H.A.R.P. Training

1. H.A.R.P. Training Health Assessment, Reporting, and Prevention

2. Aspiration

3. What is Aspiration? Definition: The drawing in of a foreign substance into the respiratory tract during inhalation.

7. Who is at risk For aspiration? • Anyone with conditions that depress or alter the level of consciousness. • Epilepsy/Seizure Disorders • Traumatic Brain Injury • Alcohol Intoxication • Conditions that affect muscle tone • Cerebral palsy • Multiple Sclerosis • Stroke Patients

8. Risk Factors? • Poor eating habits • Prader Willi Syndrome • Rapid eating • Anyone who has chewing or swallowing difficulties (dysphagia) • Age • Elderly • Infants/toddlers • Abnormalities with dentation or oral cavity • missing or loose teeth • cleft palate

9. Risk Factors? • Medications • Sedatives • Narcotics • Psychotropics • A decreased gag or poor cough reflex • Gastroesophageal Reflux Disease (GERD) • Obesity • Tracheal Intubation (tracheostomy) • implanted feeding tubes (can be nasogastric, gastric or jejunal)

10. What to Look for…. Symptoms can be obvious or subtle. • Coughing or gagging (especially during or after meals or fluid intake) • Drooling, excessive salivation • Shortness of breath, noisy breathing, difficulty breathing • Wheezing or high pitched noise heard when inhaling • Problems swallowing • Bluish or grey discoloration of the skin caused by lack of oxygen • Noisy breathing • Recurrent episodes of pneumonia or bronchitis • Runny nose or sneezing often during meals • Hoarseness • Sore throat

13. What to do if you suspect aspiration? • CALL 911 if: • Blue/gray • Can’t Speak • Difficulty Breathing • Looks extremely ill

14. If Client is Stable: • Review Medical History • Review any previous testing or concerns with swallowing • Document current symptoms • Educate caregivers on identification and prevention • Report concern to physician or nursing service • Refer for follow up or Speech Therapy Evaluation • Reportconcern to RNCM if applicable

15. Why is identification of aspiration so important? • Complications: • Airway obstruction or trauma • Difficulty breathing/shortness of breath • Infection • Pneumonia • Death

16. Tying it all together: • Aspiration is inhaling a foreign substance into the lungs. • At risk clients are a high percentage of the population we see. • Identifying the risk factors and symptoms early can help prevent or treat aspiration before complications can arise. • Responding to acute events quickly and appropriately can save lives. • Don’t be afraid to call 911 in a crisis. • Notify other staff and care managers immediately. • Referral for medical follow up, diagnostic testing, and therapy should also be done immediately. • Refer any client to RNCM who presents with multiple risk factors • Document, document, document!

17. Pneumonia

18. What is Pneumonia? • Pneumonia - Infection of the lungs • Signs • Coughing, • Fever • Difficulty breathing • Alveoli- air sacs in lungs surrounded by tiny blood vessels called capillaries • Purpose • Gas Exchange – • Bring Oxygen to the body • Expel Carbon Dioxide

20. Who is at Risk? Older Adults and Children Individuals who have trouble swallowing Individuals with poor dental hygiene Anyone with a decreased level of consciousness Individuals who have difficulty with performing activities of daily living or are immobile Anyone with a history of smoking Anyone living in close living quarters, such as group homes and any individuals attending day habilitation centers

21. Types of Pneumonia Aspiration Pneumonia • Individuals at risk for aspiration pneumonia • Individuals who have difficulty swallowing • Individuals with impaired mobility

22. Bacterial and Viral Pneumonia • Bacterial & Viral Pneumonia • Individuals who are more at risk for a bacterial or viral pneumonia include • Individuals who have difficulty swallowing • History of bacterial or viral infections • History of cancer • History of chronic illnesses • The common flu and cold can also lead to pneumonia.

23. Signs and Symptoms to look for… A productive cough or a cough in which the individual is coughing up phlegm or mucus Fever Trouble breathing or it is painful for the individual to breathe Shaking chills A fast heartbeat or complaints of a racing heart

24. When to Seek Help • If an individual is experiencing any of the symptoms from the previous slide, make sure the individual knows they need to see their primary care physician or seek medical assistance. • If the individual is having difficulty breathing, seek emergency help. • The individual also needs to seek immediate help from a doctor if: • Their cough is becoming worse. • Have a fever of 102 or higher • Have chest pain when breathing in. • Start feeling worse after having gotten over the flu or cold. • Have a weakened immune system. • Already have a serious lung disease.

25. CALL 911 IF: AN INDIVIDUAL IS EVER HAVING DIFFICULTY BREATHING AND/OR IS TURNING BLUE AND/OR HAVING SEVERE CHEST PAIN!

26. Preventing Pneumonia • Hand Hygiene • Annual flu vaccine • If the individual is sick • Advise the individual to avoid crowded places • School • Day habilitation programs

27. What to say to your individuals on how to prevent pneumonia? Always cover your cough with the inside of your arm. Wash your hands often with soap and water for at least 15 seconds, especially after coughing or sneezing. Alcohol-based hand sanitizers also work. Do not get too close (kissing, hugging) to people who are sick. Ask visitors who have colds to wear a mask. If you have a cold, stay home from work or school. Wear a mask to help from spreading the infection. Do not share towels or hankies with anyone who is sick. Eat a healthy diet. Get a flu shot each year. Ask your doctor if you need a pneumonia shot or any other vaccines. Do not smoke or be around smoke.

28. Complications • Respiratory Failure • Sepsis • Acute Respiratory Distress Syndrome (ARDS) • Lung Abscess • Death

29. Review • Types of Pneumonia • Viral • Bacterial • Aspiration • Pneumonia – Infection in the lungs • Prevention • Hand Hygiene • Annual Flu Vaccination • Education • Stop Smoking

30. Skin Breakdown&Prediction and Prevention

31. What is Skin Breakdown? AKA Pressure Ulcers or Bed Sores A localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure or injury. Injury from “inside out”

32. Risk Factors Decreased mobility Paralysis Poor nutrition/hydration Incontinence Age Behaviors/Life Style Mechanical forces (pressure/friction/shear) Pronounced bony prominences Poor circulation Altered sensation Swelling/edema History of radiation Altered Skin Condition SMOKING!

35. Stage I Pressure Ulcer

36. Stage II Pressure Ulcer

37. Stage III/IV Pressure Ulcer

38. Early Identification Skin breakdown starts out as a red or purple spot on fair skin or a shiny, purple, blue or darker spot on dark skin, which does not fade or go away within 20 minutes. When you press on the spot with your finger, it does not become lighter (blanch).  It may feel warmer or cooler than the skin around it.  The spot may feel hard or squishy under your fingers and may look swollen.  May be a small open area or blister. If you have sensation, it may be itchy or painful.  

39. Complications • Blood infection • Skin/tissue infection • Bone/joint infection • Cancer • Death

40. Prevention Prevent mechanical injury Keep skin clean and dry Eat a healthy diet Adequate hydration Avoid prolonged pressure on susceptible areas Promote circulation (ROM) Frequent skin assessments Pressure relieving devices Frequent incontinent care Skin protectants/moisturizer QUIT SMOKING

41. Take Action… • Report these changes to RNCM or PCP IMMEDIATELY: • Decreased ability to shift weight, turn, reposition, etc. • You feel using special equipment might help to transfer more safely and easily. • There are new or worsening changes in skin • If person is unable to control his/her urine or stool • Any client that has a condition or syndrome affecting mobility or skin integrity

42. Take Action… • Educate the family or caregivers on skin assessment and breakdown prevention • Encourage a balanced diet with adequate hydration • Encourage a Bowel and Bladder Program for incontinent clients • Encourage frequent position changes and increased activity level • Ensure all necessary incontinent supplies are available, i.e. wipes, barrier creams, pads and briefs. (Discourage the use of scented commercial wipes when skin irritation is present) • DOCUMENT ANY CHANGES OR ALTERATION IN SKIN INTEGRITY • Follow up with client’s to be sure skin breakdown is being treated and monitored.

43. Tying it all together: Skin breakdown is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure or injury. There are numerous types of skin break down to look for and severity can progress rapidly if left untreated. Our client population is at high risk for breakdown due the complex medical conditions or physical limitations they may possess. Complications can range in severity from minor discomfort to death.

44. Tying it all together: Your primary responsibility is to assess for and report any alterations in skin integrity to RNCM or the PCP. Provide resources for education on skin breakdown prevention, assessment and treatment, and pressure relieving devices Document any skin breakdown and all referrals made.

45. Constipation & Impaction

46. What is Constipation? • Infrequent bowel movements or difficult passage of stools

47. Identifying the Symptoms: • Fewer than three stools per week • Having lumpy or hard stools • Straining to have bowel movements • Nausea/Vomiting • Abdominal pain or bloating • Abdominal distention • Feeling as though there's a blockage in your rectum that prevents bowel movements • Feeling as though you can't completely empty the stool from your rectum • BEHAVIORAL CHANGES (especially in non-verbal client’s)

49. Risk Factors: • Most common • Decreased water intake • Poor diet • Lack of exercise • Abnormal bowel motility (IBS, gastroparesis) • Poor muscle tone

50. Risk Factors… • Neurological Disorders • Cerebral Palsy • Parkinson's disease • Spinal cord injury • Stroke • Conditions that affect hormones in the body • Diabetes • Overactive parathyroid gland (hyperparathyroidism) • Pregnancy • Underactive thyroid (hypothyroidism) • Mechanical Blockages (Bowel obstruction, cancer)