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He needed one-to-one care (special) while in hospital due to gastritis ranitidine 100mg allopurinol with visa challenging behaviour gastritis diet popcorn generic allopurinol 300 mg mastercard. He was very agitated and at very high risk of absconding gastritis erosive diet generic 100mg allopurinol with visa, often trying to gastritis prognosis order 100 mg allopurinol mastercard climb out windows gastritis symptoms belching discount allopurinol master card. He refuses to gastritis diet quotes allopurinol 300 mg online take the medication stating he does not need same or that he is being poisoned. Of the 29 behaviours assessed the most disruptive were: Pacing and aimless wandering: 5 (once or twice a day) Cursing or verbal aggression: 3 (once or twice a week) Negativism: 4 (several times a week) Handling things; 4 (several times a week) Hiding things; 5 (once or twice a day) Hoarding: 3 (once or twice a week) Verbal sexual advances: 2 (less than once a week) General Restlessness: 6 (several times a day) Medication review the consultant reviewed Mr. The Pravastatin (cholesterol lowering), Calcichew D3 Forte (bone health) and Thiamine (Vitamin B1) are stopped as these can be seen as primary prevention and not appropriate in a palliative /patient-centred approach to people with dementia. Drugs used for secondary prevention Asprin, Furosemide, Nebivolol and Tamsulosin were continued as ongoing benefit is expected, within the Mr M’s life expectancy. He has pain due to his degenerative disc disease and arthritis so it is reasonable to continue the Paracetamol. The Quetiapine (atypical antipsychotic) was increased from 50 mg bd to 50 mg tds, to help with distressing behavioural symptoms as non-pharmacological interventions failed as per the Cohen-Mansfield Agitation Inventory and the 24 Hour Behaviour Time Chart. The Mirtazipine was increased as the Mr M scored 10 on the Geriatric Depression Scale and Mirtazipine has few antimuscarinic effects and can help with sleep problems. The Sodium Valporate was increased and changed to bd in an effort to control seizures. M often refused his medications and when first admitted the staff frequently had to request the help of his brother with administration but this was unsustainable on an ongoing basis. Persisting with medication administration when a person with dementia is agitated will only escalate the behaviour that some of the medications are trying to control. Returning at a later time works for Mr M and ensures that he doesn’t feel rushed or afraid. Responsive behaviours can be challenging for staff and caregivers and they are often attempts by the person with dementia to communicate their loss of control. The sight of too many pills may trigger the resistance so presenting one at a time often helps. M may refuse the medications again but the nurses report often after a nap on the armchair he is amenable to taking his medications. M, his family and carers in a homely setting where the his uniqueness and right to choice is valued, facilitates good practice. Medication review on an ongoing basis is essential as management strategies will change as staff become more aware of the triggers that escalate responsive behaviours. This may enable non-pharmacological interventions to be used and behaviour modifying drugs may be reduced or discontinued. M’s dementia progresses, a more palliative approach will facilitate a further discontinuation of medications. Medication Review Principles Room for Review: A guide to medication review: the agenda for patients, practitioners and managers100. All patients should have a chance to raise questions and highlight problems about their medicines. N eed and indication A dverse EventsA Does the patient know why they Any side effects? Would Don’t misinterpret an adverse reaction as a new medical non-pharmacological treatments condition. Reproduced with permission from author Medication and Dementia – Palliative Assessment and Management 33 Section 5 4. H I F No T Yes T Is there another drug that may be superior O to the one in question? R D No Yes R U G Continue with the same dosing rate Reduce dose Reproduced with permission from author 34 Medication and Dementia – Palliative Assessment and Management Guidance and Resources b) Appropriate Medication Prescribing Framework 104 10 step drug mimimisation framework 1 Ascertain all current medications; 2 Identify patients at high 3 Estimate life risk of or experiencing adverse expectancy in high-risk drug reactions; patients; 4 Define overall care goals in the context of life expectancy; 5 Define and confirm 6 Determine the time until current indications for ongoing benefit for disease-modifying treatment; medications; 7 Estimate the magnitude of benefit versus harm in relation to each medication; 8 Review the relative 9 Identify drugs that may utility of different drugs; be discontinued; 10 Implement and monitor a drug minimisation plan with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician. Reproduced with permission from publisher Medication and Dementia – Palliative Assessment and Management 35 Section 5 Patient/Carer Resources 5. Assisted decision-making105 the principles of an assisted decision-making conversation is that it should. See page 41 for Additional Resources 36 Medication and Dementia – Palliative Assessment and Management Guidance and Resources 5. Challenges include: Lack of ability to self-administer, swallowing difficulties, informal caregiver burden associated with medication management complexities such as ensuring safe administration, noticing and managing side-effects, supplying appropriate information109,110,111. Instances of refusal to take medication and covert administration practices are particular areas of concern highlighted within the literature. Supporting people with dementia, families/carers and healthcare staff in navigating the difficulties associated with medication administration has potential to improve the quality of care to people with dementia, lessen caregiver burden and clarify medication administration decision-making processes for healthcare professionals. People with dementia should be supported to maintain independence in taking medications for as long as it is safe to do so. A medication management risk assessment should be performed to determine the extent to which a person can either self-administer or requires support in medication–taking. Family/carers require guidance on practical strategies to assist medication administration and adherence to a drug regimen. Healthcare professionals should be aware of the practical, ethical and legal considerations with respect to changing the form of a prescribed medication (crushing) or covert medication administration. Medication management assessment Individualised performance-based medication management assessment is recommended and should be combined with a careful drug history, proxy information and continual medication monitoring112. A number of tools are available to help healthcare providers to identify barriers for managing medications and to more adequately address an individual patient’s deficits. Providing drug reminders and organisers (assuming the person is able to use the device appropriately). Covert administration of medication Covert administration of medicine refers to when a medicine is administered in a disguised form to a person without their knowledge or consent114. There are specific provisions in the Mental Health Act 2001115 in relation to continued administration of medicines in the treatment of mental disorder for a period longer than three months for adults and children. Nurses and midwives should use existing legal and best practice frameworks for individual patient situations. Dementia Ireland A Practical Guide to Daily Living for Family Caregivers121 Please see p. Whilst many classification systems exist to grade the severity of the dementia. Here, the person with suspected dementia is evaluated by a health professional in six areas: memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care and one of five possible stages (0-3) of dementia is assigned (see below). The Clinical Dementia Rating Scale124,125 Medication and Dementia – Palliative Assessment and Management 41 Section 6 Progression of Dementia Three important influences on the life-span of dementia are the type of dementia, the stage of dementia, and whether the course of deterioration is rapid or slow126,127. Life expectancy of the person with dementia Although dementia is a progressive, life limiting and incurable condition, it is not possible to clearly predict a person’s life expectancy and this uncertainty can be very challenging for the person with dementia and their relatives/friends. Although, specific life expectancy cannot be provided, there are some indicators below that healthcare staff can provide on the probable life expectancy of the person. Clinical practice guideline on the comprehensive care of people with Alzheimer’s disease and other dementias. Barcelona (Spain)128 A comprehensive Spanish Guideline, using a Q&A format, making recommendations on the care of patients with Alzheimer’s disease and other dementias, such as, for example, vascular dementia, Parkinson’s disease dementia, dementia with Lewy bodies and frontotemporal lobar degeneration. Care Planning Guide in a Residential Setting with Assessment Tools and Side-effect profile of medications used to treat behavioural symptoms in dementia. Each drug is 5-15 minutes {Edelberg, ability to take their following four tasks with scored out of 4, with et al 1999) own medications each of their medications: 1 for each correct independently. Designed to be 2) open the container, this is then converted used in clinic to a percentage score. They are required to dispense the C) Number over: Total pills for each dose and hand number of pills exceeding them to the interviewer. Standardised assessment of patients’ capacity to manage medications: a systematic review of published instruments. Behaviours that challenge, also known as responsive behaviours, can include, but are not limited to: aggression, agitation, wandering, hoarding, sexual disinhibition, apathy and shouting. Remember – People with dementia and their caregivers require appropriate information and guidance on the management of non-cognitive symptoms and behaviours that challenge. Medication Administration Medication administration complexities include an individual’s lack of cognitive capacity to self-administer, swallowing difficulties and caregiver burden associated with ensuring safe administration and noticing and managing side-effects. Supporting people with dementia, families/carers and healthcare staff in navigating the difficulties associated with medication administration has potential to improve the quality of care, lessen caregiver burden and clarify medication administration decision-making processes for healthcare professionals. This factsheet has been developed based on Irish Hospice Foundation Dementia Palliative Care Guidance Document No 7. She takes 12 medications including aspirin 75mg, perindopril 5mg, atorvatstatin 40mg, escitalopram 10mg, memantine 20mg and donepezil 10mg. Defining treatment goals assessment of capacity must be undertaken and assisted Regular review (three monthly) of medication, including a decision-making processes initiated. In this case, Mrs M receives more than five capacity, communication and legal/ethical issues). In wishes and possible medication side effects the number of principle, only medications with symptomatic benefit should be medications could be reduced. Medication review Person–centred approach Several of Mrs Ms’ medications are for secondary prevention You meet with her husband to discuss her management. Recent evidence suggests that people with severe for any life threatening illness. The would not want to extend her life with any invasive or use of these medications in end-of-life care remains uncertain. Her swallow has deteriorated in Many believe that these medications are ineffective and most recent months and her medications are now crushed. The main challenge is determining whether these Assisted decision-making medications are helping. The recommendation in this case would be to consultation the person with dementia. If no explanation is found, medications has severe dementia her capacity to participate in certain associated with gastro-intestinal side effects, particularly medication related decision making processes may be those prescribed for secondary prevention such as statins compromised. Would Check interaction, duplications or non-pharmacological treatments be better? Don’t misinterpret an adverse Open questions reaction as a new medical Allows the person to express views. Suboptimal and inappropriate medication use is repeatedly highlighted as an issue requiring dedicated attention to facilitate the enhancement of a person’s quality of life, particularly in the advanced stages. The challenges of a person-centered palliative approach to medication management decision-making are complex in nature, and are influenced by a number of factors which include, but are not limited to; estimating life expectancy with a view to determining goals of treatment, decision-making with regard to withdrawing / discontinuing medications, administration difficulties and the limited and often contradictory research evidence provided by clinical drugs trials and explicit drug prescribing criteria specifically for people with dementia. The pharmacological management of cognitive and non-cognitive symptoms in dementia, with a particular emphasis on management of behaviours that challenge are predominant themes within the literature and key areas for decision-making in practice. Specific guidelines are available with respect to management of cognitive symptoms and maintenance of function. There is an emerging consensus regarding the management of non-cognitive symptoms and behaviours that challenge. Medication administration, a core element of medication management, can present certain difficulties throughout the disease trajectory, which requires careful deliberation in terms of the most appropriate solutions. The literature suggests that such deliberation or decision-making around medication management is predicated on core principles, including; (1) adopting a person-centered approach; (2) defining treatment goals; (3) assisted decision-making; and (4) regular medication review. The implementation of such principles to actual practice has the potential to promote the quality of life for the person with dementia/carer and provide much needed guidance for healthcare professionals. This document therefore seeks to provide healthcare professionals, with specific guidance and resources for good practice in relation to medication management. Kathleen McLoughlin Principal Investigator for Medication Management Document: Dr. Elaine Lehane, Lecturer in Nursing, Catherine McAuley School of Nursing & Midwifery, University College Cork. Hickey, Clinical Nurse Manager 2, Nurse Prescriber, Assessment & Treatment Centre, St. Draft documents were reviewed by the following international and national subject experts: National Reviewer: Dr Marie O’Connor, Consultant Geriatrician, Connolly Hospital, Dublin. Steering Committee the outputs from the Project Group were overseen by a Steering Committee convenved by the Irish Hospice Foundation comprising of: 1. Geraldine McCarthy, Emeritus Professor, University College Cork and Chair South/South West Hospitals Group. Mary Mannix, Clinical Nurse Specialist Dementia Care, Mercy University Hospital, Cork. Philip Larkin, Director of the Palliative Care Research Programme, School of Nursing and Midwifery, University Collge Dublin. Bernadette Brady, Consultant in Palliative Medicine, Marymount Hospital & Hospice, Cork. Drafts of the guidance document were reviewed by international/national subject experts (See Appendix 1 for details). Parkinson’s and Dementia Records retrieved were divided into three groups “Yes”, “Maybe” and “Reject”. A second and third screening of the “Yes” and “Maybe” folders was conducted to produce a final list for full-text review. Where there was a disagreement regarding inclusion of a record, a third reviewer was consulted. Instruments and procedures to assess manage and review patients with regard to assessment and management of pain in dementia palliative care. Collation of key themes to inform the guidance and principles of medication management and assessment by the Project Team. Medications for Alzheimer’s Disease management of cognitive symptoms and maintenance of function 3. Behavioural and Psychological Symptoms of Dementia – assessment and management of non-cognitive symptoms & behaviours that challenge 4.
It must be installed by a licensed electrician bed sensor lamp is a system where a sensor is placed on the bed and when the person gets up from bed the light automatically turns on gastritis gurgling stomach buy discount allopurinol on-line. This could include sending messages to chronic gastritis reversible purchase allopurinol 300mg online a remote location gastritis diet food recipes safe allopurinol 300mg, perhaps a call centre or family member can gastritis symptoms come go buy allopurinol line, turning lights on when movement is sensed during the night gastritis diet 2013 purchase allopurinol 300mg with amex, or providing lights and blind control for security purposes when the resident is not home gastritis child diet purchase allopurinol 100 mg without prescription. Electrical safety tips: clearly identifable light switches (use contrast or labels) electrical cord clips or tubing to keep them safe, tidy and disguised safety switches/circuit breakers to prevent electrocution replace long electrical cords on appliances with coiled or retractable ones. If the individual is unable to get to the door, entry can be enabled via the push of a button. Temperature install insulation in the ceiling or wall cavities ftting shutters or awnings to windows that are exposed to summer sun fitting heavy curtains to reduce heat lost in winter and heat gained in summer closing off parts of the home that are susceptible to extremes ceiling heater/extractor fans for bathroom split system air conditioning oil flled column heaters. Stairways paint or glue a narrow contrasting strip on the edge of each step paint the wall of the stairwell a contrasting colour from the steps illuminate stairs at all times install handrails secure loose foor coverings, broken steps or loose railings keep stairways free of objects and clutter utilise safety gates where applicable. Storage space bag to store non-seasonal clothing or items in a airtight seal leave all toxic substances in their original container and lock them away to eliminate the possibility of ingestion lockable cabinets/drawers or alarm/bells on cabinets and drawers to alert carer that they are being opened utilise clear labels/signs medication systems (see section on medication management) safe storage of documents/lock up safe use Mag locks (discreet magnetic locks) on cupboards or drawers. Kitchen and Dining Area modify doorways for increased accessibility install or change lock on kitchen door install locks on kitchen cupboards. Having a half door enables the person to still look into the kitchen but acts as a barrier to wandering into kitchen signs on cupboards remove cupboard doors or replace with transparent doors to allow ease of viewing contents shallow depth fridges can assist with easily viewing and reaching contents which may lead to reduced incidence of food being hidden and spoiling. Some of the effects caused by being admitted to hospital are: changes to routines unfamiliar people and surroundings lack of signs or cues which may result in disorientation over stimulation: changes in levels of noise, lighting and smell or presence of pain or discomfort under stimulation: being left alone or without companionship, lack of activity change in level of independence secondary to unfamiliar environment or staff ‘taking over’ tasks that the person had previously completed. The hospital environment should (where possible and practicable) provide the following for people with dementia: safety: controlled exit, hot water controls, safety switches, minimise clutter quality care in small groups have good visual access minimise unnecessary stimulation highlight helpful stimuli. Independence in task completion impacts positively on a person’s sense of self worth, self esteem and self reliance. When considering assistive technology interventions a simple approach should be utilised and only changing what needs to be changed. Caution should be utilised as every person’s reaction to technology will be individual and in some cases it may have a negative impact. Involving the person with dementia in the decision making process and trialling of items will lead to greater acceptance and use of the technology solutions. Areas where technology can be benefcial for people with dementia and their carer’s are: sleep disturbances safe use of home appliances locating misplaced items medication management orientation safe walking/wandering, way fnding summoning assistance in an emergency. According to Hernandez, Coelho, Gobbi and Stella (2009) people with cognitive decline are three times more likely to fall, than elderly people without cognitive issues. Benefts of maintaining mobility: maintain strength and endurance improved balance maintain joint mobility cardiovascular health facilitation of continence maintain independence sense of self and control. Possible warning signs that a person is falling or having near misses: bruises or abrasions furniture walks i. Possible problems or concerns that may affect mobility: any condition associated with ageing such as pain from arthritis, osteoporosis, shortness of breath or lack of energy resulting from heart and lung conditions, pain and discomfort from circulatory diseases and problems associated with deteriorating eyesight different types of dementia are more prone to falls. The person may not remember to use the aid or how to position it correctly so they will require supervision with mobility. In some cases the person with dementia has reached a stage where they need standby assistance or a wheelchair to be safe. Ensure there is a safe place to sit or stand while their eyes adjust cordon off wet areas as signs stating ‘wet foor’ are ineffective for people with dementia secure handrails, broken steps and loose carpeting in key rooms, access ways and stairwells seal carpet edges furniture guards (to cap sharp edges) consider installing safety flm on glass areas up to one metre to prevent lacerations, including shower screens that are not safety glass. Make one request at a time utilise one word commands when directing transfers or ambulation. Manual handling training may be required to teach safe transfer and handling techniques. These can work as a standalone or be linked to a call centre hip protectors these may reduce the rate of hip fractures for people in residential care. As dementia progresses the person may require physical assistance with the tasks resulting in a lack of privacy and autonomy. By focusing on the person rather than the task the person with dementia may be more willing to accept assistance. Identifying potential triggers and interpreting what the person is trying to communicate can assist in making personal care activities positive experiences. Being prepared and familiar with the person’s usual routine and normal level of involvement will also assist in positive hygiene experiences. Possible problems or concerns: diffculty with manipulating taps forget to turn off taps change in sense of perception of hot and cold unable to regulate water temperature risk of scolds fear of water fear of drowning particularly if water is being poured over their head fear of falls discomfort due to temperature of bathroom usually too cold or feeling of claustrophobia access to potentially dangerous items. If the unit detects water overfow it activates an alarm within the house and contacts a call centre thermostatic mixing or shut off valves: these devices need to be installed by a licensed plumber separate hair washing from bathing visit a hairdresser or arrange for a hairdresser to visit at home put a few drops of blue food colouring in the water to strengthen its visual impact utilise rinse or water free personal hygiene products foor tiles which contrast with wall tiles hob less shower, with grab rails, a shower chair or similar and hand held shower hose use heat lamps and warm the room prior to bathing towel warmers level foor surfaces non-slip foor tiles or treatments grab rails, powder coated provides more grip (Calkins, M 2001) keep access ways free from clutter wide entry doorway with outward swinging or sliding door or hinges to allow removal of door/easy emergency access to bathroom removal of shower screens and replace with shower curtains if appropriate 64 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice power point safety plugs may reduce electrical hazards mag locks are a magnetic lock system which can be used on drawers and cupboards. The locking mechanism is hidden and therefore doesn’t draw attention to the drawer or cupboard being locked duress alarm for emergency contact with a call centre or a nominated person; this is a standalone product that can be installed in the home without any hard wiring, making it perfect for areas such as bathrooms and toilets safe storage of medications, chemicals, hairdryers, electric razors ceiling heater/exhaust fan. All heating elements should be wall or ceiling mounted to avoid the possibility of coming in to contact with water use laminate signs or posters of bathing/grooming steps and hang them where the person can see them during the different stages of each task. Consider the type of bathing the person is used to such as shower, bath, sponge bath consider alternative bathing schedules such as daily sponge bath or semi-weekly tub bath break down the task to manageable simple steps. Gently explain each step encourage the person to complete as many steps as possible independently offer limited choices 65 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice lay out items that are required for task for example soap, washcloth, towel in the order they will be required hand items one at a time to care recipient and name the object use simple clear one step directions. Scheduling tasks for periods of the day when other family members don’t need the bathroom will allow the person to take the necessary amount of time to complete the task personalise the experience maintain dignity distraction from the task may be achieved by putting laminated pictures in the shower area demonstrate for the care recipient what you want them to do or use hand over hand techniques don’t ask if the person wants to ‘brush their hair now? The label could be a picture of the person performing the task, a drawing or picture of another person performing the task, a drawing of the objects or a label specifying the task or objects remove items belonging to other people or any items the person does not use daily put grooming items out in the sequence they will be used try to use only products and product packaging that is familiar to the person purchase several identical personal care items so that familiar replacements are available supervision or assistance maybe required when using a traditional razor, people who are used to using electric razors will shave independently for longer 66 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice if possible utilise another room when using electrical appliances. Removal of electrical appliances from the bathroom maybe necessary to avoid electrocution discuss with a doctor possible treatments for ear wax schedule regular dental visits, remind people to brush their teeth or assist them with the task visit a podiatrist, consider if the person enjoys having their nails painted or manicured use positive reinforcement and provide compliments regards their level of cleanliness and amount of effort they demonstrated if the person performs the tasks in an unorthodox but effective way do not correct them if family unable to cope with demands of bathing refer to social work for linkage to services utilise a schedule/care plan of what tasks each carer (voluntary or paid) will assist with or complete during their visit. Useful resources: the National Dementia Behaviour advisory Service 24 hours 7 days a week service 1300 366 448 Commonwealth Carer Respite Centre 1800 059 059 Commonwealth Carer Resource Centre 1800 242 636 Assisting someone to dress can be very time consuming and emotionally challenging if the person is not cooperating. Possible problems or concerns: forgetting how to dress forgetting to change clothes dressing in the incorrect order. Post steps for dressing on a large poster in the place where the person usually dresses. If reading is diffcult use pictures or drawings encourage independence with dressing. If person isn’t able to complete the whole task allow them to complete whatever steps they can be patient and allow as much time as is necessary for the person to complete steps encourage the person to change regularly. Tactfully remove soiled clothes at the end of each day and substitute with clean ones set out clothes in the sequence they are to be put on or pre-package a complete outft so that the person does not have to search for items of clothing 68 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice if physical assistance is being provided hand items one at a time to the person use simple one step instructions. Caution should be taken not to impose current values into people’s daily care install a curtain or screen to hide distracting items evaluate why the person maybe undressing frequently, do they need to use the toilet? Useful resources: the National Dementia Behaviour advisory Service 24 hours 7 days a week service 1300 366 448 Independent Living Centre Possible solutions: diffculty urinating /retention – refer to incontinence nurse (for bladder scan) simplify clothing. Try hook and loop fasteners or elastic waistbands for trousers and wrap around skirts. Select clothing that is easily washable and does not require ironing remove any confusing objects from around or on the toilet or commode such as washcloths, reading material or objects that may be mistaken for the toilet as these objects may create confusion regards the purpose of the room 71 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice use visual cues to assist with locating the toilet. Place a sign or label on the toilet door such as a picture or a photograph of the toilet in a prominent position. Leave the toilet door open and close all other doors leading to the toilet to discourage urinating in other rooms. Using large arrows to direct to the toilet from the living room or bedroom utilising sensor lights or night lights to avoid having to enter a dark room to fnd the light switch. Glow in dark strips placed around light switches or in hallway to assist in fnding the light switch or direct the person to the bathroom eliminate as many extraneous objects as possible and remove clutter from passageways or stairways place objects within triangle of effciency (nose, right elbow, left elbow) to accommodate reach limitations associated with ageing use contrasting door knobs colour contrast toilet seat with bowls and foor. An altered seat can be utilised that cleans and dries sensitive body areas or has a heated seat correct toilet height ensure toilet seat is securely fastened remove mats install grab rails or equipment to assist with transfers a commode may helpful in bedroom use a contrasting colour for the toilet paper and the wall try not to let the person become accustomed to wet clothing give a drink of water or run a tap if the person is restless and will not sit on the toilet allow them to get up and down a few times. Try distraction techniques on the toilet or calming music monitor persons fuid and food intake 72 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice safety gates can be installed at stairways remove lock from bathroom install bells or alarms on doors, cabinets or drawers to alert the caregiver when a person is opening them consider keeping a voiding diary (frequency and amount) which can than assist with establishing a voiding routine. Once a routine is established try to avoid unnecessary changes use simple one step instructions using statement form rather than questions. Only give the next instruction once the frst instruction has been completed use positive reinforcement to promote independence if family are not coping with the toileting demands refer to Continence Clinic / Continence Nurse, social work for linkage to services, respite and day centres. Utilise a schedule/care plan of what tasks each carer (voluntary or paid) will assist with or complete during their visit referral to a physiotherapist may be indicated if the person with dementia is experiencing difficulty with mobility and transfers, is unsteady, demonstrates poor balance or low endurance or if the care giver is experiencing physical strain from helping the person mobilise and transfer. Incontinence Incontinence is the loss of control of the bladder or bowel function. Being in control of these functions depends on having an awareness of bodily sensations and the memory of how, when and where to respond. The cause of the incontinence should always be investigated as it may be due to numerous medical reasons such as infection, constipation, hormonal changes and prostate enlargement. According to Dee Sutcliffe (2009) incontinence is one of the top three reasons that result in people being admitted to residential care. Alzheimer’s Australia proposes the following suggestions for managing incontinence: be sure the person is drinking adequate fuids, preferably water, 5-8 glasses. Try to establish a regular routine for drinking fuids reduce the person’s caffeine intake by using decaffeinated beverages observe the person’s toileting pattern and suggest they use the toilet at regular times that follow their established pattern utilise protective garments or disposable pads utilise suitable aids or appliances. Alzheimer’s Australia proposes the following suggestions for managing constipation: try a high fbre diet (dietician referral maybe required) and ensure the person is having adequate fuids (see above) regular exercise try to establish a routine. Useful resources: Commonwealth Carer Respite Centre 1800 059 059 Commonwealth Carer Resource Centre 1800 242 636 Referral to Continence Clinic or continence nurse Referral to social work Continence Advisory Service contact 9386 9777 country callers 1800 814 925 A doctor should be consulted if the person has had a signifcant weight loss (such as 2. Possible problems or concerns: loss of appetite dehydration or inadequate nutrition develop an insatiable appetite or craving for sweets forget to eat or drink (amnesia) or when next meal is due diffculty expressing food preferences decreasing variety of foods that are eaten could potentially lead to a vitamin defciency that could affect cognition eating again as they can’t remember previously eating consuming too much caffeine or alcohol as they forget they have already had a drink diffculty understanding mealtime instructions forget how to swallow or chew experience a dry mouth or mouth discomfort. If there is no aroma from the food use a cinnamon or orange potpourri eliminate noxious odours try a glass of juice, wine or sherry, if medications permit, before a meal to stimulate the appetite check medications for side effects, some antidepressants cause a sweet craving. Try 5-6 small meals a day have low calorie snacks available provide snacks that are easy to eat and don’t need to be refrigerated so they can be left in place that is easily seen bright coloured plates and cups can increase food and liquid intake add colour contrasting to edge of table to increase visibility use placemats that colour contrast with the table top, plates, utensils arrange utensils and crockery in a consistent manner and keep setting as simple as possible. Placemats are available with place setting outlined on them select plates and cups that have colour contrasting edges or rims to improve visibility white plates eliminates distraction from patterns colourful food on white plates to make food easier to see encourage regular and independent eating and drinking non slip mats (rubber or dyacem) 77 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice if spillage of liquids is problematic utilise a travel mug with lid straws with one way valves avoid bibs. Present fnger foods on a fat plate at a comfortable reaching distance reduce clutter: avoid lots of cutlery, crockery etc. Nutritional supplement drinks may be prescribed 78 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice for chewing problems try light pressure on the lips or under the chin, tell the person when to chew, demonstrate chewing, offer small bites for swallowing problems remind the person to swallow, stroke throat gently, check mouth to see food has been swallowed, avoid foods that are hard to swallow, moisten foods cut food into small pieces if over stuffng is an issue monitor food temperatures maximise food intake when cognition is at its best if family are not coping with the eating and feeding demands refer to social work for linkage to services, respite and day centres. Useful resources: the National Dementia Behaviour Advisory Service 24 hours 7 days a week service 1300 366 448 Independent Living Centre People living with dementia may experience frequent sleep disturbances, which can occur for numerous reasons. Discuss any potential interaction between alcohol and medication with a doctor try to incorporate exercise into their daily routine listening to relaxing music, radio or television themes associated with preparing for bed ftting sheer net curtains to reduce glare/refections or heavy window treatments to block external light sources oil flled column heaters with safety cut-off switch or air conditioning to heat/cool room prior to retiring choosing appropriate nightwear. Asking people to wear pyjamas when they are not used to wearing pyjamas/nightwear can cause confusion and distress choosing a bed that provides good support and is at a correct height will assist with independent transfers and better sleep offer alternatives to sleeping in bed such as on the couch if the person wanders at night, ensure the environment is safe to do so sensor mat detects absences from bed or chair sound and movement unit (baby monitor). The ethical and dignifed use of a monitor can support independence for the person with dementia and peace of mind for their carer voice alert door entry can be utilised indoors or outdoors. This system allows up to six pre recorded messages that are activated when a person walks through a beam infrared door beams are small units that are placed near doorways or exits. A buzzer is activated when someone passes through the beam remove electric blankets continence support. Useful resources: Commonwealth Carer Respite Centre 1800 059 059 Commonwealth Carer Resource Centre 1800 242 636 the National Dementia Behaviour advisory Service 24 hours 7 days a week service 1300 366 448 Independent Living Centre Before considering any of the possible solutions listed below, medication needs should be discussed with a doctor as some medications are not able to be stored in dispensing packs. Possible problems or concerns: forgetting to take medication taking medication but forgetting and then taking it again incorrect use of medication incorrect storage of medication using out of date medication or taking medication that is no longer required diffculty cutting or crushing medication diffculty opening bottles or containers. Possible solutions: medical/nurse review re – need for medication, dose and frequency leave medications in a visible location (if safe) store medications in a lockable cabinet that can be mounted on a wall or in a cupboard mag locks: discreet magnetic locking system can be installed on drawers or cupboards link medication times to routine activities. These are available in four different languages and with larger writing for people with visual impairment some community services will assist with medication management. It is also a convenient way of communicating about medications to various health workers. Possible problems or concerns: the person may no longer respond to the dangers associated with smoking at risk of burning self igniting furniture, clothing, or fooring leading to a house fre. Possible solutions: minimise clutter and remove potentially fammable materials from in and around the home develop a routine. Some department stores may stock fame resistant clothing purchase fame retardant furniture and fxtures Utilise a smoker’s apron. Possible problems or concerns: stove accidents: leaving hot plates or oven on, burning food or saucepans dry, burns from touching hot plates, putting inappropriate things in a hot stove. All resulting in the potential to start a fre stove skills: forgetting how to use hot plates or oven, problems with setting temperature of hotplates or oven, problems reading/using dials or leaving gas on not turning off the kettle/electric jug or toaster eating or drinking harmful substances or out of date food stuffs. New appliances may have this technology incorporated stove-top monitors electric or gas auto cut off safety device for oven or stove plug in gas alarms. These plug into a power point and detect escaping gas or unignited gas vigil electric or gas isolation system is a stove isolation system that automatically switches off after 20 minutes. These should be installed by a licensed ftter induction cook-tops use a magnetic feld to heat saucepans and their contents and the cook-top stays quite cool oven guard to prevent contact burns have circuit breakers/isolation switches installed keep emergency phone numbers, frst aid and poisons information by the phone or in the kitchen. Include the persons address and a description of where they live ensure smoke detectors/fre extinguishers are in good working order. Batteries should be changed every six months on smoke detectors and they should be vacuumed monthly to clear from dust build-up ensure safe storage of chemicals and other hazardous products reduce clutter on bench tops and cupboards store frequently used items in a prominent location that is easily accessible use labels or signs with words or pictures on cupboards and drawers open shelving or remove cupboard doors to assist with locating contents use clearly labeled or transparent containers if it is no longer safe for the person to participate in kitchen tasks, consider providing a chair so that the person can observe the carer complete the tasks 87 Dementia: Osborne Park Hospital Guide for Occupational Therapists in Clinical Practice when it becomes too hazardous for the person to be in the kitchen area consider using a lock on the door or blocking entry with furniture, a safety gate or barn door use D shaped handles on drawers easy cookbooks and shopping list food prevention and detection. These can be purchased from hardware stores or stores that sell children’s safety products delivered meals such as Meals on Wheels and Home Chef home support to assist with meal preparation, serving and prompting to eat pre-prepared meals from the supermarket family and friends helping to prepare meals or delivering food preparing large quantities of food and freezing meal size portions home delivery from restaurants eating out: you should check that the person with dementia is comfortable with the venue etc. Possible solutions: family/friends assist with cleaning or provide supervision referral to social work for linkage to community services simplifying the task simplifying equipment encourage the person to complete the parts of the tasks that they are able to do safely safe storage of hazardous products. Possible solutions: securely store cleaning products, bleaches, poisons and detergents lockable cabinets or Mag locks on cupboards and drawers food prevention and detection: devices such as food detector, pressure sensitive sink pug (magi plug)/water overfow prevention device for the sink fre prevention/lint flters thermostatic mixing valves or hot water cut off device to prevent scalds appliances: labels and signs or appliance locks, isolation switches, gas detectors, auto-cut off devices combined washer/dryer iron with automatic cut off switch if left unattended or face down iron safe: a small storage unit that the iron can be placed in as it takes approximately 30 minutes for the iron to cool down after use. Using the iron safe will prevent burns ironing cabinets to store ironing board out of view or to remove trip hazard tap cap: a cover that is designed to ft over round tap handles and prevent the tap from being used pressure sensitive sink plugs or magi plugs to prevent overfow appliance locks combined washer/dryer may assist a person to remain independent with completing laundry food detectors.
International Headache Society 2018 180 Cephalalgia 38(1) Therefore erythematous gastritis diet allopurinol 300 mg on line, symptoms may also involve the trunk and neurological symptoms gastritis diet purchase allopurinol 300 mg. Magnetic resonance imaging contribution for diagnosing symptomatic neurovascular contact in classical tri Bibliography geminal neuralgia: a blinded case?control study and meta-analysis gastritis or ulcer best allopurinol 300mg. Self-reports of pain neuralgia: a quantitative sensory perception thresh related awakenings in persistent orofacial pain old study in patients who had not undergone pre patients gastritis diet ulcer buy discount allopurinol on-line. Trigeminal neuralgia of neurovascular contact in classical trigeminal mistaken as temporomandibular disorder gastritis definicion purchase allopurinol 100mg with mastercard. Acta current mechanism explains trigeminal neuralgia in Neurochir (Wien) 1991; 108: 53?63 gastritis in english language best 300 mg allopurinol. Clinical features and long associated symptoms, objective psychiatric and term surgical outcomes in 39 patients with tumor related trigeminal neuralgia compared with 360! Br J in the diagnosis of trigeminal neuropathy and neu Neurosurg 2017; 31: 101?106. Prevalence of malformation: a rare cause of trigeminal neuralgia persistent pain after endodontic treatment and identi? J ing with posttraumatic neuropathy of the trigeminal Neurosurg 2014; 120: 1048?1054. Natural his Topical review?connective tissue diseases: orofacial tory, risk factors, clinical presentation, and morbid manifestations including pain. J Clin Pathophysiology of pain in postherpetic neuralgia: Neurosci 2004; 11: 758?760. Microvascular decompression in the management of glossopharyn geal neuralgia: analysis of 217 cases. Peripheral painful men schwannoma presenting with glossopharyngeal traumatic trigeminal neuropathy: clinical features in neuralgia syncope syndrome. International Headache Society 2018 182 Cephalalgia 38(1) visualization of the glossopharyngeal nerve. An anatomical basis for the neck-tongue neuropathic pain secondary to endoscopic proce syndrome. J Neurol Neurosurg Psychiatry 1981; 44: dures: report of two cases and review of the litera 202?208. Oral Surg Oral Med Oral Pathol Oral Radiol Elisevich K, Stratford J, Bray G, et al. Geniculate neuralgia: long-term results of sur tongue syndrome: a systematic review. Surgical treatment of patients with facial neu syndrome: occurrence with cervical arthritis as well romas. Neuroimaging diagnosis of Tolosa-Hunt syndrome: Eliav E, Kamran B, Schaham R, et al. J Am Dent Assoc 2007; radiological studies in painful ophthalmoplegia: 138: 628?633. Central post without multiple sclerosis treated by partial sensory stroke pain: clinical characteristics, pathophysiol rhizotomy for medically refractory trigeminal neur ogy, and management. Acta spontaneous pain and dynamic mechanical allody Neurol Scand 1982; 65: 182?189. Other headache disorders Comment: Several new headache entities have been described in the time between the? Headache is or has been present the existing chapters because they are being described B. Comment: It is also apparent that a diagnosis must be made in a large number of patients where very little 14. Diagnostic criteria: this code, however, must never be used as an excuse for not gathering detailed information about a headache A. Headache with characteristic features suggesting when such information is available. It should be used that it is a unique diagnostic entity only in situations where information cannot be B. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure A12. This is again because clinical experi the primary purpose of the Appendix is to present ence and a certain amount of published evidence sug research criteria for a number of novel entities that gest that the alternative criteria may be preferable, but have not been su? Many women over-report an association between Diagnostic criteria: attacks and menstruation; for research purposes, diary-documented, prospectively recorded evidence 1 A. For example, the endogenous menstrual Notes: cycle results from complex hormonal changes in the hypothalamic-pituitary-ovarian axis resulting in ovula 1. Therefore, research should separate these from the normal menstrual cycle or from the with distinct subpopulations even though the diagnostic cri drawal of exogenous progestogens, as in the use of teria do not. For research purposes a prospective diary is recom changes at this time of the cycle may also be relevant. For example, the endogenous menstrual cycle 3 cycles, and additionally at other times of the cycle. Headache (migraine-like or tension-type-like) on ceding day is day A1; there is no day 0. For research purposes a prospective diary is recom teria B and C mended, but this is not mandatory for clinical diagno B. International Headache Society 2018 192 Cephalalgia 38(1) without aura and/or criteria B and C for 1. Additional visual symptoms of at least two of the Migraine with aura following four types: 2 C. The dots are usually black or migraine and criterion B below grey on a white background and grey or white on B. Interrupted by pain-free periods of >3 hours on a black background, but also reported are transpar-! Visual after-images are dif ferent from retinal after-images, which occur only A1. These phenomena, arising from the structure of the visual system itself, include excessive? Further Comment: Other neurological disorders including rever research is needed into whether these disorders share sible cerebral vasoconstriction syndrome, posterior pathophysiological mechanisms causing visual symp reversible encephalopathy syndrome and arterial dissec toms but, meanwhile, it is hypothesized that cortical tion should be excluded by appropriate investigation. Dynamic, continuous, tiny dots across the entire photopsia, photophobia, nyctalopia and tinnitus than 1 visual? At least one other paroxysmal phenomenon asso dition, and aids physicians in recognizing it. Patients ciated with the bouts of hemiplegia or occurring complaining of visual snow as a symptom often have independently (a history of) 1. Second, in a similar argument applied to research, future studies on persistent visual symptoms need homogeneous study groups; inclusion Note: of criteria for A1. Such as tonic spells, dystonic posturing, choreoathe toid movements, nystagmus or other ocular motor A1. The possibility that it is an unusual Description: Excessive, frequent crying in a baby who form of epilepsy cannot be ruled out. At least half of episodes are associated with at Infants with colic have a higher likelihood of develop least one of the following three migrainous 5 ing 1. Migraine, the like a) unilateral location lihood of an infant with colic increases twofold. International Headache Society 2018 194 Cephalalgia 38(1) Disorders and qualifying for a diagnosis of A1. Vestibular migraine, include: However, since they also occur with various other ves a) spontaneous vertigo: tibular disorders, they are not included as diagnostic i. Vestibular symptoms are rated moderate when they addition to visual, sensory or dysphasic aura symptoms interfere with but do not prevent daily activities and for this diagnosis. Associated symptoms may occur before, Benign paroxysmal vertigo is regarded as one of the during or after the vestibular symptoms. History and physical examinations do not suggest migraine headaches are not required for diagnosis. Migraine is more common in patients with Meniere?s` disease than in healthy controls. In among migraine patients in Chinese neurological fact, migraine and Meniere?s` disease can be inherited departments. Fluctuating hearing loss, tinnitus Other symptoms and aural pressure may occur in A1. The may include a vestibular migraine/Meniere?s` disease interrelations of migraine, vertigo, and migrainous overlap syndrome. J Vestib Res 2009; Vestibular migraine validity of clinical diagnostic 19: 1?13. Migraine tion between migraine, typical migraine aura and related vestibulopathy. Menstrual appendix criteria in the third beta edition of the versus non-menstrual attacks of migraine without International Classi? During part, but less than half, of the active time characteristics: course of A3. Severe unilateral orbital, supraorbital and/or tem alternative criteria for tension-type headache pro poral pain lasting 2?30 minutes posed in the third beta edition of the international C. Severe or very severe unilateral orbital, supraorbi indomethacin tal and/or temporal pain lasting 15?180 minutes F. During part, but less than half, of the active time Alternative diagnostic criteria: course of A3. Present for >3 months, with exacerbations of ally in a dose of at least 150 mg daily and increased moderate or greater intensity if necessary up to 225 mg daily. Experts in the working group believe it d) forehead and facial sweating improves sensitivity without signi? Responds absolutely to therapeutic doses of ache attacks (alternative criteria) 1 indomethacin Alternative diagnostic criteria E. Moderate or severe unilateral head pain, with orbital, supraorbital, temporal and/or other tri Note: geminal distribution, lasting for 1?600 seconds and occurring as single stabs, series of stabs or 1. In an adult, oral indomethacin should be used initi in a saw-tooth pattern ally in a dose of at least 150 mg daily and increased C. The dose by injec symptoms or signs, ipsilateral to the pain: tion is 100?200 mg. During part, but less than half, of the active time characteristics of the disorder not fully developed. International Headache Society 2018 198 Cephalalgia 38(1) without the expected responses to indomethacin, Although attacks are mostly spontaneous, they may oxygen or triptans. Recurrent stabbing head pain attacks lasting 1?10 characteristics of nine new cases. Epicrania fugax across the surface of one hemicranium, commen with backward radiation. A structural lesion must be excluded by history, injury to the head and/or neck physical examination and, when appropriate, investigation. Some data suggest that headache may begin topography is a distinctive attribute that di? The onset and termination points head injury and headache onset is set at three months, remain constant in each patient, with pain usually but it is presumed that headaches that begin in closer moving forward from a posterior hemicranial area temporal proximity to the injury are more likely to be towards the ipsilateral eye or nose, but backward radia accurately attributed to the injury. Future studies tion is also possible from a frontal or periorbital area should continue to investigate the utility of these and towards the occipital region. Headache is reported to have developed between injury (when applicable) seven days and three months after all of the 3. Comment: the current stipulation that headache must begin (or be reported to have begun) within seven days A5. In the following suggested diag Diagnostic criteria: nostic criteria, the maximal time interval between the A. Traumatic injury to the head has occurred, asso b) loss of memory for events immediately ciated with at least one of the following: before or after the injury 1. Headache persists for >3 months after its onset seven days and three months after all of the E. In haemorrhage and/or brain contusion cases where a previous history of headache was not 2. Carefully controlled pro before or after the injury spective studies are necessary to determine whether c) two or more other symptoms suggestive A5. Headache is reported to have developed between seven days and three months after all of the A. Post-traumatic both of the following: headaches in civilians and military personnel: a 1. In a single Headache treatment after electroconvulsive treat blind comparator trial of eletriptan and paracetamol, ment: a single-blinded trial comparator between ele 20 of 72 patients (28%) complained of headaches, but triptan and paracetamol. Diagnostic criteria: Localized pain associated with seizures originating in the parietal lobe. Use of or exposure to the substance has ceased attributed to idiopathic intracranial hypertension and C. Migralepsy, hemicrania epileptica, post-ictal headache and ?ictal epileptic headache?: a proposal A9. Evidence of causation demonstrated by at least headache are toxoplasmosis and cryptococcal meningi two of the following: tis. In sened in temporal relation to worsening of these cases, the headache should be coded as 8.
Accessed January 11 granulomatous gastritis symptoms purchase 300mg allopurinol fast delivery, 2018 exposed to gastritis symptoms deutsch buy allopurinol 100mg with amex cold air; however gastritis diet drinks purchase allopurinol cheap, upper respiratory infections 7 gastritis diet order allopurinol. The six levels of health concern and what Appendix S: Physical Activity: How Much Is Needed? Increasing Access to gastritis diet generic allopurinol 100 mg with amex Drinking however gastritis diet journals buy cheap allopurinol 100mg line, for some pollutants there may be a moderate Water and Other Healthier Beverages in Early Care and Education Settings. Ambient air pollution, lung function, and airway responsiveness in asthmatic children. Wear clothing and footwear that permits easy and Appendix S: Physical Activity: How Much Is Needed? Physical activity practices, policies and environments in Washington state child care learn about age-appropriate gross motor activities and settings: results of a statewide survey. Child care center characteristics associated with preschoolers physical activity. Caregivers/teachers should communicate with parents/guards about their use of screen time/digital media in the home. Additional educational materials can (not overheated or sweaty), and that bibs, necklaces, and be found at. In situations where there are bag chair, bouncy seat, infant seat, swing, jumping chair, existing facilities with separate sleeping rooms, facilities play pen or play yard, highchair, chair, futon, sofa/ have a plan to modify room assignments and/or practices to couch, or any other type of furniture/equipment that is eliminate placing infants to sleep in separate rooms. Pacifer use outside of a crib in rooms and place them in the supine position in a safe sleep and programs where there are mobile infants or toddlers is environment. Although some state regulations require positioning, especially when the infant is unaccustomed to that caregivers/teachers ?check on sleeping infants every being placed in that position (2). Recent research and demonstration projects When infants are being dropped of, staf may be busy. Most research reviewed to guide the development of practices, beliefs, or attitudes; and these recommendations was not conducted in child care c. When hospital staf or parents/guardians of infants who Facilities do not have or use written ?safe sleep policies may attend child care place the infant in a position other or guidelines; than supine for sleep, the infant becomes accustomed to 3. State child care regulations do not mandate the use of this and can have a more difcult time adjusting to child supine (wholly on their back) sleep position for infants in care, especially when they are placed for sleep in a new child care and/or training for infant caregivers/teachers; unfamiliar position. Other caregivers/teachers or parents/guardians have Parents/guardians and caregivers/teachers want infants to objections to use of safe sleep practices, either because of transition to child care facilities in a comfortable and easy their concern for choking or aspiration, and/or their manner. It can be challenging for infants to fall asleep in a concern that some infants do not sleep well in the new environment because there are diferent people, equip supine position; and ment, lighting, noises, etc. However, this may or may transitioning to supine positioning at home and later not be true. Ofer infants opportunities to be held upright and par need for a diferent position. This can infant will be unaccustomed to sleeping supine if his or easily be accomplished by alternating the placement of her parents/guardians object to the supine position (and the infant in the crib place the infant to sleep with are therefore placing the infant prone to sleep at home). Infants typically turn their head to one side ant parents, facilities will help raise awareness of these toward the room or door, so if they are placed with their issues, promote infant safety, and increase support for head toward one side of the bed for one sleep time and proper implementation of safe sleep policies and then placed with their head toward the other side of the practices in the future. The California Childcare Health Program has available a Safe Sleep Policy for Infants in Child Care Programs. For breastfed infants, delay pacifer introduction until ffeen days of age to ensure that breastfeeding is 4. Although parents/guard Illegal Drugs, and Toxic Substances ians may choose to continue this practice at home, swad dling infants when they are being placed to sleep or are sleeping in a child care facility is not necessary or recom mended. American Academy of Pediatrics Task Force on Sudden Infant Death increased sleep periods, and improved temperature control. Swaddling and the risk of Center, Large Family Child Care Home sudden infant death syndrome: A Metaanalysis. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: 3. Staf should clean each pacifer with soap and water dling because infants legs can be forcibly extended. If an infant refuses the pacifer, s/he should not be Even with newborns, research does not provide conclusive forced to take it; 106 Caring for Our Children: National Health and Safety Performance Standards h. Pacifers and sudden infant death syndrome: What there are mobile infants or toddlers is not recommended. American Academy of Pediatrics, Back to Sleep, Healthy Child Care Mobile infants or toddlers may try to remove a pacifer America, First Candle. Cleaning a pacifer The facility should provide an opportunity for, but should before each use allows the caregiver/teacher to worry less not require, sleep and rest. The facility should make avail about whether the pacifer was cleaned by another adult able a regular rest period for all children and age appro who may have cared for the infant before they did. Later emotional and behavioral problems associated with sleep National Sleep Foundation issued recommended sleep problems in toddlers: a longitudinal study. Kelly, Y; Kelly, J; Sacker, A; (2013) Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based which include both daytime and nighttime sleep (2,3). Sleep-disordered breathing in a meta-analyses, short sleep duration before 5 years of age is population-based cohort: behavioral outcomes at 4 and 7 years. Tese rest or nap areas should be set 80% increased risk of emotional and behavioral problems up to reduce distraction or disturbance from other activities. In the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Accessed November 14, 2017 108 Caring for Our Children: National Health and Safety Performance Standards References toothpaste at least once a day reduces build-up of decay 1. The ability to do a good job brushing the teeth is a learned skill, improved by practice and age. All children with teeth should brush or and snacks during a full day in child care. Children under three years of age should have rice) of fuoride toothpaste spread across the width of the only a small smear (grain of rice) of fuoride toothpaste on toothbrush for children under three years of age and a the brush when brushing. The care if children swallow more than recommended amounts of giver/teacher should teach the child the correct method of fuoride toothpaste on a consistent basis, they are at risk for tooth brushing. Young children want to brush their own fuorosis, a cosmetic condition (discoloration of the teeth) teeth, but they need help until about age 7 or 8. Rinsing with water helps to remove food particles dental caries may be exempt since additional brushing from teeth and may help prevent tooth decay. Local dental health professionals Caregivers/teachers should encourage replacement of can facilitate compliance with these activities by ofering toothbrushes when the bristles become worn or frayed or education and training for the child care staf and provid approximately every three to four months (7,8). The dental home is the ongoing relationship aged to reinforce oral health habits and prevent gingivitis between the dentist and the patient, inclusive of all aspects and tooth decay. Care Program and Parent/Guardian Or if toothpaste from a single tube is shared among the chil 9. When children require assistance with brushing, caregivers/ Pediatric Dentistry 30:112-18. The preventive use of fuoride; Toothpaste is not necessary if removal of food and plaque b. Mouth guards for protection when playing sports; anti-caries beneft is achieved from brushing without d. Part whenever there is a question of an oral health problem; 4: Toothbrushing: What advice should be given to patients? The process of dental decay; Safety in Child Care and Early Education at nrckids. Factors described), they have not been evaluated for their ability to in Development: Bacteria. Moreover, it has not been demon dental caries in children aged 2-5 years in the United States. American Academy of Pediatrics, Committee on Practice and Ambulatory Procedures that reduce fecal contamination help control Medicine. Frequency and severity of diaper dermatitis are lower diaper and waterproof later should be changed at the same 112 Caring for Our Children: National Health and Safety Performance Standards when diapers are changed more ofen, regardless of the diaper Tere is no reason to use the toilet for stool if disposable used (1). Commercial diaper laundries use a has been associated with less frequent and less severe diaper procedure that separates solid components from the diapers dermatitis in some children than with the use of cloth diapers and does not require prior dumping of feces into the toilet. The action of fecal digestive enzymes on urinary urea diapers-clothing/Pages/Diaper-Rash. Nonetheless, since these methods If cloth diapers are used, soiled cloth diapers and/or soiled of checking may be inaccurate, the diaper should be opened training pants should never be rinsed or carried through the and checked visually at least every two hours. Reusable modern disposable diapers can continue to absorb moisture diapers should be laundered by a commercial diaper service. This prevents rubbing of wet surfaces diaper service, or in a sealed plastic bag for removal from the against the skin, a major cause of diaper dermatitis. Put the soiled teachers who speak multiple languages are involved in wipes or paper towels into the soiled diaper or directly diapering. Fold the soiled surface of the diaper inward; used for sanitizing or disinfecting, they should also be b. If reusable cloth diapers are All cleaning and disinfecting solutions should be stored to used, put the soiled cloth diaper and its contents (without be accessible to the caregiver/teacher but out of reach of any emptying or rinsing) in a plastic bag or into a plastic child. Please refer to Appendix J: Selecting an Appropriate lined, hands-free covered can to give to parents/guard Sanitizer or Disinfectant and Appendix K: Routine ians or laundry service; Schedule for Cleaning, Sanitizing, and Disinfecting. Disposable gloves, if you plan to use them (put gloves on plastic-lined, hands-free covered can. Slide a fresh diaper under the child; ointment), when appropriate, removed from the con b. Use a facial or toilet tissue or wear clean disposable glove tainer to a piece of disposable material such as facial or to apply any necessary diaper creams, discarding the toilet tissue. To reduce the contamina a disposable paper towel saturated with water and tion of clean surfaces, caregivers/teachers should use a fresh detergent, rinse; wipe to wipe their hands afer removing the gloves, or, if no d. Wet the entire changing surface with a disinfectant that gloves were used, before proceeding to handle the clean is appropriate for the surface material you are treating. Some types of disinfectants Some states and credentialing organizations may recom may require rinsing the change table surface with fresh mend wearing gloves for diaper changing. Otherwise, retained contami The procedure for diaper changing is designed to reduce nated gloves could transfer organisms to clean surfaces. If care contact with uncontaminated surfaces such as hands, givers/teachers or children who are sensitive to latex are furnishings, and foors (3). Posting the multi-step proce present in the facility, non-latex gloves should be used. If the paper is large enough, a spray bottle, always assume that the outside of the spray there will be less need to remove visible soil from surfaces bottle could be contaminated. Terefore, the spray bottle later and there will be enough paper to fold up so the soiled should be put away before hand hygiene is performed, surface is not in contact with clean surfaces while dressing (the last and essential part of every diaper change) (5). Disinfectant All cleaning and disinfecting solutions should be stored to Appendix K: Routine Schedule for Cleaning, Sanitizing, be accessible to the caregiver/teacher but out of reach of any and Disinfecting child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine References Schedule for Cleaning, Sanitizing, and Disinfecting. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th bring supplies to the changing area. Green wear, or pull-ups; cleaning, sanitizing, and disinfecting: A checklist for early care and. If the child is standing, it may cause the clothing, shoes and socks to become soiled. To avoid contamination of the environment and/or the Changing a child from the foor level or on a chair puts the increased risk of spreading germs to the other children adult in an awkward position and increases the risk of in the room, do not rinse the soiled clothing in the toilet contamination of the environment. In the daily log, record what was in the pull-up or to request a few extra pair of socks and shoes from the underwear and any problems (such as a loose stool, an parent/caregiver to be kept at the facility in case these unusual odor, blood in the stool, or any skin irritation), items become soiled (1). Whether or not gloves were used, use a fresh wipe to that is large enough to cover the area likely to be contami wipe the hands of the caregiver/teacher and another nated during changing. Note and plan to report any skin problems such as foot coverings can become contaminated and subsequently redness, skin cracks, or bleeding; spread contamination throughout the child care area. Dispose of the disposable paper liner used on the chang into the environment in this way. Infectious organisms are ing surface in a plastic-lined, hands-free covered can; present on the skin and pull-ups or underwear even though b. Wet the entire changing surface with a disinfectant that Some states and credentialing organizations may recom is appropriate for the surface material you are treating. Even if gloves are used, toward self-regulation of their bodies is a component of caregivers/teachers must perform hand hygiene afer each teaching young children. If the disinfectant is applied Disinfectant using a spray bottle, always assume that the outside of the Appendix K: Routine Schedule for Cleaning, Sanitizing, spray bottle could be contaminated. Healthy Child Care Changing areas should never be located in food preparation Pennsylvania. Healthy Children with disabilities may require diapering and the Young Children, A Manual for Programs. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th However, principles of hygiene should be consistent regard Edition American Academy of Pediatrics Committee on Infectious less of method. Tese include new siblings, stress in the family, cleaning, sanitizing, and disinfecting: A checklist for early care and or anxiety about changing classrooms or programs, all of education. Even for preschool and kin dergarten aged children, these accidents happen and these incidents are called ?accidents because of the frequency of these episodes among normally developing children. As with any hand hygiene product, supervision from one child care group to another; of children is required to monitor efective use and to avoid b. Using the toilet or helping a child use a toilet; sneezing and coughing, that travel through the air. Handling animals or cleaning up animal waste; experience a symptom, caregivers/teachers routine hand 4. While alcohol-based hand sanitizers are helpful in reducing Situations or times that children and staf should perform the spread of disease when used correctly, there are some hand hygiene should be posted in all food preparation, hand common diarrhea-causing germs that are not killed. Tese germs are teachers smoke of premises before starting work, they common in child care settings, and children less than 2 should wash their hands before caring for children to years are at the greatest risk of spreading diarrheal disease prevent children from receiving third-hand smoke due to frequent diaper changing.
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