Module 2 - Developing a Client Profile: Getting the Big Picture
Medical History and Physical Attributes
The client's medical condition impacts upon the clinical requirements of the seating and mobility system.
Primary and secondary diagnosis including dates of onset to determine:
- Progressive vs. stable condition
- Acute vs. chronic condition
- Present and future needs
- The features on the wheelchair that match the clinical condition
- How often the wheelchair will be used
Surgical history and considerations
Fractures and dislocations
Note the causes, locations and the impact on seating and posture
Some common presentations that impact on seating are:
- Hip dislocation or fractured femur - leg length difference impacts on seat depth, detached femur encourages pelvic obliquity
- Fractured tibia/fibula - leg length difference impacts on footplate set-up
- Vertebra subluxations or fractures - fixed lordosis, kyphosis, scoliosis, cervical hyperextension or flexion
- Rib fractures - check spinal column for scoliosis instead of palpating rib cage. Take precaution when applying thoracic lateral support
Orthopaedic, surgical interventions and precautions
- For example, shoulder conditions will impact on range of motion and strength during wheelchair propulsion
- A client may lean to one side to compensate for weakness or restriction
Orthotic/prosthetic device used
- Amputee - wheelchair set-up when prosthesis is on or off
- Spinal orthotic brace may impact on seat angle and backrest options
Pressure ulcer history
- WHEN (did it happen/frequency), WHERE (was the pressure ulcer), and WHAT (was the wound grade)?
- HOW did it occur?
- HOW was it managed?
See "An overview of skin and pressure area management" for more information.
More details in Module 8
Spasm
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Are there safety concerns due to spasm?
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Are there postural and positioning concerns due to spasm?
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How does the client's tone/spasm affect his/her daily life?
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Is the client properly medically managed in these areas?
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Is the client partaking in drug trials that may impact on seating outcome?
Sensation
Take into consideration the level of spinal cord injury, the completeness/incompleteness of the injury and the presence or absence of sensation as these will impact on:
- pressure care management
- hand function
- balance
- comfort and pain
A seating system may play a part in managing musculo-skeletal discomfort and pain. Establish if pain is seating-related by obtaining the following information:
- WHEN (does it start/frequency), WHERE (is the pain), and WHAT (is the pain like: dull, burning, sharp etc)?
- HOW did the pain occur?
- What triggers the onset of pain?
- What makes it worse?
- Client's perceptions of the cause, for example localised pressure, discomfort
- HOW is it managed?
- What has worked for the client as pain relief in the past, for example, bed rest, medication, change position/stretches?
- Is the client properly medically managed in these areas? See "Managing pain for adults with Spinal Cord Injury" for more information.
Cardiovascular, respiratory status and autonomic dysreflexia
- What are the implications of these conditions on the seating and mobility system?
- Seek information about exercise tolerance, endurance and oedema issues
- Are devices required for respiratory function, eg ventilator, BIPAP ?
- Is the client susceptible to autonomic dysreflexia? See "Autonomic Dysreflexia" for more information.
Bowel and bladder function
- What is the current bowel and bladder management regime and how are these carried out? (That is, what aspects of the seating and mobility system will enable the client to perform transfers on the toilet or self- catheterisation in the wheelchair and to empty the leg bag?)
- Does the client have issues with bowel and bladder incontinence? (Skin and pressure risk)
- How long does the client sit on the commode/toilet? (Pressure risk)
- What continence aids are used? Where and when? (For example, "bluey" over the pressure care cushion)
- Does the client have a supra-pubic catheter or iliostomy and if so, where? (Pelvic belt may cause pressure over the catheter site)
- Does the client have a history of recurrent bladder infections?
- Consider the medical and nursing involvement.
See "Bowel Booklet" and "Neurogenic Bladder" for more information on bowel and bladder management.
Other medical conditions/physical attributes
- Vision
- Adequate vision is required for safe independent mobility
- Hearing
- Compensatory strategies may be required for wheelchair training and independent mobility in the community environment
- Oromotor for speech and swallowing
- Is there a history of aspiration and low voice volume influenced by posture and positioning?
- Body weight
- Underweight and obesity contribute to a higher pressure risk (eg Waterlow scale)
- Client's weight can influence product selection based on the weight capacity
- See "Nutrition for adults with Spinal Cord Injury" for more information
- Body height (see also Module 4)
- Impact on equipment selection regarding size
- Assess footplate/foot support clearance from the ground
- Assess height clearance for tall clients when entering vehicles
Medications and Known Allergies
- Note medications dosage and reasons
- Note allergies, including skin allergies