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Q&A: Breathing Precautions in Home Care

Question: Is it within the scope of OT practice in home care to do breathing precautions (e.g., to decrease mucous, coughing) in preparation for activities and to use a stethoscope to listen to heart/lung sounds to monitor clients with CHF and prevent re-hospitalization?

Answer: When making these types of decisions, a prudent first step is always to consult the state licensure board since practice acts contain a legally defined scope of practice and the board is responsible for interpreting the parameters of practice. The foundations of a profession’s scope of practice are inclusion in the educational curriculum, a history of application in practice, and language in state regulation, although that language can be quite general and is unlikely to address something as specific as this question.

If you do not get a definitive response, a second but critical consideration and ethical imperative is competency to provide those interventions. Breathing precautions like chest percussion is typically an intervention performed by a chest PT who has that training. However, this training is not part of OT curricula, nor is the use of a stethoscope to assess heart and lung sounds. Yet in an effort to manage chronic diseases like CHF and keep patients at home, all clinicians involved with that patient may need to expand their skill set so long as it does not exceed reasonable scope of practice parameters and their competency. Further, since practitioners are often working alone in the home health setting, the usual medical/nursing staff who would routinely perform these functions are not readily available. Therefore, specific training and documentation of competency are critical before an OT could perform these interventions. Part of the training for heart/lung assessment must include triggers for contacting the nurse (or physician) when abnormal sounds are detected. In addition, these interventions should be done only to prepare the patient for an activity to address a performance deficit as outlined in the plan of care, consistent with the philosophical basis of occupation-focused care, not as “stand-alone” interventions.