ADLs

AT for bathing

Most homes in the US have a bathtub/shower combination either with glass doors or with a shower curtain (Mann, 1998). This is often a difficult setup for someone with a physical impairment. Getting down into the tub and out again may not be possible due to decreased balance and hemiparesis. If tub bathing is not feasible, other options include showering or sponge bathing.

To shower safely, several types of device can be used. Grab bars are an option, as discussed earlier in this chapter. A transfer bench allows a person to perform a seating transfer into the tub (Mann, 1998). After sitting, the person turns toward the front of the tub and swings one leg and then the other into the tub. One consideration when using a transfer bench is the amount of space in the bathroom as they require space outside of the tub, as well as in the tub. Also, a shower curtain must be used rather than glass doors because glass doors do not allow enough room to sit and swing the legs into the tub. The shower curtain must be positioned so that water does not spill out of the shower and onto the floor creating a safety hazard. Finally, the weight of the bench should be considered if it will be removed when others use the tub/shower.

For people who can safely perform a standing transfer, but are unable to remain standing while showering, a shower chair or bath bench is recommended. These are available in several styles. Some have backs that assist people with compromised sitting balance and some have armrests for additional stability. Again, the weight of the chair must be considered if it has to be removed for others to use the bathtub (Fig. 10.2).

Devices that control the water temperature can be installed. These devices are important for people with sensation deficits and can prevent burns. Several water temperature control devices are available, as listed at www.abledata.com (Abledata, 2004).

A hand-held shower is useful for rinsing when seated on a bath bench or shower chair. The use of a hand-held shower may also help keep water in the tub when using a transfer bench. If a person has the use of only one-hand and the showerhead does not have an on/off button, the hand-held shower can be set down into the tub while the person washes. However, hand-held showers with an on/off control are relatively inexpensive.

A variety of brushes and sponges can assist with bathing (Abledata, 2004). A long-handled sponge can help a person with impaired balance or range of motion wash their lower legs. A foot sponge is much like the long-handled sponge but narrower for cleaning toes and feet. For hands-free use, foot brushes attach to the bathtub to clean feet and toes. Finally, some back brushes can also be used to wash the lower legs.

Many assistive devices are available for soap and shampoo dispensing. A push button dispenser is useful for an individual who is unable to use both hands to open a shampoo bottle and pour it into the other hand. People who are unable to press buttons could use hands-free motion-activated dispensers. A soap swing can turn any bar of soap into "soap on a rope." Soap is placed in the soft mesh bag that doubles as a bathing sponge. The mesh bag is attached to a long nylon rope that is mounted to the wall.

AT for dressing

Dressing requires body movement and the use of both hands. To put on socks and shoes, a person must have good trunk flexion and be able to maintain balance (Mann, 1998). Furthermore, tying shoes involves the use of two hands and fine motor coordination. Dressing can be challenging when one side of the body is weak and balance is impaired.

A person with decreased balance should have a sturdy chair to sit on while dressing. A chair with arms may be helpful for transferring, but the arms may interfere with putting on a shirt. Beds are not an ideal platform for dressing as they are often too soft for an individual to maintain an upright posture.

A long-handled shoehorn may help in putting on shoes (Fig. 10.3). The person has to point their toe into the shoe and get the shoehorn behind the heel before they begin to push down into the shoe. Sometimes the affected leg will have an ankle-foot orthosis, or AFO, which is already in the shoe and acts like a shoehorn. Similarly, the end of a dressing stick can act as a long-handled shoehorn. The dressing stick can also assist in getting pants over feet and pulling them up to the knees where the hand can take over. Reachers can also be used for donning pants.

Fasteners like buttons, zippers, and snaps are often difficult to manipulate due to hemiparesis or decreased fine motor coordination. For many people with these impairments, pull-on pants and pullover shirts are easier because there are no closures. Likewise, sport bras in an extra size may be easier for women to pull over than using a rear closure bra with hooks or even a front closure bra. Velcro can also be substituted for hard-to-close fasteners. Elastic cuff links allow a person to slip their hand through cuffs without unbuttoning them. Button extenders enable a person to pull a button-up shirt over the head (Abledata, 2004).

Figure 10.3. Long-handled shoehorn.

Devices are available to assist in fastening clothes that have buttons, zippers, and laces. For garments with buttons, button aids can compensate for fine motor impairment and can be used by one hand. Also, zipper pulls can be added to zippers and allow a person with use of only one hand to zip a garment. They are larger than the typical zipper lever so people with fine motor impairments can grasp the pull as well. Elastic laces can be placed in shoes, which make donning them similar to slip on shoes. The laces come in different colors, widths, and styles. Other devices to fasten shoes include Velcro and shoelace fasteners that can be used to lock shoelaces in position.

For a person with diminished fine motor control or hemiplegia, jewelry can also be challenging to don. Clip-on earrings or earrings with hooks rather than posts are easier to put on with one hand. Necklaces and bracelets with magnetic clasps may be easier than other traditional jewelry clasps (Abledata, 2004).

AT for grooming

Typically, flossing is a two-hand task, but a disposable or non-disposable dental floss holder can make flossing with one hand possible (Mann et al., 1995b, September). Brushing dentures also requires two hands. However, denture brushes with a suction cup make it possible to clean dentures using one hand (Abledata, 2004). A toothpaste dispenser is available that has a slot for the toothbrush: the device dispenses the appropriate amount of paste when the person presses the dispenser lever.

For an individual with decreased fine motor coordination, an electric shaver may prevent cuts. This may be especially helpful for a person who shaves with the non-dominant hand due to hemiplegia.

A few items that make nail care easier for people with hemiplegia or hemiparesis include adapted nail clippers, emery boards, and nail brushes. Fingernail clippers for operation with one hand are available, although for some individuals it may still be difficult to clip the nails on the unaffected hand. A foot-operated nail clipper is also available (Abledata, 2004). An emery board with a suction cup allows one-handed use for filing nails. Nailbrushes with suction bases can be used to clean under nails for people with hemiplegia.

AT for toileting

Several options for hygiene assistance are available. Pre-moistened wipes make it easier to cleanse after toileting if hygiene is difficult (Mann, 1998). Also, use of a bidet rather than toilet paper can be beneficial for people who are unable to maintain balance while wiping themselves. Add-on washing devices serve the same purpose as a bidet at much lower cost.

Raised toilet seats may make it easier for someone with hemiparesis or hemiplegia to get on and off the toilet. If the person requires extra support or something to push on when transferring, raised toilet seats with armrests can be used. The Toilevator is a device that raises the toilet from the bottom up, so the person is still sitting on his or her own toilet seat. The Toilevator adds a section between the floor and the bottom of the toilet.

At night, a person with hemiplegia or impaired balance may require a significant amount of time to get from bed to the bathroom to use the toilet. To avoid an accident on the way to the bathroom, the individual may use a urinal or a bedside commode (Fig. 10.4). Urinals may be gender specific or unisex (Mann, 1998). The weight of the urinal is important for a person with hemiplegia or hemiparesis. The weight of the urinal after it has been used should also be considered. Another option is a bedside commode. These are available in many different styles, including commodes with removable arms, swing away arms, or stationary arms (Abledata, 2004). A consideration when prescribing a bedside commode is how the indi

vidual transfers. A commode with a seat lift helps the person move from sitting to standing.

AT for eating and drinking

Assistive devices are available that make eating with one hand easier. Some of the adaptive utensils that make cutting food with one hand easier include rocker knives, rocker fork-knife combinations, and roller knives (Abledata, 2004). Roller knives look similar to a small pizza cutter. Rocker utensils have an edge the shape of a semi-circle that is used to cut food. To prevent spilling, a person with poor coordination or decreased cognition may use bowls and plates with built up edges, plate guards, dishes with non-skid bottoms, and cups with lids.

AT for walking and mobility

A variety of mobility devices are available for people with impaired balance or gait. Canes support up to 25% of a person's weight (Mann, 1998). Canes are usually single-end or have multiple feet, such as a quad cane. Quad canes offer more support than single-end canes, but are heavier.

Walkers can support up to 50% of a person's body weight (Mann, 1998). Types of walkers include hemi-walkers, platform, standard, front-wheeled, and four-wheeled. Hemi-walkers are used by people with hemiplegia. These walkers offer more support than a quad cane, and are still used with one hand. A platform walker allows the person to put the affected hand and forearm in a trough on the walker and then bear weight through the upper arm to push the walker forward. Standard walkers and front-wheeled walkers provide support to people with impaired balance, but the person must grasp both sides of the walker to use it properly. Finally, four-wheeled walkers provide some support and are able to move faster than standard and two-wheeled walkers. Four-wheeled walkers have a seat that allows the user to rest when needed. Some four-wheeled walkers have a bin under the seat for carrying objects.

Walker accessories can help the user transport items while walking. They include walker bags, baskets, and trays. Bags are useful to transport items that do not have to stay upright. Baskets allow transportation of items in an upright position, but may interfere with the individual approximating counters and cabinets. Trays are another alternative for carrying objects and allow the user to approach counters and cabinets closely, but do not allow the person to use a walker seat to rest.

Wheelchairs are another category of mobility device (Chapter 11 of Volume II). There are many different types of wheelchairs, including manual wheelchairs, power wheelchairs, and power assisted wheelchairs. In positioning someone post-stroke in a wheelchair there are several important considerations. Initially, how will the person propel the chair? Will they use their hands and feet, just one foot and one hand, no feet and two hands? If they are going to use one hand and one foot (or one hand, which is very difficult), then the person needs a wheelchair that can be maneuvered on one side. Additionally, the person may need lateral support to maintain an upright posture in the wheelchair. A tray table, half tray, or arm trough may be used to keep the patient's arm in a safe position. The individual may need a seat alarm or seat belt if he or she does not have good insight into the deficits present and is at risk of trying to walk. Another consideration when positioning someone is the type of wheelchair cushion they should use. If the person is not very mobile and is at risk of developing pressure sores, a pressure-relieving cushion would be best. But if the person is able to shift in the seat and transfers often, a less expensive foam cushion may be appropriate. Finally, a brake extension on the affected side allows the individual to reach with the unaffected hand to lock the opposite brake. If the person has residual memory impairment, an automatic braking system may help prevent falls.

Scooters are a less expensive alternative to power wheelchairs, but they offer less support (Mann, 1998). Often motorized scooters have baskets to allow transportation of objects. Many stores carry motorized scooters with baskets.

People who have a neurologic condition and use a wheelchair or scooter have to consider how they will get around their home, vehicles, and community. Many people who use these devices use wheelchair ramps and lifts.

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