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.History1. If the resident self-propels the wheelchair,a) what does s/he use? __ One arm __ Two arms __ One foot __ Two feetb) where does s/he go? __ Bathroom __ Dining room __ Activity room __ Outside2. If the resident sits in the wheelchair,a) for approximately how many hours per day?b) during which activities? __ Resting __ Eating __ Watching TV __ Recreation3. 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 __ No6. 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 __ BothOther Equipment: _____________________________________________________________________Observe the patient sitting and supine and complete the Observation box below.ObservationPelvic Tilt: __ Posterior __ Anterior Thoracic Kyphosis: __ Mild __ Moderate __ SeverePelvic Rotation (forward ASIS*): __ Left __ Right Scoliosis: __ Mild __ Moderate __ SeverePelvic 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 SpineIdentify 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 ChairReason: 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 ForwardReason: 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 RestReason: 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 excursionReason: 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 DifficultiesReason: 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. Current as of 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
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