Pediatric PT Goal Writing Notes PDF

Slide 4.4: Goal Writing in Pediatric PT ICF Model emphasizes: Function, impact and health rather than disability Understanding functional deficits associated with a health condition promotes better Pt management...

Slide 4.4: Goal Writing in Pediatric PT ICF Model emphasizes: Function, impact and health rather than disability Understanding functional deficits associated with a health condition promotes better Pt management A more holistic model of health Utilizes goal setting Requires evaluation of outcomes Requires communication among colleagues Functional Limitations -During PT eval: determine what functional limitations the individual has. -Consider how functional limitations are inhibiting or restricting a person’s activity and participation -ICF model considers factors that facilitate or hinder overall functioning V ability to execute task socially defined role Environmental factors Setting at home Setting at school Motivation of the individual intrinsic Amount of family support Accessibility to assistive devices Personal factors how do these influence fxn Age Gender Lifestyle Fitness Coping styles Cultural beliefs Pain experience Interventions Identify: impairments, functional limitations and activity limitations → Create plan of care Interventions: minimize disability and use function as an outcome In pediatrics, ICF model emphasizes importance of child's environment on their functional outcomes Environment = physical world + values & attitudes of family and community Accessibility to services & support impacts overall daily function Goal-Setting in Pediatrics ICF model helps for goal-setting: Goals are created to increase activity and participation Goal creation favors strengths of child: Focuses on how to build on these strengths to accomplish new tasks Family-centered approach: Focus on child and family interests and values Increases child and family motivation and improves therapy outcomes SMART Goals: think who, what, where, when, and why significant, self owned, sensible why S: Specific: What is it that will be accomplished? What actions are you hoping/planning to take? how - M: Measurable: you want to indicate how you will measure progress. meaningful,motivational, manageable A: Achievable: make sure the goal and objective is not out of reach and realistic; Answer: How can the goal be accomplished (i.e. new skills, knowledge, techniques, habit, different routine) attainable, aligned, action valuable oriented, appropriate - R: Relevant: Consider how applicable and significant the goal is. realistic, reasonable, rewarding T: Time-Bound: timeframe to accomplish goal think about frequency too & time based, trackable E - ethical, enjoyable, engaging R - recorded, rewarded, realistic, relevant, research-based Slide 4.5: Play Based Interventions play = work of children Play: Important for Developing Gross Motor Skills Play: what the child “wants to do,” not “has to do” “how do you want to play” play = no outcome, just intrinsically motivating Practice and Repetition Play allows failure: try again and try again and again and again → succeed and do it again and again Embrace and foster the learning curve (athletes even go thru learning curves) *Typically developing children do not perform tasks perfectly, don’t expect perfect Play Can Happen with Any Activity, Any Item, Any Where (increase practice & repetition helping w/ learning curve) Play Allows the Child to Participate PTs can direct play, but the child’s engagement with the activity allows them to take ownership and incorporate what they learn at a deeper level (foster by giving praise, intrinsic motivational, non tangible rewards) Requires creativity and flexibility of the PT o PTs must evolve to take the child’s input and interests and make it therapeutic o Warning: Creative kids almost always have a way to get out of the task ☺ plan a.b.c.d Summary Play: important part of development Embrace the learning curve: repetition PTs can direct play (engineer environment) PTs must evolve to take the child’s input and interests and make it therapeutic Slide 4.6: NICU and the Role of PT (neonates = 0-12 months w/ medical fragility (physiological, behavioral, development vulnerable) Focus of NICU PT: consultation and family education o Neonatal PTs play important roles in the interdisciplinary neonatal care team o Key Role in educating the caregiver team and family Positioning and handling Individualized care giving Therapeutic interventions NICU: PT Referrals Infants born prematurely or at full term that show signs of CNS impairment, neuromuscular or orthopedic problems, multiple medical or genetic problems, abnormal feeding behaviors, etc Low Apgar scores are closely monitored (Apgar is an assessment of physiological function) Assigned 1 and 5 min after birth and again at 10 if a low score is assigned Correlated with neurological complications 1 minute: 8-10 score = normal 1 and 5 minutes: 0-3 score = resuscitation (risk of death and neurological complications) Full term infants with microcephaly, hypoxic ischemic encephalopathy, neuromuscular diseases, myelomeningocele, genetic syndromes, etc. Premature Birth: Infants born before 38 weeks gestation and at higher risk for medical complications and developmental disabilities May lead to visual impairments, sensorineural hearing loss, learning disabilities, attention deficit/hyperactivity disorder, and other developmental and neurological problems NICU: Common Medical Complications: PT Referrals Cerebral palsy most: common developmental disability related to premature birth & low weight Intraventricular hemorrhage (IVH): most common CNS complication related to premature birth. Is bleeding in ventricles of brain (1 = least severe 4 = most severe) Periventricular leukomalacia (PVL): CNS complication, linked to premature birth Ischemic infarction of white matter adjacent to lateral ventricles within 4-6 weeks Retinopathy of prematurity (ROP) causes abnormal development of vascularization in the retina after birth Infants born at full term with: microcephaly, hypoxic ischemic encephalopathy, neuromuscular disease, myelomeningocele, genetic syndromes, Erb’s palsy, torticollis, positional deformities, amniotic band syndrome, feeding abnormalities, arthrogryposis Severe respiratory diseases may require high frequency ventilation & extracorporeal membrane oxygenation (ECMO) (severe hypertension/pneumonaia but can risk cns problems) Complications may include seizures, IVH, cortical atrophy, muscle tone abnormalities, feeding difficulties, and other problems Types of Care in the NICU: Newborn nurseries are defined by levels of care provided Level I: provides routine maternal and newborn well-baby care Level II: more specialized, providing additional care short-term ventilations, neonatal monitoring with some medical interventions Level III: NICU that is equipped for smallest and most ill infants Types of Care in the NICU: 1. Developmentally supportive care: Individualized caregiving and Controlled Environment o Individualized caregiving guided by infant’s ▪ Physiological reactions ▪ Behavioral cues ▪ Signs of stress in response to immediate environment o Controlled Environment = developmentally supportive care here o Cycled or dimmed lighting o Clustered care o Decreased stimulation o Decrease noise levels o Minimal handling o Specific handling techniques 2. Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) o Observation of infant’s behavior, with individualized recommendations for handling and care based on infant’s specific responses 3. Kangaroo care, or skin-to-skin contact o Helps have more rapid maturation of vagal tone, more rapid improvement in behavioral state organization, longer periods of quiet sleep & alert wakefulness & shorter periods of active sleep PT Exam and Eval in the NICU: Chart review -History For premature infants: use corrected age until 3 y.o.: infant’s age from time they are 40 weeks gestation -Current medical status PT needs to monitor physiological and behavioral response to handling Precautions and contraindications scores May show signs of stress with handling= be conservative Negative behavioral responses: Hiccups, Frowning, Turning away from a noise or face PT Exam and Eval in the NICU: Behavioral state and alertness -Moving through various degrees of alertness indicates CNS maturity we want to work w/ them An infant may move through various stages of alertness in a matter of minutes during this Stages: Deep sleep, light sleep, drowsiness, quiet alertness, and crying Premature infants: erratic transitions through stages; little time in quiet alert Use behavior state to guide decision making and treatment -Visual and auditory systems Tracking of visual field and reactions to certain stimuli Auditory system: should respond to stimuli by quieting to voice or turn toward voice PT Exam and Eval in the NICU: Positioning Evaluate infant’s ability to maintain flexion in prone, supine, and sidelying Educate parents and caregivers on positioning/handling & benefits of each Post positioning program at bedside Flexion: promotes symmetrical neck movement, ease of breathing Prone: maximal support to chest wall Supine: promotes maximal observation of the infants face and chest, ease of care Sidelying: helps maintain hands together and LEs flexed; encourages self-calming behaviors such as hands to midline, face or mouth Look for signs child is avoiding handling: Skin color changes, hiccups, finger splays, lower extremity stiffening and extension, frowning, turning head away from noise or face PT Assesses tolerance in various positions- benefits of positions is communicated to staff/family Sleep position recommendation: Supine: due to risk of SIDS with prone position Side lying is discouraged due to ease of rolling to supine PT Exam and Eval in the NICU: Positioning: Calming Behaviors -Coping with stimulation Self-calming: hand to face or mouth, sucking on hand, fingers, thumb, or pacifiers, maintaining a flexed posture, hands or feet to midline, closing of the eyes, gaze aversion, or a drowsy state to controlled stimulation Assisted calming: Nesting, position in flexion, holding in flexion, slow rocking, swaddling, quiet voice PT Exam and Eval in the NICU: Muscle tone and reflexes Assess with resistance to passive movement Primitive reflex testing: Moro, plantar grasp, placing, stepping: Best to test in quiet alert state Observation of movements Muscle tone is decreased in premature infants and full-term infants who are ill Deep tendon reflexes also indicate tone and asymmetries PT Exam and Eval in the NICU: Active movement and strength Assess when awake and alert UEs and LEs should be smooth and symmetrical Active movement patterns: bring hands to midline, hands to mouth/face, pulling at a tube, LE extension Strength assess in how infant moves head, neck, trunk, and extremities against gravity Feed by mouth is landmark skill: Ability to feed by mouth = DC from NICU to home Summary PTs serve a key role in the NICU: Positioning, Team approach, Family education *Advance practice required Slide 4.7: Early Intervention and the Role of PT Early Intervention (EI) Physical Therapy: IDEA Part C Individuals with Disabilities Education Act (IDEA) of 2004 (Public Law 108-446) Federal law that supports provision of public education for all children regardless of nature or severity of their disability Part C of IDEA: an optional federal program that supports early intervention for infants and toddlers, birth up to 3 years All states currently are participating in Part C IDEA Part C Implementation In EI Implementation of IDEA Part C is the responsibility of each state through a lead agency appointed from education, health, human services, public health, or another related state agency Part C requires that multiple agencies work together and collaborate on meeting the needs of infants and toddlers and their families in their states and communities Eligible children have a developmental delay or a medical diagnosis that has a high probability of a developmental delay States define eligibility criteria for developmental delay by addressing child’s development in cognition, physical, communication, social/emotional, and adaptive (self-help) domains or areas Eligible infants & toddlers are entitled to EI in natural environments where children live, learn, play EI services are provided, as necessary, to meet developmental needs of child and needs of the child’s family related to family’s ability to enhance the child’s development Family Life and Community Life Family Life Community Life -Daily routines, play activities, household chores, -Family activities and outings, going on errands, entertainment, rituals, celebrations, and social play activities, community events, outdoor activities activities, participation in church/religious groups -Examples of family-life environments: Kitchens, and/or community organizations, sports backyards activities/events -Examples of family-life activities: Eating, playing, -Examples of community life environments: gardening Playgrounds, parks, libraries, restaurants, etc.)  Modeling Family/Caregiver = Primary Influencer - Physical Therapy: An Early Intervention Service PT is one of the EI services under Part C of IDEA PT: can be the only EI service a child needs, or it may be part of a coordinated, multidisciplinary program PT is provided as part of child’s Individualized Family Service Plan (IFSP) through a family-centered care approach PT supports families in promoting their children’s development, learning, and participation in family and community life PTs use their knowledge and skills specifically related to motor and self-care function, assistive technology, and medical/ health care service to provide a unique contribution to the IFSP team PTs provide service by collaborating with the team, exchanging information with family, and integrating interventions into everyday routines, activities, and locations IDEA Process And The IFSP -Parents are an integral part of IDEA process, including development of Individualized Family Service Plan (IFSP) Must be notified of their rights, including right to due process -IFSP: process of planning, decision- making, and implementation of EI services for children and their families -Team develops outcomes, objectives, and strategies that will guide the provision of EI services in natural environments -Team determines amount (frequency & duration) and location of EI services, including PT, to support child’s & family’s outcomes & objectives Due Process “hearing requests” -Parents have legal rights if they disagree about whether requirements of Part C of IDEA are being followed -Under Part C of IDEA, parent have the right to file a due process complaint when they want a hearing officer to make a decision about EI services for their child and family -Examples Parent disagree with results of child’s evaluation regarding his or her eligibility for Part C Parent thinks EIS provider is not providing the services included in child’s IFSP FUNDING FOR PHYSICAL THERAPY in EI -Under IDEA, early intervention Child Find, evaluation and assessment, service coordination and development of the IFSP must always be provided free of charge -EI services are free except when federal or state law provides for a system of payments by families, including a schedule of sliding fees -Local agencies may access other funding sources, i.e. state’s Medicaid with parental consent -Inability of parents to pay or utilize personal insurance must never prevent delivery of Part C services -Additional rules and requirements about funding may be decided by the state Child Find Under federal law, public schools must look for, find, and evaluate kids who need special education Covers kids from birth through age 21 Applies to all kids: Homeschooled, Public school, Private schools, Migrants, Kids without homes EI Summary -Part C of IDEA: optional federal program that supports EI for infants & toddlers birth up to 3 yrs. -All states currently are participating in Part C -Eligible infants/toddlers: entitled to EI services in natural environments where children live, learn, play -Goal: meet developmental needs of child and needs of child’s family related to family’s ability to enhance the child’s development -PTs provide service by collaborating with the team, exchanging information with family, and integrating interventions into everyday routines, activities, and locations Slide 4.8: School Based Setting and Role of the PT Implementation of IDEA, PART B School Services: Primary purpose: ensure that children with disabilities have available to them a free appropriate public education (FAPE) that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living IDEA Implementation: Part B Individual student’s needs are determined using student data and evaluation(s) Parents/guardians are integral participants in the evaluative process and collaborate on the development of Individualized Educational Program (IEP) as part of the IEP team Parents/guardians must provide consent for evaluation and services and have rights to due process in the event consensus cannot be reached by the team Specially designed instruction (SDI) and related services are individualized, linked to measurable student goal(s), and applied as documented in each student’s IEP IDEA requires coordinated services to address transition from Part C to Part B & from public school to work, further education & /or community engagement following school IDEA, ,the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, and the Technology Related Assistance for Individuals with Disabilities Act provide a range of services to support students who require them for equal access to education The IEP Team  At least every 3 years School-Based PT PT is one of related services under Part B of IDEA Student eligible if needed to: address educational needs and PT expertise required PTs work collaboratively with student’s IEP team; participate in screening, evaluation, reevaluation, program planning, goal development, transition, providing intervention, and collecting data to monitor progress PTs design a plan of care (or intervention plan) and implement PT interventions—including teaching, training, and support of family and education personnel, and documentation of progress—to help the student achieve their IEP goal(s) Support students in accessing and participating with peers in their educational environments Determine needs for appropriate assistive technology, supplementary aids, accommodations, and strategies to promote practice, participation, motor development, access, self-determination and safety as related to their school day Use a variety of delivery models across a service continuum from one-to-one intervention to consultation in support of student’s least restrictive environment (LRE) Should understand the PT specific roles and responsibilities, policies of LEAs, state and federal educational agencies, and laws impacting services for students with disabilities Transition Services EI to preschool Preschool to elementary school Elementary school to middle school Middle school to high school High school to adult community After high school education: college, job training programs Employment Summary: PT Under IDEA B Under IDEA B , PT is a related service Intervention in education setting Is NOT provided to remediate medical diagnoses and/or physical impairments  IS provided to help students achieve their learning and participation goals despite the existing diagnosis driven impairments Schools are responsible for services needed for students Discontinuation of related services occurs when: Skills needed have been incorporated into school routines When needed supports are in place without the addition of services or when student no longer needs related service support to progress on goals/objectives Slide 4.9: Pediatric PT in Rehabilitation Settings Versus Schools Compare: Rehabilitation Settings versus School Based PT Compare: Rehabilitation Settings versus School Based PT Summary: Pediatric Rehabilitation PTs play an important role in helping a child and family PT: a teacher, guide, advocate, & coach who empowers children to maximize their fullest potential