NC home care association offers pediatric manual
Here is a sample of the seizures care plan
Looking for a pediatric home care manual? The North Carolina Association for Home Care (NCAHC) in Raleigh offers one — with new updates.The manual features sample job descriptions and skills inventories for multidisciplinary home care staff. Care plans in the manual include failure to thrive, seizures, home phototherapy, ostomy care, and home apnea monitoring.
Here are the manual’s guidelines for definition of the problem, staff qualifications, patient referral, patient admission/development of the plan of care, implementation of the plan of care, coordination of services, and the transfer/discharge process for children with seizures. (The attachment to give to parents of pediatric seizure patients and one of the four sample care plans for the child with seizures are inserted in this issue. Note: These charts are copyrighted.)
A convulsion is an involuntary contraction and relaxation of a muscle group. A seizure is the sudden onset of a convulsion. When a child experiences recurring seizures, the physician may diagnose the condition as epilepsy. Epilepsy may be idiopathic or secondary to trauma, hemorrhage, infections, toxins, or biochemical in nature.
Neonatal seizure — definition and types.
Seizures during the newborn period may be subtle (horizontal deviation and jerking of the eyes, staring, paroxysmal blinking, lip smacking, or bicycling movements of the limbs) or more overt (repeated stereotyped multifocal clonic or tonic movements) and may occur one at a time or repetitively.
Therapeutic management.
The goal of any seizure therapy is to control the seizures or decrease their frequency, and when possible, to determine and correct their cause. An equally important goal is to assist the child who has recurrent seizures to "live as normal a life as possible."1
Drug therapy.
Drug therapy plays an important role in seizure control and thus helps to prevent secondary brain cell damage from the excessive neuronal discharges and hypoxia associated with continuing seizures.
Anticonvulsant (antiepileptic) drugs raise the threshold of neuronal excitability by "reducing the responsiveness of normal neurons to the sudden, high-frequency nerve impulses that arise in epileptogenic focus."1 The goal of the physician prescribing drug therapy is to find the appropriate anticonvulsant drug or drug combination that will provide the best seizure control possible with the fewest undesired side effects.
Children on drug therapy for seizures will require close monitoring for drug effectiveness and side effects. Drug levels, blood cell counts, urinalysis, and liver function tests, as appropriate, all provide valuable information to the physician as he or she monitors the child’s condition and medical regimen.
Qualifications of staff.
1. licensed nurse with experience in pediatric physical/social/interactional assessment skills, knowledge of normal child development, characteristics of infantile and childhood seizures, causes of seizures, anticonvulsant therapies and side effects, and knowledge of pediatric blood drawing;
2. certified nursing assistant with pediatric experience;
3. licensed therapist with pediatric experience and knowledge of growth/development;
4. social worker with family-center assessment and counseling skills.
Criteria for admission.
Patients must meet general admission criteria of the agency.
Patient referral.
A. General referral information required:
1. weight and date of birth;
2. name and relationship of primary caregivers;
3. names and results of any tests performed (i.e., EEG, drug levels, evoked potentials), medical doctor’s impression of cause of seizures;
4. description of the child’s seizures (length/frequency);
5. medication history (effectiveness/side effects/reasons for discontinuing);
6. existing underlying illnesses and prognosis;
7. etiology of seizures;
8. diet history if indicated;
9. reimbursement information (prior approval, letter of medical necessity, billing information).
B. Physician’s orders:
1. The home care nurse will collaborate with the physician to establish the frequency of the home visits and to develop the plan of care.
2. Current medication orders will be included.
3. Current diet orders/restrictions will be specified.
4. Any activity restrictions will be noted.
5. Any blood work/labs ordered will be included.
Patient admission/development of the plan of care.
A. Prior to developing the plan of care, an initial assessment should be performed that will include the following areas:
1. baseline data — weight, vital signs, review of systems;
2. nutrition — diet restrictions;
3. seizure activity;
4. medications — knowledge of meds (drug levels, side effects, use of brand names vs. generic drugs, medication regimen);
5. caregiver/patient interaction — how each feels about the seizures;
6. environment/safety — adequacy of home environment and need for safety measures (i.e., padding in crib, helmets for toddlers/school-age child, etc.);
7. emergency preparedness — knowledge of CPR, use of 911;
8. culture/social — cultural and religious beliefs regarding seizure activity and causes;
9. caregiver adequacy — caregiver knowledge, maturity, commitment to parenting, ability to respond to stressful situations, mental/physical limitations (i.e. substance abuse, depression, mental retardation), parenting skills/child care skills, need for referral to community resources;
10. growth and development — need for pediatric physical therapy or occupational therapy referral or referral to community resources;
11. equipment needs.
B. Based on the assessment, a patient problem list will be developed that may include the following:
1. alteration in airway potency;
2. knowledge deficit related to disease process;
3. knowledge deficit related to medications;
4. potential alteration in child/parent bonding;
5. potential alteration in child’s self-esteem;
6. potential safety hazards.
C. Development of measurable goals/ outcomes specific to the problem list/ nursing diagnosis.
D. Development of interventions specific to the problem list/nursing diagnosis.
Implementation of the plan of care.
A. Visits should be carried out as ordered on the plan of care and should address the needs identified on the problem list. Interventions should focus on goal attainment.
B. Teaching should be geared to the educational level of the child’s caregiver and to any other special needs as appropriate.
C. Documentation of the home visit should include the assessment findings, skilled services rendered, and the caregiver’s and child’s response to the interventions and teaching. Standard documentation also should include weights (and if applicable, charted progress on an accepted growth chart such as Ross or Mead Johnson — available for boy and girl, premature infant, term infant, and older child.) Standard documentation should include a log of the child’s seizure activity.
Documentation should speak to the caregiver’s adequacy and ability to follow the plan of care (medication regimen), safety, the status and functioning of any equipment in the home, and the child’s progress and goal attainment. Any physician contact or activity related to service coordination also should be documented.
Coordination of services.
A. Interagency referrals — Routine and prn follow-up with the health department, clinic, and/or the medical doctor should take place in order to monitor the child’s seizure status, lab work, growth and development, and medication regimen (effectiveness of anticonvulsants).
B. Community referrals — Should be made as necessary to resources such as Parents and Children Together, child services coordinators, support groups, and the Developmental Evaluation Center.
C. Intra-agency referrals — May also be needed to utilize available resources within an agency. Coordination from the medical doctor may be needed.
Transfer/discharge process.
A summary of the care provided and the patient’s status is necessary if a patient transfers to another agency, if the patient moves outside the agency’s services area, or at the time of discharge. Patient discharge is indicated upon physician order when the seizure activity reaches the level of expected control.
Upon discharge, the parent/caregiver and child (as appropriate) should be able to: state their understanding of the disease process, medication regiment, use of emergency services, safety measures, and have demonstrated ability to follow-up with the medical doctor.
[Editor’s note: For more information about NCAHC’s pediatric home care manual (Publication No. 440-023), call (800) 999-2357.]
Reference
1. Waley LF, Wong DL. Nursing Care of Infants and Children. 4th ed. Missouri: Mosby; 1991.
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