Medically Based Pediatrics from Hospital to Outpatient Flashcards
1
Q
What is the pediatric continuum of care starting in the hospital and ending in community based settings?
A
1) Acute:
- - Intensive care unit (PICU)
- - Medical or surgical care unit: specialized areas in cardiac, hemoc, and psychiatric
2) Inpatient rehabilitation
3) Ambulatory or outpatient services
4) Community based settings
2
Q
What is acute admission?
A
- Child is usually typically developing prior to current referral; medical management of symptoms is key focus
3
Q
What is rehabilitation admission?
A
- Usually follows acute stay, designed to be a longer time designated for restoring strength, endurance, function, and impacted skills in order to return home
4
Q
What is chronic hospitalization?
A
- Admissions occur due to exacerbations of chronic conditions or progression of illness, may need modified continuation of outpatient services
5
Q
What is special program admission?
A
- Admission of child to a specialized program such as feeding or day rehab program
6
Q
What are external influences on pediatric hospital-based services?
A
- Health care laws
- Health care costs
- Insurance/3rd part reimbursement
- Accrediting agencies
7
Q
What are OT goals for acute pediatric hospital stays?
A
- Time spent at the hospital can be very short
- LTGs usually are designed to be met within 1-2 weeks
- STGs usually are designed to be met quickly within a few days
- Goal is to improve client factors:
- Improve full active ROM and strength to prevent deformity, contracture, or scar formation
- Improve safety of swallow
- Improve visual perceptual deficits
- Improve cognitive/processing functions
- Another goal is to improve occupational level:
- Enable child to return to pre-morbid level in school or community
- Return to age appropriate play and ADL skills
- Support and improve child’s social participation
- Must know biomechanical factors before assessing occupations and activities
8
Q
What types of diagnoses are seen in pediatric rehabilitation?
A
- Accidental injury
- Violence
- Disease (TBI, SCI, Cancer, Stroke, Encephalitis, CP)
- Surgical intervention
9
Q
What are two common surgeries for cerebral palsy?
A
- Crouched Gait Surgery
- Dorsal Rhizotomy
10
Q
What are traditional pediatric requirements for rehabilitation?
A
- Same as adult rehab
- 3 hours of therapy a day, 5 days a week (only includes PT/OT/SLP and there are fewer therapy hours on the weekend)
- Evaluations must be completed within 48 hours of admission
- WeeFIM assessments on a weekly basis
- Weekly Team Progress Note to submit to insurance in order to maintain coverage
11
Q
What are pediatric rehabilitation requirements for neuro-trauma?
A
- Less than 3 hours of therapy a day
- Reduced therapy status due to medical severity. tolerance, or due to young age/endurance
- May focus on family education: positioning, oral stim, how to keep child safe during ADLs
12
Q
What are pediatric rehabilitation goals?
A
- Often looking at a 2-8 week stay
- LTGs within one month
- STGs within a week
13
Q
What are pediatric rehabilitation OT interventions?
A
- Prevention
- Restoration
- Modification/adaptations for ADL skills
- Equipment evaluation/reassessment
- Community re-introduction
- Resumption: using existing skills to foster independence and resumption of activities
14
Q
What are frames of reference in the pediatric rehabilitation setting?
A
- Biomechanical: ROM, strength, muscle tone, can they track, does the child tolerate sensation?
- NDT: weight bearing status, tone - normalizing synergistic patterns, trunk control
- Sensory processing: inpatient and outpatient - music/sound, lighting, weighted blankets, therapy balls
- Visual information processing: how can environment or activity be reorganized so that the child can be successful in the hospital?
15
Q
What are pediatric outpatient interventions?
A
- Continuation of rehab or inpatient services. The focus is to return to pre-morbid function in all occupational areas
- Focus on habilitation and establishing new developmental skills including:
- Sensory processing
- Fine motor skills
- Strengthening
- Splinting needs
- Attention
- Coordination
- Feeding
16
Q
What are pediatric outpatient goals and frequency of interventions?
A
- Goals: time varies
- LTGs are written for 6 month-increments
- STGs are written for 1-2 months (4-8 visits)
- Frequency of intervention varies based on setting and client’s needs
- Outpatient day programs: 3-5x/week. Typically seen for 3-5 hours a day - PT/OT/SLP
- Standard outpatient: 1-2x/week or 1-2x/month. Typically seen for 45 min to an hour a session
17
Q
What setting are infant toddler programs and school based therapies?
A
- Pediatric community-based settings
18
Q
What does OT look like in pediatric community-based settings?
A
- May or may not charge for OT services
- May work in conjunction with other team members towards a common goal, not necessarily for direct OT intervention (i.e. OT as part of autism diagnostic group or OT working as a group leader at community substance abuse camp)
- May work as a consultant: may evaluate current programs and give suggestions for program quality improvement (i.e. work with an educational team at a school to select furniture to support better sitting and movement postures for children with special needs
- May work at community re-integration programs: therapists work with children in actual childhood environments to better re-integrate them into the community after illness or injury (i.e. have therapy in McDonald’s Play Place to work on child play in a typical environment or have an adolescent work on visual motor integration at a video arcade
19
Q
What does OT look like in the pediatric community Clubhouse model?
A
- Community based facility where participants are “members” and have a share in responsibilities to maintenance and operation of clubhouse with staff
- Focus on function and interdependence
- IADL training:
- Social development
- Self-care education/training
- Job training
- Healthy leisure exploration
- Time management
20
Q
What are common roles and goals of OT in pediatric community settings?
A
- May vary depending on nature of community based agency
- Advocacy for children and families
- Encouragement of improved function within naturalistic environment
- Types of intervention:
- Promote/create
- Maintain (daily routines and health management)
- Establish/restore
- Prevent
- Adapt/modify
21
Q
What is the evaluation progression in inpatient pediatrics?
A
- Focus on current skill level
- Be mindful of limited medical stability: always identify precautions prior to evaluation (i.e. weight bearing precautions, EVD’s, PO status)
- Start with biomechanical evaluation: ROM, head control, sitting balance, cognitive awareness
- Progress to functional skills as able: ADLs, fine motor skills, feeding/swallow, social skills
- Standardized testing: Coma-Near-Coma, CRS-R (Coma Recovery Scale-Revised), MMT, WeeFim - if child is participating in ADLs, Bayley, Peabody, HELP
- There is usually less standardized testing to start with when evaluating a child in the hospital
- The Bayley, Peabody, and HELP are usually done closer to time of discharge
22
Q
What is the progression of graded sensory input in inpatient pediatrics?
A
- Visual input: eyes open > tracks > locates objects on command
- Auditory input: turns to sounds > tolerates TV or music, follows commands
- Tactile inputs: tolerates touch (provide different sensations that are soft/rough/textured) > holds an object and does tactile exploration > tolerates handling for positioning
- Olfactory input: provide various familiar smells and watch for reactions: vanilla, orange, peppermint, cinnamon, chocolate
- Vestibular input: tolerates position changes
23
Q
What are important things to remember with pediatric inpatient strengthening and ROM?
A
- Strengthening should begin on day 1 because strength is lost after just 3 days of laying in a hospital bed
- Strength is necessary for all functional skills
- Patients may require more strength than is typical for their age in order to be independent in all functional areas
- Good strength allows children to move in a more efficiently
- Provide passive stretch where movement is limited
- Tenodesis stretch to facilitate grasp for SCI C5-C7
- Consider splinting: resting hand splint, lon or short opponens splint, intrinsic minus splints
24
Q
What does the WeeFIM assess in pediatric eating?
A
- Assesses safety of swallow
- Change in hunger: digestion speed and constipation. Consult with dietician/medical team for medications
- If UE’s are not affected then progress feeding from an inclined bed, to eating in w/c, to eating in standard chair. May use a w/c tray or bedside table for positioning purposes
- Assesses pace of eating (initiation of bites and swallows), functional motor skills for eating, and need for set-up of meal
25
Q
What is common adaptive equipment for pediatric feeding?
A
- Universal cuff
- Plate guard
- Adaptive utensils
- Mobile arm support
26
Q
What is the progression of grooming in the pediatric WeeFIM?
A
- Bedside table > at sink at w/c level > standing at sink
27
Q
What is common adaptive equipment for pediatric grooming?
A
- Suction tooth brush if needed
- Universal cuff or built up handle for toothbrush
- Brush/comb in universal cuff or long handled brush/comb
- Bath mitt
- Mounted hair dryers
28
Q
What is the progression of upper extremity dressing in the pediatric WeeFIM?
A
- Inclined bed > in w/c > ring sit in flat bed > sit EOB
- Progress is based on patient’s overall balance and trunk mobility
- May need to learn one handed technique
- UE dressing is usually easier than LE dressing
29
Q
What is the progression of lower extremity dressing in the pediatric WeeFIM if a child has a TBI or CVA?
A
- In bed with elevated head and rails > sitting EOB > standing
30
Q
What is the progression of lower extremity dressing in the pediatric WeeFIM if the child has a SCI?
A
- In bed with elevated head and rails > in flat bed with rails > in flat bed without rails > in w/c
31
Q
What are necessary skills in order to master LE dressing?
A
- Anterior pelvic tilt
- No hip precautions
- Transition supine to ring sit
- Sitting balance in ring sit
- Leg management
- Rolling
32
Q
What is the progression of donning/doffing socks and shoes and common adaptive equipment used?
A
- Ring sit in bed > in w/c or standard chair
- Long handled shoe horn (push knee down to push foot into shoe)
- Leg lifter
- Reacher
33
Q
What is the progression of bathing in the pediatric WeeFIM?
A
- Begin with bed baths
- Dependent lift or use of Hoyer lift to reclining bath chair or supine bath cart (generally completed by nursing. Any incision sites must be cleared for bathing)
- Begin bathing on transfer tub bench
- Pt must be able to tolerate sitting upright for 15 min
- Initially the pt may still need a dependent lift
- Progress to slide board transfers using a pillow case
- Goal is to use lateral transfer, SPT, or step into tub/shower
34
Q
What is common AE for pediatric bathing?
A
- Wall mounted soap pumps
- Hand held shower attachment
- Long handled sponge
- Water control safety gauges
- OT should provide recommendation for appropriate shower chairs and assist team in obtaining AE prior to discharge
35
Q
What are helpful hints for toilet transfers in the pediatric setting?
A
- It is difficult to independently complete slide board transfers onto a commode unless it has swing away/drop down arms
- Stand pivot transfers, Hoyer Lift, or 2 person dependent lift if needed
- Recommend toilet transfer board to start
- Public restrooms and home bathrooms often have limited space
- Patients will need to have advanced dressing skills to dress in a w/c or in standing to be independent with toileting on a toilet
36
Q
What is the catheterization process in pediatrics?
A
- It is taught by nursing staff
- OT’s role is to guide and teach positioning techniques: abduction of legs and recline in w/c
- OTs recommend adaptive equipment as necessary: leg separator with/without mirror, house holder (for boys in order to cath with one hand), and w/c bag to hold supplies
- Clothing management
- Teach in bed, then w/c, and then on toilet
37
Q
What is OT’s role with a bowel program?
A
- The bowel program is taught by nurses
- OTs guide and teach positioning techniques: forward and lateral lean
- OTs recommend adaptive equipment as necessary: suppository inserter (child must have good trunk control to lean over and use one hand) and flexible handled mirror
- Clothing management: onto commode pants on and off
38
Q
What are pediatric IADLs and advanced skills?
A
- Home accessibility
- Community re-integration
- Return to school
- Wheelchair skills
- Sports and leisure
39
Q
How is home accessibility addressed in pediatrics?
A
- Provide universal design book
- Family can provide pictures and/or video of home
- Problem solve recommendations
- Accessible entrance with ramp as needed (2 accessible exits in case of an emergency)
- Bathroom: width of door and space to access tub/shower and toilet with appropriate equipment and transfer
- Bedroom: carpet height if propelling a w/c, accessing closets, and height of bed for transfer
- Kitchen: difficult to access counter tops and sink, accessing items from refrigerator and cabinets, and meal prep training begins as an inpatient
- Environmental control: Ability KC and Coalition for Independence - telephone access
40
Q
What is are considerations and goals for pediatric community re-integration?
A
- Considerations: transportation, child’s interests, time restraints, cathing/feeding/medicine schedules, “to go bag!”
- Setting goals: community mobility, social interaction, confidence, money management, endurance
- Home visit to prep for discharge
- Therapist should try and go on one outing before discharge, and in addition, parents should try and take an outing before discharge
41
Q
How are car transfers approached?
A
- Two person assist slide board transfer
- Independent slide board transfer
- Independent lateral transfer
OR - Stand pivot transfer
- Independent standing transfer
42
Q
What are adaptations for writing and typing when child returns to school?
A
- Universal cuff/vertical holder
- Short and long wanchik
- Klick pen holder
- Typing sticks
- Mouthstick
- Mobile arm support
- Missouri Assistive Technology: evals, equipment and training for computer access
- Hardware: adaptive keyboards, switch access (sip and puff, jelly bean, switch adapters)
- Software: on-screen keyboard, voice activated, word prediction
43
Q
What are common back to school accommodations that need to be made?
A
- Cathing: schedule (likely one time at school); nurse may need to assist initially as child transitions to independent (lay down vs w/c and store supplies in nurse’s office or bag on w/c)
- Plan for if bowel or bladder accident occurs
- Pressure relief at beginning and end of every class
- School books: may have 2 sets (one for at home and one for at school) and use of iPad to reduce number of supplies carried
- Accessing backpack or bag on w/c: transport lighter items, AE (reacher, leg loop), or school notebooks, etc.
- Cafeteria: assistance needed for tray, carrying items, reaching, and navigating
- Adaptive PE initially
- Navigation: hallways, locker, classrooms, curbs or ramps at school, elevator pass, may need additional passing time between classes
- Desk in each room that is w/c accessible
- Priority seating
- Transportation to school and fieldtrips
- Note taker
- Test accommodations
44
Q
What are w/c skills that are needed with assistance or independence in order to navigate one’s environment?
A
- Opening doors
- Ramps
- Wheelies
- Curbs
- Stairs
- Floor to w/c transfer
45
Q
What are accommodations that may be needed for sports and leisure activities?
A
- Swimming: goal progression. May need flotation and assistance: static vs swimming. May need assistance transferring in/out of pool: floor raised lateral/slide board transfer to tub bench; from edge/corner of pool: water shallow to deep; w/c to floor transfer
- W/c sports and events
- Sports w/c: cambered/angled wheels, click straps at waist and legs, one or two back wheels, front bumpers, low back
- Special Olympics
46
Q
How does hospitalization impact a child?
A
- Significant stressor to family
- Acute phase: family in shock, overwhelmed with feelings of guilt
- Change or loss: a traumatic or sudden illness may significantly change the child’s personality, level of functioning, and potential for future development
- Isolation may result since children are away from typical childhood environments. Parents/caregivers may be restricted by visiting hours
- Homesickness
- Fear: young children may have distorted views of why they are being hospitalized -punishment or causal result of being bad
- Anxiety
