Medication administration

Transcription

1 Medication administration Once you complete this section, you should be able to: 1. Demonstrate metric conversions 2. Demonstrate calculations 3. List the five rights of medication administration 4. List methods of administration 5. List the steps for appropriate documentation 6. Indentify special considerations for medication administration 7. Indentify methods to safely administer medications and prevent errors Contents Introduction Policy Steps of medication administration Taking the initial order of verifying the order Calculating the dosage Preparing for administration Administering the medication Documenting medication administration Special considerations in pediatric medication administration

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3 Medication administration Introduction Safe and accurate administration of medications is one of a nurse s most important responsibilites. Good judgment is critical for safe drug administration. The nurse must understand a drug s actions and side effects, administer it correctly, monitor client s response, and provide medication teaching. Every nurse should possess a current drug book and carry it with them to a client s home. Policy BAYADA Home Health Care has established procedures to ensure safe medication administration and management in the home. In order to prevent pediatric medication errors, nurses should ensure that they are familiar with the medication before giving it, double-check their orders, minimize distractions during administration, and improve communication between other nurses and family caregivers. Another way to prevent errors is to check two client identifiers before administering a medication. Examples of client identifiers include: client name, address, date of birth, client number, client orders, and client medications/prescriptions Facial recognition is considered a client identifier after the initial assessment or first visit by the nurse Nurses may never administer a medication that was drawn up or pre-poured by another person, including another nurse Steps of medication administration Medication administration includes the following steps: 1. Taking the initial order or verifying the order. 2. Calculating the dosage for accuracy. 3. Preparing for administration. 4. Administering the medication. 5. Documenting the medication administration. 205

4 Medication administration Best practice: Without a prescription, the parents should not administer the medication until the dosage is verified. Best practice: Include the prescription (Rx #) number on the order. Taking the initial order or verifying the order Upon arrival to your initial shift for a client, validate the medications on the Medication Profile and Treatment Record with the current physician orders. Then verify that the correct transcription has been made to the Medication Profile and Treatment Record. Medication changes can occur in various ways: A parent or a nurse from another agency may report a change A new medication with the client s name on it is in the home A new medication is on the medication record without a corresponding order A telephone order from the physician If there is a medication change but the nurse can not get verification from a physician, the nurse cannot give the medication. The parents may give the medication until verification is obtained and documented (but without a prescription, parents should not administer the medication until the dosage is verified). When there is a new prescription bottle with the client s name on it in the home, the nurse can write an order from the bottle, then transcribe the new information on to the Medication Profile and Treatment Record and administer the medication. When there is a new nonprescription medication in the home, the physician must be called to obtain an order prior to administration by the nurse. When there is a written prescription from the physician in the home, an order must be written and the prescription attached. If a medication is noted on the Medication Profile and Treatment Record without a corresponding order in the chart, the physician must be contacted and notified of the medication, dosage, and the start date. If the medication is to be continued, a verbal order is obtained. When receiving a verbal medication order from the physician, an order is written and is read back to the physician for verification of accuracy. All medication orders must include: Name of medication Dosage Route Frequency Duration Parameter for use for PRN medications 206

5 Medication administration The five rights of medication administration: 1. Right client 2. Right medication 3. Right dose 4. Right time 5. Right route Calculating the dosage Safe medication administration depends on the nurse s ability to calculate drug dosages accurately and measure medications correctly. The inability to calculate the correct volume of a drug dose accounts for the majority of pediatric medication errors. (Weeks et al ) A careless mistake in placing a decimal point or adding a zero to a dosage can lead to a fatal error. The physician, client, and family depend on the nurse to check the dosage before administering a drug. This is especially important when taking care of a child because the dose is often calculated by the child s weight. Calculating children s drug dosages requires caution. A child s metabolism and small size necessitate smaller dosages than adults. Children and adolescents are at greater risk than adults for medication errors because children have immature physiologies as well as developmental limitations that affect their ability to communicate and self-administer medications (Hughes and Edgerton. 2005). The pediatric nurse should take every precaution to prepare and administer the appropriate and safe dose of medication for each individual child. It should never be assumed that the physician has calculated and ordered a safe dose or that the pharmacy has calculated and dispensed a safe dose. Nurses administering the medications are responsible for their actions and should take all necessary steps to prevent harm or injury to clients. Reviewing the five rights of medication administration is an important step in avoiding errors, so make sure you have the right client, right medication, right dose, right time, and right route. Below are basic drug calculations and conversions to ensure that your client receives the right dose of medication. Drug Calculation Basic Formula D (desired) x (vehicle, drug form) H (on hand) Example: Order reads: Amoxicillin 500 mg PO q6h 2.2. Available: Amoxicillin 250 mg/5 ml Body Weight, kg 1 kg or 1,000 gm = 2.2 lb To convert pounds to kilograms divide the number of pounds by Example: D x V = 500 mg x 5 ml A child s weight is 66 pounds H 250 mg 66 divided by 2.2 = 30 kg 2 x 5 ml = 10 ml 207

6 Medication administration Liquid Conversion 30 ml (cc) = 1 oz = 2 tbsp = 6 tsp 15 ml (cc) = ½ oz = 1 tbsp = 3 tsp 5 ml (cc) = 1 tsp 1 ml (cc) = drops (gtts) Metric Conversion Grams (g) Milligrams (mg) (325) (64) (32) (16) Safety with decimals Be particularly careful when writing decimal points, as they can be overlooked or fall on a line and not be seen. Children require small doses of medications, so the margin for error is extremely narrow. A misplaced decimal point can result in the delivery of a dose 10 times the intended dose. Never write over numbers, letters, or decimals. Note an error by drawing a single line through it, initial, and rewrite. Always use a leading zero for decimals less than 1 Example: 0.3 mg, not.3 mg which could trick the eye into missing the decimal and reading 3 mg Never use a trailing zero at the end of a decimal Example: 2.5 mg, not 2.50 mg which could be misread as 250 mg, a hundredfold increase Preparing for administration 1. If appropriate, explain the procedure at the level of the child s understanding and allow for expression of fear. 2. Select the most appropriate measuring device and administer the medication. For preparation of liquid medications, use a syringe for accurate dosage; even if a medication dropper and measuring cup are in the home. For nasogastric, gastrostomy, or jejunostomy administration, use elixir or liquid suspension whenever possible. 3. When possible, provide choices to allow the child some control. To encourage cooperation with older children, ask what they would like the medication mixed with or how they would like to take it. 208

7 Medication administration 4. If the child s parents are available and willing, ask for their assistance to help divert the attention of the child and to provide comfort and support. 5. Administer the medication as quickly and gently as possible. 6. Try to maintain a consistent routine for daily medication administration. 7. Praise the child for good behavior after medication administration. Administering the medication Administration of medication can be a traumatic experience for children. Proper approach to administration can facilitate the process and enhance the child s understanding of the importance of taking medications. The following table can be used as a guide for the various methods of administration and guidelines of administration for the infant, toddler, or school-age child. Routes for medical administration Route Infant Toddler School-age Oral Hold in a semireclining position, elevating the head and shoulders. Place the dropper or syringe along the side of the tongue and slowly drop the medication in small amounts. Wait for the baby to swallow between each drop. May suck from a needleless syringe, a dropper, or nipple in small increments at a time. Do not mix with a full bottle of formula Use a medicine cup or spoon after accurately measuring the correct dose. Squeeze the cup and put it to the child s lips, allowing the child time to swallow. Allow the child to hold the medicine cup (if able) and offer a drink, if not contraindicated Teach the child to place the pill or capsule near the back of the tongue and immediately swallow fluid, such as water or juice. If the child is unable to swallow pills, the pills may need to be crushed and put in food or juice, unless contraindicated Subcutaneous Common sites for all age groups include the lateral aspect of the upper arm, the abdomen, and anterior thigh 209 Give the child some The needle angle to do, such as sque for all age groups someone s hand, s is 90 o or counting

8 Medication administration Optic Place supine, with head tilted. Gently clean the eyelid and lashes of any secretions or old medication, wiping from inner canthus to outer. Use one hand to pull the lid down, exposing the conjunctival sac. Rest the other hand that holds the dropper on the infant s forehead. The solution or ointment is applied to the conjunctival sac without touching the tip of the tube to the eye. Ointment is applied in a thin ribbon from inner canthus to outer. Gently close the eyelids and wipe excess medication away. Same procedure as infants. Playing a game may be helpful. When possible, administer eye drops or ointments before bedtime or nap time, since vision will be blurred for a while. Ointment may be applied while the child is sleeping. Same procedure as infants, except schoolage child may be able to remain sitting with the head extended, looking up. Provide explanation and direction. Otic Place in a sidelying position with the affected ear uppermost. Clean the external ear. Gently pull the earlobe down and back. Insert the dropper just inside the external ear, so that the drops fall along the inside of the ear canal. Keep the head in that position for a few minutes. Same procedure as for infants. If the child can keep their head still, may place supine with the head turned to the appropriate side. For a child younger than age 3 years, pull the earlobe down and back. Same procedure as infants, except grasp the upper ear and gently pull upward and outward. 210

9 Medication administration Rectal Place in a sidelying position. Use a water soluble lubricant or warm water to lubricate the suppository. Do not use Vaseline. Cut the suppository lengthwise, if indicated, to give half the dose. With your pinky finger, insert pointed end first into the rectum one inch, holding the buttocks together for 5 10 minutes Same procedure as infants. Same procedure as toddler, but may use index finger to insert suppository. Nasograstic (NG) Orogastric (OG) Gastronomy (GT) Jejunostomy (JT) Gastro Jejunostomy (G/JT) Check for correct placement of NGT, OGT, or GT, if ordered. Do not mix medication with enteral formula. Same procedure as infants. If administering tablets, crush to a fine powder and dissolve in a small amount of warm water. Same procedure as infants and toddler. Intramuscular The vastus lateralis is the muscle used most frequently in infants because it is the most developed and has no large blood vessels or nerves, minimizing the risk of injury. Do not use an air bubble in the syringe. Air bubbles can affect the medication dosage. The ventrogluteal muscle can be used after a child has been walking for about 1 year. The deltoid muscle can be used in toddlers for amounts of ml Do not use an air bubble in the syringe. Air bubbles can affect the medication dosage. Same procedure as for toddlers. For children who have never walked, the vastus lateralis should be used. Do not use an air bubble in the syringe. Air bubbles can affect the medication dosage. 211

10 Medication administration Documenting medication administration As home health care professionals, we are responsible for accurate documentation in the client s home chart of all medications administered to all clients. The Medication Profile and Treatment Record is used to document medications and treatments given on a monthly basis. Sign out all medications at the time they are administered by initialing the boxes that correspond with the correct date and time. At times, the client s parents may administer medications during your shift. In those instances, leave the box blank on the Medication Profile and Treatment Record and document the medication given by the parents in your Nurse s Note. In cases in which a medication has been discontinued or changed, make the appropriate alterations to the order on the Medication Profile and Treatment Record by drawing a line through the remaining boxes, dating, and initialing the discontinued or changed order. If the dosage or time of administration changes, the entire order must be rewritten in a new set of boxes on the Medication Profile and Treatment Record. It is not acceptable to draw a line through the dosage on the old order and write in the correct dosage. When a dosage is changed, you must call the pharmacy to get a label change for the medication bottle. When a medication is held, the physician and clinical manager must be notified. The reason the medication is held should be documented in your nurse s notes and an H written in the corresponding box on the Medication Profile and Treatment Record. Abbreviations BAYADA Home Health Care has a standardized list of unacceptable abbreviations, acronyms, and symbols. (Refer to policy Do Not Use Abbreviations List) Listed below are some commonly used abbreviations with the acceptable complete spelling that should be used instead: cc = ml (milliliter) ml = milliliter gtts = drops kg = kilogram mcg = microgram mg milligram L = liter tbsp = tablespoon tsp = teaspoon A.D. = right ear O.D. = right eye A.S. = left ear O.S. = left eye A.U. = both ears O.U. = both eyes < = less than > = greater than Special considerations in pediatric medication administration When a pediatric client is receiving medications in the home, special considerations are made to ensure that the correct medication and dosage are given at all times, even when nurses are not present. The following topics are a few of the considerations related to medications administered in the home. 212

11 Medication administration Labeling of medications Medications must be properly labeled. Any time a home health care professional prepares medication to be given at a later time (eg, for parent or caregiver to give or to accompany a child out of the home), the nurse must label the medication. The label must include the following: drug name, strength, amount, expiration date (when not used within 24 hours), expiration time (when expiration occurs in less than 24 hours), date prepared, and type and amount of diluent (for compounded IV mixtures and parenteral nutrition solutions). Storage of medications Storage of medications is an important function of safe medication administration. Drugs must always be kept out of the reach of children, with the lids on drugs tightly secured. Certain medications also need to be kept refrigerated. If you are unsure about the proper way to store any medication, please remember that you can always refer to your drug book or call a pharmacist. Discontinuation of medications Discontinued medications should be kept away from the client s area and current medications to prevent errors. Families should be encouraged to dispose of expired medications. High-alert medications Precautions must be taken when administering high-alert medications in the home. High-alert medications are those that have the highest risk of causing injury when misused. Precautions to take include checking the dose, rate, and client identity when administering high-risk medications, clarifying the orders with the physician, and being familiar with the medications identified as high-alert. Another precaution is to keep similar looking medications in separate places (see Lookalike, sound-alike medications, below.) For example, insulin and heparin should not be stored near each other because they are similar in appearance and are both ordered in units. Single-dose containers should be used whenever possible. Experimental medications Home health care professionals review experimental drugs on a case-by-case basis and administer them with a physician s order and the consent of the client. A copy of the drug protocol is kept in the home and in the office. Nurses involved in the administration of experimental drugs will be oriented to the medication and the procedure and provided with educational materials as needed. Adverse events Nurses are responsible for responding appropriately in the event of an adverse reaction. The medication should be immediately held and the doctor, pharmacist, 213

12 Medication administration client s family, and the clinical manager should all be notified. If indicated, appropriate emergency procedures should be followed, including calling 911. Proper documentation should be maintained, including the completion of an Incident Report. Narcotics Special consideration is given to clients receiving narcotics and nurses must know the drug s interactions and side effects. Medications that are in tablet or capsule form and must actually be counted include all Schedule II substances (eg, Dilaudid, Demerol, Fentanyl, methadone, MS Contin, Oxycontin, Percocet, Roxanol, Roxicet, and Tylox). A count of the number of capsules or pills remaining must be entered each time the medicine is administered by a home health care professional. For clients who receive 24-hour care, Schedule II substance tablets or capsules are counted by both nurses together at each shift change and documented on a Narcotic Record Sheet (form # 758). For clients who receive less than 24-hour care, each nurse should count the Schedule II substance tablets or capsules upon arrival at and before departure from the home. If a discrepancy is noted, the nurse should report the problem to the clinical manager immediately. When family members assume responsibility for the client s care during nonservice time, the family members should be instructed to follow proper documentation procedures when administering narcotics. If it is noticed that the family members are not following the procedure, the clinical manager should be notified. Narcotics should be disposed of down the drain, with a witness present. The nurse and the witness should sign the Narcotic Record Sheet in the appropriate section for disposal of medications. Look-alike, sound-alike medications Certain medications have names that either look alike or sound alike. For example, Zantac, which is a drug for the GI tract, and Zyrtec, an antihistamine, may easily be mistaken for each other when quickly reading the medication label. To prevent medication errors, we have developed a procedure to alert clients and caregivers. The clinical manager will alert you to any look-alike, sound-alike medications the client may be taking and provide you and the family with instructions how to differentiate between the two. For example, the medication bottles of the lookalike, sound-alike medications will be marked to alert caregivers to check that the proper medication is being administered. Conclusion With the knowledge and understanding of a drug s actions and side effects, how to administer the drug correctly, monitor the client s responses and provide medication teaching, medications will be administered safely and accurately. 214

13 Medication administration Before continuing on to the next section, answer the following questions by circling the appropriate letter. Check your responses with the answers below. 1. Katie has a temperature of F axillary. She has an order for Tylenol 15 mg/kg q4h PRN fever > axillary. Tylenol Infant Drops (80 mg/0.8 ml) is available. Katie weighs 8 pounds. What is the correct dosage? (A) 0.54 mg. (B) 40 mg. (C) 54 mg. (D) 80 mg. 2. A 6-year-old who weighs 20 kilograms is to receive erythromycin ethylsuccinate (ESS) 12.5 mg/kg PO every 6 hours. The ESS is available as a liquid containing 200 mg/5 ml. How many ml should the child receive with EACH dose? (A) 1.6 ml. (B) 5.0 ml. (C) 6.25 ml. (D) 6.0 ml. 3. A 10-month-old who weighs 9 kilograms has an order for 32 mg of phenobarbital PO BID. The recommended dosage range for this medication is 5 to 8 mg/kg in 24 hours. A nurse should recognize that the dose ordered is: (A) Within normal range. (B) Lower than normal range. (C) Higher than normal range. 4. All of the following are one of the five rights of medication administration EXCEPT: (A) Right dose. (B) Right time. (C) Right physician. (D) Right client. 215

14 Medication administration 5. According to our company policy on drug administration and the five rights of medication administration, a nurse should do which of the following prior to giving medications to the client? (A) Check two client identifiers such as name, address, client number, or date of birth to ensure that it is the right client. (B) Ask the client or family what medications need to be given. (C) Give only those medications you are familiar with. (D) Administer the medication based on the directions on the label on the bottle. 6. Which of the following is the acceptable method used to measure oral medications for a toddler? (A) Measuring spoon. (B) Syringe. (C) Household teaspoon. (D) Medicine cup. 7. On which of the following forms does the nurse document that a medication was given? (A) Addendum to the Plan of Care (B) Home Care Flowsheet (C) 485 (Physician Plan of Care) (D) Medication Profile and Treatment Record 8. If the client s mother tells you she administered the scheduled morning medication, how should you document this? (A) Nothing needs to be documented. (B) In the narrative portion of the Nurse s Note. (C) Put your initials in the corresponding boxes on the Medication Profile and Treatment Record. (D) Indicate on the Medication Profile and Treatment Record that the medicine was given by the family. 216

15 Medication administration 9. You arrive at the start of your shift and your client s parents inform you that the physician phoned in a new antibiotic order. You see the pharmacy bottle. The medication is to start tonight and continue for 10 days. What is the appropriate step you should take? (A) Have the parents administer the medication because there is no order. (B) Complete an order with the new medication. (C) Don t start the medication until the next day so the dayshift nurse can verify the order. (D) Call the clinical manager to obtain the order. 10. Kevin was just prescribed Depakene for his seizures. His initial dose is 15 mg/kg PO daily. He weighs 55 lbs. The syrup is available in 250 mg/5 ml. What is Kevin s dose? (A) 25 ml. (B) 375 ml. (C) 7.5 ml. (D) 10 ml. 11. Amoxicillin 125 mg 3 times a day is ordered for a child with otitis media. Amoxil suspension contains 250 mg of amoxicillin in 5 ml. How many ml would you give this child per dose? (A) 2 ml. (B) 2.5 ml. (C) 125 ml. (D) 375 ml. 12. A 5-year-old girl is prescribed 240 mg of Panadol PRN every 4 to 6 hours. Her mother has Panadol elixir which contains 120 mg of Panadol in 5 ml. How much would you give her? (A) 2 ml. (B) 10 ml. (C) 5 ml. (D) 240 ml. 217

16 Medication administration 13. Which of the following is true about look-alike, sound-alike medications? (A) Ask the physician for a different medication so the two similar medications do not get confused. (B) A process should be put in place to differentiate between the two medications. (C) They should be taken at the same time to avoid medication errors. (D) They should be separated from all the other medications. 14. An 8 year old nonambulatory client is receiving Lupron injections IM every 4 weeks. In choosing an injection site, you will consider which of the following: (A) The amount and character of the medication to be injected. (B) Size and general condition of the muscle mass. (C) The child s ability to assume the required position safely. (D) All of the above. 15. You are providing care for a child with heart failure (HF). The child s mother has requested that you not give the morning dose of Lasix as ordered. She is going out with the child and doesn t want to change a wet diaper. Even though you have explained why this would be potentially harmful for the child and emphasized the need to follow physician s orders, the mother remains firm in her request not to give the medication. You should do all of the following EXCEPT: (A) Follow the mother s request. It is only one dose and the mother has the right to make that decision. (B) Notify the clinical manager. (C) Document this clearly in your Nurse s Note. (D) Notify the physician. 16. A 3-year-old client with a seizure disorder is on a ketogenic diet and is to be started on penicillin V for URI. The order states penicillin V 125 mg TID GT x 7 days. The penicillin V is available in 250 mg tablets. How many 250-mg tablets should you give? (A) 1 tablet. (B) 2 tablets. (C) ½ tablet, (D) Inadequate information available. Answers: 1. C, 2. C, 3. A, 4. C, 5. A, 6. B, 7. D, 8. B, 8. B, 10. C, 11. B, 12. B 13. B, 14. D, 15. A, 16. C 218

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18 Safety Once you complete this section, you should be able to: 1. List age and developmental factors 2. List environment-related risk factors 3. Discuss emergency responses to various risk factors 4. Discuss infection control and standard precautions Contents Introduction Effects of developmental alterations on safety Age-appropriate safety precautions Infant level precautions Toddler level precautions School-age level precautions Potential for abuse Falls risk assessment Basic home safety Emergency preparedness at home Infection control

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20 Safety Introduction Home should be a place where a child feels safe and secure. However, home can also be a place full of hidden hazards that can cause serious injury or even death. Most pediatric injuries are preventable, according to the American Heart Association (AHA). Injuries are the leading cause of death for persons ranging in age from 6 months to 44 years. The AHA suspects that at least half of the pediatric injuries that were fatal could have been prevented with supervision and safety precautions. The first step in preventing injury of a child is to be aware of the dangers you may encounter. Age-related risk factors are based on normal growth and development. Safety requirements presented here are based on children at various age levels and are delineated by age for normally developing children. Bear in mind that as a child crosses to the next age level, many of the safety issues related to the previous age remain a concern. So while reading these sections, be sure to keep the previous-level precautions in place as you implement the new-level precautions, until the child is truly beyond the concerns for the younger group. Effects of developmental alterations on safety Although safety precautions are generally based on a child s chronological age and developmental progress, most of the children you encounter in home health care will not follow the typical growth and development timeline. Remember that a child s developmental level must be evaluated in light of their cognitive level and physical abilities. The evaluation of the child may indicate very different levels of ability in each area. In order to institute adequate safety precautions, the cognitive age level must be known and various developmental levels of your client must be identified. Together, these variables will outline the risk factors to be addressed. Questions to consider include: 1. Are the child s age and functioning level the same? 2. Developmentally, is the child cognitively above, below, or on normal level? This dictates the age level of precautions you should use. 3. Is the child s physical ability above, below, or on normal level? This will help target what which age-appropriate precautions are applicable and where the concerns and risks will be. After reviewing the following scenarios, decide what level safety precautions would be appropriate. 222

21 Safety 1. A 19 year old with encephalopathy, intractable seizure activity, nonresponsive, bed-bound. Answer: Infant level precautions would be appropriate based on equal physical and cognitive levels. 2. A mobile, interactive, pubescent 14-year-old, cognitive level age 3 years old. Answer: Toddler/preschool-level precautions viewed from a 14- yr-old height and eye level would be appropriate. Placing objects that carry potential harm (ie, medication) on a higher shelf may no longer be adequate due to the child s physical development. A concern will be emerging sexual curiosity based on physical development and hormonal changes. Lack of understanding of consequences coupled with a childlike trust and desire to be liked heighten this child s risk for abuse. 3. A 13-year-old cognitively intact child with quadriplegia, and physically unable to function independently. Answer: Infant-level precautions are appropriate due to physical disability. Observation for depression and suicidal ideation would be prudent despite the client s level of disability. 4. An 8-year-old with dwarfism, the size of a 2-year-old, cognitively at age level. Has several varying physical disabilities but is mobile with increasing independence. Answer: Due to size and physical abilities, toddler precautions are appropriate. Client may begin to exhibit a desire to participate in sports and other group activities. Lack of age-appropriate physical development may pose certain risks with these activities. If this occurs, limits may need to be set and specific precautions and safety gear used. Children often need protection not only from hazards they encounter but also from hazards caused by an older or younger children. To keep up with the possible dangers, the American Academy of Pediatrics (AAP) suggests that the child s developmental capabilities in relationship to their environment be evaluated regularly by asking: 1. How far can they move? 2. How high can they reach? 3. What objects attract their attention? 4. What can he or she do today that they couldn t do yesterday? 5. Who is spending increasing or decreasing time with the client? 6. Who or what are they trying or beginning to imitate? Age-appropriate safety precautions In this chapter, safety concerns are presented for the age level of a normally developed child and labeled by specific categories of activity or concern. In home health care, the child may be encouraged to develop beyond their current 223

22 Safety capabilities such as attending school or therapies such as swimming and biking may be introduced. Often the child with special needs will have adaptive equipment to enhance the experience (equipment will be discussed in the Rehabilitation chapter). Clinical alert: Sudden infant death syndrome (SIDS) is the death of an infant that cannot be explained by medical history or other causes. The cause is unknown. Most SIDS deaths occur in the first 6 months of life. It is known that SIDS is more likely to occur if the infant sleeps on the stomach. Therefore, all infants should be placed on their backs for sleep and turned side to side to prevent flattening of the occiput. When on their side, they should be propped to prevent rolling to their stomach. An infant should never sleep on, be wrapped in, or sleep with objects such as pillows or stuffed animals that might trap exhaled air near the face. Infant level precautions Logically, the environment of very young infants should be easy to make safe and control. However, caregivers must always be alert to potential dangers as infants develop and gain skills. Crib safety 1. Mattress should fit snugly in the crib, so the child s face cannot get trapped between the mattress and the crib. 2. Soft bedding materials such as pillows and comforters should not be used in the crib. 3. Cribs should not be placed near a window with coverings, blinds, or drapes that have hanging or dangling cords 4. Distance between side rail slats should be no more than 2⅜ inches. 5. Crib should be tested for lead paint. 6. End panels should not have cutouts that can trap heads, arms, or legs. 7. Side rails should be checked periodically for loose rails, and caregivers notified. 8. Crib gyms and mobiles should be removed when the child can crawl. 9. Mattress should be lowered as child grows; mattress should be at lowest level when the child learns to stand. 10. Bumper pads should be removed when the child can pull to standing position. Bath time safety 1. Set the water heater for the whole house at no higher than 105 F, or place a scald guard on the bathtub plumbing. 2. Check water with a thermometer if available or with your wrist before putting the child into the water. 3. Check the temperature of the water at several different spots in the tub because temperature may not be uniform throughout. 4. Never leave the child unattended in the tub, even if in a safety ring or infant tub. 5. Do not leave the child in the care of the siblings while child is in tub. 224

23 Safety 6. Fill the tub with only 1 to 2 inches of water. 7. Use a skid-proof mat. 8. Keep all electrical appliances away from the tub water area. 9. If the infant has myringotomy tubes that may not be exposed to water, ensure that no water enters the canal by using ear plugs or wax to block the water entering into the canal. Notify the physician if you think that an exposure may have occurred so that appropriate prophylaxis can be started. Car seat safety 1. Car seat should have a 5-point harness. 2. Seat is rear-facing until 1 year old and child weighs 20 pounds. 3. Car seat should only be installed in the back seat of the vehicle, never in the front with a passenger air bag. 4. When properly installed, car seat should never wiggle more than ½ inch. Clinical alert: The most important precaution for an infant is constant adult supervision. Accidents often happen because adults are unaware of what the infant can do. Infants progress quickly and achieve new skills when you least expect it. Fall precautions As infants approach toddlerhood, they become more mobile. An infant starts by wiggling, pushing self off of objects, and rolling. Some children at this age are creeping, crawling, and even walking. Before crawling: 1. Keep crib rails in up position. 2. Changing table should have a guard rail and safety strap for securing infant in place 3. Middle of the changing table should be slightly lower than the sides. 4. Never leave a child unattended on a changing table, in high chairs or swings, or in other baby equipment. 5. Always secure safety straps when placing an infant into a seating or positioning device. 6. Always keep one hand on the infant on any high surface. If you cannot hold the infant, place in a crib, in a playpen, or on the floor. Once crawling: 1. Use gates at top and bottom of stairs to ensure the child s head cannot get caught in any gaps between stair rails and to prevent falls down the stairs. 2. Do not allow infant to use a walker instead use stationary activity centers with a turning seat. 3. Use locks on closed windows. 225

24 Safety 4. Use gates on the lower half of open windows. Choking precautions All infants learn about the world around them by using their senses of sight, touch, and taste. During the first few months of life, an infant sucks on anything within reach a fist, pacifier, toys, and other items. At this age, assume anything they can reach will go directly into their mouth. 1. Keep small items out of reach. 2. Do not feed hard bites of food. 3. Be conscious of toys with small break-off pieces. 4. Encourage all caregivers to learn CPR. 5. As mobility develops, add toddler-level choking precautions. Toddler level precautions Toddlers age 1 to 3 years enjoy running, climbing, mimicking parents, and exploring. During this time, their physical abilities are increasing rapidly but their ability to understand the consequences of their actions is not developed. Supervision remains key to safety. Clinical alert: Children have been crushed and killed when climbing on kitchen stoves, bookshelves, grandfather clocks, chests of drawers, and china cabinets. Falls Falls are almost expected at this age of discovery and development. A child who is learning to take first steps or to master moving more quickly will trip and fall. The following basic precautions will alleviate added risks: 1. Use anti-skid properly fitting footwear. 2. Clean up all spills promptly. 3. Secure area rugs. 4. Get rid of clutter in walk ways. 5. Clear stairways. 6. Put safety gates at the top and bottom of the stairs. 7. Do not allow a child to climb the stairs alone until the child has mastered the steps safely 8. Encourage consistent use of the banister for balance. 9. Be aware of sharp corners use corner covers if possible. One of the biggest issues at this age is climbing. Many children find themselves in serious trouble by climbing or attempting to climb things. Precautions against falling specifically related to climbing are: 226

25 Safety 1. Install anti-tipping devices on large items so the child doesn t fall when climbing on them. 2. Arrange furniture so it does not provide easy access to windows and stairs. 3. Avoid stackable toys in a playpen. 4. Keep doors closed and locked. 5. Use window locks, guards, or gates. 6. Windows should be blocked from opening any further than 2 inches, if a window must open at all. 7. Soft impact play surfaces are preferable. 8. Toy chests should have a safety latch to prevent the lid from falling on a child. Burns 1. Keep young children away from appliances such as irons, curling irons, blow dryers, heaters, and toasters. 2. Use the back burner on the stove, and if using the front burner turn handles on pots and pans away from the front of the stove. Clinical alert: Cords from blinds and draperies have strangled children under the age of 5. Install cord holders on a window frame so the cords can be wrapped up and kept out of the reach of children. Choking 1. Toddlers will put anything in their mouth. 2. Keep small items such as coins, marbles, safety pins, tacks, etc. out of reach. 3. If the item is small enough to fit through a standard-size toilet paper roll, it is too small for a young child to play with. 4. Toddlers will imitate adults and enjoy playing dress-up, so caution should be taken with items they could place around their necks. 5. Not understanding the consequence of strangulation, a toddler may pull an item tightly around the neck and not be able to remove it. Poisoning 1. Keep all poisons, medications, and cleaning fluids out of reach in a locked cabinet. 2. Do not take vitamins or medications in front of children. 3. Never call medication candy. 4. Have syrup of ipecac on hand for use only if directed by poison control 5. Keep Poison Control telephone number by the phone:

26 Safety Car Safety 1. Use front-facing car seat only if child is both 20 pounds and at least 1 year old. 2. Car seat must have a 3- or 5-point harness. 3. Car seat is placed in back seat of car. Preschool level precautions Children at ages 3 to 5 have much-improved physical coordination. There is the physical ability to climb and reach unexpected heights. Preschoolers have a great desire to do things independently of parents and caregivers and have an active imagination. The combination of increasing physical skills, the desire for independence, and active imaginations can result in new dangers. Children s physical abilities are often far beyond their judgment and attention span. Their lack of understanding of the consequences of their actions and their distractibility increases the likelihood of placing themselves in potentially dangerous situations. Clinical alert: The American Academy of Pediatrics does not recommend swimming lessons for children younger than 4 years because: You may be less cautious because you think the child can swim. Young children who are repeatedly immersed in water may swallow so much of it they develop water intoxication which can result in convulsions, shock, and even death Because preschoolers require frequent and repeated verbal enforcements to maintain safe limitations, many of the toddler precautions should be carried over and maintained for the preschool-level child. Frequently, the new activities introduce outdoor safety issues related to territory, strangers, crossing the street, and the introduction of various play equipment. The goal during this time is to give the child the opportunity to try new activities, while the nurse continually evaluates situations that could be dangerous. Safety factors will vary based on each activity. Riding toys Require children to wear a properly fitted helmet when riding tricycles or other wheeled vehicles or toys. Water play 1. Be aware of small bodies of water the client might encounter such as fish ponds, ditches, fountains, rain barrels, watering cans, and even filled buckets used to wash a car. 2. Wading pools should be emptied and put away after each play session. 3. Children who are swimming, even in a shallow pool, must be constantly supervised and in your direct line of vision. 4. Remember that even a child who knows how to swim still needs to be watched constantly when in the water. 228

27 Safety Car safety 1. A child weighing between 40 and 80 pounds may transition into a beltpositioning booster with a 3-point seat belt. 2. A booster seat is recommended for a child up to 80 pounds with a height of 4 feet 9 inches, so when seated without a booster, the knees bend over the edge of the seat. 3. Each state has its own requirement regarding when the use of a booster seat can be discontinued. Contact your clinical manager if you are unaware of your state s requirements. School-age level precautions This category covers children from age 6 years up to the beginning of puberty. Even though the ages in this category stretch a wide span, the concerns remain the same. Car safety 1. All children under age 13 should ride in the back seat of the car to protect them from dashboard and air-bag injuries. Older children of short stature are the safest in the rear seat of the vehicle with the safety restraints properly fastened. If the client must sit in the front seat, position the seat as far back from the dashboard as possible. 2. Become fully familiar with the proper use of any booster or child safety seat you use for a client. 3. Know your state-specific guidelines, because a child up to age 12 may need to be seated in a positioning booster seat by state law. 4. Alteration in muscle tone and head control may require the use of a car seat for transport for some children well beyond the age of 13. Street safety Children must be taught: 1. Cross the street at the corner with an adult if possible. 2. No running or playing in the street. 3. Look both ways before crossing. 229

28 Safety 4. What the colors of the traffic lights mean. 5. We walk against traffic, we ride with traffic. 6. If a car is present but stopped, cross only if the driver waves okay. Sports Team sports and activities provide the building blocks to various skills utilized throughout life. Sports provide exercise and a general sense of well-being while enabling the child to build vital social skills. Exercise may reduce the chances of obesity and lessen the risk of diabetes. Childhood sports injuries may be inevitable but unless otherwise indicated, involvement in sports is important. To decrease the risk of injury, make sure proper protective gear is used every time the child plays. Also, maintain proper hydration by providing water and sports drinks. Bicycles As with all physical activities, bicycling is not without its hazards. Children are at risk of injury from falls resulting from exceeding their own ability level or swerving to avoid striking a motor vehicle or a fixed object. The bicycle helmet is very effective in preventing or lessening the severity of brain injury during a bicycle crash. Fitting the helmet correctly Correct fit is essential and includes: 1. Positioning the helmet on the head so it sits low on the forehead and is parallel to the ground when the head is upright; the wearer should be able to see its lower brim when looking all the way up. 2. Installing or removing inside pads to make the helmet snug. 3. Adjusting the chin strap so it fits comfortably but snugly with no more than 2 fingers inserted between the strap and the chin. 4. Check the security of the chinstrap the helmet should not come off or shift over the eyes when the child tries to shake it off. Safe helmet use 1. A bicycle or multisport helmet should be properly fitted and worn each ride. 2. A young child who rides as a passenger must wear an appropriate sized helmet and be placed securely in a bicycle-mounted child seat or preferably a bicycle-towed child trailer. 230

29 Safety 3. A child should be at least 1 year old with sufficient muscle strength to control head movement during a sudden stop, even with the additional weight of the helmet. 4. Any helmet involved in a crash or otherwise damaged should be discarded and replaced. Helmet use is only one aspect of bicycle safety and does not substitute for the child s knowledge and practice of the rules of the road, sufficient visibility to drivers, and other safety measures. Water safety Drowning ranks second as the leading cause of death in middle childhood. Most often, these tragedies occur when children swim without adequate adult supervision and in most cases, these children and their caregivers have overestimated the child s swimming ability and their own knowledge of water survival skills. Here are some guidelines to keep school-age children safe in and near the water: 1. Make sure children older than age 4 learn how to swim from an experienced and qualified instructor. 2. Never allow a child to swim alone or play by or in water away from the watchful eye of an adult, ideally one who is trained in CPR. 3. Do not allow horseplay that may result in injury. 4. Prohibit children from diving unless someone has already determined the depth of the water and checked for underwater hazards. 5. Do not allow swimming in areas where there are boats or fishermen, beaches with large waves, a powerful undertow, or no lifeguards. 6. Make sure children understand that swimming in one body of water may be different from swimming in another. 7. Do not rely on an air mattress, inner tube, or inflatable toy as a life preserver. 8. If the pool has a cover, remove it completely before swimming. Do not allow a child to walk on the pool cover. 9. Keep a safety ring with a rope by the pool at all times and a phone in the pool area with emergency numbers clearly indicated. 10. Do not allow young children to use Jacuzzis or hot tubs. They are dangerous as young children can drown or become overheated in them. 11. A child must always wear a life preserver when swimming or riding in a boat. A life preserver fits properly if you can t lift it over the child s head after he or she has been fastened into it. For a child younger than 5 years, particularly a non-swimmer, the life preserver should also have a flotation collar to keep the head upright and the face out of the water. 231

30 Safety 12. Children should never be permitted to swim during a lightning storm. 13. Backyard swimming pools should be enclosed with high and locked fences on all four sides, especially the side that separates the house from the pool. Adolescent-level precautions Adolescence begins with the onset of physiologically normal puberty and ends when an adult identity and behavior are accepted. This period of development corresponds roughly to the period between the ages of 10 and 19 years, which is consistent with the World Health Organization s definition of adolescence. The leading causes of death among adolescents are motor vehicle accidents, suicide, homicide, poisoning (including accidental overdose), and drowning. The leading causes of illness or injury are trauma, mental health issues, sexually transmitted infections, acquired immunodeficiency syndrome (AIDS), and eating disorders. Frequently, alcohol or other forms of substance abuse, risk-taking behaviors, and poorly developed decision-making skills are contributing factors leading up to these injuries and illnesses. Clinical alert: Never leave a potentially suicidal client alone. Suicide In the past 25 years, while the general incidence of suicide has decreased, the rate for those between 15 and 24 has tripled. It is one of the most common causes of death in adolescents. Suicide is often precipitated by depression, substance abuse, and social or behavioral problems. Most sources believe that for every single teen who attempts suicide there are 50 others who have considered it. Half of those who have made one suicide attempt will make another, sometimes as many as two a year until they succeed. The majority of suicide attempts are expressions of extreme distress and not just harmless bids for attention. For an adolescent, a traumatic event, no matter how minor when viewed from an adult perspective, can be enough to push them over the edge into a severe depression. Losing a girlfriend or boyfriend, failing a test, or getting into an accident can threaten the delicate balance of the adolescent s self esteem, sense of identity, and desire for independence. This imbalance may result in suicidal ideation. Health care professionals should be aware of the following signs in adolescents who may attempt suicide: Talking about death and wanting to die Complaining of being a bad person or feeling rotten inside Suicidal thoughts, plans, or fantasies Previous suicide attempts Friends who have attempted suicide 232

31 Safety Giving away of personal possessions Giving verbal hints such as I won t be a problem much longer. Become suddenly cheerful after a period of depression Having signs of psychosis hallucinations or bizarre thoughts Teen Depression Depression often goes unrecognized, but is frequent among teens and a common sign of possible impending suicide. In younger children and adolescent boys, it may seem that the child is simply angry or sullen. If this lasts more than a week with no relief, and if there are other signs of depression, the child should be evaluated by a professional. Signs of developing depression are: Unhappiness Gradual withdrawal into helplessness and apathy Isolated behavior Drop in school performance Loss of interest in activities that formerly were sources of enjoyment Feelings of worthlessness, hopelessness, helplessness Fatigue or lack of energy or motivation Change in sleep habits Change in eating habits Self-neglect Preoccupation with sad thoughts or death Loss of concentration Increase in physical complaints Sudden outbursts of temper Reckless or dangerous behavior Increased drug or alcohol abuse Irritability or restlessness Substance abuse Sometimes teens try alcohol or other drugs to relieve depression. Unfortunately, the drugs themselves have a depressant effect, lowering inhibitions against selfinjurious behavior. The adolescent ends up feeling worse while under the influence and commits a rash, impulsive act that he or she wouldn t have done if sober. Some young people who have never expressed a suicidal thought have 233

32 Safety taken their own lives when they were drunk although the cause is not always known, often it appears to be to ease the pain of disappointment or loss. Suicide prevention Adults can help prevent suicide by fostering open, honest communication with teens. If a teen trusts you enough to come to you with a problem, take time to listen immediately because delay may only fuel the teen s feelings of doom. Consult with the child s physician immediately for appropriate evaluation and counseling. Although in home health care, the children you encounter may not be physically able to attempt or carry out such thoughts of suicide, they may still have them and could ask a friend to assist them. If anyone in your care voices these feelings, do not ignore them. Report any thoughts or expressions of potential suicide or suicide ideation to your clinical manager. Potential for abuse Developmentally delayed children, whether physically or cognitively impaired, are at a higher risk for abuse and neglect. In general, the causes of abuse and neglect of children with disabilities are the same as those for all children; however, there are several elements contributing to an increased risk for impaired children. 1. Children with chronic illnesses or disabilities often place higher emotional, physical, economic, and social demands on their families. 2. Parents with limited social and community support may be at especially high risk for mistreating children with disabilities because they may feel overwhelmed and unable to cope with the care and supervision responsibilities required. 3. Parents of children with communication problems may resort to physical discipline because of frustration over what they perceive as their child s intentional failure to respond to verbal guidance. 4. The requirement of special health and educational needs can result in failure of the child to receive needed medications, adequate medical care, and appropriate educational placements, resulting in child neglect. 5. A lack of respite or breaks in childcare responsibilities can contribute to an increased risk of abuse and neglect because parents are exhausted and emotionally drained. Many children with disabilities require multiple family caregivers and health care professionals. This contact with numerous individuals increases the opportunity for abuse. Children with disabilities are often perceived as easy targets because their intellectual limitations may prevent them from being able to discern the experience as abuse. Children may be unable to differentiate appropriate from 234

33 Safety inappropriate pain because some forms of their daily therapy may be painful. Impaired communication abilities may prevent them from reporting the abuse. Remember, these children are dependent on their caregivers for their physical needs. They are accustomed to having their bodies touched by adults on a regular basis. And since children with disabilities are often conditioned to comply with authority, they could fail to recognize abusive behaviors as maltreatment. Due to decreased opportunities for the child to develop a trusting relationship with an individual, the abuse may never be disclosed. On the other hand, one advantage of the home health care child s situation is the presence of a large number of professionals in the home and the increased probability that someone will detect the injuries or signs of abuse early. Adequate care also decreases the amount of stress placed on the primary caregiver, which can help prevent abuse. Falls risk assessment Our company policy aims to minimize all clients risk for falls by conducting a falls risk assessment of the client upon admission and with continuous reassessments. Appropriate interventions are implemented and education is provided as part of the Plan of Care. The pediatric clinical manager or initial nurse will assess each child for risk factors for falls at the initial assessment. Following the assessment, should the child be determined at risk for falls, the clinical manager will provide instruction and collaborate with staff to put into place appropriate interventions and precautions to prevent injury to the child. Any learning needs of the child or caregivers will be addressed with educational materials and training, as needed. The interventions, including precautions and ongoing education, will be incorporated into the Plan of Care immediately. As children grow in size, cognition, and ability, reassessments may alleviate, reveal additional, or alter the probability of the current falls risks. Some of the children in home health care will fall, despite one-on-one care. The fall might even be a direct result of our care. Many times we encourage these children, with physician approval and possibly therapist s direction, to move beyond their current level of ability. Just as many normal developing children stumble and fall when learning to walk or run, these children with special needs will fall attempting new activities. This fact does not dismiss the need for a fall prevention plan. The goal for this type of child s plan may be to decrease or eliminate the probability of falls or it may merely decrease the impact or probability of the injury caused by the fall. All falls, despite the nature of the fall, lack of injury, family request to not inform, or the fact that it occurred when a nurse wasn t present are to be reported to the office immediately. The clinical manager will always follow up with the caregiver 235

34 Safety and employee, and after reassessing the child, will make revisions to the Plan of Care, if necessary. Basic home safety Starting with the initial assessment, we do everything in our power to provide a safe environment for our employees and clients. It is the first nurse in the home, typically the clinical manager, who inspects the home, conducts a safety screening and makes required recommendations to be followed either before or when care begins in the home. Based on the findings of the safety evaluation of the home, specific instructions are prepared. The family may be given instructions for areas that need to be addressed related to hazards or safety before the start of care. Instructions may be given to the office staff about safe staffing. In some cases, if there are concerns about the safety of the general location of the client, we may only allow care to be provided during particular hours. There may be instructions communicated to you that may include information on specific fall prevention measures; proper use of medical equipment; storage, handling, and access to supplies, medical gases, and medications; and identification, management, and disposal of hazardous material and waste. In some cases, we may not be able to assume care of a client if a safe environment cannot be established. Safety issues are re-evaluated every 2 months during the clinical manager s visit. However, whenever you are in the client s home, you should constantly be evaluating the situation and report any safety concerns to your clinical manager immediately. On your arrival to your client s home, observe and ensure that: 1. You know the evacuation plan. 2. You know where the fire extinguisher is (if available). 3. Emergency numbers are posted near the phone or accessible in the client chart. 4. The phone is accessible. 5. A minimum of two exits are unobstructed. 6. Alarms are set and functioning on all equipment. Equipment safety-specific concerns to evaluate include: Primary caregiver s ability to use required equipment. Presence of equipment manuals Presence of back-up power source or plan Proof of equipment inspection and monitoring annually Use of Oxygen warning sign posted 236

35 Safety Use of free-flow protected feeding pumps Some general home safety concerns include but are not limited to: Keeping medications out of reach, in a locked cabinet, in childproof containers Keeping anything with swallow-sized batteries out of reach Locking dangerous items in cabinets Keeping cleaning products out of reach, labeled Poison, in original containers, away from food Ensuring that matches, cigarettes, and vitamins are out of reach Keeping space heaters 3 feet away from curtains, paper, oxygen, and furniture Keeping knives and sharp items out of reach Locking the tops of doors to keep children from entering basements and garages Keeping plants out of reach Fire safety is also addressed with every client and employee and is monitored throughout the caregiving process. Every home that has a pediatric client under our home health care has a case-specific evacuation plan in place as developed by the clinical manager. The plan includes an escape route and procedure for escape. Although the client s home has been evaluated for fire hazards and fire prevention and a plan has been initiated by the clinical manager, you personally must be aware of what constitutes a fire hazard and report any such hazard immediately to your office. Every field employee receives at orientation Becoming a Hero: A Guide for BAYADA Home Health Care Employees which includes discussion of basic home safety. You must be able to recognize signs that would indicate there is a fire in the home such as abnormal heat, smell of burning, presence of smoke, or visible flame. If a fire occurs, you should complete the following steps: 1. Alert everyone in the house. 2. Proceed with the planned evacuation. 3. Call 911 from the closest available and safest means of communication. 4. Do not attempt re-entry into the home. 5. Do not delay evacuation by gathering personal possessions. 6. If the child is on oxygen, turn off the oxygen and remove the child from the area. 7. Do not bring oxygen with you. 237

36 Safety In addition to the home environment, we regularly monitor the safety of procedures and equipment. You are expected to fully comply with all safety guidelines provided and report any concerns or safety hazards immediately to your clinical manager, who will investigate and rectify any issue so it will not recur. Special considerations in pediatric medication administration When a pediatric client is receiving medications in the home, special considerations are made to ensure that the correct medication and dosage are given at all times, even when nurses are not present. The following topics are a few of the considerations related to medications administered in the home. Incident reporting Employees are notified during orientation that it is mandatory to report all incidents to their clinical managers immediately. An incident is defined as any happening that is not consistent with the routine operation or the routine care of a client. It may be an accident or a situation that might result in an accident. An incident may also be any variance in the provision of care that results in injury or potential harm to the client, the client s family, or our employee. Incidents may include but are not limited to: Loss or breakage of client property or equipment Equipment or medical device failure Endangerment of clients or employees Refusal of treatment that compromises safety Procedure error that results in injury or trauma Untoward outcomes such as drug reactions or IV therapy complications Attended or unattended falls Medication errors Motor vehicle accidents involving a client or employee s vehicle that is being used during BAYADA care Any staff accidents or occupational exposures that require treatment, lost work days, or hospitalization, including incidents that identify safety hazards previously unrecognized Equipment use errors Noncompliance with policies, procedures, or treatment plan Personal injury from lifting, falling, or transporting equipment When an incident occurs, you must respond to any sustained injury appropriately and then report to the client services manager or clinical manager immediately. The director of the office should be fully apprised of the occurrence. Information is gathered and compiled to be documented. Immediate action is taken with all 238

37 Safety incidents. If not yet involved, the clinical manager is immediately informed about any client incidents that are clinically relevant. Depending on the severity of the issue, a home visit may be conducted to assess the situation and documentation of the results of that visit will be provided to the physician, client, family, and employee. Emergency preparedness at home An emergency is defined as a serious situation or occurrence that happens unexpectedly and demands immediate action. In accordance with this definition, we must be prepared to respond to various medical emergencies. We must be able to adapt to unexpected alterations in the care environment and provide transport or sudden evacuation in order to provide a truly safe environment. It is our goal to implement practices and precautions that will make emergencies infrequent. Our emergency preparedness plan includes activities designed to lessen the severity, prepare for, respond to, and recover from the most likely events that would suddenly and significantly affect our ability to provide continuing care to our clients. Before your first shift, the specific plan of treatment, the client s routine, the client s equipment, and the emergency plan must be fully reviewed. Your knowledge and ability to anticipate and respond to any emergency is essential. Some of the various emergency response components will be discussed in detail. In each client s home there will be physician s orders that will guide you in the care of your client. As a nurse in the home, you are required to have such orders for all treatments you will be expected to provide. There will be times when you will call the physician for new orders or guidance in relation to your observations. However, as a trained medical professional, in an emergency situation when required action is needed beyond the written orders, your response must be to perform all necessary interventions and call for emergency personnel assistance. First aid First aid consists of clinical observation and common sense. Life supporting first aid prevents cardiac arrest and saves lives, said Peter Safar, MD, the founding father of CPR. Persons who know first aid* are equipped to do an assessment and perform key components of specific skills with minimal equipment until emergency personnel arrive. First aid principles are applied to various emergencies including medical, physical, and environmental injury. *Remember, CPR is a secondary component of first aid. Transport The ultimate goal in pediatric home health care is to provide all the medically needed care and still allow and assist the child to just be a child. In striving for 239

38 Safety this goal, transports become commonplace. Children receiving home health care often attend school, family outings, and play dates. Some children have even gone on extensive vacations with nursing assistance. Of course, they also get transported to physician appointments and therapy sessions. The definition of transport is commonly viewed as leaving the home, but in reality it is more than that. Any time a child leaves the area in their home where all there needed equipment is kept, they are, in accordance with home health care standards, being transported, even if within the same home. Because transporting is so common in home health care, we have developed guidelines and policy for a transport bag known as the Go Bag, to be used in certain situations. Every child requires a bag of supplies and each client s situation must be evaluated and a Go Bag developed specific to that client s needs. When transporting a child, you must think of several things: 1. Length of time you will be away from the home 2. Medical treatments and personal care needs that may be required during that time 3. Supplies that will be involved to meet these treatment needs 4. Potential emergencies that could occur with this child 5. Supplies that would be needed to deal with any emergency that could occur 6. Medications that might be used for emergency management readily available, properly stored, and within their expiration dates 7. Amount of supplies (ie, enough) in case your time away from home is unexpectedly extended 8. Treatments that may be required immediately upon your return home The contents of the Go Bag must be checked at the beginning of each shift, restocked after use, and kept with the client at all times. Hazards Hazards are obstacles or sources of danger. The following possible hazards have been identified as posing the greatest risk to our nurses ability to provide service to clients and communication with clients and staff. This list is based on a companywide analysis of office locations, community make-up, actual occurrence or likelihood of occurrence, impact on the population served, and impact on access to clients homes: Severe winter storms snow or ice Power or utility failures Floods Building fires 240

39 Safety Tornadoes or hurricanes Transit strikes Wildfires Loss of power Power loss may occur without warning, and in some areas, frequently. This can impact our ability to provide the child with necessary treatments and may even compromise safety. If the power goes out, ensure the child is safe and stable, and then investigate the reason for loss of power. Verify if the power is out only to client s house, the neighborhood, or a bigger area. If there is a family member at home, have them do the investigation while you provide care to the child. If you are alone in the house, check the circuit breaker, if accessible. If it is not an internal issue, call the power company. If the power outage is extensive and will last a while, discuss an alternate location where the family can stay until power is returned. If the child is unstable and has lost function of required safety equipment, the child must be transported immediately. Call for emergency assistance if necessary. Local or national disaster or emergency situations These situations can also affect our ability to provide care and impede the ability for staff to get to the client s home. It may be so severe that the home may need to be evacuated. We continue to provide reliable home health care in these situations and your office has a plan to continue functioning and provide assistance to our professionals as needed. Primary caregivers, priority levels, and evacuation plans were established on admission and consistently reviewed to assist with the proper and safe management of the client. Primary caregiver We require a family or friend primary caregiver for each child that we provide professional care for. This caregiver must be an adult who is known and is willing and able to provide care to the client. The primary caregiver must be available to provide all care when nurses are not present. In an emergency, a caregiver may be responsible for multiple days of care without the assistance of nurses. Because of this, we have established a priority level system to fairly distribute services during an emergency or disaster. Priority level This priority level is decided upon admission by the clinical manager based on the degree and frequency of medically necessary treatments and available social support. This priority level is evaluated regularly with each client assessment. There are three levels utilized to distinguish various client priorities for need of service. 1. Priority level 1 Assigned to clients with care needs beyond the primary caregiver s ability to safely provide or that caregivers cannot safely provide 241

40 Safety over an extended period of time. This may include but is not limited to the care of clients with infusions, tracheostomy or ventilator, and those receiving around-the-clock care. 2. Priority level 2 Assigned to clients whose need for service can be delayed. These children can go without medical treatment so long as the caregiver can provide all necessary care in a safe manner over a short period of time. Expectation of the caregiver is limited to short periods of time only, and staffing. will be arranged to provide care and support, even if staff is available only for short periods of time. 3. Priority level 3 Assigned to clients who have good social supports, trained caregivers, and can be left under their care until the emergency subsides. When a disaster or emergency occurs, the client services manager or clinical manager will contact the clients in order of priority level to assess status, safety, and scheduling needs. If travel is impacted and limits access to client s home, a crew of emergency drivers including office staff may be assembled to assist with transport. The office will contact you and discuss your client s priority for service. Understand that priority is given to those who are at greatest risk if their services are interrupted. You may be asked to remain with your client until their caregiver or another employee arrives to relieve you. You may be informed that your client can go without care until the emergency is resolved, however, the pediatric client can never be left unattended. What this means is that the primary caregiver, who is capable of assuming and providing the appropriate care must be present in order for you to leave. If you are in the client s home at the time of the disaster, you will need to stay until the primary caregiver or a designee arrives to relieve you. Subsequently, you may be asked to go to a different client on your next shift based on the priority of care needs at that time. For priority level 2 or 3 clients who cannot be immediately served due to the nature of the emergency, the client or the client s family is instructed to provide care. The staff will provide individualized phone instruction and guidance on the specific treatment or procedure. If the timeliness of care cannot be established safely, the client will be referred to the local hospital emergency department or other appropriate community resources. Our main objective during an emergency is to provide our clients with needed care in a safe, timely, and efficient manner, while ensuring overall client and employee safety. Infection control The Centers for Disease Control and Prevention (CDC) is the leading source of guidance for infection control issues in all health care in the United States. We use the most recent CDC information available when developing and updating our policies. Additionally, each office is responsible for following their county and state regulations related to infection control. The CDC continually updates recommendations based on new research findings and this section will discuss the basic concepts in guidelines for practice. 242

41 Safety Standard precautions Standard precautions is the practice of treating all blood, body fluids, secretions, excretions except sweat, as if it were infected with a blood-borne or other pathogen, and avoiding all unprotected contact with this material. These precautions are designed to reduce the risk of transmission from both recognized and unrecognized sources of infection. Standard precautions are used during the care of all clients when performing procedures that may require contact with blood, body fluids, secretions, excretions, nonintact skin, and mucous membranes or any item that is soiled or contaminated with any of these substances. Key practices related to standard precautions include hand hygiene, use of personal protective equipment, handling of soiled dressings, equipment and linen, and safe handling of sharp instruments. Because standard precautions have a consistent and comprehensive approach to infection control, they have been adapted into our home health care practice. Adherence to standard precautions is required to assure both the healthcare professional s and the client s safety. An employee is instructed on Standard Precautions during orientation and it is reviewed annually. Precautions are also taught to clients and family and caregivers and are reinforced throughout the time the client receives care. Hand hygiene Hand hygiene is a general term that applies to the methods used to reduce microorganisms on the hands. It includes hand decontamination, hand washing, hand care, nail care, and glove usage. Hand decontamination is the most effective way for healthcare workers to reduce client infections and infectionrelated deaths. Upon the start of care, we strive to promote proper infection control in a client s home by establishing the appropriate equipment and supplies. An adequate supply of alcohol-based waterless hand gel is provided to every employee or left in the client s home. Also, antimicrobial soap and paper towels can be left in the client s home when the situation requires. Personal protective equipment (PPE) PPE is provided to each employee or left in each home. Gloves, gowns, masks, and protective eyewear will be provided to employees and required for use based on the specific procedures being performed, the type of exposure anticipated, and as directed by the clinical manager. Always decontaminate hands prior to donning and after removing protective equipment. All personal protective gear must be removed before leaving the client s home. When disposing of protective equipment, it should be placed in a plastic bag and then in the client s trash, in accordance with local ordinances. 243

42 Safety Gloves are worn when there is reasonable anticipation of contact with blood, body fluids, and other potentially infectious material. Hands should be decontaminated immediately before and after use of gloves. Gloves should be removed if they become ripped, torn, or soiled. The use of double-gloving is suggested when removing and decontaminating blood or body fluid spills, to decrease the risk of contaminations. With double-gloving, the top pair can be removed leaving a clean pair of gloves in place to maintain protection and prevent cross-contamination while completing the task. During decontamination, it helps to ensure there is not a breach in your protection because the decontamination solution may compromise the integrity of the gloves. The gloves must be removed promptly when the task is completed before proceeding with the next task or procedure to prevent cross-contamination. Apron and gowns are clean, nonsterile, nonpermeable covers that are worn to protect and prevent soiling of clothes and skin during procedures that have the probability of generating splashes or sprays of potentially infectious materials. These are disposable, single-use items. Contamination from a splash may occur if reuse is attempted. Wear a gown when there is substantial contact with a client or environment with potential for exposure to uncontrolled, uncontained blood or body fluids that could contaminate clothing or skin. This would include use with a client who has uncontrolled incontinence with infection present in the stool or urine or a client who has a heavily draining wound. Masks and eye gear are used to protect skin and mucous membranes. A mask, goggles, or face shield should be worn for the procedures that are likely to generate droplets and splashes or sprays of blood or body fluids. Hazardous waste Standard precautions should be used to reduce the risk of injury or exposure when handling hazardous waste. Nurses are responsible for recognizing hazardous materials and waste in their work environment and must take appropriate measures to protect their clients and themselves. Some common sources of hazardous waste are soiled linens, disposable supplies, soiled dressings, diapers, gloves, spills of infectious materials, and sharps. Any disposable material that has been contaminated with hazardous waste should be double-bagged and disposed of in a securely fastened plastic bag prior to disposing in the household trash. Soiled laundry must be handled with care. In order to avoid contamination, use PPE and hold linens away from your clothes. When possible, place laundry into a bedside collector and use it to transport to the washing machine. Keep any laundry items that are soiled with bodily fluids separate from the rest of the laundry. Soiled clothes and linens should be washed in hot soapy water and thoroughly rinsed free of bodily excrement or exudates prior to being laundered. 244

43 Safety Supplies and equipment are either single-use or reusable. Single-use items should be discarded as clinical waste, and nondisposable items should be appropriately cleaned and disinfected or sterilized before reuse. The procedure for cleaning common noncritical, semicritical, and critical items is reviewed in our company policy. Also, the manufacturer and the equipment supplier may provide instructions for acceptable agents and the correct process to disinfect or sterilize various supplies. These instructions should be present in the client s home chart. Single-use items that are to be reused against manufacturer s advice require physician orders for reuse and proper disinfection. If you are unable to locate specific directions, please consult your clinical manager. Spills need to be cleaned up and the area should be decontaminated. Employees will double-glove and use other appropriate attire during removal and decontamination of blood or body fluid spills. Liquid materials typically are absorbed while bulk materials are scooped up. As soon as possible after a spill, the area and equipment should be decontaminated with 1:10 bleach solution. Needles and sharp instruments should be handled with great care. Nurses must try to prevent injuries when using needles or other sharps while preparing for, performing, or cleaning up from procedures requiring the use of a sharp. The use of engineered needle safety devices is required. It is the responsibility of the nurse using a sharp to dispose of it in a sharps container as soon as possible after use to ensure that it has been safely discarded. Laws related to the disposal of sharps will vary between states as to whether the sharps receptaclemay be disposed of in the trash. Per the Occupational and Safety Health Administration (OSHA), regulated waste containers are required to be labeled with the biohazard symbol or be color-coded. Exposure Exposure to infection can occur to the employee or the client. An occupational exposure is an employee s direct exposure to a client s blood or other potentially infected fluids, body tissues, or personal belongings. Employees can be exposed following a blood or urine spill, a client s coughing, the removal of dirty wound dressings, or when pricked by a used needle. If exposed, immediately wash the contact site with soap and water or flush your mucous membranes with water or normal saline. Then notify your clinical manager of the incident so you can be given instructions on how to obtain follow-up medical care and any necessary ongoing treatment. To minimize or prevent an occupational exposure: 1. Think about what you are doing. Examine your work area for needles, sharps. and other dangerous objects. 2. Wear appropriate PPE when providing personal care or if you are ever at risk of exposure to infectious materials. 245

44 Safety 3. Make sure you are prepared to carry out your tasks. Have all your supplies handy and extra PPE available if you need it. Place the sharps container and any other devices that may be needed as close to the work area as possible. 4. Act in a safe and conscious way to provide the personal care or treatment the client requires. 5. Don t forget that the single most effective way to prevent the spread of disease is through adherence to hand hygiene practices. A client exposure occurs when the infectious material is transmitted from the employee to the client. The home health care client s immune system may be altered because of a lack of immunizations, medication induced, or surgically induced or impaired due to a disease process. For this reason, it is important to use standard precautions to protect our clients. Employees should notify the clinical manager as soon as possible when they exhibit signs or symptoms of a contagious disease, have a physician confirmation of a contagious disease, or suspect they may have contracted a contagious disease from a client. Pets Although concerns about health risks exist, the number of people who integrate pets into their home and remain healthy demonstrate that good practice can minimize the risks of disease and parasite transmission from animals to humans. Still, animals can pass on germs or parasites to people. A person s age and health status may affect the immune system, increasing the chances of getting sick. Clients at risk include children younger than 5 years old, children with HIV/AIDS, and children undergoing cancer treatments or on anti-rejection medications following organ transplants. For this population, pets in the home may be unadvisable. Good hygiene and sanitary practices will help people avoid contracting diseases from animals. Employees must decontaminate hands after contact with pets before moving on to any other task. Do not let the child put anything in their mouth that has had contact with the pet. Avoid inhalation of pet secretions, litter dust, dried droppings that have turned to dust, and aquarium water. If you need to clean up a soiled area, wear disposable gloves and mask and use solutions to disinfect the area. Discard all cleaning debris in plastic-sealed bags. Domesticated animals such as dogs and cats tend to have fewer risks for disease transmission, however, these days not all house pets are of the traditionally domesticated kind. Different types of animals can carry different diseases and some animals may be more likely than others to carry diseases that could transfer to people. Children with affected immune systems should avoid reptiles, baby chicks and ducklings; puppies and kittens younger than 6 months old, and pets with diarrhea. Birds of the parrot family should be kept away from rooms where the children will play or sleep. If infected, these birds can transmit an airborne respiratory illness to humans. 246

45 Safety The CDC recommends that after an outing where a child may be in contact with farm or zoo animals, the child s hands should be washed thoroughly with soap and water. There are many different areas in home health care that require evaluation and utilization of infection control measures. As an employee, you will be updated and reeducated yearly on proper techniques and policy changes. Always call the office and talk to your clinical manager if you have a question related to infection control. 247

46 Safety Before continuing on to the next section, answer the following questions by circling the appropriate letter. Check your responses with the answers below. 1. What would be a concern for a 12-year-old whose cognitive developmental level is age 2 years? (A) Allowing the child to play outside unattended. (B) The child riding belted-in on a swing. (C) The child should not play outside. (D) Don t let the child play with other children. 2. Safety precautions instituted for a pediatric client are based on: (A) Chronological age. (B) Physical ability. (C) Cognitive ability. (D) All of the above. 3. Emergency procedure in the home is: (A) The parents responsibility. (B) The clinical manager s responsibility. (C) The field nurse on duty s responsibility. (D) All of the above. 4. If there is a fire in the home, you should: (A) Review the evacuation plan for directions. (B) Exit with the client then go back to get the supplies. (C) Grab the Go Bag and go to a predetermined destination with the client. (D) Call 911 then exit the home. 5. When do you call 911 when providing CPR assistance to an 11-year-old child? (A) Immediately. (B) After performing 1 minute of CPR, because it s a child. (C) When another person is on the scene. (D) Never. 248

47 Safety 6. When transporting a child, you must think of which of the following: (A) The length of time anticipated away from the home. (B) What medical treatments, supplies, and personal care will be needed while out. (C) How to be appropriately prepared for any potential emergency. (D) All of the above. 7. BAYADA Home Health Care utilizes which type of infection control? (A) Universal precautions (B) Individualized precautions (C) Standard precautions (D) None of the above. 8. The client begins to cough while you are holding him, spattering a small amount of mucous into your eyes. What should you do? (A) Don t be concerned unless irritation and drainage develop in the eye. (B) Call the clinical manager after your shift is over. (C) Rinse your eyes and call the clinical manager or first available supervisor immediately. (D) Send in a request for eye protection to prevent this incident in the future. Answers: 1. A, 2. D, 3. D, 4. C, 6. A, 6. D, 7. C, 8. C 249

48 Safety References Guide to Pediatric Fall Prevention. Bayada Nurses; Becoming a Hero a Guide for Bayada Nurses American Heart Association, Health Care Provider Basic Life Support Course Handbook; American Heart Association. Heartsaver First Aid Course Handbook Safe home program, subdivision of statewide comprehensive injury prevention program by Massachusetts department of public health funded by the federal division of maternal child health Children s traffic safety program from Vanderbilt University in Nashville Tennessee-funded by Department of Transportation and the Tennessee Governor s Highway Safety program Dr Peter Safar, professor of resuscitation medicine at the University of Pittsburgh School of Medicine ( the father of CPR ). Quote. The forum for family and consumer issues. North Carolina State University. Winter 1997;2(1). Hammet WS, Kirby SD. Protecting young children in the home. North Carolina Cooperative Extension Service, North Carolina State University. Aherin RA, Todd CM. Developmental stages of children and accident risk potential. International Winter Meeting of the American Society of Agricultural Engineers; Barsley-Marra, BL. Understanding and encouraging your young child's large motor development. University of Missouri-Columbia; Eisenberg A, Murkoff HE, Hathaway SE. What to Expect, the Toddler Years. New York: Workman Publishing; Hammett, WS, Mock JE. Safety on the farmstead. Unpublished manuscript. North Carolina State University; Shelov SP, Hannemann RE, eds. Caring for Your Baby and Young Child, Birth to Age 5. New York: Bantam Books; Prevent your grandchildren from being poisoned: Safety alert. (#5041). United States Consumer Product Safety Commission. Washington, DC: US Consumer Product Safety Commission;

49 Safety Yearns M, Oesterreich. The cybernet children s health and safety directory: home safety a checklist for parents health and safety Rodgers GB. Bicycle and bicycle helmet use patterns in the United States in J Safety Res. 2000;31: Centers for Disease Control and Prevention, National Center for Health Statistics Mortality Tapes. Hyattsville, MD: Division of Data Services, National Center for Health Statistics; US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS). Bethesda, MD: US Consumer Product Safety Commission; 1999 Injury-control recommendations: bicycle helmets. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1995;44(RR-1):1 17. Thompson RS, Rivara FP, Thompson DC. A case control study of the effectiveness of bicycle safety helmets. N Engl J Med. 1989;320: Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries: a case-control study. JAMA. 1996;276: Thompson DC, Nunn ME, Thompson RS, Rivara FP. Effectiveness of bicycle safety helmets in preventing serious facial injury. JAMA. 1996;276: Sacks JJ, Kresnow M, Houston B, Russell J. Bicycle helmet use among American children, Inj Prev. 1997;2: National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System (BRFSS). Howland J, Sargent J, Weitzman M, et al. Barriers to bicycle helmet use among children: results of focus groups with fourth, fifth, and sixth graders. Am J Dis Child. 1989;143: Parkin PC, Spence LJ, Hu X, Kranz KE, Shortt LG, Wesson DE. Evaluation of a promotional strategy to increase bicycle helmet use by children. Pediatrics. 1993;91: Schieber RA, Kresnow MJ, Sacks JJ, Pledger EE, O'Neil JM, Toomey KE. Effect of a state law on reported bicycle helmet ownership and use. Arch Pediatr Adolesc Med. 1996;150:

50 Safety Ni H, Sacks JJ, Curtis L, Cieslak PR, Hedberg K. Evaluation of a statewide bicycle helmet law via multiple measures of helmet use. Arch Pediatric Adolescent Med. 1997;151: Hatziandreu EJ, Sacks JJ, Brown R, Taylor WR, Rosenberg ML, Graham JD. The cost effectiveness of three programs to increase use of bicycle helmets among children. Public Health Rep. 1995;110: US Department of Health and Human Services. Healthy People Vols 1 and 2. 2nd ed. Washington, DC: US Government Printing Office; National Highway Traffic Safety Administration, National Center for Injury Prevention and Control, and Federal Highway Administration. National Strategies for Advancing Bicycle Safety. Washington, DC: US Department of Transportation; Safety Standard for Bicycle Helmets. 63 Federal Register (1998) (codified at 16 CFR 1203). Powell EC, Tanz RR. Tykes and bikes: injuries associated with bicycle-towed child trailers and bicycle-mounted child seats. Arch Pediatric Adolescent Med. 2000;154: Child bicycle safety act. American Academy of Pediatrics. Pediatrics. 2001;108(4): C.html&soc=AAP&srch_typ=NAV_SERCH Preventing sports injuries: tips for back-to-school athletes. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health Hall JR Jr. Children Playing with Fire. National Fire Protection Agency; March C.html&soc=AAP&srch_typ=NAV_SERCH rch%20&%20reports/fact%20sheets/home%20safety/children%20playing%20 with%20fire&cookie%5ftest=1 252

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53 Rehabilitation Once you complete this section, you should be able to: 1. Discuss the significance of educational intervention plans 2. Indentify the members of the multidisciplinary team and their functions 3. List adaptive equipment Contents Introduction Educational intervention plans Early intervention program Individualized educational plan The multidisciplinary team Adaptive equipment Orthotics Stander Crutchers, walkers, gait trainers Wheelchairs Lifts Vestibular and positioning Augmentative communication Bath equipment

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55 Rehabilitation Introduction Rehabilitation nursing is a specialty practice area within the scope of professional nursing that is especially important in pediatric home health care. Many times, a daily goal for each of our clients is to have a chance to just be a kid. Nurses working with children must have assessment skills, in-depth knowledge of normal growth and development, and knowledge of interventions that promote the achievement of them. Appropriate communication skills and knowledge of condition-appropriate play are necessary to help the client reach developmental milestones at their own pace. Play, an essential component of how children learn about the world, should be part of each client s rehabilitation plan. Rehabilitation nursing involves the diagnosis and treatment of human responses to actual or potential health problems resulting from altered functional ability and an altered lifestyle. The approach is holistic, caring, and optimistic. Typically, the nurse provides comfort, therapy, and education, promotes health-conducive adjustments, supports adaptive capabilities, and encourages achievable independence. The goal of the pediatric rehabilitation process is to enable children to maintain current function while striving for maximum potential, and if possible, ultimately become a contributing member of society. Pediatric rehabilitation nursing is the driving force. As a subspecialty, rehabilitation nursing uses an interdisciplinary approach to address the prevention, diagnosis, treatment, and management of congenital and childhoodonset physical impairments. These can be any related or secondary medical, physical, functional, cognitive, psychosocial, or vocational limitations or conditions. Working with physically impaired children requires the identification of functional capabilities and the selection of interventions, with an understanding of both the life course of the disability and the continuum of care. Educational intervention plans In 1990, major changes to the Education for All Handicapped Children Act created the Individuals with Disabilities Education Act (IDEA). Two important sections were developed in IDEA: Part B specified the public school system s responsibility for providing services to eligible children ages 3 to 21 and Part C gave states the option to provide early intervention services for eligible infants and toddlers from birth through 2 years. As of today, all states except Kentucky provide services under Part C. Early intervention program Typically, the earliest at-home rehabilitation service the pediatric client receives is the Early Intervention Program (EIP). This is a sustained and systematic effort to assist families with children from birth to 3 years who are disabled and developmentally vulnerable. This program s services are designed to meet the 257

56 Rehabilitation child s needs in physical, cognitive, communicative, and psychological development and in self-help skills. The purpose of these services is to enhance the development of the infant or toddler with disabilities, to minimize their potential for developmental delay, and to optimize the abilities of the families to meet the special needs of their children. Early intervention is a process. It begins with an initial assessment from which the Individual Family Service Plan (IFSP) is developed. This family service plan is based on the concept that parents have the primary role in nurturing and providing early learning experiences but they may require assistance or instruction to effectively care for a child with special needs. The team will provide the family with interventions, teach them how to use them, and then intermittently evaluate effectiveness, making necessary changes as needed. The pivotal person in the infant/toddler s EIP experience will depend on the areas showing developmental delay. Because the issue of basic gross motor function, primarily trunk control, must be established to achieve other milestones, in many cases the pivotal person is the physical therapist (PT). The PT works on movement and functional dysfunctions and provides the client with environmental stimuli and cues to enhance development. The offered interventions are based on the infant s rapid growth and foundational development and their ability to actively participate, learn, and form attachments. The developmental outcome will be determined by the client s biologic condition and some environmental factors but the structured programs can improve their abilities. The primary role of the physical therapist is enhancing stimuli and learning that would normally be provided by play and exploration. This includes assisting the client with positions and movements to enhance sensory motor processing and overall learning. Physical therapy may play a critical role in the client s achievement of functional independence and eventual integration into the school system. The therapist can perform a gross motor exam to determine the developmental age and ability of the client, then determine functional goals. These goals can include rolling or sitting independently, ambulatory skills, improved motor control, and planning new functions to improve quality of life. Therapists often contribute in decisions about assistive devices for the client; educate families on handling and positioning the client; teach the client functional movement, stability, and skills; and provide important sensory input to a client with a compromised nervous system. As a home health care nurse, you may have the opportunity to work directly with the EIP staff, be given written directions from them, or receive secondhand information from the parent. Always contact your clinical manager to discuss the situation. Remember, you must have physician orders to provide any therapy interventions. 258

57 Rehabilitation Individualized educational plan As the child approaches the age of 3 years, the multidisciplinary team starts transition planning to prepare the child to begin services through the special education system, if needed. To meet the eligibility criteria, the client s disability must interfere with the educational process and normal school performance to the extent that special education assistance is needed. According to Part B of IDEA, Every child must have a multidisciplinary evaluation by a team. This team, working with the family, is responsible for designing an individualized education plan that has specific education and therapeutic strategies and objectives. By law, every child must be educated in the least restrictive environment. These criteria support the concept of integrating all children into educational programs, offering extra supports and services to facilitate inclusion for those who need them. To do this, the evaluation team may recommend related services including transportation; speech pathology, audiology, psychological services, physical and occupational therapies; recreation, social work services, and possibly medical services for diagnosis and evaluation. The additional services may also include one-on-one nursing care during school hours and/or during transportation. The parents must approve the IEP and once signed, the school is committed to providing the services. The plan must be reviewed annually and signed by the family in agreement with the terms. The multidisciplinary team An effective multidisciplinary team comprises varying professionals representing those involved in the client s care. Team members usually include: Physical therapist (PT) Typically concentrates on motor development Occupational therapist (OT) Focuses on functionality and develops adaptations to assist the client Speech therapist (ST) The focus of a speech pathologist or feeding therapist varies based on the client s oral motor development for speech, feeding, and swallowing. With some clients, alternate communication may be established and the therapist works with the client to gain some oral motor control to assist with secretion management; some therapists concentrate on vocabulary expansion for both comprehension and expressive purposes Augmentative technology specialist Develops a specific augmentation tool to help the client with communication such as enhancing simple yes no answers or offering a computerized system for the client to give more varied and personalized statements Physicians Special providers of various disciplines based on the client s significant medical condition are all involved in the team. Generally the primary care physician is also part of the team 259

58 Rehabilitation Rehab CRRN Provides an overview of what can be functionally expected and safely obtained within the limits of the client s specific condition and changes goals based on their changing development. The CRRN can also assist with realistic obtainable goals to maintain function, varied sources of assistance with obtaining adaptive equipment, and services for clients. A team of rehabilitation nurses who can provide expertise with rehab issues will use our concept of Bayadability to help. The team can assist by troubleshooting issues over the phone or provide an in-home consultation. Ask your clinical manager if you think your client could benefit from this Nursing team Nurses provide daily care to the client, know the client s medical routine, and are aware of the client s tolerance of the treatment and activities. Nurses are able to provide information to the team that help your client make developmental strides Teacher Knows what is to be covered and needs to be involved to discuss adapting the environment or concepts to assist the client Parents Provide information and insights to make the plan effective based on knowledge of their child s ability and personality. Parents should be encouraged to participate in all aspects of the IEP Adaptive equipment A piece of adaptive equipment is a device that allows a child to access his or her environment. The equipment can facilitate the child s function by: 1. Providing physiologic support. 2. Completing something that is absent, allowing the child access or control despite functional disability. Each of these adaptive equipment types will be described in the scenarios below. A client with neuromuscular disease has gross motor delays because motor skills are motions carried out when the brain, nervous system, and muscles work together. This client may lose or never achieve gross motor skills the bigger movements by large muscles in the arms, legs, torso, and feet. Envision this child s posture as sliding down, slumped over in the chair, chin resting on the chest. Without the gross motor control, the child s fine motor skill, which includes the small movements of the small muscles of the fingers, toes, wrists, lips, and tongue, cannot be accessed. In this case, the child cannot achieve fine motor skills due to the lack of trunk control. How can this child speak with the weight of the head pinning the chin to the chest? Only when trunk support and proper head alignment is provided may some fine motor movements be possible. 260

59 Rehabilitation In this picture, the child s spine is now straight and the head is held upright, allowing the jaw to move freely. This will enhance the ability of fine motor development, tongue movements, and some possible speech with therapeutic intervention. Picture this same client enrolled in school. Despite the trunk support, the child is not able to move an arm or grasp a pen. How can there be active participation in class and demonstration of knowledge if they cannot independently do school work or homework? These can be accomplished with utilization of another piece of adaptive equipment (there are many options, some simple and creative, others high-tech) that can be applied. In this case, the client has trunk support and there is controlled movement noted to one finger. Using that functional ability, an augmentative device such as a switch can be adapted to allow navigation of the computer by movement of that single finger. Accessing control of the computer system allows the client to independently do school work. During the client s school years, whether at home or in school, the home health care professional will be exposed to many types of adaptive equipment utilizing both of these concepts. The types of equipment and the need for it will change with the child s developmental ability, physical growth and cognitive ability. This section will review the most common types of adaptive equipment seen in home health care. Orthotics Orthotics is a specialty within the medical field concerned with the design, manufacture, and application of orthoses, which are some of the most common pieces of rehabilitation equipment used by pediatric home health care clients. An orthosis can be used to support, align, prevent, or correct deformities. Orthoses are also used to control spastic joints to improve the function of movable parts of the body. This section will discuss the most frequently used orthotics. When placing orthotics on the client, start with the most basic support needed and add on (and do the reverse for removing the orthotics). For the neuromuscular-impaired child, for example, the spinal vest would be placed first to provide functional trunk support, a basic and primary gross motor function. Next apply ankle foot orthotics (AFOs) which require the knees to be bent and the feet flexed to support the physiologic norm for foot and lower leg alignment, ultimately providing support to leg muscles and posture. If the child needs to be in a standing position, this would require knee stabilization, so the knee immobilizers would be placed last. 261

60 Rehabilitation Conversely, when removing the orthotics, remove the higher-function supports first, then remove less important supports, and remove the least functional support last. Remove the orthotics starting with the most advanced stabilization to the least. In this case, first remove the knee immobilizers, then the AFOs, then the spinal vest. Spinal jacket or vest Also known as a body jacket or lumbar-sacral orthosis (LSO), the spinal jacket is available in two styles one is a single piece and the other is two pieces. The vest is typically used to provide support and immobilization of the spine after spinal rod placement, for scoliosis correction, and for postural support. The vests are made of rigid foam or lightweight plastic. The device sits over the hips and supports the spine from the lumbar and sacral sections to the thoracic region. The single-piece vest has the opening in the front and fastens across the chest and abdomen. It usually takes two people to help get the client into the vest. The vest must be spread apart and held open while the client is placed in it, to ensure proper alignment. The single-piece vest is more restrictive and can require frequent replacements because there is little room for growth. The two-piece vest consists of back and front pieces and the two overlap slightly over the abdomen and chest while straps secure the vest in place. This style can be applied by one person but can be difficult to maintain in proper alignment. Replacement of this vest is less frequent because it does allow for some physical growth. Neck collars and braces are designed to immobilize the cervical spine. Clients whose chin rests on their chest with their eyes fixed on the floor have poor quality of life and difficulty with social contacts. This flexed-neck posture interferes with breathing by compromising the airway, making eating and swallowing difficult, and decreasing communication abilities. Weakness in the neck muscles results in an unstable upper body, which causes fatigue, discomfort, and pain. Clients with neck-muscle weakness are vulnerable to injury. If the head suddenly falls backward, forward, or sideways, the sudden excessive force can cause muscles and ligaments in the neck to tear or overstretch. An event like this can cause serious injury to the cervical spinal cord or vertebrae. Through effective management of neck-muscle weakness, complications of pain and injury can be prevented or treated. Finding the best methods for supporting the head in an upright position to protect against injury is essential. 262

61 Rehabilitation Rigid neck supports can immobilize weakened neck muscles but are frequently uncomfortable and can inhibit speech and swallowing. The soft collar or cervical collar is more flexible brace than a rigid neck support, while still being an effective support to hold up the head or keep it securely in alignment during changes of position. Any type of neck support, however, can fail to properly position the client s head because of postural problems, such as rounded shoulders or forward head and spinal misalignment. These deviations, along with inappropriate seating systems, contribute to neck discomfort and shoulder contractures, increasing the possibility of injury. The child with advanced neck weakness should wear a cervical collar when being transferred from one seat to another or riding in the car. Resting hand splints Used to immobilize the wrist, fingers, and thumb in a functional position, resting hand splints ultimately preventing contractures. They are also used frequently for clients with spasticity caused by upper motor neuron lesions. Although the hand splint may not always be helpful, it can not only prevent contractures but also help lengthen shortened finger flexors. Care must be taken with thumb position to monitor for increased spasticity. An alternate treatment is serial casting. When the splint is removed, encourage functional use of the hand or provide passive range of motion. Ankle foot orthosis (AFO) controls the range of movement in the client s ankle and foot. It may be fixed or hinged depending on the child s needs. Indications for an AFO include foot drop, weakness in the ankle, or control of spasticity when walking. Spasticity causes the child to tip-toe walk. Many types of AFOs exist and may include the knee and hip orthoses. Knee ankle foot orthosis (KAFO) is an AFO for protection, correction, and support of the knee joint. A KAFO support is frequently used in low-level spinal cord injuries. KAFOs with a knee lock are generally used to keep the knee from bending when there is a loss of or weakness of the quadriceps. In cases of adequate strength when only support of the ligaments is needed, the lock and foot section are not required. 263

62 Rehabilitation The knee orthosis or a knee brace acts as a support that allows the joint to continue to function. Knee immobilizers also offer support but inhibit function of the joint. They are rigid, which prohibits the flexion of the joint to protect it from injury. Knee immobilizers are often used when a client is placed in a stander or for weight-bearing purposes, to maintain alignment and to provide support to the joint. Hip knee ankle foot orthosis (HKAFO) is a combination of two KAFOs with extensions to include the pelvic and trunk area. The pelvic area can be held by a belt or strap but a more rigid pelvic section or band is more common. HKAFOs are constructed of metal with plastic or leather. These are used when stability or power of the hip-joint is reduced or absent and in other conditions. HKAFOs are most commonly used for children who suffer from neuromuscular disorders such as spina bifida, cerebral palsy, or high-level paraplegia. Normally HKAFOs are made with articulation at the hip with a hip joint incorporated into the design, but in very rare instances they are made without articulation at the hip. The joints may be designed to be free, allowing flexion and extension (within limits), or to be lockable. Lockable joints can usually be disengaged for sitting. When the hip joints are locked and the pelvic section is relatively rigid, a reciprocating gait is usually not possible. Ambulation is achieved by a swing-through or hopping type of gait, using either a walker or forearm crutches. Both legs are moved together as one unit by a swiveling and rocking motion. If the client has some hip flexor power and good trunk control, the pelvic section can be made flexible enough to allow reciprocating gait, even with locked hip joints. Reciprocating gait orthosis (RGO) is also an HKAFO but with one major difference: this device allows one leg to be place ahead of another, more like normal walking. This is achieved by linking the two KAFOs together by a band, two cables, or a push-pull rod that transfers movement energy from one leg to the other. As one leg is flexed or brought forward, it causes a reciprocal extension of the other leg, allowing for a much smoother gait and reduces the amount of effort needed to walk. A walker can often be abandoned for forearm crutches. RGOs are typically used for individuals with a lesion level of T12 to L3 who lack adequate strength to maintain hip extension but have good upper arm strength. Successful use of this device requires high motivation and minimal contractures. It is reportedly used most successfully for children with spina bifida starting as young as 2½ years old. Even though 264

63 Rehabilitation HKAFOs psychosocially increases independence, due to the difficulties in application and removal, their use is often terminated before or around the mid-teens and it is rarely used in adults. General care of orthotics All orthotic devices need to be cleaned regularly with a damp cloth and soapy water and then left to air dry. If straps and padding become worn, they can be replaced. If you think your client is outgrowing the device, encourage the primary caregiver to contact the orthotist. Each orthotic is custom fit for the child and can take 2 or 3 weeks to replace. Instructions given by the orthotist should be followed so the orthosis works effectively. The client should wear thin, plain cotton clothing under any orthosis to reduce rubbing and irritation to the skin and bony prominences. If the client has bilateral orthoses, make sure they are put on the correct feet. The straps should be on the outside of each leg. When putting any AFO on the client, bend the knee to 90 degrees and put the heel fully down and back into the heel of the AFO. It can help to gently lift the client s toes upward to check that the heel is right down in the heel of the AFO. Fasten the ankle strap first, then the calf strap, followed by the toe strap, making sure all the straps are fastened securely. The client should always wear shoes or trainers with the AFO unless it is worn only when in bed. Trainer shoes are ideal because they are wider and deeper than normal shoes. Insoles of normal shoes may need to be removed to give a proper fit. Any new orthotic device should be worn no more than ½ hour at a time on the first day, unless otherwise directed by the orthotist or physiotherapist. The time can be increased to an hour a day on the second or third day and wearing time can continue to increase as the child gets used to wearing the device. Regardless of the tolerance to wear, skin checks must be performed on a regular basis. It is common for an orthosis to cause a slightly red line on the skin along the border but this should disappear within ½ hour after removal. If the child has any pain, skin marks that do not disappear within ½ hour, or blisters, stop using the device and call the orthotist and your clinical manager immediately. Stander Weight-bearing is important for the health and development of bones and muscles because pressure enhances joint development and endured joint compression enhances muscle development. The results from standing are the same whether the client is able stand independently or with assistive devices. The act of standing can improve overall bone strength and respiratory and bowel function. In addition to weight-bearing benefits, standers have a psychosocial impact because they allow children to be on eye level with their peers. There are two types of standers, the prone and the supine stander. 265

64 Rehabilitation A prone stander is made for a child to lie on the stomach and is used for children who need to strengthen their extensors and have good head control. This stander places the child in a more upright position, causing more weight-bearing through the long bones. It is thought that the use of a prone stander has an increased effect on bone density. For clients with flexion contractures, supine standers (also known as tilt tables) may be easier to use than prone standers because the pressure is taken up by the extensor surfaces. These standers are recommended for clients without adequate head control. Supine standers are flat and easy to use the child can be transferred directly from a bed. Once stabilized in a flat position, the client is slowly elevated as tolerated to a standing position. Crutches The simplest form of assistance with ambulation that exists is the crutch. Pediatric clients frequently have orthotics and use crutches with forearm supports for support during ambulation. Walkers Walkers provide balance and arm support. Children typically use a walker with wheels or a rolling walker to assist them with mobility. Learning to use a walker can be frustrating and exhausting for the client and the parents. The body consumes more oxygen when using an assistive device, so initially the gait can be slower or endurance may be shorter. Both the client and the parents should be encouraged during the initial process of using the walker. There are anterior and posterior walkers. The anterior walker is placed in front of the body and the client leans slightly forward and pushes it as they move. The posterior walker is placed behind the child, providing support from behind and requiring more upright posture and trunk expansion. Gait trainers For children who are able to walk when given external support, a gait trainer can be utilized. Because the fear of falling results in increased spasticity, the gait trainer gives the child a stronger 266

65 Rehabilitation sense of security and better control. Most of the models available allow for pieces to be removed over time so the child may eventually be able to use a regular walker or even be walk independently for short distances. Wheelchairs By simplest definition, a wheelchair is a mobile chair. There are many types, shapes, sizes, and brands available. They can tilt, have the ability to grow with the child, or have special headrests, molded seating, and/or positioning adaptations. Wheelchairs can be costly and some insurance policies have limited coverage but it is important that the client have the most appropriate chair for his or her intended use, which ultimately is to maximize the child s physical potential and developmental growth. Young children typically start off with a stroller-type of wheelchair until the client s anticipated growth, needs, and specifications can be determined. Wheelchairs are operated either manually or by power. Manual chairs can be manipulated by the client in the chair or pushed by the caregiver. Power chairs are wheelchairs that are controlled electronically. The most commonly used electronic control is the joystick control panel that is located near the child s dominant hand. This placement or type of control panel can be modified if muscle strength or control is an issue. A power chair offers children who can not manipulate their chair with their arms the ability to move without help from others. Power mobility can be instituted as early as age 18 months. For children who have limited or no use of their extremities, switches are built into the head rest. These switches may require the head to push on the switch or can consist of a proximity switch that controls the power wheelchair whenever the child moves their head near the switch, without requiring direct contact. Another option is the sip and puff switch. This has a flexible mouthpiece that can be mounted to the wheelchair s headrest or can be fitted over the ears and behind the neck. Two separate actions can be controlled by the sip and puff. 267

66 Rehabilitation Access A ramp is required to provide access to any area in which a sudden incline obstructs clear access. It is not recommended that wheelchairs be popped up or bumped down stairs (no matter how few), because that can cause damage to the wheelchair or injure the client, the employee, or the caregiver. There are various types of ramps some are portable and some are permanent. Mobile ramps are commonly seen in home health care. There are guidelines that list safe use for various ramp lengths. For example, to pick the appropriate size ramp for entry into a van, the height from the ground to the van floor should be compared to the number of steps that would be required to enter the van. When a ramp is needed for a client, the clinical manager should request a BAYADAbility consult. Wheelchair lifts One option for van access is a lift system. Most have hydraulic powered fold/unfold and up/down cycles. The lift is operated by controls on a hand-held controller, wireless remote control, or the controls are mounted on the lift itself. There are many models and designs; some of which are intended for installation in the side or rear door of a domestic full-size van. The lift platform will fold up securely next to the door as shown above. Securing for transport As the client s nurse, you are responsible for the child s safety during your shift. If the client is being transported in any vehicle, you need to be completely versed in exactly how to secure the wheelchair in that vehicle. This includes not only how to secure it but also how to evaluate if it is properly secured. There are varying types of restraint systems used to secure a wheelchair for transport. The docking securement system consists of a stationary base and the wheelchair is backed onto 268

67 Rehabilitation and attaches to the dock. Docking securement devices allow the client in the wheelchair to secure and release the wheelchair without assistance. The dock can be attached to the rear of the vehicle or on the floor. When first securing a wheelchair using a docking securement device, your clinical manager should check with the wheelchair manufacturer to ensure that the specific wheelchair model has been successfully crash-tested with their docking system. When using tie-downs, the wheelchair should have an accessible metal frame on which the straps and hooks of the system can be attached at frame junctions of the wheelchair; these straps and hooks should not be removable pieces. Clinical alert: When riding on a school bus, the transportation personnel are responsible for securing the wheelchair. However, you should assess that the client is properly secured before transport. Whatever the type of wheelchair restraint system used, a seatbelt system with both pelvic and upper torso belts must be used in order to protect the client during a car accident or sudden braking, and to minimize the likelihood of injury caused by contact with the vehicle. If a child has poor muscle tone and lacks head control, there is an added concern when transporting in a vehicle. Any sudden move could cause a strain or injury to the neck area. The use of one of the various securement devices should use to protect the C-spine from any unpredictable movements. 269

68 Rehabilitation Transfers in and out of wheelchairs Many wheelchairs have multiple supports and securing devices. When transferring any child into or out of the wheelchair, remove what supports and devices you can to allow clear access to the client. Most wheelchairs have removable arms. Many of the supports on customized wheelchairs are adjustable, so they cannot be easily removed but may have a lever so the piece can swing out of the way. When the lever is pushed, the padded support can be lifted up to disengage the locked position and the piece swings away from the client. The most common supports used that swing out of the way are lateral supports that run along the trunk of the child. Supports can also be found near the head, hips, and knees. The support near the knees is called an abductor support and it is used to prevent the knees from being held tightly together, which can cause strain and injury to the hips. The lever for the abductor support is found under the seat and flips down out of the way for transfer. Lifts When a client first begins to receive home health care, manual lifts and transfers may be possible if the child is small. As a child grows, the manual lift becomes more difficult and unsafe for the client and the caregiver. The prospect of incorporating a lift into a client s home most often begins with a sensitive discussion with the family because they have grown with their child and they may want to continue to lift them; also, they often may state that they do not want another piece of equipment in their home, which may be the case. However, even with proper body mechanics, strain on the parents and caregiver s backs can cause injury. If the client requires repetitive transfers throughout the day, if the child is tall and has hypotonia, if the child has severe spasticity, or if the client weighs more than 50 pounds we believe that now is the time to discuss the need for a lift with the family. Getting a lift can be a lengthy process, so once there is the need is established, notify your clinical manager for a BAYADAbility consult. The following are issues to be considered before obtaining a lift: Convincing the family of the need and receiving their support 270

69 Rehabilitation Clinical alert: When using a floor model lift, always have the base open to its widest point for maximum stability. Identifying the best lift for the client Find funding through the insurance or other sources to cover the cost for the lift required There are many types of manufacturers and models of lifts. Some are manual or hydraulic while others are electric. There are also compact lifts, some that fold and some that are fixed to the ground or wall for stability. There are many types of ceiling lifts some require construction because they are attached to ceiling beams and some are not permanent because they use tension poles. Overhead lifts must have their batteries charged and most have a safety release to lower the client out of the lift if there is a power outage or malfunction. Although many styles and sizes of slings are used with lifts, a sling that is recommended by the manufacturer of the lift must be used with that lift. Some have head supports, some have cut-outs and some have varying loops for attachment to the lift. If the sling is not appropriate or not used as directed, the client will not be secure or safe for transfer. 271

70 Rehabilitation Every lift and every child in a lift will be different. Be familiar with the specific equipment s function, safety features, and precautions. When looking at rehabilitation goals and enhancing a child s life by providing access to activities other children do, lifts can be used for more than daily transfers. Depending on the type of lift, it could also provide the client access to tub baths, swimming pools, and gait training, among many other activities and places. Vestibular positioning The vestibular system, located in the semicircular canals of the ear, is the sensory system that provides the leading contribution about movement, spacial orientation, and sense of balance. This system can involve many areas of development related to coordination, balance, posture, reflex integration, dizziness, visual motor, sensory organization, and general motor function. The vestibular system comprises two main components: 1. The vestibular ocular reflex is how the eyes and ears work together to maintain balance. 2. The vestibular spinal reflex is how the inner ear works with the spinal cord to monitor and control the extremities achieving balance. Basic items used in vestibular therapy are swings, balls, and rolls. The goal is to increase the child s function by training or retraining the nervous system to compensate for movement changes by adaptation or habituation. Other ways to assist a child in maximizing function is with use of positioning items, which include rolls, wedges, side-lyers, and specialized seating. 272

71 Rehabilitation Rolls are used for vestibular therapy but are also designed for assistance with extension, flexion, and postural exercise that enhance neurodevelopment and positioning. Wedges can be used to position the child prone while allowing access to an activity. The use of the wedge improves balance and muscle control. It is recommended to be used for gross and fine motor activities. Some wedges may have slots built in to maintain hip alignment, preventing rotation. Specialized seating provides symmetrical support to the head and trunk to encourage midline control. The seat has a built-in abductor to keep the legs in position. Typically the knees are bent at a 90º angle with a foot plate to keep feet in position. A tray used with the seat can be adjusted to accommodate the client s needs and still maintain the function and effect of the seat. These special seating systems can be used throughout childhood and adolescence. There are two simple variations to these seats: 1. High/low or up/down chairs These seats can be utilized with height adjustment. 2. Corner seating Available as a desklike chair or a floor model. The floor model promotes sitting for a longer time while decreasing reflex muscle tightness and can also sometimes be used as a bath seat. Many of these positioning devices may be located in the home or classroom to be used during the day. When approved by a therapist, these devices can act as follow-up therapy and get the client involved in an activity on a different physical level. 273

72 Rehabilitation Argumentative communication There are various ways to enhance a child s communication some use sign language, flip books, or computerized communication devices. Typically, the first augmentative device introduced is a switch. The Big Switch is a popular basic switch that works well in many situations but does not fit all needs. There are many different styles, sizes, and sensitivities of switches designed to meet the needs of various situations. Some examples are: cordless, latch, timer, dual, grasp, joggle, micro, pillow, pneumatic, slammer, string, hand, finger, body, light, vibration, music, plate, proximity, saucer, sip, puff, breath, textured, wheelchair, bedside, wireless, and sound activated. An important issue is switch access how a switch is mounted and positioned for the client to use it. The right switch without the right access is useless to the client. A switch can be accessed by almost any body part. Finding the right combination of switch and mounting system is trial and error. A client with a limited range of motion or a highly individualized need should have an augmentative therapy assessment on switch devices. Bath equipment Use of a traditional bathroom can be difficult for children with physical disabilities. With the use of the right equipment such as bath seating and commodes, access to facilities can usually be obtained. Many types of bath chairs and commodes are available and some come in a combination of both. Some models will grow with the client and others will need to be replaced as growth occurs. To obtain the proper equipment for fit and the child s needs, an evaluation should be completed in the environment with the child. 274

73 Rehabilitation Like all areas of care, continual assessment of the process, equipment, and the particular child involved should be done. In some situations, the bathroom may not be accessible, despite the use of equipment. As the child grows, a bathroom that was suitable when the child was younger may no longer be safe. For example, a 9 year old very tall client weighs 55 pounds and has hypotonia. Lifting this client from the tub can be a risk to the client or caregiver because the client s size makes it difficult to get a firm hold of them and utilize proper body mechanics. At this point, a new evaluation should be completed. Depending on the size of the bathroom, a raised bath seat or a hydraulic seat could be used. If the size of the bathroom would not accommodate either, then the following alternatives could be discussed: A stationary lift to transfer the client in and out of the tub Use of another bathroom with more space Use of a shower chair in a stall shower if available Home modifications Until a safe transfer and bath access is in place, this client should receive bed baths to maintain personal hygiene. Another issue for this same client could arise with the use of a potty chair. Proper seating for the client is with the feet on the floor with the knees bent at a 90- degree angle. If the knees are bent less than 90 degrees the chair could tip and if they are bent more than 90 degrees the chair will not provide the proper support for the client. When the angle has to be altered or the client is not supported, the chair must be replaced. The next size chair would be a commode chair. Although it may seem too big for the child, these commodes adapt to the child with growth. Different styles (over-the-toilet chairs, flexible seats, shower chairs) are available with various features (securing belts, lateral supports, head supports, leg rests, tilt options). 275