Practical Strategies for the
Day Service Nurse
A REVIEW of NURSING SYSTEMS, PROCESSES
and COMPETENCIES
Robert Peters, RN
Day Service Nursing Coordinator
AHRC-New York City
History of IDD
• Historically people with handicaps (physical, mental and intellectual
conditions) occupied 'deviant' status
• Object of dread, ridicule, evil/possessed person, sub-human, diseased.
• Stigma remains to some degree, diseased organism treated with so-called
"medical model"
• “Historical ghosts” – fears, prenatal testing
History of IDD
• Europe 1800 Jean-Marc Itard met Victoire of Aveyron, the so-called "Wild
Boy of Aveyron," and began what is regarded as the first documented
case of special education.
• United States in the 19th and 20th centuries, "feeblemindedness"
and "mental deficiency“
• 1851, New York State Asylum established - eventually known as the
Syracuse State School, then Syracuse Developmental Disabilities Services
Office.
• ‘Institutions,' 'schools,' or 'colonies,' originally called, operated a
philosophy of treatment and training, relatively normal living conditions,
educated residents, and provided opportunities for work on the grounds.
History of IDD
• Early 20th century, things get worse – dumping grounds
• Philosophy of eugenics – “Social Darwinism”
• Sterilization of IDD, especially women, strongly advocated by medicine
and government
• Germany, euthanasia became official medical policy sometime around
1920
• US, euthanasia practiced and advocated early 20th cent.
• 1940’s American Psychiatric Association editorial endorsed legal
euthanasia of mentally retarded children and the provision of
psychotherapy to parents to relieve them of their guilt!
History of IDD
• 1930’s 1940’s depression, WWII, fiscal resources dried up, institutions
had fewer staff who were less trained. AMAP. Beginning to get very
crowded, but no children younger than five admitted
• 1945 - Letchworth Village (130 buildings!) 20-30% overcrowded, 200
children sleeping in living rooms and on mattresses on the floors.
• 1945 State Schools begin admitting children under five.
• Late 40’s - as soon as the facilities at Willowbrook State
School were available, limited numbers of infants could begin to be
admitted
• 1952 – Willowbrook opens, reaches 6000 individuals
History of IDD
• 1940’-1950’s: parent groups begin to form, dividing into
community-based groups and institutional-based groups
•
First charitable organizations begin to form:
NYSARC - 1949
UCP – 1949
Lifespire – 1951
YAI – 1957
Heartshare – 1970’s
• Parents groups, parental initiative and parental power
AHRC History

1948 some parents try to found “nursery school”
 Jan 1949, AHRC “founded”
 “It would seem that the pent up energies of many years
propel us forward and we move with a motion and volition
beyond our control." - Joseph T. Weingold, 1950
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1953 nursery for preschoolers
 1954, sheltered workshop
 1957 day center, school, clinic and recreation
 1959 OMRDD formed
AHRC History
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1970, group residence
1971, camp
1972, Geraldo
1970’s, de-institutionalization
1970’s, day treatment centers proliferate
1977 early intervention
1980’s, Medicaid waiver
1990, Americans with Disabilities Act
AHRC History
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1985, Sibling program
1986, “HIRE” - supported work project that involves job training and
placement in competitive employment
1988, Bronx Seniors program
1995, community services TBI
2006, Director of Individualized Supports – person centered planning
2008 , College – Kingsborough Community, CSI
2009 , Without Walls – all 5 boroughs
Today the agency:
• Educational Services (early intervention through high school – autism)
• Day Services
• Camping & Recreation – weekends, trips etc.
• Service Coordination - MSC
• Employment & Business Services – supported job, jobs in the community
• Residential Services, many types, includes skilled 24/h nursing, respite
• In-Home Services
• Family & Clinical Services – counseling, psych testing, OT/PT/speech
• Department Individual Services & Supports – person centered planning
• Legal - Guardianship and Advocacy
• Sobriety
Day services
 Day Treatment centers (in which abilities of the individual to function more
independently and in the community are fostered)
 Vocational workshops (wherein structured work environments are offered for
those who need them)
 Day Habilitation (a goals-oriented program involving recreation, education,
culture, community exploration, voluntarism and work) – both site based and
“Without Walls”
 Employment and Business Services – competitive and supported employment
settings, spun off day service
 Managed care – do the same, or more, with less – remain hopefully optimistic
Day services
 Larger centers: 228 people with 2 RN’s, 190 with 1 RN
 Small center: 50-80 people, RN covers 2 or more sites, on call very important
 Smaller center: colleges (non-certified) have about 20 students each, RN only
assigned to review physicals, create protective oversight plans and do
trainings
 Non-center: “Without Walls”, non-certified, 1 RN oversees
 Focus being IN THE COMMUNITY
Nursing Regulations – Day Services
• Nurse Practice Act – Art 139 of Education Law
• ADM-2003-01 : Nursing Supervision of Unlicensed Direct Care Staff
• Other OPWDD regulations, ADM, memos, alerts, guidelines
• “Nursing in OPWDD” (67 pages), October 2012 – talks about frequency of
visits, nursing ratio 1:50 or less, plans of nursing services (PONS), required
orientation within 3 months of hire – RESIDENTIAL CENTRIC
Nursing Regulations – Day Services
How ADM-2003-01 is a CORE DOCUMENT for the day programs:
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Applicability --- intention
RN decides what can be delegated and to whom
RN must supervise unlicensed staff in nursing delegation
RN must be on call for supervision
Nursing plans
Staff trained on conditions
Diabetes care, RN must have OPWDD training and annual update
Nursing Regulations – Day Services
• What does apply?
• 624 regulations – Incident reports, abuse-neglect, Justice Center, medication
errors, reports of death.
• 633 regulations – rights, confidentiality, access to care, supervision
responsibilities, staff training, first aid, CPR, emergencies, medical treatment,
TB, meds-AMAP, OTC’s, other medication rules, DNR, HIV
• 633: Self medication assessment, use the RES one or complete, done for
people who live at home and take meds at program
Nursing Regulations – Day Services
• What does apply?
• 635 regulations – finance, reimbursement, environment (building, life safety
code)
• “Dignity of Risk” – provide choices with reasonable and available options
• What does apply? – annual physical exams (see handout), other medical,
health and safety information
• Challenge to know the current health status, assess risk and provide nursing
oversight
Nursing Regulations – Day Services
So why even have nurses in the day programs?
• Tradition – they were included based on the “school model”
• Reality, it’s not just Band-Aids and “hand washing”
• ADM 2003-01 makes it clear that they are required unless the program does
not give meds, delegate any tasks, perform any nursing procedures, or
require any specialized training – not real
• More individuals with diverse health status in the community
• Triage and chronic disease management
• Saves money, if not for the agency paying salary, for families and society
• Nurse is part of the continuum of care, for people living at home, the day
program nurse may be key to the person’s health
Day services – nursing plans
• Day Hab Plan – includes safeguards necessary to provide for the person’s
health and safety while participating in the habilitation service.
• Protective Oversight Plans (aka the POP):
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Medical Alerts
Allergies
Special Diets
Support for Safe Eating
Adaptive Equipment
Behaviors of Concern
Supervision/support needs in the community/program
Likes/Preferences AND Dislikes/what doesn’t work
Fire Safety
Transportation Safety (also notes “travel training”)
Day services – nursing plans
• Protective Oversight Plans (POP) are reviewed by all new staff, annually
reviewed, must be reviewed immediately if there is a change in the POP
• Staff training on the POP must be documented
• Staff must know the POP for the people that they support and care for
• A lot of responsibility for non-nurses, day program nurses must provide both
good supervision of staff and encouragement to know their people and the
person’s safety needs at all times
• Staff can always go back and review and re-review the POP, annual trainings
should reference who has what in the day program
Day services – nursing plans
• Enhanced Protective Oversight Plans (EPOP) – for special “behavior of
concern,” “level of supervision required,” and/or “preventive/supportive
strategies”
• “Health Emergency Profile” (HEP) aka “nursing assessment” is part of the
“Ready To Go” packet
• Protocols (detailed care plans) will be attached to the POP if needed.
• AND the POP will cite the Protocol (See attached protocol) if applicable
Day services – Medical protocols
What is a Protocol?
DEFINITION: A protocol is a simple written plan authored by the supervising
clinician, understood by staff, to follow the details of care in addressing the health
or safety of an individual.
It must contain the following 11 elements:
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9.
Name of the person
Reason for the protocol
Location, size, amount etc. as needed
Procedures to be followed or done
What to report to the clinician who authored it (problems)
Name and signature of clinician
Date protocol was written/annually reviewed
Sources of Information used to write protocol (includes Rx)
PROTOCOL REVIEW DOCUMENTATION for the
author/clinician to re-affirm annually that the protocol is still
in effect
10. An attached STAFF REVIEW form where staff document
that they reviewed or were trained on the protocol
11. Other attachments as needed to fulfill the definition of a
protocol (if needed)
Day services – Medical protocols
Individualized Medical PROTOCOLS:
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Asthma protocol
Bowel monitoring protocol
Case management protocol*
Catherization protocol
Diabetes protocol
Epipen protocol
Helmet protocol
Ostomy device protocol
Restraints protocol
Day services – Medical protocols
Individualized Medical PROTOCOLS (Continued)
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Safe Eating protocol – Dysphagia
Seizure protocol
Skin Surface Check protocol
Temporary or OTHER protocol
Transfer protocol
Urinary device protocol
Day services – Medical protocols
• Medical PROTOCOLS can either be completed by the RN based on MD orders
or received “as a protocol” form the residence, MD, SLP, PT etc.
• Day services uses standardized templates
• Some templates adjust elements, for example the Seizure Protocol can
include if the person has:
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VNS magnet and how to use
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Oral clonazepam after X amount of minutes
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Diastat rectal gel after X amount of minutes
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Variable time within to call 911 (the standard being 5 minutes)
Day services – Medical protocols
• Staff must be trained on the protocol
• Only AMAP’s would be trained on medication specific protocols.
• Anyone can be trained to use Epipen, must be explained
• POP would say:
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“Must see nurse or AMAP if….” or
“Person must always have an AMAP when going on trips” or
“PRN medications must always be taken out with the person”
Day services – Medical protocols
• Some protocols are designated NURSE ONLY, and might not be delegated
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Catherizations, tube feedings or tube meds (even though
permissible)
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Some Diabetes Protocols (complexity, diabetes pumps)
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Case management (done by the nurse only, appointments can be
delegated)
• While some protocols really should be delegated to non-nursing staff,
emptying of urine and colostomy bags – toileting
EPIPEN
INDIVIDUAL: James Frost
ALLERGIES: Bee stings and eggs
LOCATION OF EPIPEN: In EPIPEN HOLDER located in the Nursing Office
NOTE: the Epipen must go out into the community with staff, please sign it in
and out for trips
The EPIPEN should only be used if the person is experiencing an
ANAPHYLACTIC REACTION.
The signs and symptoms of an anaphylactic reaction are:
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Difficult or noisy breathing
Swelling of lips, tongue, throat, face or eyes
Feeling of apprehension, sweating, weakness or shock
Weak and rapid pulse
Dizziness, fainting, loss of consciousness
Hives or welts on the skin
Flushing of the skin
Itching
Anaphylaxis is an emergency situation. Treatment of anaphylaxis consists of:
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Administration of EPIPEN
Calling 911 immediately
Maintaining the ABC’s of CPR (airway, breathing, circulation)
An incident report should be made after EMS arrives and cares for the individual
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Name of agent administered (EPIPEN)
Dose administered
Time of administration
Site of administration
Cause of anaphylaxis, if known
Name of Nurse: Rob Peters, RN
Signature/Title: Robert Peters, RN
Date above protocol was written: 12/21/13
Sources of Information for above PROTOCOL: Rx from Dr. S. Adams, 12/18/13
SEIZURES
VNS and Diastat
INDIVIDUAL: Jason Hernandez
You must always TIME a seizure (minutes and seconds), this is critical as it determines
when and if 911 will be called or when and if emergency medication will be given.
It is a 911 emergency for all people having seizures when:
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The person is having repeated seizures for 30 minutes or longer
The person appears to be injured
The persons color remains poor
The person does not start breathing after the seizure has stopped
(Start CPR)
Prolonged confusion remains after the seizure (more than 10-15
minutes)
The person is not responsive, does not regain consciousness, after
the seizure
The seizure looks very different from the person’s usual pattern
(increase in number, longer lasting, changes in post-seizure behaviors
not seen before in this person)
Usual type of seizure: Other: Lenox Gastaut Syndrome, cluster
seizures
Seizure Protocol (include both VNS and Diastat), note Diastat
requires a Nurse or AMAP:
TIME THE SEIZURE
At start of seizure activity, SWIPE VNS magnet over the VNS
implant site (located between left armpit and collar bone) and hold
there for 3 seconds (count: "one, one thousand", etc). Wait 20
seconds and repeat swipe again if necessary. If necessary, wait
another 20 seconds and repeat again (total of 3 swipes if
necessary)
If seizures last > 5 minutes, or if cluster seizures repeat 3 or more
times, nurse or AMAP should administer Diastat Rectal Gel as
ordered.
If seizures last > 5 minutes, or if cluster seizures repeat 3 or more
times, nurse or AMAP should administer Diastat Rectal Gel as
ordered.
Magnet Location: Specify: In Jason's backpack and also in the
nurses office in the drawer labeled "VNS magnets"
Other Emergency Medication Used: NONE
Name of Nurse: Sally Jenkins, RN
Signature/Title: __________________________________________________
Date above protocol was written: 5/14/14
Sources of Information for above PROTOCOL: Rx Diastat 3/13/14, Rx VNS 2/3/11,
still in effect
Day services – Medical protocols
• Protocols must be reviewed annually (in-service trainings) OR when new staff
care for the person
• Any changes to a protocol (based on an MD order) = that the POP might need
to be revised, the protocol re-written and staff re-trained on the updated
protocol
• When one part changes all parts are set in motion
Protocols and Protective Oversight Plans are a lot for staff to remember
and can be a challenge to follow, support and encourage your staff in being
the eyes, ears and hearts that we need them to be
Nursing – Supporting DSPs
• New hire agency (OSHA etc.) and department orientation
• Agency trainings (AMAP, dysphagia, diabetes management, CPR, first aid)
• Annual in-service trainings:
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Hot/cold weather
Seizures
Diabetes
Skin injury checks
Triage for the non-nurse (head injury, falls injury forms)
And as needed: Diastat, Epipen, Glucagon, Ostomy care, VNS,
Aging, Alzheimer's, psychotropic’s, flu and colds, nutritional
concerns
Day Services – Staff Support
• AMAP supervision (pouring's with the RN present, in addition to
re-cert)
• Daily AMAP observations if AMAP’s give meds those days
• Dysphagia supervision
• Flu vaccine free to staff
• Staff meeting updates
• Nurse meeting with site supervisors (see Team Meetings for
Nurses and Directors)
• ISP meetings – attends with DSP as needed
• Personal relationships, nursing advice
Day Services – Staff Support
Nurse must support DSP code of ethics: (see handout)
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Person-centered support
Promote physical and emotional well-being
Integrity and responsibility
Confidentiality
Justice, fairness and equity
Respect
Relationships
Self-determination
Advocacy
Day Services – Staff Support
Nurse must support DSP core competencies for SUPPORTING GOOD HEALTH:
(see handout)
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Team work
Teach/support positive behaviors
Meal planning, food prep
Knows medical, physical, psychological, dental needs
Prevents illness & disease, teaches person
Responds to S&S illness/injury and knows emergency procedures
Safe clean environment
Documents and protects health information
Understands/implements good health practices
Day service and residential nurses
“Unity is plural and, at minimum, is two.” – Buckminster Fuller
Day service and residential nurses
NURSE:
Shift
Weekends
Nights
On Call
Caseload/Ratio
Case manages
Really responsible?
Wants to trade places?
More satisfied?
Residential
24/7
Yes
Yes
Yes
Yes (50 max)
Yes
Yes
No
Yes
Day Program
M-F, 9-4
No
No
Yes, some
No
Sometimes
No
No
Yes
Review of Survey Monkey questionnaire, discussed at AHRC Nurses Meeting 9/19/14
Day service and residential nurses
• Seeing each other as collaborators – taking care of the same person
• Avoiding un-necessary CONFLICT
• Shared challenges: new admissions more medically challenging, more
challenging behaviors, more risk, more work loads
• Nurses work in isolation, without peer support or other clinicians on a daily
basis, dealing with emotional boundaries
• Job description highly regimented-detailed, limited room for innovation, sharing
and experimentation
Strategies for supporting “shared individuals”
• Collaboration between residential nurses and day program (all environments) is
not a luxury but a necessity
• Remain person centered
• Go Zen and Pema!
• Use the nursing process, discuss
the area where clarity is needed,
try to resolve on professional
level, seek help as needed
• Remember – we both nurses!
Strategies for supporting “shared individuals”
• Meet and communicate with “the other nurse” – bond as nurses, focus on the
real problem
• Regularly meet with other nurses at your agency, or at zone meetings, at
trainings, professional organization (NYSNA) – reach out, network, ask to see
what others do
• Seek consultations from administrators, compliance, medical directors, nurse
educators, other nursing peers, “human rights” committee, other “team”
members
• Is there any medical or nursing research that may assist resolution
• “Take the initiative. Go to work, and above all co-operate and don't hold back on
one another or try to gain at the expense of another.” – Buckminster Fuller
Communication
• Day Program communication challenges:
• Intra site relationships (co-workers)
• Intra agency relationships (other departments)
• Inter agency relationships (outside agencies, DDSO)
• Relationship with family
• Relationship with guardian, CAB, other
• Relationship with other care providers, clinicians
• Relationship with the person
Communication
Work towards collaboration with residence, family etc.
• Changing the culture of communication
• Teamwork
• Training together
• Mutual respect
Communication
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Use an expected and known agenda
Use a team meeting approach
Share nursing decision making – collaborate nursing judgment
Communication is key to advocacy and coordination of care
“Don't fight forces, use them” – Buckminster Fuller
Communication
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Improving Clinically focused RELATIONSHIPS
Take pride in your practice
Communicate effectively
Embrace a team approach
Speak up when you notice a problem or error
Avoid negative behaviors
Know the context
Have a sense of humor
Make the goal - UNDERSTANDING
Case Study 1 – Bowel Monitoring
Normal bowel function:
• Normal frequency of bowel movements can range from 3 times a day to 3
times a week.
• Doctors often define constipation as a stool (or bowel movement) frequency
of less than 3 times a week.
• Discomfort may be reported or observed as straining, hard stool, or feelings
that client is unable to empty the bowel.
• Normal stool in an adult or child (not infant) is brown, soft and formed.
• White or clay-colored stool, black/tarry stool, bloody, thin ribbon-like stool,
narrow/pencil-shaped stool, hard or liquid stool is usually considered
abnormal.
Case Study 1 – Bowel Monitoring
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People with chronic constipation report they feel that they have a lower quality of life.
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People who have only one or two bowel movements per week are more likely to have
obesity, diabetes, diverticulosis, hemorrhoids, and colon cancer.
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Constipation may lead to complications including fecal impaction, ulceration, bowel
obstruction, sigmoid volvulus (the bowel twisting in a loop), incontinence of stool,
rectal prolapse, urinary retention, possible dizziness (and falls).
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Increasing intestinal distension (stretching of the intestines) may lead to loss of blood
flow to the bowel, perforation, and tissue death.
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Untreated, a bowel obstruction can cause hypovolemic or septic shock and death.
Case Study 1 – Bowel Monitoring
Factors that may contribute to constipation:
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Dietary factors - low residue (low fiber) diet, not drinking enough liquids
Inactivity and immobility - movement disorders, gait disturbance (difficulty with
walking and balance), wheelchair use, scoliosis, cerebral palsy, quadriplegia,
paraplegia
Environmental factors - lack of routine, lack of privacy, schedules that cause the client
to ignore the urge to have a bowel movement (defecate)
Structural abnormalities - hemorrhoids, tumors, narrow openings
Smooth muscle or connective tissue disorders - amyloidosis, scleroderma
Depression
Neurological disorders such as stroke, Parkinson’s disease, spinal cord tumors
Metabolic/endocrine disorders - high calcium, low potassium, low or high thyroid
hormones (hypothyroidism or hyperthyroidism), diabetes, Addison’s disease
Case Study 1 – Bowel Monitoring
Factors that may contribute to constipation include many medications :
Opioid analgesics – Morphine, codeine
Non-steroidal anti-inflammatory drugs (NSAIDS)
Antacids – Tums
Anticholinergic drugs - Cogentin/benztropine, scopolamine (transdermal), atropine
Antidepressants - particularly lithium and tricyclics
Antipsychotics - Risperdal, Zyprexa, Haldol, Seroquel, Mellaril, Thorazine
Antihypertensives - Captopril, Catapres/clonidine, Inderal/propranolol
Antiarrhythmics - calcium channel blockers especially verapamil
Diuretics - Diamox, Lasix, Hydrochlorothiazide
Anticonvulsants - Klonopin, Neurontin, Lamictal, Dilantin/phenytoin, Topamax, Depakote,
Antihistamines – Benadryl
Antilipidemics - Lipitor
Case Study 1 – Bowel Monitoring
Maintaining Healthy Bowel Function:
• Serve and eat foods high in fiber instead of refined carbohydrates and
concentrated fats. Vegetables, fruits and cereals are high in fiber. Some
foods can act as natural laxatives: figs, prunes, pears, raisins, and
rhubarb.
• Added intake of liquids should accompany an increase in fiber intake.
Adults need at least 8 glasses of non-caffeinated beverages per day,
unless a fluid restriction is required because of a medical condition.
Fruit juices and warm liquids can be helpful.
• Age-appropriate exercise program.
Case Study 1 – Bowel Monitoring
Maintaining Healthy Bowel Function:
• Establish a routine for bowel movements that includes a regular time
and
privacy. A bowel movement is most likely to occur an hour after
meals
• Positioning is important while attempting a bowel movement. Squatting
increases pressure on the rectum and encourages use of abdominal muscles.
• Treatments used for constipation include bulk laxatives (psyllium or bran), stool
softeners (Colace and Surfak), stimulants (bisacodyl or senna), osmotic
laxatives (lactulose, milk of magnesia, sorbitol, sodium salts), lubricants (mineral
oil), and enemas.
• With bulk laxatives and stool softeners, enough liquids must be taken to make
them work.
Case Study 1 – Bowel Monitoring
Monitoring bowel function:
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It is important to have an established procedure for monitoring bowel function and
responding to changes.
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People should be asked on a daily basis whether they have had a bowel movement.
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The information needs to be documented in order to learn what the individual’s
normal routine is and to monitor for the development of problems.
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Be sure to monitor the bowel function of clients who have had recent abdominal
surgeries, injuries, medication changes, and changes in diet or activity level.
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Since many clients are unable or unlikely to communicate verbally because of
cognitive challenges, staff must also be skilled at detecting non-verbal signs of pain or
discomfort.
Case Study 1 – Bowel Monitoring
SIGNS AND SYMPTOMS OF CONSTIPATION
• Change in bowel frequency (decrease) or consistency
• Soft, paste-like stool in rectum or hard stool with oozing liquid stool
• Feeling of rectal fullness
• Straining at stool
• Decreased or hyperactive bowel sounds
• Report of feeling abdominal fullness or pressure
• Distended (swollen) abdomen
• Indigestion
• Severe gas
• Nausea
• Other - back pain, headache, decreased appetite
Case Study 1 – Bowel Monitoring
SIGNS AND SYMPTOMS OF A BOWEL OBSTRUCTION
• Abdominal pain - may be described as dull, squeezing or ill-defined,
constant, or "colicky" (a sharp pain that may come and go)
• Abdominal distension - swollen abdomen may push on diaphragm and
affect breathing
• Nausea and vomiting
• Decreased urine output (from dehydration which is possible even without
vomiting)
• Constipation
• Fever, chills
• Abnormal bowel sounds
Case Study 1 – Bowel Monitoring
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How does day program balance the need of the individual’s safety with the
need for privacy and autonomy
 What can be done for situations where the day programs feels that
compliance would be impossible
 Is there technological solution
Dysphagia
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Impacts over 22% of the population over the age of 50- per ASHA- American
Speech Language and Hearing Association
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The aging and developmental disabled population often require the
assistance of caregivers to assist with ensuring safe swallowing and diet
orders are followed for multiple reasons including:
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Maintaining adequate nutrition and hydration
Providing the least restrictive diet to allow for maximum enjoyment at
meals
Promote independence and safety with eating and drinking
Dysphagia
Aging and Swallowing Issues
 As people age other factors can impact safe swallow function –
dementia, Parkinson's, stroke
 Dental issues such as weakened or broken teeth can impact chewing
 Sensory changes as we age can impact how foods smell and taste
decreasing appetite or desire to eat
 Osteoporosis can cause positioning issues of the head and neck that can
make it difficulty for people to have the ideal posture for safe eating and
drinking
 Muscle Fatigue and Atrophy can cause the muscles involved with
swallowing to not be strong enough to execute a safe swallow as before
Dysphagia
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Willowbrook: The average feeding time for children who could not feed
themselves was about three minutes. This was done by shoveling mashed up
food into the children's mouths, leading to the most common form of death
for children at Willowbrook, aspiration pneumonia.
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People with IDD at risk for dysphagia (including weight loss and
dehydration), choking and aspiration
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OPWDD choking alerts, aspiration alert
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ADM 2012-04: Choking Prevention Initiative
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“Many people served by OPWDD have problems chewing and/or swallowing
food, placing them at possible risk for choking or aspiration” – CPI manual
Dysphagia also affects Meds
Medication administration can also be impacted if a person has dysphagia.
There can be specific orders on how to administer medication that may
include:
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One pill at a time
All pills crushed and in applesauce, pudding, or yogurt
A combination of crushed pills and pills cut in half
Medication should always be given with the person is sitting
upright, not laying flat in bed
Know which meds can be crushed, consult with MD
Instruction/precaution on the MAR
Dysphagia
OPWDD timeline to get into compliance:
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•
•
ADM 2012-04 dated 8/17/12
6 weeks to start new training, curriculum provided & standardized
CPI-1 by 2/28/13 (online and for everybody)
CPI-2 and completion of ADM elements by 8/30/13 (hands on training
for “identified applicable parties”
Identified applicable parties:
- prepare food, assist with dining, feed or supervise
individuals on a modified diet
- supervisors of staff above
Dysphagia
Plan for ADM 2012-14 – agency wide initiative
I.
II.
III.
IV.
V.
VI.
VII.
TRAINING (included a “Bridge Training”)
UPDATING OF ORDERS
UPDATING OF FORMS
UPDATING OF Nursing Policies
UPDATING OF Other Policies
UPDATING OF MATERIALS AT THE SITES
IMMEDIATE PLAN
Dysphagia
Plan for ADM 2012-14
By late October:
10%
32%
Currently Trained
Require Bridge
Not Trained
58%
Dysphagia
Plan for ADM 2012-14
The following dietary definitions no longer allowed by the ADM:
1. Chopped
2. Bite Size
3. Mechanical Soft
Based on survey, day program has 226 individuals on modified food or fluids.
Of these 226, 153 are on a chopped, bite size or mechanical soft diet and will
require an update their “Dietary Orders” to conform to the ADM.
Dysphagia
Plan for ADM 2012-14
32%
Requires New MD Order
No Change
68%
Dysphagia
Plan for ADM 2012-14
The plan for these 153 individuals - nurses at the sites
to send home a copy of the new Dietary Orders form with a cover sheet
by agency medical director explaining the ADM and our requirement
for updating the person’s orders.
Cover letter dated November 1, 2012 with a deadline for
completion of December 3, 2012. We anticipate delays in receiving
updated orders and expect that some will continue to arrive after the
deadline. Compliance will need to be discussed.
Dysphagia
Plan for ADM 2012-14
• As the updated MD orders are received for these 153 individuals, the nurse
(or nutritionist supervised by the nurse) will do the following:
• Review all existing feeding protocols. Those with Chopped, Bite Size, or Mechanical
Soft diets (the old terms) will be manually corrected by the nurse or nutritionist
based on the updated MD orders to conform to the ADM. Manual corrections will
follow agency standards (single line strike through, print correction above, sign and
date of person making the correction)
•
Update and correct the individuals Protective Oversight Plans with the new
definitions.
•
Train staff on all updated diet orders, updated feeding protocols and updated POP.
Dysphagia
Plan for ADM 2012-14
• Updating of Dietary Orders Form
• Updating of department and agency policies - When one part changes all
parts are set in motion
• Towards the end of July 2013, out of 153 people who needed updated dietary
orders, only 4 were still pending.
• One MD refused to change the order despite multiple communications, the
agency medical director called him directly to resolve.
On the INTRA-NET
Dysphagia
Staying in compliance with ADM 2012-04:
• All new admission diet orders must comply with the ADM
• Continued training of new staff: CPI-1 upon hire, the online
course materials
• As needed training of staff in CPI-2
• Use of Excel to track:
a. Person
b. Coordinator – nutritionist or nurse who oversees
c. Modified Food, Fluids
d. Protocol
e. Supervision required (lunchtime life guard)
f. Staff assigned, with back-ups
Dysphagia
Staying in compliance with ADM 2012-04:
• The RN and nutritionist must review all new or updated DIET ORDERS and if a
change to the Dysphagia & PICA list is needed they will DO THE FOLLOWING
immediately upon receipt of the new order:
• Email the nursing supervisor: Name of the individual, Type of food consistency,
Type of fluid consistency, Whether an additional feeding or safe eating protocol is in
effect (and attached to the POP), Level of staff supervision required, Names of the
staff assigned to supervise or feed the individual after having confirmed with AHRC
Staff Training that staff has passed 4 hour dysphagia training (CPI Part 2) and are
listed in training records as having passed and are “up to date”
Dysphagia
Email the nursing supervisor immediately:
• Verification that the POP has been updated with the new information
• File the original feeding order into the chart, stamped DO NOT REMOVE
• If necessary, review that the protocol is attached to the POP and staff trained
IMPORTANT: nurses must support staff during mealtimes, offer
encouragement and makes sure any problems are reported.
Case Study 2 – Multiple Challenges
 What is the role of the family in Emily’s care
 Does their care meet the needs of the individual, of the program
 Is there a concern with multiple health care providers, who should be
coordinating them when the family cannot
 Any concerns with using a DSP as a translator in this case
 Should APS be contacted
Community health variables
•
•
•
•
•
•
•
•
•
Day program - “school nurse modeled”
Health of individuals and health of the group
Outbreaks: flu, chicken pox (varicella-shingles), head lice,
pink eye, scabies, pneumonia, Molluscum contagiosum,
strep, active TB
Closing of programs (norovirus, food poisonings)
Specialized cleaning or disinfecting requirements
Transportation issues
Informing other agencies, local health department, OPWDD
Medical clearance requirements
Challenge: trying to reduce ER visits
Site based acuity levels
• See the forest for the trees
• Review of major risk factors (hand out)
• Could add other factors: age, autistic, behaviors
• Review given staffing (nursing, AMAP, other)
• Make a nursing determination based on quantifiable
• Determine: Low, moderate, high
• What to do if everything is HIGH
• What does an acuity level mean?
Medical Clearance (see handout)
•
Focus upon health of the community – group, herd
•
RULE: Risk to themselves or others? Still symptomatic? RN decides
•
Supports at home to get the clearance, how likely
•
Customer service and lost billing/revenue
•
Relationship with family/residence (problem of keeping someone at
home)
•
Usually: FLU, other contagions, N/V/D, hospitalization, change in ADLs
Thank-you
Special thanks to my nursing colleagues at AHRC
Iris Finkelstein, RN and Marcia Richman, RN
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Larson, Jennifer. Seven Secrets to Improving Nurse–Physician Relationships. NurseZone.com. July 9, 2014
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2013
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