CarePlan-Medicaid Waiver

Specified Need: Monitor growth patterns, nutrition, immunizations; coordinate care with specialists; treat childhood diseases

Goal: To ensure that Eliana is maintaining weight and height for a child her age, and is free of childhood diseases

Treatment Plan: Eliana will be seen regularly to monitor growth and development, receive immunizations, and diagnose and treat illness.

Specified Need:

• Monitor respiratory status related to reactive airway/ wheezing, hypotonia, and high aspiration/suffocation risk. 
• Evaluate efficacy of pulmonary medication regimen (Xopenex, Atrovent, Pulmicort, Singulair, Scopolamine).  
• Continue interventions to minimize risk of death by aspiration/pneumonia, including: 

1. Q3hour nebulizer treatments, 
2. chest physical therapy, 
3. the Vest, 
4. Cough Assist, 
5. oxygen as needed, 
6. nasal and oral suctioning as needed around the clock.  

Goal:

• To slow the deterioration in respiratory status as long as possible using as few medications and interventions as medically necessary. 
• Try to maintain maximal comfort for Eliana in the face of progressive respiratory failure.

Treatment Plan: Pulmonary re-evaluations, laboratory monitoring as needed, assessment of reactive airway illness and GE reflux, and monitoring of blood oxygenation. Follow-up of in-home nebulizer treatments, suctioning, chest PT with the VEST, and airway clearance with the Cough Assist machine.

Medications: 

• Xopenex via nebulizer every 3 hrs & PRN
• Atrovent via nebulizer every 12 hrs & PRN
• Singulair via PEG once daily
• Pulmicort via nebulizer every 12 hrs
• Scopolamine Transdermal patch every 48 hours

Specified Need: Monitor status of

• reflux, 
• aspiration, 
• PEG feedings, 
• intake and output, 
• nutritional status, 
• GI bleeding, 
• gut motility and 
• constipation.

Goal:

• PEG tube feeds will be well tolerated and sufficient to help maintain adequate growth and comfort. 
• Aspiration will be prevented. 
• Reflux will be kept in remission. 
• GI Bleeding will remain in remission.  
• GI motility and constipation will improve.

Treatment Plan: GI physical examinations as needed with monitoring of PEG status, constipation, reflux, nutrition, and lab work. 

Medications:

• Peptamen Junior Enteral Feedings every 6 hours with 2tsp yogurt
• Prevacid via PEG twice daily
• Reglan via PEG every 6 hours
• Benadryl via PEG every 6 hours
• Miralax via PEG every day as needed
• Polyvisol vitamin drops via PEG every day
• Maalox via PEG twice a day and as needed

Specific Need:  

• Regular eye examinations.  
• Follow up on corneal abrasions and delayed healing due to chronic dry eyes and limited blinking.  
• Outpatient eye procedures to keep eye partially closed. 
• S/P left eye surgery in October 2009.  
• Now - need for right eye assessment and possible surgery.

Goal:  Healing of corneal abrasion, prevention of future abrasions and infections.

Treatment Plan:  

• Appointment March 2011 to assess the need for right eye surgery.  
• Follow up on left eye in June 2011. 
• Hourly application of artificial tears to both eyes; 
• lacrilube ointment to both eyes at least 3 times a day.

CLICK HERE FOR MORE

Specified Need: Monitor neurological/neuromuscular status, including seizure activity, myoclonus, and muscle spasms

Goal: To slow the deterioration in neurological status, treat seizures, and try to maintain maximal comfort for Eliana in the face of neurodegenerative decline.

Treatment Plan: Follow up as needed; anti-seizure and muscle relaxant medications. 

Medications:  

• Klonopin 1.0 mg 4X/day
• Lamictal 100 mg at 12pm and 75mg at 12am
• Baclofen 2.5mg 2X/day & 5.0mg 1X/day
• Zavesca 100mg 3X/day
• Diastat 10mg PRN 

Specified Need:  Monitor endocrine status related to precocious puberty

Goal:  Halt or slow changes related to puberty if treatment acceptable to patient and family.  Provide education and treatment options.

Treatment Plan:  Follow up as needed; laboratory tests as indicated; discussion of treatment options with family; treat if indicated.

* Monitor intake and output.
* Check for residual feedings every 6 hours before medications are given
* Gastric venting every 6 hours before medications, and again after Cough Assist treatments, and as needed
* Assess breathing and respiratory status around the clock.
* Monitor oxygen saturations every 4-6 hours if stable, and around the clock if unstable
* Monitor temperature and other vital signs every shift if stable, and every hour if unstable
* Monitor for seizures and provide seizure precautions around the clock.
* Minimize and monitor hypersensitivity to touch and sudden movements by providing a calm, soothing, and quiet environment.
* Dispense PEG feeds via Kangaroo pump every 6 hours, each feed lasting 1-2 hours 
* Dispense free water via PEG after feeds every 6 hours 
* Monitor for reflux and vomiting.  Reposition head and body as indicated
* Clean Tube feeding bags and tubing every 6 hours after each feeding
* Prepare and Dispense medications via PEG:

•        Prevacid twice a day (6am & 6pm)
•        Singulair once a day (12 am)
•        Klonopin 4 times a day (6-12-6-12)
•        Lamictal 2 times a day (12am & 12 pm)
•        Baclofen 3 times a day (6a, 12p, 6p)
•        Reglan 4 times a day (6-12-6-12)
•        Benadryl 4 times a day (6-12-6-12)
•        Miralax once a day (9am)
•        Zavesca 3 times a day (12a, 6p, 12p)
•        Maalox 1 time a day (12pm)
•        Polyvisol one time a day (9am)
•        Ambrotose one time a day (9am)
•        Polyvisol with Iron one time a day (9am)

* Dispense and administer medications via Nebulizer :

•        Xopenex every 3 hours & PRN (12-3-6-9-12-3-6-9)
•        Atrovent every 12 hours & PRN (6am & 6pm)
•        Pulmicort every 12 hours (9am & 9pm)

* Brush teeth and oral mucosa after each Pulmicort treatment twice a day
* Provide oral stimulation with toothettes, tooth brushes
* Provide manual Chest Physical Therapy (CPT) after each Nebulizer treatment as needed
* Provide CPT using the VEST every 12 hours and PRN
* Provide ongoing nasopharyngeal suctioning of secretions throughout the day as needed and after nebulizer/chest PT treatments.
* Provide airway clearance with the Cough Assist machine at least 4 times a day before meals
* Provide oxygen via nasal cannula as needed
* Clean Suctioning tubing after each suctioning throughout the day
* Clean suctioning equipment daily and sterilize
* Clean nebulizer equipment after each treatment and sterilize
* Clean Cough Assist face mask after each use and sterilize
* Clean syringes after each use
* Tub bath or bed bath each day for hygiene
* Provide skin care with moisturizer one to two times a day
* Provide physical therapy exercises as per PT instruction to increase range of motion, prevent contractures, increase strength, for approximately 30 – 60 minutes each shift.  Exercises include range of motion, stretching, sitting supported, and propped on all fours as tolerated.  
* Provide positioning in kid kart seat 
* Treat ankle contractures with AFO’s for 2-3 hour intervals
* Treat wrist contractures with wrist splints
* Rotate/change positioning during sleep to improve lung function and decrease risk of pneumonia, every 2 hours.
* Place in Trendelenberg position as needed to allow for postural drainage of lung secretions.
* Place artificial tears into both eyes every 2 hours.
* Place Lacrilube eye ointment into each eye 4 times a day.