Category: Advancing Modules

Training and support for conversation – partners

In the early stages of rehabilitation, the SLT meets with Steven and his family to provide information for supporting conversation and to begin conversation partner training.

Steven’s youngest son Michael discusses that he struggles to communicate with his Dad. Steven and Michael both end up feeling frustrated at times.

The SLT provides information about aphasia and the communication strategies and resources that can be successful in supporting conversation and connecting with each other.

Through a series of meetings, Steven and his family practise and discuss these strategies and techniques with the SLT.

Watch the video and observe how, by using some basic supported communication techniques, Michael and Steven’s interaction changes.

Calculating the correct dosage

Angela’s weight is 58 kg. Using the chart below calculate the correct IV bolus and infusion dose for Angela.

Body Weight/Drug Dosage Chart for Alteplase 1mg/ml
Body Weight (Kg) Approx. Body Weight (Imperial) Total rTPA dose (mg) IV Bolus 10% of total dose (ml) IV Infusion 90% of total dose (ml/hr)
40 6st 4 36 4 32
42 6st 8 38 4 34
44 6st 13 40 4 36
46 7st 3 41 4 37
48 7st 7 43 4 39
50 7st 12 45 5 40
52 8st 2 47 5 42
54 8st 7 49 5 44
56 8st 11 50 5 45
58 9st 1 52 5 47
60 9st 6 54 5 49
62 9st 10 56 6 50
64 10st 1 58 6 52
66 10st 5 59 6 53
68 10st 9 61 6 55
70 11st 63 6 57
72 11st 4 65 6 59
74 11st 9 67 7 60
76 11st 13 68 7 61
78 12st 3 70 7 63
80 12st 8 72 7 65
82 12st 12 74 7 67
84 13st 3 76 8 68
86 13st 7 77 8 69
88 13st 12 79 8 71
90 14st 2 81 8 73
92 14st 6 83 8 75
94 14st 11 85 8 77
96 15st 1 86 9 77
98 15st 6 88 9 80
100 15st 10 90 9 81
> 100kg, use 90 mg maximum

The thrombolysis is started.

The next stage

Giving thrombolysis treatment – Alteplase

Patients admitted with stroke within four and a half hours of definite onset of symptoms who are considered suitable, should be treated with intravenous alteplase 0.9mg/kg/body weight, up to a maximum of 90mg (Grade A evidence).

Diluted with sterile water to 1mg/ml 10% of the total dose is administered as an initial intravenous bolus over 2 minutes, the remaining 90% is administered as an infusion using syringe pump over 1 hour.

The thrombolysis dosage is calculated on the patient’s weight, that is 0.9 mg/kg up to a maximum of 90 mg tPA.

To obtain an accurate weight you could:

  • Use a weighing PAT slide
  • Roll the trolley onto portable scales
  • Transfer the patient using a weighing hoist
  • Normal scales if the patient can transfer or stand safely
  • Ask the patient if they know a recent weight
  • Ask their next of kin if the patient is unable to speak
  • Review the patient’s medical records to see if they have been weighed recently

For more detailed information on Alteplase see:

A picture of actilyse

 

Other possible complications

Indicate which of the 5 signs are likely to indicate that Angela has an extracranial bleed or angio-oedema? True or False:

Should Angela be offered thrombolysis?

Clock showing the time at 09:00

Angela is a 65 year old lady who was previously healthy and well. She presented with a right sided facial and upper and lower limb weakness and right homonymous hemianopia. Her blood pressure is 160/90. The CT scan results are below. No contraindications have been identified. Time of onset of symptoms was 7.40am, it is now 9am.

Scan report showing cerebral infarction
The CT scan shows an area of early cerebral infarction in the left hemisphere (see yellow arrows).

There is some swelling, loss of distinction between grey and white matter so that the basal ganglia and cortex are no longer visible. Confusingly grey matter (i.e. parts of the brain where the cell bodies and nuclei of the neurones are) appears whiter on CT scans than grey matter (i.e. the brain tissue made up of the fibres connecting neurones together).

Ischaemic changes occur as a result of a blockage of the blood flow to an area of the brain, which causes brain cells in the area to die.

What does the CTA show?

Angela's CTA scan
This scan shows that both middle cerebral arteries (arrows) are normal

There is no evidence of a large artery occlusion or other abnormality of the extracranial or intracranial vessels.

Select the correct answer below about Angela’s treatment:

Prioritising actions to facilitate early thrombolysis

The CT and CTA have been requested.

Things to do whilst waiting for the CT scan

View text alternative for feedback on each of the priorities.

It is important not to waste time on things which can be done after the thrombolysis has been given.

Resources

Everyone has a role to play in supporting communication and small changes can have a significant impact. Look out for signs of frustration and focus on the techniques that Steven finds helpful. Remember though, sometimes, even with the best resources and effort, supported communication can still be challenging.

Further resources

NES: IPAAKS Informing and Profiling Augmentative and Alternative Communication(ACC) Knowledge and Skills[PDF]  This learning resource is available on TURAS Learn. (NHS Education for Scotland).