Comprehensive Guide to Clinical Foundations for Speech-Language Pathologists: Vital Signs, Precautions, and Patient Assessment

Professional Introduction and the Value of Interdisciplinary Teams

• Speaker Profile: Dr. Jory Davis     * Affiliation: University of Mississippi Medical Center (UMMC) School of Nursing, Department of Graduate Studies.     * Academic Roles: Faculty member teaching at the Master’s and Doctor of Nursing Practice (DNP) levels.     * Clinical Experience: Total of $22$ years in healthcare. This includes $6$ years as a nurse and $16$ years as a Family Nurse Practitioner (FNP).

• The Interdisciplinary Team and Holistic Care     * Speech Language Pathologists (SLPs) are instrumental and central members of the interdisciplinary healthcare team.     * Holistic Care Definition: An approach that looks at the patient in their entirety, identifying every team needed to create a comprehensive care experience.     * Role of SLPs: They restore abilities often taken for granted until lost, such as speaking, swallowing, and drinking.     * The Impact of Expression: SLPs help patients regain the ability to express their feelings and needs, which is vital for quality of life.     * The Psychological Aspect of Recovery: Patients often experience fear when attempting to swallow (fear of pneumonia) or frustration over dietary changes (e.g., transitioning from a steak to thickened liquids or pureed foods).

Essential Hospital Precautions and Clinical Signage

• NPO Status (Nil Per Os)     * Stands for "Nothing by Mouth."     * SLPs must verify the reason for NPO status, especially if they have an order for a swallowing study but the patient is marked NPO.

• Fall Risk Precautions     * Patients may not realize their level of impairment and may ask anyone (including the SLP) for help getting out of bed or going to the bathroom.     * SLPs must look for fall risk signs to identify patients requiring significant assistance or mechanical aids like a Hoyer lift.     * Specific considerations: Patients may be on strict protocols to sit up for specific durations or may need urine samples collected, which an SLP might not be aware of.

• Isolation Precautions     * Types include Contact, Airborne, and Droplet precautions.     * The primary goal is the safety of the healthcare provider and preventing infection transmission.     * Providers should check the nurse’s desk or the isolation cart outside the room if the status is unclear.     * SLPs should evaluate if significant isolation precautions should delay specific interventions (e.g., a swallowing study) in favor of patient stability.

• Oxygen Use     * Visual indicators: Nasal cannula or other delivery devices.     * Importance: Activities or interventions may cause a drop in oxygen saturation ($O_2$ sats), necessitating close monitoring.

Physiological Monitoring and Equipment

• Telemetry     * Continuous cardiac monitoring to track heart rhythms and rates.     * Vital for determining if the heart is being overloaded during physical or cognitive activities.

• Pulse Oximetry ($O_2$ Saturation Monitoring)     * Continuous monitoring of oxygen levels.     * Anecdote regarding personal saturation: Dr. Davis shared a personal clinical experience where she was severely anemic and could not maintain her sats while moving. Despite feeling okay to brush her teeth, her oxygen levels dropped significantly on the monitor, triggering an ICU monitoring team alarm.     * Key Lesson: SLPs must coordinate with the nursing or monitoring team before beginning activities that might cause O2 drops to prevent unnecessary emergency responses.

Vital Signs and Clinical Indicators

• Core Vital Signs     * Blood Pressure ($BP$).     * Heart Rate ($HR$).     * Respiratory Rate ($RR$).     * Oxygen Saturation ($O_2$ Sat).     * Temperature ($T$): Normal is approximately $98.6\,^{\circ}\text{F}$.

• The Fifth Vital Sign: Pain     * Pain assessment is a standard requirement for nursing documentation.     * Effect on Therapy: A patient in pain is unlikely to participate effectively. Conversely, high doses of pain medication (e.g., Morphine, Percocet) can reduce alertness, increasing the risk of aspiration or poor participation.

• Heart Rate ($HR$)     * Normal range: $60 \text{ to } 100\,\text{bpm}$.     * Tachycardia: A heart rate higher than $100\,\text{bpm}$, indicating the heart is overworking.     * Athletic Variance: Some highly athletic individuals may naturally have a heart rate below $60\,\text{bpm}$.     * Medication effects: Beta blockers can artificially lower heart rate.

• Respiratory Rate ($RR$)     * Normal range: $12 \text{ to } 20\,\text{breaths/min}$.     * Tachypneic: A respiratory rate greater than $20$. High respiratory rates can lead to a reduced mental state.

• Oxygen Saturation ($O_2\text{ Sat}$)     * Ideal range: $95\% \text{ to } 100\%$. The "sweet spot" is $98\% \text{ to } 100\%$.     * COPD/Lung Disease Considerations: Patients with chronic emphysema or COPD may naturally run lower ($93\% \text{ to } 94\%$). High amounts of oxygen can be dangerous for these patients because they cannot "breathe off" the $CO_2$ properly.

• Blood Pressure ($BP$)     * Textbook Normal: $120/80\,\text{mmHg}$.     * Clinical Note: The blood pressure cuff size is critical. An improperly sized cuff on a person with large arms can produce inaccurate, often falsely elevated, readings.

• Rule of Clinical Observation: Always look at the patient, not just the machine. Technology is useful until it is not; if the monitor says $100\%$, but the patient looks unstable or is breathing heavily, the clinical observation takes priority.

Patient Orientation, Alertness, and Assessment

• Orientation Levels ($A \& O \times 4$)     * Person: Does the patient know who they are? (Verify name to ensure the right patient).     * Place: Does the patient know where they are?     * Time: Does the patient know the day or year?     * Situation: Does the patient understand why they are in the facility?

• Assessment Steps for the SLP     * Reduced alertness significantly impacts swallow safety and therapy participation.     * Interaction Checklist: Introduce yourself clearly (Name and Role), ask the patient for their name, and verify the day/year.     * Environmental Awareness: Be aware of the "Full Moon" effect or psych issues that might impact safety. Check for recent bad medical news or family dynamics that could affect the patient's headspace.

Clinical Reasoning and Safety Scenarios

• Scenario 1: Potential Aspiration and NPO Status     * A patient is coughing, on oxygen, and newly marked NPO.     * Clinical Decision: Do not proceed with a swallowing evaluation. Investigate the change in status, document the concerns clearly, and determine who ordered the study despite the clinical signs.

• Scenario 2: "Circling the Drain"     * Data: $BP = 88/54$, $HR = 122$, $RR = 30$, $O_2\text{ Sat} = 86\%$.     * Action: This patient is physiologically unstable. Even if the patient appears awake and talking, the SLP must call for help and have the nursing staff evaluate the patient immediately before any intervention.

• Scenario 3: Non-arousable Patient     * Patient (e.g., "Mr. Thompson") is difficult to arouse, has slurred speech, and is coughing/choking on water.     * SLP Advocacy: If a patient is on a full diet but showing these signs, the SLP should recommend a diet reduction (thickened liquids or NPO) to the medical team to prevent aspiration pneumonia.

• Professional Development and Patient "Buy-In"     * Clinical reasoning develops over time with experience.     * Explain the "Why": Tell patients precisely why you are performing an intervention (e.g., "We are doing XYZ so we can get you to ABC").     * Celebrate Small Wins: Encourage patients when they move from thin liquids to thickened liquids or other milestones. These "small wins" also help prevent clinician burnout.

Questions – Discussion

• Dr. Davis to Students: Asked about their current academic year (Year $2$) and upcoming clinical rotations.
• Faculty (Dr. Cook): Clarified that students have completed on-campus training and will start off-campus rotations in August across the state of Mississippi. Second-year studies are online.
• Clinical Advice: Dr. Davis encouraged students to read patient charts thoroughly to understand the "why" behind their admission (Stroke, TBI, Cardiac event) and to understand the patient's social context (e.g., being a primary caregiver).
• Contact Information: Dr. Davis offered herself as a resource for students rotating through UMMC in Jackson, MS.