Reflective log - MDT working and trismus

1. Think of a recent therapy session or event.

I assessed a 48 year old patient who had had a left sided pontine bleed and presented with a moderate flaccid dysarthria and LMN facial weakness involving the upper and lower portion of her face on her right side.

I was unable to explain the patient’s trismus (jaw opening to a max of 12mm) by looking at her neurological symptoms. The patient’s jaw also deviated towards her right (weaker) side when depressed. I developed an exercise program including resistance jaw exercises and stretches to alleviate the patients trismus. After 2 months the patient was able to activate muscles on the right side of her face but her jaw trismus had not changed. I organised a joint session with the lead physiotherapist who thought that jaw muscle massages, stretches and neck stabiliser exercises in lying might help. I contacted the botox team to see if they would consider looking at the patient’s jaw, however they stated that they would not look at jaw’s. Eventually I asked a doctor to refer the patient to the maxillofacial department.

2. Describe the session/experience

I accessed support from multiple specialists concerneing the patients jaw. In the maxillofacial appointment they stated that the patient’s trismus was likely to be due to a fracture when she fell onto the pavement after having her stroke.

3. What did this session make you feel?

I felt that I should have referred the patient to specialists sooner since trismus is not one of my areas of expertise. I also felt that it was important to evaluate whether the patient had achieved the goals we set (to be able to fit a malteser into my mouth) in order to consider whether I needed to change the therapy plan or seek an expert opinion. The medical team had missed the jaw fracture as well and I think that it was important to consider the patient’s quality of life, as this is something I would not normally work on directly in therapy.

4. What has this session has taught you?

 - To look for expert opinion in the MDT.

 - To consider the impact of impairments on a patient’s quality of life.

 - To keep the MDT up to date on the progress of my therapy programs and what I work on in therapy.

Reflective log - personalised cuing therapy

Reflective Log 17.04.13 – Personalised cuing therapy

1. Think of a recent therapy session or event.

The patient I had a session with had a severe expressive aphasia and moderate receptive aphasia. He was able to generate single words and some sentences but this was very effortful for him. I had a joint session with his son (who he lives with).

2. Describe the session/experience

I did not fully assess the patient as he was unlikely to engage with formal testing and was likely to have extreme difficulties with expressive language tasks. I assessed his ability to read single words by using written words e.g. days of the week, to support the patient with answering autobiographical and orientation questions. I also informally assessed his comprehension by observing a functional cognitive screen and having a conversation with the patient and his family. I printed out picture symbols and written words to support the patient during conversations. The patient was able to access AAC (written words and picture symbols) for comprehension and expression. However during a family meeting and outside of therapy sessions e.g. in groups, the patient refused to use AAC.

I interviewed the patient’s son asking for 12 words that would be functional for the patient at home and then created personalised semantic prompts for each word. E.g. Target: football, Prompts: your son has a pub team called army and navy, you coached ….. at hackney fields, you support Millwall. I included sentence completion cues and phonemic cues. The patient was able to name half of the words with the cues and engaged with the activity. I handed over to the patient’s son that he could continue the activity.

3. What did this session make you feel?

I felt out of control when the patient refused to use AAC support to communicate during the family meeting. I had not considered that the patient would want to concentrate on who was talking to him in the family meeting and not on the key words I was writing or my attempts at facilitating his communication. Once I knew that the patient was reluctant to use AAC functionally I was able to plan for a functional therapy program around speech.

4. What has this session has taught you?

I would visit the patient before the family meeting to explain what would happen and to hand over any important information. This may have helped the patient to feel prepared and they then might have accepted some support to communicate. I have also learnt that involving the patient in choosing therapy targets and interviewing the patient’s family to find out what would be functional for them is essential in order to engage a patient in therapy.

Continuing Care Panel CCP

Continuing Care Panel

Continuing care – care provided over a period of time to meet physical and mental health needs that have arisen due to disability, an accident or illness.

1.     Continuing care + Social care – care available in a variety of settings which may include NHS/ social services. It is described as a joint package of continuing care. The care provided by social services is means tested.

2.     NHS Continuing Healthcare – complete package of onoing care arranged for and funded by the NHS. Free. Can be delivered in your home or in a nursing home. The primary care trust (now GP commissioning consortia – so which area your GP is located in matters) is responsible for deciding your elegibility.

A Department of Health document – provides guidelines on assessment and elegibility for continuing care. All GP consortia should use the same paperwork.

Eligibility for Continuing care

Depends on…….

1.     Nature  - type of needs – effect on health/well-being

2.     Intensity – extent(quantity) and severity (degree of needs).

3.     Complexity – Knowledge/skill needed to monitor + manage care.

4.     Unpredictability – changes in care that are difficult to manage.

We consider eligibility when a patient is near discharge and the picture of their long term needs is clearer, or when their needs are being reviewed.

3 tools are used:

-       consent needs to be gained from the patient or their family for this process (or lasting power of attourney).

-       Patients can be fast-tracked for a quick decision when near the end of their lives.

1.     CCP checklist – determines if a full assessment is required. Full Ax = a) high levels of need in 2 or more areas, b) Moderate levels in 5 or more domains or 1 high and 4 moderate, c) 1 high level of need in a priority level on the DST.

2.     Decision Support Tool – Supports decision making by providing evidence, and focuses on health. 12 areas of need with a 6 point rating scale from – no need to priority. 1. Behaviour 2. Cognition 3. Psychological/emotional needs 4. Communication 5. Mobility 6. Nutrition 7. Continence 8. Skin 9. Breathing 10.Drug therapies/medication 11. Altered states of consciousness 12. Any other needs – the MDT completes the DST and puts down all the supporting evidence/ observations.

3.     Health Needs Assessment – brings together all of the information – this is then presented with the DST and a social work assessment of need to a continuing care panel.

Areas specific to SLT

Communication

-       Ability to communicate basic needs consistently – if not present these needs need to be interpreted by skilled members of staff.

-       Verbal/ non verbal

-       Ability to understand instructions, follow directions and participate in activities of daily living.

Nutrition

-       PEG or NG – need skilled staff members to administer a feeding regimen

-       Dysphagia – how safe? How much supervision/ support required.

-       Risk of malnutrition/ dehydration

An Example summary:

The patient will require support with her feeding, her PEG feed, medication, all personal care, care of her pressure areas, toileting and medication. The patient regularly wanders and is at risk of falling. For these reasons the patient will require 24 hour care and support from nurses to feed her via her PEG and administer her medication and support from carers trained in working with people that have severe cognitive impairments. The patients care needs can fluctuate for example she may increase her wandering at times or may develop swollen feet and pressure sores due to sitting in her chair too long. The patient benefits from a toileting regime and monitoring of her oral intake. She is able to engage in some activities in a limited manner, for example with gardening. The patient is at risk of developing a low mood if she is not supported to engage in activities. The Multi-disciplinary team recommends NHS funded nursing care to ensure that all of the patients needs are met. 

Feedback from my supervisor:

- Supply the following information

Nature  - type of needs – effect on health/well-being

2.     Intensity – extent(quantity) and severity (degree of needs).

3.     Complexity – Knowledge/skill needed to monitor + manage care.

4.     Unpredictability – changes in care that are difficult to manage. 

  - Be specific about what type of care you recommend and why.

- - Give examples

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Dysphagia competency 4

Here's a case history performa i've developed for one of my dysphagia competencies:

Case History

Interview Questions (Patient/family) 1.     Do you choke or feel any discomfort when eating/drinking? 2.     Does it feel like food gets stuck when you swallow? Where? 3.     When did your swallowing problem begin? 4.     Has your swallowing gotten worse, better, or remained the same? 5.     Do you have any problems swallowing particular foods/ liquids? Which ones? 6.     Is there anything that helps your swallowing?

Medical Information 1.     Diseases/ surgery/ history of dysphagia (Parkinson’s, stroke, cancer)? 2.     Pulmonary status (intubation? Tracheostomy/COPD/pneumonia)? 3.     Current nutritional intake (Nil By mouth, NG-tube, PEG) 4.     Medical status (SpO2 level <90, respiration rate 40+?, activity level?) ·   SpO2 Level (<90?) ·   Respiration rate +40? ·   Activity level (bed bound?) ·   Weight loss/ dehydration/ malnutrition 5.     Cognition/ mental status - ability to cooperate (alertness, orientation, memory, language, neglect). ·   Naming ·   Orientation Q’s ·   Reproducing drawing ·   Simple commands ·   Alertness

Reflective log: Next of Kin

1. Think of a recent therapy session or event.

I had a meeting to decide the next of kin for a patient who had severe language impairments. The patient had had a LMCA infarct and presented with global aphasia. On impairment based assessment (picture/ object naming etc) the patient did not perform well. He was able to match objects to pictures and understood single words. He was inconsistent with 2 and 3 stage instructions. However in context the patient laughed appropriately at jokes and appeared to understand some conversation in context when given gestures. I had a meeting with the patient’s nephew, his nephew’s daughters, the OT, the discharge coordinator and the carer support worker.

2. Describe the session/experience

I gave feedback on the patient’s communication and fed back the results from my language assessments. I gave examples e.g. he laughs appropriately at jokes in context and he was not able to match spoken sentences to pictures. I then answered questions on whether I thought the patient had capacity, stating that I thought he had capacity for decisions which were simple, concrete and in context. I gave the patient an object of reference (his house keys) and asked him who he wanted as his next of kin, having his nephew on his left side and a picture of his niece on his left side. I asked the question in different ways and the patient responded consistently.

3. What did this session make you feel?

I felt under pressure to make a decision that could have a large impact for the patient. I decided to break down the information I did know and apply it to the new situation, being clear that I thought the patient had capacity for some specific situations.

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

- introduce the topic to the patient before the meeting.

- get a second opinion from the psychology team.

5. What has this session has taught you?

- Give examples of the type of decisions I feel a patient can make.

- I can use objects of reference/ total communication to support a patient’s comprehension during a capacity assessment.

- Carer support workers have a lot of knowledge about NOK, power of attorney, paying bills etc.

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

- Capacity – do more research on this.

- Next of kin – the powers

- Power of attorney – what this means and how you go about getting this. 

Capacity Assessments

Key areas needed for capacity:

1. Understand the information.
2. Indicate a clear Yes/No response.
3. Weigh up the impact of the different choices.

Often weighing up the necessary information is the most difficult for patients since it involves abstract thinking.

Advice from my supervisor:

• Decide if a patient has capacity as a MDT e.g. you might not know enough about the consequences of a decision.
• Ask the same question in different ways.
• You can only decide if a patient has capacity for a single decision/ question, capacity may be different for different decisions.

Mental Capacity act 2005

The mental capacity act aims to:

Ensure that people are given appropriate help/ support to enable them to make their own decisions.

-        Assist and support those who might lack capacity

-        Discourage those who care for them from being overly restrictive/controlling

-        Balance people’s rights to autonomy with safeguards for person’s who do not have capacity.

 

Core principles

-        The person is assumed to have capacity – the assessor needs to demonstrate a lack of capacity.

-        Attempts need to be made to allow the patient to participate in decision making.

-        If a patient does not have capacity whatever decisions are made must be in their best interests (considering  their ‘past and present wiehes/ feelings’, consulting relevant others).

What is a lack of capacity?

1.     Lack of capacity is decision specific e.g.  a patient may have the capacity to: Make decisions about some treatments but not others.

2.     Mental capacity fluctuates from time to time. Therefore we have to identify the optimal opportunity to discuss things with the patient.

 

Lasting Power of Attorney (LPA)

-        Enables people to appoint attorneys to make personal welfare decisions (including healthcare and medical treatment decisions) on their behalf for a future time when they might lack capacity.

-        Different people (attourneys) may be appointed to take different decisions e.g. finantial vs. health.

-        Example decisions: about: where the donor should live, day-to-day care, giving/refusing consent to a medical examination/treatment.

-        Is unable to consent/ refuse a treatment for the donor if the donor is able to make a decision.

-        An attorney has no power to consent/ refuse life sustaining treatment unless the LPA document explicitly says so and cannot demand treatments the medical team does not believe are clinically necessary.

Is the clinician liable for the decisions they make?

-        The act ensures that health/ social care staff receive statutory protection from liability for certain acts as long as they can prove that they were in the patients best interests and carried out in accordance with the principles of the act.

-        Clinicians are not protected against negligence e.g. do something in the patients interests but in a negligent fashion.

 

The court of protection

-        Takes on all of the decisions related to mental incapacity.

 

IMCA Independent Mental Capacity Advocate

-        Provide independent safeguards for people who lack capacity to make certain important decisions and have no one close to them.

-        Appointed in 2 circumstances: 1. When a serious medical treatment is being proposed, 2. Where there is a proposal to arrange accommodation/ change accommodation.

Factors that affect capacity

-        Fatigue – keep sessions short, allow for rest periods, choose the time of day when the person is at their best.

-        Complex language – simplify.

-        Amount of info – provide only relevant info

-        Cultural/ ethnic/religious factors – consider whether someone else could assist e.g. a member of a community group/ religious group.

Reflective log: Discharge 08.05.13

1. Think of a recent therapy session or event.

I had a discussion about discharge with a patient. This patient had a LMCA infarct in his non-dominant hemisphere causing a mild flaccid dysarthria and facial weakness and some mild cognitive communication impairments. I completed the LA- trobe questionnaire with the patient and his partner. The patient and his partner identified: going over and over the same ground in conversation, and carrying on talking about things for too long in his conversations as key communication attributes that had been exaggerated by the patient’s stroke. The patient reported that premorbidly he had a tendency to be verbose when he was anxious and to repeat information. The patient also worked as a lecturer and as a performing musician. The OT and physiotherapist reported that the patient was unable to multitask and that when he talked too much and repeated information he was less productive in therapy.

2. Describe the session/experience

I spoke with the patient about speech and language therapy. The patient formed communication guidelines in his own words about how he would like therapists to give him feedback when his communication was disrupting sessions. I then spoke to the patient and we agreed that he would come to communication and newspaper group and would complete some facial weakness/ sensation exercises (for a very mild right facial weakness) but would be discharged from SLT.

3. What did this session make you feel?

I felt that by involving the patient in his discharge I was able to address his concerns and give him the information he needed about his condition.

5. What has this session has taught you?

- To consider which is the best setting to work on cognitive communication difficulties and perhaps discharge patients if I feel SLT input is not appropriate in this setting.

 – if they do not impact on therapy perhaps they are best worked on in a rehab rather than acute units or in the community.

- To ensure that the patient is able to access therapy and that their communication is not negatively impacting on other therapies (e.g. OT/PT).

- To get extensive pre-morbid communication information on patients with suspected cognitive communication impairments.

Dementia - Eating and drinking guidelines

Currently i've been working with a few patients who have late stage dementia and are developing dysphagia. I've been researching some general eating/drinking advice for patients with dementia:

• Try to keep the eating environment calm and free from distractions.
• Feed at times of the day when the person most alert.
• When giving meals encourage positioning which is most comfortable for the individual and facilitates safe swallowing.Consider appropriate nutritional supplements in addition to high calorie meals, snacks and drinks.
• Where possible facilitate self-feeding (hand over hand support).
• Prompt/ give small mouthfuls/sips.
• Allow the person to see the food/drink and warn them what is happening e.g. this is apple juice, i'm going to give you a sip.
• Use foods/dinks that are strongly flavoured e.g. cranberry juice/ lemon juice, or those that are hot or ice cold as these can stimulate a stronger swallow response.
• If the person does not open their mouth, try: - verbal prompts to open their mouth - tactile cues to help them open their mouth by resting the spoon/ spout on their lower lip.
• Ensure the person has swallowed before offering another mouthful.
• If the swallow does not happen, try the following: - verbal prompts to swallow - gently massaging under the chin in a front back motion as this may encourage a swallow - an empty spoon. This may help to stimulate a further swallow as they will think they have had another mouthful of food.