT’s can prescribe build up soup e.g. the cal shake (made with milk).

7.    There are thickened supplement dinks in grade 1 and 2 however they are slightly thinner than thickened fluids of the same grade.

Reflective log 28.05.13 – Aspiration pneumonia

1. Think of a recent therapy session or event.

My patient sounded very chesty and gurgily on a Saturday. She had recently been put on 3 yogurts a day. On a swallow examination the patient was able to manage the yogurt with one throat clear post swallow. She appeared to have a weakened swallow and slightly delayed swallow trigger. On water the patient coughed clearly post swallow.

2. Describe the session/experience

I put made the patient nil by mouth and assumed the patient may have had an aspiration pneumonia. I was surprised that this would have happened so quickly and that the patient would sound so gurgily/ chesty as their only inralke was 3 yogurts a day. The patient had been on a puree meal at her last hospital, an NG-tube was put in place over the weekend due to the patient inhaling some soup. The patient was transferred to us with a NG tube. The doctor found that the patient’s NG-tube had been dislodged. This may have meant that the patients aspiration was due to her tube feeding.

3. What did this session make you feel?

I felt that I may have missed some signs of aspiration. As the patient had clearly aspirated on water and shown clear indicate=ors ithought that it was odd that they had not shown any indicators when eating yogurt and had aspirated. I had acted cautiously by putting the patient on 3 yogurts a day rather than backl on a puree meal.

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

I would have asked the doctor whether they thought the patient had developed aspiration pneumonia due to their oral intake much sooner.

5. What has this session has taught you?

- Ask/ find out the reason for chest infections since it may not be related to oral intake.

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

- Other causes of pneumonia

Reflective log 24.05.13 Crushing tablets

Reflective log: Severe expressive aphasia and apraxia of speech

1. Think of a recent therapy session or event.

One of my patients was refusing to swallow her medication to the extent that it affected her I and R levels. I mixed crushed medication with some yogurt since it was bitter and a very thick consistency so hard for the patient to swallow. I thought that as the medication was crushed already it would be alright to mix it with yogurt. I then spoke to my supervisor and a pharmacologist about crushing medication.

2. Describe the session/experience

My supervisor advised me not to get involved in administering medication since crushing medication/ giving it with substances other than water affects its properties.

3. What did this session make you feel?

I felt concerned that I had got involved in a clinical area without clearly consulting guidelines and my clinical responsibility.

5. What has this session has taught you?

- To contact the pharmacist if I have any questions about the administration of medication.

- To keep to providing advice about what the patient may be able to swallow but not becoming actively involved in the administration of medication.

6. What will you do before the next session?

- Contact the pharmacologist to ask questions concerning the crushing and administration of medication.

Interview with the Pharmacist

PO - on drug chart means orally administered (other routes: rectal, transdermal e.g. hyoscine, sublingual, parenteral).

SLT assessment - we advise on whether a patient can 1) chew drugs and 2) whether they can swallow tablets.

NG tubes = thinner tube than PEG tubes so can be more difficult to give medicines through.

Carers - should only give medicines from a dosset box.

Bioavailability 
Percentage of the administered dose that reaches the patient's systemic circulation. Altered by formulation e.g. route of administration since drugs can be metabolised by GI bacteria/ GI mucosa/ liver before reaching systemic circulation.

•  Drugs which have a modified/ sustained release cannot be crushed since this will affect their   pharmacokinetics.
• Liquid preparations are available for some medications but are expensive.
• Medications are not licenced if they are crushed.
• Tablets with a ridge for breaking in the middle are unlikely to be sustained release.
• Some drugs should not be mixed with yogurt/ juice since acidity may cause a chemical reaction.
•  Dispersing is a better option than crushing tablets i.e. put the tablet in water and mix.

·      www.medicines.org.uk – click on the drug name to get specific administration information.

·      The pharmacologist is going to research if thickener is safe to be mixed with medication.

Videofluoroscopy case 1

I've been starting to analyse videofluoroscopies as part of my dysphagia competency program and thought it would be usefull to compare my observations to the structured reports patients are given. Here goes no. 1.

VF feedback

My observations

Clinical Report

Solids Delayed swallow trigger, residue in the valleculae, able to clear residue with a cough, decreased sensation? Fluids Tipped back – decreased oral control, delayed swallow trigger, residue in valleculae, penetration, able to clear residue with a second swallow Summary Oral stage – reduced coordination of chewing and reduced base of tongue to pharyngeal wall approximation. Pharyngeal stage – delayed swallow trigger, significant valleculae residue, penetration but no aspiration.

Oral Phase: Lip closure was slightly reduced resulting in mild lip spillage. Tongue control was adequate for cohesive bolus formation and for oral to pharyngeal transfer. Tongue function was slightly reduced resulting in mild oral residue, piecemeal oral clearance and, on fluids, premature spillage into the pharynx to the level of valleculae sinus. Chewing was slightly reduced due to reduced jaw movement and tongue weakness with decreased range of movement. Palatal elevation was adequate resulting in complete velopharyngeal seal. Pharyngeal Phase: Initiation of the swallow reflex occurred when the bolus reached the level of the valleculae. This was considered to be slightly delayed. Base of tongue to posterior pharyngeal wall approximation was reduced resulting in poor bolus propulsion through the pharynx.  There was subsequent mild base of tongue and valleculae residue post swallow. There was evidence that clearing soft and normal diet residue from the valleculae was more effortful than clearing yogurt; indicated by facial expression, reported feeling of the bolus sticking and effortful swallow, also cough triggered in response to normal bolus, although there was no evident penetration/aspiration. Hyolaryngeal excursion was adequate to facilitate epiglottic to arytenoid closure and upper oesophageal sphincter opening. Pharyngeal contraction was slightly reduced resulting in mild valleculae residue after the swallow. There was no evidence of aspiration during the study. There was trace penetration of the laryngeal vestibule above the level of the vocal cords with normal fluids but no penetration into the subglottic space. The trace penetration of thin fluids was cleared on the initial swallow. There was no penetration of the laryngeal vestibule with food, although a clearing cough was triggered on normal bolus. Compensatory Techniques: The following strategies were trialed with thin fluids: Multiple spontaneous swallows were effective to clear base of tongue and valleculae residue. Prompted smaller sips were beneficial to achieve less effortful swallow.

SUMMARY

Mrs …….. presented with mild oral phase dysphagia characterized predominantly by:

• Slightly reduced tongue function.

There was mild to moderate pharyngeal phase dysphagia characterised by:

• Delayed initiation of the swallow reflex
• Reduced base of tongue to posterior pharyngeal wall approximation and reduced pharyngeal contraction resulting in:

• poor bolus propulsion through the pharynx
• mild base of tongue and valleculae residue post swallow

There was no evidence of aspiration and only trace penetration, which was cleared on the initial swallow, during the study.

The findings of this assessment are consistent with generalized progressive muscle weakness secondary to Muscular Dystrophy.

RECOMMENDATIONS:

• Thin fluids
• Soft moist diet – to help keep the bolus more cohesive and to reduce valleculae residue.

      e.g. having extra gravy/sauce with your food.

• Small mouthfuls/sips
• Allow time for multiple clearing swallows to clear residue before taking another mouthful/sip

Reflection

·      ANATOMY: The adult larynx is located around the level of C3-6, the hyoid can be seen on the VF and is a marker, as is the epiglottis.

·      Focusing on a) Oral Phase b)Transfer and c) Pharyngeal phase was useful rather than everything as a whole.

·      Looking for aspiration down the airway anterior to the oesophagus was useful.

Reflective log: Challenging dysphagia patient

1. Think of a recent therapy session or event.

I had a patient who was discharged from A and E with significant aphasia and right upper limb hemiplegia after having a LMCA infarct. The patient was supported at home by his family who took time off to be with him. The patient was coughing and showing signs of aspiration on thin fluids. He was also showing signs of aspiration on a soft diet. I recommended that he have thickened fluids and a soft mashed diet and observed him during a mealtime. This patient had a severe expressive and moderate receptive aphasia.           

2. Describe the session/experience

I explained to the patient that he would need thickener in his drinks to make it safe to drink. I used gestures to support his comprehension. The patient became very agitated when he saw me putting thickener in his drinks and refused to drink. He also ordered toast and cornflakes for breakfast with nursing staff. I organised a joint session with the patient’s daughter to explain why he required a modified diet and used written words and pictures to explain my rationale to the patient. The patient communicated that he had had normal food when discharged and was angry to be in hospital and didn’t was thickener. After a few sessions with his daughter the patient would sometimes drink thickened drinks but would regularly get thin tea from domestics.

3. What did this session make you feel?

I felt stressed because the patient was at risk of aspiration. I organised a risk management program with nursing staff and got the patient to agree to a videofluoroscopy in order to have evidence to present to him. I felt uncomfortable recommending modified consistencies that the patient disliked. It took me a while to realise that the patient understood the information I gave him but decided to ignore it. The patient also had memory problems which complicated the process of giving him advice and information. I felt that the patient was not safe to go home and fed this back to the team. The patient resented this information.

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

I would find out information about a patients character before giving them information they might resent. I would also organise to give the patient information while their family is present. Later on I gave the patient a diary to support their memory and to use in therapy sessions as a conversation prompt. I would do this earlier and make a visual poster for the patient explaining the rationale for swallowing advice and relating it directly to their symptoms (red in face, coughing on food/ drink). This might support their comprehension and could be used by the MDT to prompt the patient to remember information.

5. What has this session has taught you?

I have learnt that I need to carefully write up risk management plans if a patient refuses advice. I have also learnt that I should provide written or visual advice to a patient. This advice can be used as a prompt by other members of staff and used by patient s as a memory aid. I should also relate advice directly to the patient’s symptoms/ presentation and try to use as much clinical/ observational evidence as I can.

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

I need to find out what our clinical obligations are when developing a risk management plan.

Reflective Log 25.04.13 –Dysphagia

1. Think of a recent therapy session or event.

I assessed the swallow of a patient on the stroke unit. The patient had had a previous RMCA and R cerebellar stroke, new left superior cerebellar infarct and left front cortex infarct. She was initially very low arousal but became medically stable.

2. Describe the session/experience

The previous SLT had trialled teaspoons of water and thought that the patient might have aspirated on the second teaspoon. The patient appeared to have weak tongue muscles but was able to cough on command. I trialled the patient on yogurt. Over the next few days the patient managed increasing amounts of yogurt. When she was fatigues the patient would throat clear and cough. I predicted that this may lead to residue build up in her valleculae and clearing coughs/ swallows. The patient was pulling out her NG – feed regularly and the consultant doctor was keen to know if a PEG would be needed for discharge. I asked nursing staff to assist the patient to have yogurt three times a day and to stop when she showed signs of aspiration. My supervisor advised me to trial a puree meal sooner rather than later since the patient had been making quick gains in OT and PT.

3. What did this session make you feel?

I felt that I needed to review my treatment plan more often since the patient was beginning to recover more quickly in other therapies. I needed to consider the patients discharge date more when planning their therapy since she could not be discharged with an NG-feed. Furthermore by getting more practice swallowing the patient is likely to be able to manage more and to transition onto oral feeding.

4. What has this session has taught you?

- To consider the long term goal of swallowing therapy/ dysphagia risks.

- To consider a patients therapy progress in other therapies.

- To balance caution with risk when thinking about maintaining and developing oral intake.

Reflective Log 16.04.13 – Cognitive Communication Impairments

1. Think of a recent therapy session or event.

I assessed a patient who had a right MCA infarct with a craniotomy who was 23 years old. I used the FAVORS assessment and the mount wilga assessment to look at his executive functions and language abilities.

Recommendations: Present info orally/ break down large pieces of information – support John with reading (highlighting key words), Give John a structure and explain the aim of tasks (e.g. beginning we will. Middle, end – wh are doing this task because…), repeat key information for John, give him time to process information, check his understanding.

Main difficulties aren’t with language they are with executive functioning, impulsivity, memory, attention, initiating, weighing up facts and making informed decisions. He has been able to use strategies given to him.

The assessments took a long time to complete and were not very motivating for the patient. I gained useful information to feedback to staff on the ward. Furthermore the patient had low insight into his pragmatic communication difficulties e.g. topic maintenance, appropriateness, impulsivity. The patient engaged with goals around planning meals however I did not directly address his pragmatic difficulties.

2. Describe the session/experience

During therapy sessions I feedback assessment results and made a visual aid to support the patients comprehension of his performance, strategies he could use and strategies staff could use to support his communication. The patient appeared to understand the information but was unable to remember it. He did not use the visual aid I had prepared for him and needed prompting to use any of the strategies.

3. What did this session make you feel?

I felt that my therapy session and plan was ineffective for the patient and that he did not fully understand what we were trying to achieve. I feel that I should have enabled the patient to contribute more to his goal setting and therapy plan. Because the patient had difficulties initiating his goals were suggested by me.

4. What has this session has taught you?

- Assess pragmatic skills e.g. by recording a conversation or with a patient and family communication questionnaire such as the LA trobe (one for the patient – how they have changed – what like before and now).

- Organise more group work for the patient to get feedback in.

- Involve patients’ family in goal setting/ therapy treatment plans when the patient has cognitive communication difficulties as they may be better placed to think of functional goals and may be better at giving the patient pragmatic feedback.