Appendix B7: Wheelchair Seating Assessment (Text Description)

The Falls Management Program Manual

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.

Page last reviewed February 2010
Internet Citation: Appendix B7: Wheelchair Seating Assessment (Text Description): The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanwsa.html