MED SLP EXAM 1

Dental deviations include the following:

* Congenitally missing teeth
* Malrotated teeth
* Ectopic teeth (abnormally located)
* Supernumary or duplicated teeth (extra)

Malocclusions include the following:

* Overjet/overbite, often associated with Class II malocclusion (upper teeth protrude    beyond lower teeth)
* Underjet/underbite, often associated with anterior crossbite or Class III malocclusion (lower teeth protrude beyond upper teeth)
* Open bite (teeth do not fully occlude)
* Lateral (buccal) crossbite (lower teeth buccal to upper teeth)

Speech and resonance assessment : Begins with an interview & a perceptual assessment

Parent concerns/observations, medical hx, diagnoses, surgical hx, dev hx, feeding hx, sleep concerns, therapy hx

Speech and resonance assessment: Depending on findings/results

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instrumental assessment may be warranted.

Speech and resonance assessment: Goals of perceptual eval

* Determine dx and possible cause
* Obtain info to make recs/treatment plan 

Speech assessment

Single word articulation tests are not the only part for perceptual speech/VP assessments. Repetition of speech samples is fast, easy and representative.

Perceptual evaluation of Resonance:  Need to determine TYPE of resonance

1. Normal resonance
2. Hypernasality
3. Hyponasality
4. Cul-de-Sac resonance
5. Mixed resonance

Perceptual evaluation of Resonance:

  Determining severity

1. normal
2. mid
3. mild-moderate
4. moderate
5. moderate-severe
6. severe

Severity does not really matter. If the structure is abnormal, it requires treatment. What is MOST important is to determine TYPE of resonance

Error types for children with a history of clefts

* Obligatory
* Compensatory

**Obligatory Errors**

* Correct placement 
* Errors are just related to the structural or functional deficit 
* Oral nasal fistula  - get air leak through their nose 
* May have high arched palate and very crowded jaws, skinny pointed maxilla –  can't produce the /s/ due to lack of space 
* Dental deviation malocclusion
* Can't have correction until the structure is fixed 
* Hypernasality on vowels, liquids, and glides 
* We do not fix them, structure is problem

**Compensatory Errors (compensating)**

* errors in place of articulation or direction of airflow
* Placement is wrong ( I can't make a t k g so I through glottal stops as all stops because they can't get intra oral pressure all goes out nose  ) 
* Build up  and release air pressure in VF 
* Air on intra oral pressure sounds
* Can't make intra oral pressure 
* Can't match what they hear 
* Hearing and cog challenges 
* Try to change into obligatory 
* Replace sounds with stops 
* I can't do sound so I put it somewhere else and compensate

General feeding considerations for infants with cleft lip and/or cleft palate: Mechanics of extraction

* Munching pattern/compression provides compression of nipple (bottle/breast)
* Not effective for efficient extraction
* Suction = negative pressure
* This allows for effective milk transfer from the bottle or breast
* Requires sealed oral cavity
* They cannot do this if they have a cleft lip/palate ^ 
* Unable to seal oral cavity
* Inability to create negative pressure (the suction force)
* Inefficiency w/ milk AKA extraction
* Poor extraction → reduced total intake + increased energy expenditure → failure to thrive

General feeding considerations for infants with cleft lip and/or cleft palate: What you should do

* Feeding optimization 
* Specialized bottles/parent education
* Positioning 
* Caloric management 
* Reflux management

General feeding considerations for infants with cleft lip and/or cleft palate: Role for SLP

* typically evaluates and treats early feeding/swallowing issues 
* Educate nurses, caretakers/parents regarding feeding recommendations including feeding position, appropriate nurses/nipples etc. 
* Recommend further diagnostic testing as needed (MBS, FEES, etc.) 
* role of an SLP from prenatal to adolescence in the care of children with clefts/craniofacial diagnosis

**Appropriate roles for SLPs include, but are not limited to:**

•counseling persons with cleft lip and palate and their families regarding communication- and feeding/swallowing-related issues and providing education aimed at preventing further complications relating to these conditions;

•educating other professionals about the needs of persons with cleft lip and palate and the role of SLPs in diagnosis and management;

•screening individuals who present with cleft lip and palate; determining the need for further assessment and/or referral for other services;

•conducting a comprehensive, culturally and linguistically appropriate assessment of speech, language, resonance, voice, or feeding problem associated with cleft lip and palate;

•diagnosing speech, language, resonance, voice, or feeding disorders associated with cleft lip and palate;

•referring to other professionals to rule out co-occurring conditions, determine etiology, and facilitate access to comprehensive services;

•making decisions about the management of speech, language, resonance, voice, and feeding/swallowing problems related to cleft lip and palate;

•developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria;

•consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate;

•remaining informed of research in the area of cleft lip and palate and helping advance the knowledge base related to the nature and treatment of these conditions;

•advocating for individuals with cleft lip and palate and their families at the local, state, and national levels

•serving as an integral member of an interdisciplinary team working with individuals who have cleft lip and palate and their families/caregivers; and

•providing quality control and risk management.

What is a cleft?

* Abnormal opening in an anatomical structure
* Usually a congenital malformation due to abnormal fusion during fetal development

What are the different types of Cleft Palates

* unilateral
* bilateral
* complete
* incomplete

unilateral cleft

one sided cleft

bilateral cleft

both sides have cleft

complete cleft

cleft that extends through the lip, nostril sill, alveolar ridge, & incisive foramen

Incomplete cleft

* cleft that does not extend all the way to incisive foramen
* microform is one type

different types of atypical resonance

* **Hypernasality**
* **Hyponasality**
* **Cul-de-Sac resonance**
* **Mixed resonance**

**Hypernasality:**

Too much sound production in the nasal cavity while producing n, m, and ng sounds. May cause a low volume due to the reduction of sound through the oral cavity and absorption of sound in the pharyngeal/nasal cavities

**Causes of Hypernasality:**

* Velopharyngeal opening
* Submucous cleft palate
* A large oronasal fistula
* Phoneme specific hypernasality due to mislearning

**Hyponasality**:

A reduced amount of nasal resonance when speaking, specifically on n, m, and ng sounds.

**Causes of Hyponasality**:

* Caused by blockage in nasopharynx or nasal cavity due to:
* allergies
* common cold
* adenoid hypertrophy
* hypertrophic tonsils

**Cul-de-Sac resonance**:

occurs when sound resonates in a cavity (oral, nasal, or pharyngeal) but is “trapped” and cannot exit because of an obstruction (sound is muffled)

* Acoustic energy is blocked from exiting at a cavity’s normal outlet
* Sound cannot be released, so it stays in the cavity and is muffled
* Sound is absorbed by soft tissues
* Low volume

**Causes of Cul-de-Sac resonance**:

* microstomia (small mouth)
* ‘mumbling’: speaking without opening the mouth completely

**Mixed resonance:**

elements of inconsistent hypernasality, hyponasality, and/or cul-de-sac resonance in connected speech

Failure of fusion during fetal development caused by:

* Environmental teratogens
* Mechanical factors
* Chromosomal abnormalities
* Genetic syndromes

Environmental teratogens: __**Teratogen**__

* Chemical agents that can interfere with embryonic development, causing a malformation

Environmental teratogens: Environment

lead, radiation, pollution

Environmental teratogens: Drugs and ingested substances

* phenytoin (Dilantin), valium, corticosteroids, smoking, alcohol

Environmental teratogens: Viruses

* rubella, influenza

Environmental teratogens: __**Maternal nutrition**__

nutritional deficiencies or obesity with diabetes

Environmental teratogens: __**Physical interference**__

Crowling in utero that restricts mandibular growth

Week 4-9 of Embryonic development

* primary palate formation
* frontonasal prominence (FNP)- forms forehead, nose dorsum, and apex
* nasal placodes develop later bilaterally, pushed medially
* paired maxillary prominences- form upper cheek and upper lip
* paired mandibular prominences- form lower cheek, chin and lower lip

Week 4 of Embryonic development

pharyngeal arch (come out of crest cells) formation: first pharyngeal arch contributes mandible and maxilla

Week 7 of Embryonic development

primary palate formation: lip, maxillary processes and frontonasal prominence (nose)

Week 9 of Embryonic development

* secondary palate
* fusion occurs in the human embryo in week 9 of gestation
* this requires the early palatal shelves growth, elevation, and fusion
* many fusion events are occuring during this period between each palatal shelf, to the primary palate, and also to the nasal septum

__**Sequence of development**__

•Before the palate forms, the tongue is in a **superior/posterior (up and back)** position in the nasopharynx

•Palatal shelves of the maxilla are in a **vertical** position on each side of the tongue

•Mandible migrates **down & forward**

•Tongue drops **down & forward** with the mandible growth

•Palatal shelves move from **vertical to horizontal** position, starting with the incisive foramen and moving backward

•The median palatal suture closes from the incisive foramen to the end of the maxilla

•The velum is fused in **midline** toward the uvula

•The oral surface forms **before** the nasal surface of the hard palate and velum

Vital Signs: Body Temperature

measures body temperature

Vital Signs: Pulse Rate

measures the number or heart beats per minute

Vital Signs: Respiration rate

measures the number or breaths per minute

Vital Signs: Blood pressure

Is not considered a vital sign, but is often measured along with the vital signs. This measures the force on the walls of your arteries

Vital Signs: SPO2: Oxygen Level

Measures the amount of oxygen in ones blood

**Nasogastric tube**

* Placed for those who cannot eat by mouth
* Reasons can vary
* We don’t place them, but we work with many patients across the lifespan that have them
* Feeds the stomach directly
* Feedings can be:
* continuous (drips a small amount into the stomach all day)
* Bolus (entire amount given over 30 minutes)

**ND tubes**

similar to NG-tubes, but they go through the stomach and end in the first portion of the small intestine (duodenum)

**Nasojejunal Tube**

* Nose through stomach and into the jejunum of small intestine (further than ND)
* Can’t do bolus or more meal-like feeding

**Gastronomy tube**

* Usually more permanent that “n” tubes
* Directly into the stomach

**GJ tube**

* Tube into the  stomach is the G tube
* The J portion is the jejunostomy tube going into the jejunum

**TPN**

* way to provide  nutrients by bypassing digestive system
* feeding intravenously (through a vein)

 Red blood cell count (RBC):

The blood’s ability to carry O2 and Nutrientst hrough the body. Reduction in red blood cell populations and hemoglobin transport may occur due to reduced production or due to early death or loss of red blood cells, as is often seen in gastrointestinal (GI) bleeds

Hematocrit (HCT):

Percentage of red blood cells in total blood volume

 Hemoglobin (Hgb):

Percentage of red blood cells in total volume of blood Hemoglobin attached to and transported by the red blood cells is responsible for transporting oxygen molecules throughout all parts of the organism Measures the blood’s capacity to carry oxygen. Can indicate blood loss

Contact

* Prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient’s environment
* Also used when a wound is draining, incontinence or other bodily discharge

Droplet

To protect from droplets that are infected and produced from an individual during coughing, sneezing, talking or certain procedures such as suctioning.

Airborne

Used for patients infected with illness that are transmitted via the airborne route

general importance of an SLP's understanding of lab values and why we should care

* Help to determine a patient’s overall health
* Used for screening (1)
* Give information about medical stability of a patient
* Used to assess readiness for mobility interventions (2)
* Important in clinical decision-making
* Increased number of patients with complex care needs

Different levels of student to fully autonomous doctor.

Med student, intern, resident, fellow, attending

ICU

there are different ICUs for different things e.g., C(V)ICU, NICU, TICU

Stepdown

* people usually go here when they leave the ICU
* Transitional floor, also known as intermediate care, telemetry or tele

General Floor

* Sometimes referred to “the floor(s)” when talking about leaving ICU and being “transferred to the floor”
* Can still be dx specific care (on the floor under GI attending, on the floor under cardiology attending)

Observation

we don’t feel comfortable sending you home but you're not too sick to be admitted. They monitor to see if you get worse enough to be admitted or if you get better to leave

define and understand the different code statuses

Full Code

* Patient/family wants aggressive,

life-sustaining measures

* CPR (ACLS/BLS), intubation,

medications

DNR/DNI

Comfort measures only

* CMO or “Comfort care”

Chronic

develops gradually, lasts for extended period of time (months-years); may worsen

Acute

develops suddenly, lasts for fairly short time

Degenerative

Worsens gradually over time

how SLPS positively contribute to patients care in acute care/medical settings

* Swallowing treatment and assessments
* Voice treatment and assessment 
* Counseling related to comm disorders

parts of a chart (where to find relevant information)

* order


* History and physical
* Lab and diagnostics
* Vitals signs
* Medications
* Reports
* At the top there is usually alerts

Causes of VPI 

* History of cleft palate: 20-30% have VPI despite surgery
* Submucous cleft palate (overt/occult): anterior orientation of the levator veli palatini muscles
* Deep pharynx: PPW sits on cervical spine/cranial base anomalies cause deep pharynx; velum may be normal but can’t reach PPW d/t depth
* Adenoid atrophy: begins at age 6, can increase the depth of the pharynx (risk is greatest w/ hx of cleft or SMCP)
* Irregular adenoids: (marked indentation/protrusion) prevents a tight seal causing nasal emission

If a child has **moderate to severe** resonance issues and they have surgery, YOU MUST WAIT FOR SURGERY to clear you for compensatory strategies. VPI, no speech until CLEARANCE

if a child has a mod to serve VPI

* they need surgery, pin port of the soft palate to pharyngeal wall
* can not start targeting them until the surgeon clears it for us