First complete the History box below. You will need to talk to the resident and/or nursing staff to answer some of the questions.
History
1. If the resident self-propels the wheelchair,
a) what does s/he use? __ One arm __ Two arms __ One foot __ Two feet
b) where does s/he go? __ Bathroom __ Dining room __ Activity room __ Outside
2. If the resident sits in the wheelchair,
a) for approximately how many hours per day?
b) during which activities? __ Resting __ Eating __ Watching TV __ Recreation
3. List the resident's skin problems or sensory deficits. _____________________________________________________
4. List the resident's unsafe behaviors. __________________________________________________________________
__________________________________________________________________________________________________
5. Is the resident able and willing to follow directions? __ Yes __ No
6. If the resident is not comfortable in the wheelchair, describe the problem. _____________________________________ __________________________________________________________________________________________________
7. List current equipment.
Wheelchair Type: ________________________ Cushion Type: ______________________________
Other Supports: _________________________ Footrests: __ Left __ Right __ Both
Other Equipment: _____________________________________________________________________
Observe the patient sitting and supine and complete the Observation box below.
Observation
Pelvic Tilt: __ Posterior __ Anterior Thoracic Kyphosis: __ Mild __ Moderate __ Severe
Pelvic Rotation (forward ASIS*): __ Left __ Right Scoliosis: __ Mild __ Moderate __ Severe
Pelvic Obliquity (low ASIS*): __ Left __ Right Leg Length Discrepancy: L ________ R ________
Range of Motion (ROM) Measured in Supine:
Hip Flexion (Normal > 90º): Left ___________ Right ___________
Knee Extension with Hip Flexion (Normal < 70º): Left ___________ Right ___________
Ankle with Hip and Knee In Flexion: Left ___________ Right ___________
Comments: ________________________________________________________________________
*Anterior Superior Iliac Spine
Identify the resident's seating problem and the underlying reason from the choices below. Select from the list of suggestions those that you think will improve the resident's seating.
Problem: Resident Slides Out of Chair
Reason: Posterior Pelvic Tilt
__ Contoured cushion with large well space
__ Ischial shelf/Antithrust cushion
__ Solid seat insert with back support
__ Other solid seat insert _________________
__ Seat belt attached at 80º-90º
__ Hemi-height wheelchair
__ Drop seat
__ Footrest adjustment
__ Adjustment to angle of w/c back
__ Wheelchair with adjustable back
__ Adjustable back seating system for w/c
__ Back support modifications to w/c
__ Lap tray
__ Other ________________________________
Reason: Inadequate Hip Flexion
__ Seat-to-back angle adjustment to fit hip flexion
__ Contoured cushion with trough for femur(s)
__ Other ________________________________
Problem: Patient Leans To Left, Right, or Forward
Reason: Flexible Pelvic Obliquity
__ Adjustable foam, fluid or air cushion to raise cushion under low side
__ Other ________________________________
Reason: Fixed Pelvic Obliquity
__ Foam, air or liquid cushion to fill space between bony prominence and seat surface on low side
__ Other ________________________________
Reason: Flexible Pelvic Rotation
__ Contoured cushion with support for femurs & greater trochanters
__ Seat belt attached at 80º-90º
__ Other ________________________________
Reason: Fixed Pelvic Rotation
__ Contoured cushion with large well space
__ Cushion modification to support both longer and shorter extremities
__ Other ________________________________
Reason: Asymmetrical Trunk or Scoliosis
__ Deeper back system with lateral supports
__ 3-point support systema
__ Lateral support with accommodation on opposite side
__ Hip bolster with accommodation on opposite side
__ Arm support
__ Adjustment to back of wheelchair
__ Other ________________________________
Reason: Anterior Pelvic Tilt, Falling Forward, or Kyphosis
__ Contoured cushion with large well space
__ Ischial shelf/Antithrust cushion
__ Solid seat insert with back support
__ Other solid seat insert _________________
__ Seat belt attached at 80º-90º
__ Adjustment to angle of w/c back
__ Wheelchair with adjustable back
__ Adjustable back seating system for w/c
__ Other ________________________________
Problem: Feet Not Staying On Foot Rest
Reason: Limited Knee Extension
__ Foot plate and hanger adjustment
__ Angle-adjustable foot plates
__ Custom modification by DMEb supplier
__ Drop seat
__ Hemi-height wheelchair
__ Other ________________________________
Reason: Ankle Contracture
__ Foot plate adjustment
__ Angle-adjustable foot plate
__ DMEb consultation
__ Placement of feet on floor (if foot propeller)
__ Drop seat
__ Hemi-height wheelchair
__ Cushion w/ adequate posterior thigh support and space behind knee for full excursion
Reason: Nonfunctioning Lower Extremity
__ Cushion with adequate posterior thigh support
__ Front hanger adjustment (with thigh/cushion contact)
__ Full foot plate that extends from heel to toe
__ Foot plate adjustment
__ Heel loops
__ Leg rests
__ Other ________________________________
Problem: Propelling Difficulties
Reason: Feet Not in Correct Position
__ Removal of one foot plate for foot propulsion with adjustment of other foot plate for nonfunctional foot
__ Cushion depth adjustment for full leg excursion (notched one side for one-foot propeller)
__ Drop seat
__ Hemi-height wheelchair
__ Thicker cushion to raise seat
__ Other ________________________________
Reason: Inefficient Propelling
__ Review of engineer wheelchair inspection/ensure repairs completed
__ Adjustment of cushion/seat height
__ Adjustment of handrim/wheel position
__ Replacement wheelchair
__ Poweredc
__ One-handedc
__ Other ________________________________
Problem: Pain or Skin Breakdown
__ Jell or air cushion to assist in healing skin ulcer
__ Cushion to distribute pressure
__ Cushion to accommodate fixed deformities
__ Other ________________________________
Problem: Unsafe Behavior
__ Contoured cushion with large well space
__ Ischial shelf/Antithrust cushion
__ Solid seat insert with back support
__ Other solid seat insert _________________
__ Seat belt attached at 80°-90°
__ Hemi-height wheelchair
__ Drop seat
__ Adjust angle of w/c back
__ Wheelchair with adjustable back
__ Adjustable back seating system for w/c
__ Other ________________________________
Signature: ________________________________________ Date: ______________________________
a Three point support system: 1) thoracic region at most extreme point of scoliotic curve; 2) just under axilla, avoiding axillary pressure; 3) low pelvis. Attach supports to chairback or back support system.
b Durable Medical Equipment.
c If resident demonstrates competence.
