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?

Subcortical Aphasia

I've just assessed a patient who presented with subcortical aphasia.

Neurology

• Subcortical structures are involved in a cortical-subcortical loop and are involved in monitoring and selecting lexical input.
• The loop triggers the release of language segments after semantic monitoring (regulatory function).
• Damage to subcortical structures (in this case the left Thalamus, Internal capsule and Insula) may lead to declarative memory difficulties (facts/names/events..) and associated naming difficulties (lexical semantic access).
• Typically grammar, comprehension and articulation are relatively intact.
• Primarily this form of aphasia presents as a naming difficulty with some auditory comprehension impairments which could be due to verbal memory/attention deficits rather than a true language deficit.

Heres a language sample from the cookie theft picture description task:

'washing up going on, cookie jar, accident going on water spilling, water going, cookie jar, falling off the stool'

My Medication

I've developed an aid to explain to a patient with aphasia why it is important she takes her medication. The patient was not complying with medication and very frustrated about her lack of control in the hospital environment. I am working to ensure she understands more about her stroke and why she needs to be in hospital so that she will engage more with activities on the ward.

My Medication

Medication	Why I take it
CLOPIDOGREL	·     To prevent blood clots forming and to prevent another stroke.
AMLODIPINE	·     To control my blood pressure and prevent heart attacks.
RAMIPRIL	·     To reduce my blood pressure.
GLARGINE	·     To control my blood sugar (diabetes).
SIMVASTATIN	·     To prevent heart attack/ strokes by controlling my cholesterol.

Re-feeding syndrome and dysphagia

Re- feeding syndrome
Introduction

• I've recently had a patient who had pharyngeal dysphagia and re-feeding syndrome. I was trialling oral intake with the patient using yogurt and water. A few days after admission the patients swallow deteriorated further due to re-feeding syndrome and then improved.
• The consultant doctor reported that low phosphate, magnesium and potassium caused by re-feeding syndrome affects neuo-muscular function and therefore swallowing.
• Global atrophy caused by nutrition may also cause weak swallow musculature.

History

• First described in prisoners of war when they started to eat again after prolonged starvation.
• Eating again appeared to precipitate cardiac failure.

Mechanism

1. During starvation fat and protein are catabolised.
2. When the body shifts back to carbohydrate metabolism insulin is secreted again, which stimulated cellular uptake of phosphate and causes low serum phosphate levels.
3. Phosphate is required for ATP production (ATP transports chemical energy within cells).
4. Hypertension, arrhythmia's, electrolyte depletion (Mg is used in nerve and muscle cells, K is used in neuromuscular junctions), hyperglycaemia and dysfunction of various organ systems e.g. Cardiovascular, musculoskeletal, neurologic and immune systems.

Relevance to stroke patients

• Patients with neurological dysphagia fed via a PEG or NG-feed are at risk of re-feeding syndrome.
• Serum phosphste levels below 0.50 mmol/l = re-feeding syndrome.
• When patients have re-feeding syndrome their swallow function is likely to be affected: Weaker pharyngeal muscle contractions, reduced swallow coordination and oral stage muscular impairments may be observed.
• Patients with re-feeding syndrome are likely to have their swallow improve once they are treated.
• Intravenous phosphate is used to treat re-feeding syndrome.

References:

Hearing, SD (2004) Re-feeding syndrome, BMJ, 328(7445), 908-909.

Marinella, MD (2004) Re-feeding syndrome: Implications for the inpatient rehabilitation unit, American Journal of Rehabilitation, 83:65-68.

Lip Reading - dysarthria therapy

I'm currently working with a patient who has lower motor neuron right facial weakness and a flaccid dysarthria. I've been developing my array of dysarthria therapies and together we came up with an idea......

Lip Reading

• Method: The patient and therapist have a list of the same words. The patient picks out a word (the SLT doesn't see it) and lip reads the word. The SLT guesses what the word is. This could be stepped up to simple sentences.

• Aims: To work on - over-articulation and facial weakness (with facilitative tapping) while giving novel feedback.