Category: Advancing Modules

Multidisciplinary team meeting notes

VINCE McLANACHAN

Medical: Patient complaining that he can’t see out of his left eye

Occupational Therapist: During self-care session, patient missed items on his left

Physiotherapist: Patient independently mobile but very cautious when going through doorways

Dietitian: Getting adequate nutritional intake

Nurse: Patient startled when approached from his left. Family report that Vince has problems with reading and watching TV in the dayroom

Plan: Continue assessment
NIGEL SMITH

Medical: Patient reports no particular problems and wants to go home

Occupational Therapist: Patient ignored everything to his left side when in OT kitchen

Physiotherapy: Patient bumps into doorways with his left side. Poor safety awareness

Dietitian: Unsure of food intake, food charts to be completed

Nurse: Patient needs help with washing and dressing, not turning to left side. Family are concerned that Nigel doesn’t look at them and keeps looking to his right

Plan: Continue assessment

Case 1: Vince and Nigel

Vince and Nigel together

Meet Vince and Nigel

photo portrait of Vince

Vince is a 64-year old widower. He is currently unemployed. His hobbies include walking his dog and he enjoys betting on the horses.

photo portrait of Nigel

Nigel is 68 years of age. He is a married man and has been retired for 3 years. He is a keen golfer and reader.

Both Vince and Nigel have been admitted to the acute stroke unit with right hemisphere strokes and seem to be demonstrating similar symptoms. Nursing staff report both patients to be less responsive if approached from their left. This has also been noted by their visitors. These concerns are discussed at a team meeting.

Introduction (ii)

Vision is our dominant sense. It helps us to gather information about the world around us and to carry out our daily living activities effectively. We need to both receive and interpret visual information for normal visual functioning to occur. Following a stroke, several visual problems can occur depending on the site and size of the lesion.

Warren (1993) provides a hierarchical framework for the assessment and treatment of visual skills in which each skill level is dependent on those below it. This highlights the need to assess basic visual functions (at the bottom of the pyramid) as they form the foundation for the higher visual processes.

Reproduced with permission from the creator of the hierarchy Mary Warren PhD, OTR/L SCLV, FAOTA. Associate Professor Emerita of Occupational Therapy at the University of Alabama at Birmingham (UAB); visAbilities Rehab Services Inc.

Learning points

Core competency 11 – ‘Change in Vision‘ introduces vision after stroke.

This advancing module focuses on four visual problems which are commonly seen after a stroke. You will work through three scenarios covering visual field loss and visual neglect, visual perception and eye movement problems.

On completion of this module you will:

  • Have knowledge of visual problems following a stroke
  • Have knowledge of assessment methods and screening processes for visual problems after a stroke
  • Recognise the importance of the identification and differentiation of different visual perception problems which have similar presentations, but may have differing origins and treatment requirements.
  • Understand the impairment and functional limitations which may occur with different visual problems
  • Have knowledge of the referral pathways for visual assessment and interventions after a stroke
  • Have an understanding of the treatment approaches and strategies which may help people with visual problems after a stroke
  • Have knowledge of the professionals and services who can help people with visual problems after a stroke

Introduction

Introduction - Speech bubble

Module authors

Dr Christine Hazelton, Optometrist (Ophthalmic Optician) & Research Fellow, NMAHP Research Unit, Glasgow Caledonian University

Group members

Darren Brand, Senior Orthoptist, NHS Ayrshire and Arran

David Logan, Senior Visual Rehabilitation Specialist, Visibility Scotland

Dr Monika Harvey, Associate Professor, School of Psychology, University of Glasgow

Thérèse Lebedis, Consultant AHP / Occupational Therapist in Stroke, NHS Grampian

Serena Battistoni, eLearning Interactive Content Developer, Chest Heart & Stroke Scotland

 

Advisor

Charlie Chung, Rehabilitation Manager/Stroke Specialist Occupational Therapist, NHS Fife

This module was originally developed by:

Module lead

Thérèse Lebedis, Consultant Occupational Therapist in Stroke, NHS Grampian

Group members

Darren Brand, Senior Orthoptist, NHS Ayrshire and Arran.
Charlie Chung, Clinical Specialist Occupational Therapist, NHS Fife
Pauline Halliday, Clinical Specialist Occupational Therapist, NHS Lothian
Monika Harvey, Associate Professor, School of Psychology, University of Glasgow
Christine Hazelton, Optometrist (Ophthalmic Optician), NMAHP Research Unit, Glasgow Caledonian University
David Logan, Low Vision Coordinator, Visibility

Critical readers

Prof Martin Dennis, Professor of Stroke Medicine, University of Edinburgh
Dr Nadia Northway, Programme Organiser, Glasgow Caledonian University
Dr Fiona Rowe, Senior Lecturer, University of Liverpool
Margaret Somerville, Director of Advice & Support, Chest Heart & Stroke Scotland
Dr Ailie Turton, Senior Research Fellow, University of the West of England

12: Vision after stroke

Introduction

On completion of this module you should have a critical understanding of 4 visual problems which are commonly seen after a stroke:

  • visual field loss
  • visual neglect
  • visual perceptual disorder
  • eye movement problems

The answers to all the test questions are contained within the module. This information may be provided in the ‘Additional Information’ boxes on some of the pages.

 

Conclusion

Conclusion - Completed jigsaw

Having completed this module the learner should now know about:

Clinical research

  • Asking and answering questions to improve stroke care
  • Different types of studies for different types of questions
  • Randomised Controlled Trials (RCTs) being the best for determining whether a treatment works or not

Evidence

  • Synthesising the results of relevant research
  • The Cochrane Library

Evidence based guidelines

  • How evidence based guidelines are developed and know about levels of evidence

Clinical standards

  • The seven national stroke standards
  • The Local Development Plans and Stroke Improvement Plan for stroke unit admission

Clinical audit

  • The Scottish Stroke Care Audit (SSCA) and how to access reports
  • Interpreting the reports on performance

Service improvement

  • The Managed Clinical Network (MCN) and its role in quality improvement
  • How audit data can be used to drive improvements
  • Priorities from Better Heart Disease and Stroke Care Action Plan
  • Local action plans including training and education

High quality care for all

  • Delivering quality care to all patients in line with standards/guidelines
  • The individual’s contribution to improving the quality of stroke services
  • Raising unanswered questions and facilitating research

Topic Loops:

Key Messages

  • All patients should have their swallow screened following an acute stroke. This should be carried out within 4 hours of admission to hospital and before food/ drink/ oral medication, using a standardised assessment method to identify any difficulty in swallowing safely.
  • It is important that the result of swallow screening is clearly documented in the patients’ medical records.
  • Swallow screening should be carried out in whichever ward/ area the patient is admitted to and should not be delayed until the patient is admitted to the stroke unit.
  • The stroke unit team should be contacted to carry out the swallow screen if no appropriately trained person is available on the ward.

Outcome

Over the next few months Nurse Bond and colleagues continued to implement their local action plan and received monthly reports from the SSCA. The graph below shows the improvements they made in the number of patients who were swallow screened within 4 hours of admission to hospital.

A graph that shows Scottish Stroke Care Audit performance against NHS QIS Standards for aspirin

Quiz

Q.Which of the following would improve performance against the swallow standard? Select True or False for each one.