We started off our day by going to get a patient who has been at the facility for about a week. They usually go out to smoke breaks during the day so it's always easier to get them in the morning before all the day's activities begin. As we were bringing them to our office to do their therapy we were informed that they were being transferred today to a memory care facility elsewhere. Obviously at that moment the nurse who told us made a mistake because the patient did not know they were being transferred today, they said that they thought their wife was going to come in and talk about it and make a decision today. They didn't respond well to this new news that was brought to their attention and since they were supposed to be leaving today we weren't supposed to do therapy with them. We took the patient back to their room and they were very upset about the whole situation and mentioned how they just wanted to go home and didn't want to be locked up anymore. We sat down with them and tried to explain why it would be good for them to go to the other facility rather than staying at Heartland. This patient had a stroke which ended up causing damage in their frontal lobe of their brain; this clouded their thinking and their ability to make decisions and understand what they were doing. Over the weekend they got out a door and fell during the night and hurt their head badly and had a few scrapes and bruises elsewhere. They don't have 24/7 surveillance on them and that's what they need right now. Heartland can't offer 24/7 surveillance for the patient so it'd be a safer option to go to this other facility that specializes in recovering front this type of damage done to someone's mind. Safety of the patient always comes first and in this case the patient isn't safe at Heartland and isn't being offered all the care they need in order to recover faster. Each recovery center has a purpose and sometimes people have to go to multiple in order to receive full care and being able to recover faster and get back to their lives before their accident or whatever medical problem they have to recover from.
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Today I got to observe estim being done on a patient, estim is the same thing as NMES that I explained in one of the blogs before this. It allows the patient to receive therapy for their swallowing in order to increase their results and their swallowing strength at a faster pace. On the other hand my mentor's, Diane's, co-therapist was working with a new patient today while I was in the room. The patient had lived on the top floor of the facility for awhile but, when they first got to the facility they weren't in need of speech therapy. They had started to develop some form of dementia overtime and were ordered to speech therapy to do an evaluation on the patient and decide if they should begin to receive speech therapy or just keep living how they were before. Since the patient had many signs of advanced dementia the speech crew decided to put them on their case load and try to see what they could do to potentially help the patient. Today was their first therapy session and they did puzzles during it but, at different times during the therapy the speech therapist would ask them questions like: What day of the week is it? Do you know what month it is? How about the year could you tell me what year it is? What is your room number? The one question the therapist kept repeatedly asking was, What is your room number? Every time they were asked that question they would say I don't know and start kind of laughing. The question was asked to them about 15 times during the 45 minute session. Finally, at the end of the session they were able to answer the question with 53 which was close to what the real answer was which is 63. That would be a small success and a sign of progress being made. By asking a patient with dementia simple questions you're able to work their mind a little and get the wheels turning in their brain. This was just so interesting to me because even though the person was asked the question so many times and then given the correct answer right after they said I don't know they were able to forget the answer instantly as they went back to the activity they were working on. I did a little bit of research during one of my last intensives about dementia but in the future I would want to deeply research the subject and really understand how dementia affects someone's brain in different ways. When working with a dysphasia patient your main goal is to improve their swallowing strength in order to make sure no food gets into their airway. You may wonder how a speech therapist strengthens someone's swallowing, is that even possible? It is possible and is done by using Neuromuscular Electrical Stimulation (NMES). Neuromuscular Electrical Stimulation is used to treat dysphasia by administering small electrical impulses to the swallowing muscles in the throat through electrodes attached to the skin. The patient exercises their swallowing muscles for periods up to an hour while receiving concurrent electrical stimulation. The electrical stimulation when applied in this manner accelerates muscle strengthening and increases the effectiveness of the exercise therapy. With the patient they do this swallowing exercise every day and a more advanced one every other day in order to speed up the process so they can get back to eating all foods as soon as possible. The patient makes progress throughout the treatment but results don't show up for awhile depending on what their swallowing strength was before they started treatment. A person's brain is like a maze in a weird sort of way. One of the patients today asked my mentor, Diane, this, "Why do you give me all these mazes to do? They don't do anything but make my head hurt." Diane's response was, "They are supposed to help your cognitive thinking and increase your memory." The patient then responded with, "If you really think about it our thinking is just like a maze itself." This really opened my mind to a new understanding of how our brain actually works. There are so many parts of our brain and each functions in their own special way but if one is hurt or doesn't work as well as it should it affects the rest of the brain and how it functions. For example, some of these patients memory isn't the best this causes the way they process stuff to be different than it was since they can't retain information the same way they did before. This one change in the brain caused other problems in the rest of the brain as well so by receiving therapy you don't just improve one part of your brain you improve how it functions as a whole overall. Our brain is one of the most complicated things and is one of the hardest things to rehab or fix. My mentor was only going to come in for a half day today and was only going to see 3 or 4 patients so I decided to take a day and reflect on what I've experienced these last two weeks and research some more on certain topics I was interested in that involved speech therapy. A topic that kept coming up throughout the two weeks was cognitive thinking. I already mentioned cognitive thinking in some of my earlier blog posts but I want to go into more depth of what it actually is and how you implement it into speech therapy through daily exercises of the brain. Cognitive thinking is used to improve a person's memory and understanding of something that it being said to them. For speech therapy at HOP we use worksheets that make people use cognitive thinking in order to work their brains and hopefully improve their memory or understand things in a quicker way. These worksheets range from unscrambling words to doing word search puzzles. Some worksheets are easier and are for people who are beginning to work their brain for the first time while some worksheets are harder for people who have been doing speech therapy for awhile and have become more advanced and need more of a challenge for their brain. These worksheets are unique to this speech therapy at HOP I haven't been able to observe other places but they found all of their own worksheets and have added or taken away some to adjust to what works best and shows the most results. I also dug more into swallow studies; I had a whole blog earlier dedicated to this subject since I was able to observe one live. It caught my attention as well so I did more research on that topic and will be talking about it in my final presentation as well. Today was a research day which was needed so I could understand more of what I'm observing and experiencing which will help me present it in a more understanding way.
Beginning speech therapy with a new patient is complicated and requires a lot of concentration and making sure you pay attention to everything the patient is doing. You have to pay super close attention because you have to note certain behaviors that they have; these behaviors might cause problems in the future during therapy. For example, today was a patients first speech therapy session since their evaluation so we started off by giving them simple pattern games where they had to fit certain shapes into a traced out sheet/outline. You could tell during the entire therapy session that the patient had a bit of anxiety which was causing them to be jumpy and worrying about everything which took their focus away from the therapy they were supposed to be working on. Concentration wasn't there so effort wasn't very present either. This behavior is noted and sent along to nurses at the facility in case a medical change should be made because of this. For example, if someone is already on medication for anxiety and they have the behavior like the patient did today then the nurses might increase their anxiety medication in order to make the patient more relaxed and be better overall in their daily activities such as speech therapy. Paying attention to a patient's behavior is very important no matter who you are or what your job is in the facility because if you don't know what's going on with the patient you can't help them and the only reason they're at the facility is because they need other people's help. I got to observe a swallow study today also known as a FEES which is seen as the medical side of speech therapy. A swallow study consists of a small tube with a camera on the end of it that is being put through your nasal cavity all the way down to your throat near the esophagus and vocal chords. A swallow study is used to see if a patient should have their meal plan changed because they have swallowing issues that pose a threat to their safety because choking could become a frequent hazard. To test a patient's ability to swallow the speech therapist doing the procedure gives them three different cups of water that have three different consistences, to sum it up thin to thick liquids. They also test how the patient does with a liquid food like apple sauce, a half liquid half solid food like a fruit cup, and a dry food like a cracker. All of the food and liquids that are tested are colored blue or green prior to the procedure in order for the speech therapist to be able to see if any of the food or liquids is getting stuck in the patient's air way after the action of swallowing. If food or liquids gets stuck in the patient's air way we have a problem and a threat to the patient's safety. How the problem is addressed is usually a diet change in the best interest of the patient and therapy might be recommended in order for the patient to strengthen their muscles in their throat to be able to swallow in the future and get back to a regular diet when eating. The speech therapist works together with the dietitian of the patient who is having trouble swallowing certain things in order to make adjustments specific for the patient and in their best need. In this case the patient today was having a hard time swallowing a thin liquid such as water. They were slow when swallowing so they would end up having the liquid go into their air way since they couldn't swallow fast enough to stop it. You could see small traces of the colored water left in the air way of the patient in between the vocal chords when we were doing the procedure. After we got the final results from the speech therapist that came in to do the procedure we were able to make a plan for the patient and figure out what further actions needed to be taken in order to improve their swallowing ability. I didn't only get to witness a swallow study today I also got to witness a new patient evaluation. When a new patient is admitted or referred to speech therapy the first time a speech therapist sees them they do a whole evaluation of everything the person can do and so on. They ask a lot of questions about what happened to the patient in the past medical wise like if they had a stroke a few years ago or some other medical problem. They then move on to evaluating their mind by giving them simple directions to see if they are able to follow them or if they have trouble remembering them. There is a speech portion of the evaluation as well to see if they slur their words or anything like that but I wasn't able to observe that portion of it but, I'm hoping to see another in the remaining time I have shadowing. Here is an example of a swallow study during the procedure. If you don't like gross images don't watch this video https://www.youtube.com/watch?v=l8eICovpb28 In order to work a patients mind who wants to increase their memory skills or being able to retain information quicker we promote cognitive thinking. Cognitive thinking is when a person uses their cognitive inputs in their brain to be able to piece together and create an understanding of something. For example, when you're given letters in a different scrambled order and are told to rearrange them to make a word you use your cognitive inputs in your brain to make an understanding of what word you can spell out of the words you were given. Cognitive skills are used to comprehend, process, remember and apply incoming information. During my time at HOP so far I have been able to see patients work a lot over the past few days with cognitive thinking. They do puzzles where they are required to put certain shapes of specific colors in an outline or they do worksheets like the example I gave above to help work the mind. These tasks challenge the patients mind and requires them to use different parts of their brain to find the answer they are looking for and complete these tasks efficiently and correctly. Cognitive thinking is something that is super interesting but, super complicated at the same time. I'm fascinated to see by the end of this observation study if any of the patients have made progress in their memory retention. At Heartland of Perrysburg they have two floors in their facility where patients stay. The top floor is mostly all patients who have stayed at HOP for a long time, it's more like a nursing home where people plan on living there until the end. The bottom floor is all patients who have just had a stroke or just got a surgery and don't have people at home that are able to care for them in every way they need. Some of these patients have families but, their families aren't able to give them 24/7 attention and care at the time so they stay at HOP until they are able to go home and care for themselves on their own or just need a little assistance. These patients tend to stay for short periods of time and then leave after and don't receive therapy anymore after they leave. This tends to be a problem for speech therapy because most of our patients are people who are living downstairs and are only at the facility for a short amount of time. If we're lucky the patient will make a little bit of progress over the small amount of time we spend with them in therapy. The hard part is making sure they continue to work their brain when they are sent home because most people just stop working on helping bring back their memory or strengthen it once they go home. They have no motivation to keep working on those type of things by themselves. There are a small amount of patients though who do work on it when they go home but they are more motivated than others. We can only help them as much as they want to help themselves, we can't force them into wanting to get better. When patients come to Heartland of Perrysburg they're evaluated by someone right away so that they can be put into worker's schedules for therapy or specific instructions for how they eat, etc. Some patients are ordered/referred to speech therapy for issues with swallowing, Speech therapists don't only work with people to improve their speech and memory they also look at how people swallow, this is the medical side of speech therapy. Most people tend to think that a speech therapist only works with people who have a lisp or a speech impediment but, as I mentioned before they do so much more and work with so many people not just younger people. Speech therapy tends to people of all age.
Heartland of Perrysburg is one of the facilities that takes all patients with medicaid and medicare. Most of their patients that are admitted were homeless or living on the streets by themselves before they came to HOP. They didn't have anyone to help them with medical issues they were having or anyone to just take care of them so that's why they are at HOP now. A good percentage of our patients at speech therapy have these backgrounds of living by themselves. Most of these patients that were living on their own without a home had strokes a few years ago and didn't get treated in any way for it because they didn't have anyone to tell or be helped by. These untreated strokes lead to the patients having trouble with their memory and now they're with us in speech therapy to try and retain some of their memory back from what was lost. For example, there is the one patient who had a stroke in his 50's but didn't get any help to recover from it afterward because he was living on the streets by himself, he has no family at all also. Their memory was affected heavily by their stroke that they had so we are trying to work with him now in hope that maybe some of the memory he had lost may come back even if it is a small amount. This problem tends to keep reoccurring with people today especially these patients at HOP. It's a sad thing but, we are trying to help these people in any way we can. |