all of rehab combined

things to consider in WC selection

• pt’s disability and functional ability

• pt’s age, size, stature, and weight

• expected use

• pt’s needs

• temporary or permanent use

• prognosis; potential for change in pt’s mobility

• mental and physical condition of pt

WC Reimbursement Guidelines: Medicare

• requires WC meet patient’s needs for 5 years

• rents WC for set period before purchasing it

  • up to 15 months

  • allows for changes early on

  • changes very difficult after purchase date

WC seating and positioning

• mobility

• function

• safety

• prevent deformity/tissue damage

• efficient propulsion

• reduced repetitive strain injury

• postural stability/support

• increased sitting tolerance

can one get a new WC < 5 years?

• only if significant change in function can be documented

• must create a case for why old WC is no suitable

WC Reimbursement Guidelines: Medicaid

• eligibility every 5 years for WC

• eligibility every 3 years for cushion

• funding outside guidelines is difficult

after how long should a WC pt shift their body to prevent pressure sores…

after every 15 minutes

how does the CMS define restraints

• something the pt cannot remove easily which then restricts freedom of movement or access to one’s body

what is not considered a restraint

• orthopedic prescribed devices

• surgical dressings/bandagers

• protective helmets

• stuff used to protect the patient from falling out of bed

• stuff that allow the patient to do certain activities without the risk of physical harm

WC Evaluation

• sitting balance

• stability

• reaching ability

• method of propulsion

• transfer method

• ability yo change positions

• sitting posture

seat height measurements (extra information)

• hands should be able to reach posterior rim

• tip of middle finger at hub (the circle in the wheel/middle)

• 100 - 120 degrees of elbow flexion at top of push cycle

• 70 - 80% of weight over rear wheels

• footrest 2 inches from floor (if using legrests)

seat height (if too high)

• difficulty getting knees under table or desk

• difficulty reaching rims for propulsion (shorter push stroke)

• poor posture when forearm rests of armrests

• difficulty propelling WC with feet (can’t reach floor)

seat height (too low)

• difficulty standing due to low COG

• difficult with lateral transfers

• improper weight distribution (increase on ischial tubes of sacrum)

• longer push stroke (bad for elbow, shoulder, and wrist health)

• if footplates are lowered to compensate, may drag floor

seat height / leg length (for leg rest)

• measure from user’s heel to popliteal fold, and add 2 inches to allow footrest clearance

  • have some space under

• average adult size: 19.5” - 20.5”

• should be able to insert 2 - 3 fingers lengthwise between the posterior thigh and seat to a depth of 2”

footrest must be at least [ ] in from the floor

2 inches

leg length: foot plates too low

• increased pressure to posterior thigh

• insufficient clearance - unsafe mobility

leg length: too high

• increased pressure on ischial tubes

• difficulty positioning under table

• decreased trunk stability due to lack of thigh support

seat depth

• from front to back

• should be able to place 2-3 finger widths between front edge of seat and popliteal fold

• measure from posterior buttocks to popliteal fold, then subtract 2”

• Adult average: 16”

• consideration: leg length discrepancy

seat depth: too short/shallow

• decreased trunk stability (less support under thighs)

• increased WB on ischial tubes (body wt shifted posteriorly due to lack of thigh support)

• poor balance (decreased BOS)

seat depth: too long/deep

• increased pressure on popliteal fossa

• skin discomfort

• circulation compromise

seat width

• should be able to slide each hand between the pts hips and clothing guard of the chair with minimal contact (1” each side)

• measure widest aspect of hips/buttocks, then add 2”

• avg adult: 18”

  • in TX → more like 20”

seat width: too wide

• difficult propulsion (can’t reach rims)

• difficult with sit to stand (can’t push up effectively)

• difficult with lateral transfers (too much ground to cover)

• difficult to fit through narrow doorways

• postural deviations due to learning

seat width: too narrow

• pressure on greater trochanters

• difficulty changing position

• difficulty wearing orthotics, braces, bulky garment

back height

• should be able to fit 4 finger widths between top of back rest and floor of axilla

• measure from seat to floor of axilla, with pts shoulder flexed to 90 degrees, then subtract 4”

• consider if WC cushions will be needed

  • if yes you need to add to the original number

back height: too high

• difficult propulsion

• scapular irritation (due to rubbing)

• decreased balance dur to trunk inclined forward

• note: higher backs may be necessary for support and stability

back height: too low

• decreased trunk stability

• postural deviations

armrest height

• olecranon process - seat/ground (whatever the pt is sitting on)

• measure from seat of chair to olecranon process with elbow flexed 90 degrees, then add 1”

• consider if a WC cushion is needed

  • may need to add to the original number

armrest height: too high

• difficult propulsion (can’t reach rims)

• difficult sit to stand

• postural deviations due to elevated shoulders

• limited functional use of armrests

armrest height: too low

• poor posture

• back discomfort due to excessive trunk flexion

• decreased balance

• difficult sit to stand

seat to back angle - greater than 90 degrees

• pelvic rotates posteriorly, hips slide forward, sacral sitting, trunk kyphosis

• body mass behind COG

• may elicit extensor tone

seat to back angle - less than 90 degrees

• depending on available hip flexion

  • pelvic posterior tilt and hips slide forward

  • OR anterior tilt and trunk becomes unstable

WC Propulsion Biomechanics

• use trunk when going forward

  • encourage a forward lean to get a better momentum to go forward

adaptable housing

can make adaptations or renovations to fit needs

• Built to be modified or adjusted easily to meet accessibility needs when required

universal design housing

open concept with minimal walls, doors, and hallways

• lever door knobs and faucet handles

• lower height lighting controls

• recessed areas under sinks, cabinets, and counters

• varied heights of countertops

ADA

• enforceable prohibitions and standards that ban discrimination based on disability

• extend civil rights for people with disabilities - access to public accommodations and services

• federal antidiscrimination legislation designed to remove employment and access barriers for individuals w disabilities

ADA Title I

employment

ADA Title II

public service

ADA Title III

public accommodations

ADA Title IV

telecommunications

ADA Title V

miscellaneous provisions

disability

A physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment.

physical or mental impairment

Any physiological disorder, condition, cosmetic disfigurement, or anatomical loss affecting body systems, or a mental/psychological disorder such as intellectual disabilities, emotional illness, or learning disorders.

reasonable accommodation

Modifications or adjustments to a job, work environment, or way tasks are performed to enable a person with a disability to perform essential job functions.

undue burden

• A significant difficulty or expense for an employer or entity when providing accommodations, considering factors like cost, resources, and the entity's size

• requirement that would cause a significant difficulty or expense to provide

• a small coffee shop is asked to install a $50,000 WC ramp but cant bc it expensive. they can call it an “…” and offer an alternative such as curbside pickup

qualified individual with a disability

A person with a disability who meets the job's skill, experience, education, and other requirements and can perform essential functions with or without reasonable accommodation

covered entity

Organizations subject to the ADA, such as employers, labor unions, and employment agencies, as well as public accommodations and state/local governments.

handicap

An older term often used interchangeably with "disability," though "disability" is now preferred as it focuses on societal barriers rather than limitations of the individual.

basic assessment: residence and workplace

• external features

  • ex. sidewalk/driveway, approach to entrance

• internal features

  • ex. door widths, presence of stairs, furniture configuration

basic assessment of community

• public transportation

• sidewalks, curb cuts, and crosswalks

• shipping convenience

• entry to buildings

• access to public buildings

• access to recreation areas and facilities

accessible housing

• functional environment for w/c use

• residence in which a person with a disability is able to function as independently as possible

• options: construct using principles of universal design or modify/adapt existing structures

• single story with open floor plan

WC accessible house - Hallway and Sidewalk width

36”

WC Accessible house - door width

32”

WC accessible house - ramps

36 - 48” wide

• no more than 1” rise for each foot of length (no more than 8.3% grade) ramps longer than 30” bed to change direction and have landings

WC accessible house - turning radius

60” (or 5’x5’)

transfer

safe movement of a person from one surface, location, or position to another

minimal assistance (Min A)

pt performs > 75%

moderate assistance (mod A)

pt performs 50 - 74%

maximal assistance (Max A)

pt performs 25 - 49%

dependent (dep)

total assistance required

required documentation for transfers

• amount of type of assistance required

• amount of time to complete transfer

• level of safety demonstrated

• level of consistency of performance

• equipment or devices used

4 general parameters for determining appropriate transfer

• evaluation, including patient experience and physical ability

• the medical record information available

• information from the patient

• goals of treatment

precautions - burns

no sliding/shearing due to wounds & skin grafts

precautions - hemiplegia

• no pulling on extremities, esp UE

• fragile affected shoulder

sternal precautions (CABG)

• no pushing/pulling with UEs

• no horiz abd with ER

• no lifting UE > 90 degrees (flx and/or abd) if flap present

posterior hip precautions

• no hip flex past 90 degrees

• no hip adduction beyond neutrals

• no hip IR

anterior hip precautions

• no ER

• no hyperextension

spine precautions

• no bending

• no lifting

• no twisting

• must log roll

hip ORIF

• 0 hip precautions

• may have WB restrictions mild/moderate r

S&S to mild/moderate allergic reactions

• itchy watery eyes

• sneezing

• hives

S&S to severe allergic reaction

• swelling of face/mouth

• difficulty swallowing and speaking

• wheezing

• difficulty breathing

• abdominal pain

• nausea

• vomiting

• dizziness

• syncope

allergic reactions - initial treatment

• identify allergen if possible

• apply cool compress

• observe for signs of distress

• obtain medical assistance

treatment for severe allergic reaction

• check airway - may need to begin CPR

• assist with administration of emergency allergy meds (Epipen)

• position to prevent shock

lacerations

• prevent contamination and control bleeding

• wash hands, wear gloves

• apply sterile towel or gauze

• elevate

• apply pressure to bleeding wound

• if arterial (spurting blood), may need to apply pressure to an artery proximal to the wound (brachial or femoral artery)

shock - S&S

• pale, moist, cool skin

• shallow and irregular breathing

• dilated pupils

• weak and rapid pulse

• diaphoresis

• dizziness or nausea

• syncope

shock - definition

• acute peripheral circulatory failure caused by derangement of circulatory control or loss of blood

• reduce or remove cause and prevent or reduce extent of physiologic state of shock

orthostatic hypotension can be caused by…

• antihypertension medication

• hypotension

• pt immobilized in recumbent position for extended periods

burns - what to do

• prevent wound contamination, relieve pain, and prevent shock

• cut away clothing near burn site (but NOT clothing that lies over burn site)

• remove jewelry

• place clean or sterile dressing/towel over area (moist)

• DO NOT apply any cream, salve, ointment, butter, lard, etc

• if chemical related - wash with copious amounts of water

convulsions/seizures

• protect person from injury

• provide for person’s modesty and privacy

• place person in a safe location

• do NOT attempt to restrain or restrict the convulsions

• monitor respiration rate and quality

• keep pt’s airway open. NEVER place finger or object in pt’s mouth

• once convulsions subside, turn pt’s head to one side in case of vomiting

• loss of bowel and bladder control is common

heat exhaustion - define & S&S

• least threatening to life

• cause: hot, humid environment; vigorous physical activity; dehydration; depleted body electrolytes

• profuse diaphoresis

• shallow rapid breathing

• weak rapid pulse

• pale color

• normal/sightly elevated temp

• normal pupils

• unconscious

• nausea/vomiting

heat stroke - define & S&S

• MEDICAL EMERGENCY

• cause: hot, humid environment; vigorous physical activity; dehydration; depleted body electrolytes

• dry, no diaphoresis

• labored breathing

• strong rapid pulse

• flushed or gray color

• elevated temp (106 - 110)

• pupils contract, then dilate

• unconscious

• nausea/vomiting

heat exhaustion - what to do…

what to do…

• cool pt - cool compress, shady area

• counteract effects of dehydration

• no salt tablets !

• replenish fluids - electrolytes

heat stroke - what to do…

what to do…

• seek medical attention

• semi-reclining position

• shady area

• monitor HR and respiration rate

• cool pt quickly with large amounts of cool water, cool compresses, ice packs

hypoglycemia (insulin reaction)

• sudden onset

• pale, moist skin

• excited, agitated

  • fight to flight is usually activated in the body

• normal breath odor

• normal to shallow breathing

• no vomiting

• moist tongue

• hungry

• not thirsty

• absent or slight glucose in urine

• provide some form of sugar

hyperglycemia (acidosis)

• gradual onset

• flushed, dry skin

• drowsy

• fruity breath odor

• deep labored breathing

• vomiting present

• dry tongue

• not hungry

• thirsty

• large amounts of glucose in urine

• DO NOT GIVE SUGAR, medical emergency

autonomic dysreflexia (hyperreflexia) in SCI

• for T6 level and above SCI injuries

• massive sympathetic system response to a noxious stimuli occurring below the level of injury, which can’t be controlled by higher brain centers due to SCI

• medical emergency

• CAN LEAD TO STROKE, SEIZURES, OR DEATH

WC fitting: name what and how much you are supposed to add

• seat height: +2 / +0 (if leg propeller)

• seat width: +2

• seat depth: -2

• back height: -4

• armrest height: -1

microorganism

germ, bug, microscopic organism that could cause disease

• dont necessarily make use sick

subjective

history, complaints, prior level of function, home situation

objective

tests and measures

• ROM, MMT, Mobility/Gait, balance, skin teg/sensation, posture, palpation, ADLS, cognition; Determines Functional Abilities

assessment

assesses data collected, develops problem list, determines therapy diagnosis, (also determines if pt needs therapy), rehab potential, final destination

plan

goals and expected functional outcomes, frq, duration, interventions

Interprofessional Collaboration

When professionals from different fields (like doctors, nurses, and therapists) work together to provide the best care for patients.

• MD, RN, PT/OT/ST, SW, CM

Intraprofessional Collaboration

When professionals within the same field (like different types of nurses or therapists) work together to improve patient outcomes.

• PT/PTA; OT/COTA

Barriers to effective communication

• excessive distance

• increased noise

• decreased comprehension

• language too complex

• cultural differences

• illegible

• ask for patient to repeat instructions back to you

• get interpreter if necessary

communicating with persons with disabilities

• interact with respect

• squat to eye level

• shake hands using left hand as appropriate

• take visual and hearing deficits into effect

interdisciplinary POC

• team approach working towards common goal

• can all “round” together

who can modify the POC

PT only

pt can be discharged to:

• home

• home with home health

• SNF

• long-term care

• ALF

• inpatient/outpatient rehab

evaluation by MD: by admitting physician

H&P (history and physical)

evaluation by MD: by other physicians

Consultations

HIPPA (Health Insurance Portability and Accountability Act)

A U.S. law that protects patient privacy by setting standards for the secure handling of health information.