Eli's Rehab Report

Published on Wed Feb 10, 2010 PDF

Prevent skin breakdown and positioning problems while enhancing quality of life.

A wheelchair should be an enabler, not a device that causes pressure ulcers, dependence, depression -- and even dysphagia -- due to poor positioning. But your rehab team can play a key role in care planning by asking key questions and making keen observations during treatment. Start by asking if the resident really needs a wheelchair as much as he's using it, advises Deborah Gavin- Dreschnack, PhD, a health science researcher at the James A. Haley VA Patient Safety Research Center in Tampa, Fla.

Setting a patient goal of ambulating at least occasionally can sidestep negative effects of chronic wheelchair use, she says.

If the resident does require a wheelchair, make sure it's a good fit. That's the most important thing, emphasizes Kate Brewer, PT, MBA, GCS, VP of Greenfield Rehabilitation Agency Inc. in Milwaukee. When the resident is in the wheelchair, look to see if his knees are at a 90-degree angle and his feet are supported by the leg rest. "The feet should not be dangling or too far out ahead," Brewer advises.

Danger: "If the person isn't positioned correctly, his legs can catch on tables and doorframes," Brewer cautions. "The hips should also be at a 90-degree angle," she adds.

And the knees should be level with the hips. Can you squeeze your hands between the person's hips and the side of the chair? If not, the chair is too small. And that can cause friction and/or pressure ulcers, and impede mobility, Brewer cautions.

Conversely, if you see spaces between the person's hips and sides of the chair, the wheelchair is "probably too big," Brewer adds. And "that can be a problem if the person's arms can't fit over the wheels so she can propel herself."

Tip: A resident with kyphosis may need a wheelchair with a contoured back that accommodates the hump of the apex of her kyphotic back, Gavin-Dreschnack says.

Cool tool: Consider using the Resident Ergonomic Assessment Profile for Seating (REAPS). The quick assessment can help identify those in wheelchairs who need a referral to therapy, advises Gavin-Dreschnack, who devised the tool.

Any level of caregiver can do the assessment, she says. In fact, "the hands-on caregivers are generally the best sources of information," although "everyone should have input," she adds.

Choose the Right Pressure-Relieving Devices The person in a wheelchair should have a cushion in the chair -- "and not the pillow from the bed," says Joyce Black, RN, PhD, former president of the National Pressure Ulcer Advisory Panel and a nursing professor at the University of Nebraska in Omaha. You can choose from three or four types of cushions on the market, she adds. "One is made out of air cells and is very versatile and cleanable."

Watch for: If your facility uses the air cell cushion, the person in the wheelchair may feel odd when the air cells move under him or her, Black says. You might suggest foam cushions as a cheaper option, but they're not cleanable, Black notes. And placing a piece of plastic over them "defeats the purpose of using them." If your facility uses the foam cushions, make sure they are at least two inches thick, advises Carol White, RN, MS, ANPC, GNPC, DNP, CLNC, principal of National HI Inc. in Huntington, Ind.

Also replace them once the person starts leaving an imprint in the foam after sitting on it, adds Black. "A person who will be permanently in a wheelchair due to spinal cord injury or multiple sclerosis, etc., should have a cushion designed for him or her."

Motorized wheelchairs and scooters can be a safety hazard in the nursing facility. "If a person can't propel himself using the wheels and requires a motorized wheelchair, therapy should evaluate whether the person can use it safely," advises Brewer. "The person has to be able to navigate tight corners," for example. The "same is true of motorized scooters," she adds.

Mix Up the Seating Arrangements

Talk to the nursing manager about offering wheelchair dependent residents different seating options throughout the day. "Moving the patient between a bed, wheelchair, and stationary chair (i.e., recliner) can provide different angles of body alignment and vary points of pressure, which may also decrease the risk for skin injury," says White. For example, staff can wheel the person in a "Lazy Boy" type recliner to participate in group activities. The person could also spend time in a regular chair in his room when socializing with visitors or working on an activity. "Varying sitting surfaces may actually help normalize the patient's experience," White says. "The more we can deinstitutionalize the [nursing home] setting, the more often we can improve" the patient's mood and quality of life, she adds.