Performing activities of daily living involves a variety of sensory, motor and cognitive skills. Acquisition of basic self-care skills is an important part of the socialization process. As the development approach teaches, independent mastery of these activities generally proceeds in an orderly and predictable manner. Typically a person gradually assumes more and more of an active role in self-care, as the caretaker assumes a more passive role. If you understand what an individual is able to do by him/herself you will be able to help facilitate independence and the acquisition of new skills rather than frustrate the person by demanding either too much or too little. Often skills are in a transitional phase, which means that the person is still in the process of learning to utilize a new skill efficiently. It may be necessary to provide additional time and/or opportunities to complete tasks. It is also important to praise all efforts to help foster self-esteem and perseverance.
This section will discuss six important areas:
- Positioning - general rules for handling and positioning during a variety of activities;
- Eating - problems in eating; adaptive equipment
- Body Mechanics - mechanics of lifting, carrying and transferring; using a wheelchair;
- Dressing - dependent and independent dressing skills; use of braces
- Bathing - use of adaptive equipment
- Toilet Care - assisting with toileting; use of adaptive materials; scheduling.
1. Positioning:Many children are unable to move from one place to another independently. The physical manifestations of their condition may include weakness, paralysis or poor coordination due to a lack of voluntary control over muscles or difficulty in maintaining equilibrium. Invariably there is some type of abnormal muscle tone. Increased muscle tone is referred to as "hypertonic," and the individual may exhibit "spacticity" in various muscle groupings. Decreased muscle tone is known as "hypotonic," and muscles may appear "floppy." When muscle tone fluctuates from hypotonic to normal it is known as "athetoid."
Normal coordinated movement is based to a large extent on reflexes. Reflexes are classically viewed as predictable motor responses that follow specific sensory input. A person who has central nervous system damage may exhibit reflexes in an exaggerated form, and be unable to move out of abnormal postural patterns without assistance. Proper handling and positioning techniques is important in order to maximize comfort level and the ability to interact with the environment.
Contracture occurs when a joint cannot move through its full range because muscle on either side has shortened at a resting state. Contractures can be prevented if the person's body is kept in correct alignment when resting, and daily exercise and moving of the limbs through the normal range is followed. It is important to move and re-position an individual with physical disabilities often so as to provide various types of motor stimulation and to decrease the possibility of pressure sores and joint fixation.
- Always have the individual in a symmetrical position (both sides of the body look the same.)
- Have hips and knees and feet at least at a 90-degree angle.
- Flex the head and roll the shoulders forward. Flex the hips and knees up to help break up excessive muscle tone.
- Use safety straps and shoulder harness as necessary. Make sure the straps are not too tight and interfering with breathing.
- Use only the necessary adaptive side and back supports on a wheelchair.
2. Eating:In many families socialization takes place around the dinner table. It is important that the individual with special needs be encouraged to participate with other members of the household to the fullest extent. Information pertaining to eating should be discussed with the parent/guardian. It is imperative that you be informed of food allergies, reactions to medications, type and texture of food and frequency of meals. Positioning is also important when assisting an individual with eating or when attempting to feed someone. Pay attention to the following:
- Body positioning: relax the individual and place him/her in the desired position. An ideal position for eating is upright sitting so the head is aligned with the body. Avoid feeding an individual who is lying down. Consult with the family in special circumstances. Proper positioning during eating will help relax excessive muscle tone and/or help strengthen muscle if the tone is low. When positioning an infant or child in a high chair make sure:
- The trunk is erect - you may have to place side rolls next to the body to keep the trunk straight. You can make side rolls from rolled-up towels. Be careful not to crowd the child with too many rolls.
- Hips are next to back of chair - secure the chair's seat belt around the hips to keep them in place. You may need to place a non-skid surface on the seat of the chair to prevent sliding out of the seat. (Non-skid bathtub decals can work).
- Knees are bent over the edge of the chair - If the individual is too far back in the chair you may need to add a back support to bring him/her forward. Do not bring the individual too far forward to prevent falling out of the chair.
- Feet are placed on footrest - Avoid dangling the person's feet. You may need to build up the footrest with books or cardboard. Feet should be flat on the footrest so that the angle between ankles and feet is 90 degrees, and between knees and legs is 90 degrees. Toes should not be pointed up or down.
- Head is erect or slightly bent forward - Do not permit the head to tilt backwards when feeding. You may have to provide support behind the head, under the curve, to give needed control. Watch that the head does not lean to the side. Do not allow the head to "flop" forward or backward. The head should be held in the middle, looking straight at you.
- Arms are on top of tray - Arms should not be under tray or out to the side.
When an individual is seated in wheelchair or a "travel chair" be sure to:
- Watch for a straight trunk, head in the middle position, feet secure and hands on top of the tray.
- Place the chair in the most upright position that can be tolerated by the individual.
For individuals seated at a table in a regular chair make sure that feet are supported. You may need to place a footstool under the table for the feet. Keep the hips positioned next to the back of the chair and maintain upright posture. A towel or large sheet can be used as a seat belt to prevent slumping forward. The individual may need to lean the elbows on the table for support, but whenever possible hands should be placed on top of the table, not dangled at the side.
As much as possible follow the normal eating routine of the family (e.g. time of day, preparation, routines). Maintain a pleasant mealtime atmosphere. Speak quietly and calmly. Eliminate excess noise and distractions. If the individual cannot see the food, use voice and touch cues. Describe what you will be feeding him/her, or what is being served for them to eat. Individuals with hearing impairments should be able to see the food at all times, however continue to talk to the person. Signing or picture communication can also be used to help the person understand what they will be eating.
Many individuals experience oral sensitivity to food texture, taste and temperature. They may be uncomfortable with utensils being placed in the mouth. Always check with parents/guardians about the best way of assisting with eating when these issues are present. Avoid startling the person and keep your voice calm and reassuring.
Some individuals will have difficulty with chewing and swallowing. They may engage in frequent coughing or choking when eating. Watch the person and allow him/her to cough without patting on the back as long as he/she is able to cough. If you see that he/she is gasping for air begin procedures for clearing an obstructed airway.
The inability to keep food or liquids inside the mouth may be the result of an inability to keep the mouth closed. You may provide assistance by placing a finger or thumb at the jaw joint with your middle finger or thumb under the chin. Use the other free finger to push up on the lower lip.
Spoons should fit the size of the mouth. Spoons with built-up handles allow individuals to hold the spoon better. Flatter bowls make the removal of food easier, and a higher rim on plates allows the scooping of food against the edge. Dividers in infant plates help to keep foods separate. Using insulated plates can keep food temperatures constant. Foam pads, clay substitute, non-skid plates or a suction cup placed under the plate will assist an individual with self-feeding while keeping the plate in place.
3. Body Mechanics:When lifting, transferring or carrying a person who is physically disabled it is very important that you observe the following principles of body mechanics. Practicing them will help to prevent possible strain or injury to your lower back, and insure a safe lift for the individual.
The term "handling" refers to methods for holding or lifting a person with developmental disabilities. Always prepare for what is going to happen. Tell the person what you are going to do, use a gesture or a familiar signal so that the individual understands. Allow the individual to assist in moving as much as he/she is able, and as long as it does not require excessive effort or strain. Handle the person slowly and securely. Maintain the same posture on both sides of the body, with good body alignment. Handle at the shoulders, hips and through the trunk - not by the arms or legs.
Plan the move/lift.
Make sure you have ample room for good footing and the path is clear for carrying.
Stand so you do not have to twist as you lift.
Lift by straightening the legs is a steady upward thrust and, at the same time move the back to a vertical position.
The person's weight should be kept as close to you as possible
Keep your back straight, not arched.
Change direction by stepping around and turning the whole body.
Lower in a slow and even manner, bending your legs.
Although some individuals who use wheelchairs may have sufficient arm strength and coordination to transfer in and out of their chair independently, many will need assistance. Always ask the parents/guardians to show you the method used for their child. An additional issue to consider is that often respite care may take place in the home of the provider.
It is important to think about ways in which you can make your home more accessible, such as removing floor rugs from central pathways, rearranging moveable furniture or making minor adaptations to entry or foyers (such as wooden ramps over extra steps).When transferring individuals into or out of wheelchairs, always remember to:
Make sure the chair is locked when taking a person out of it or putting him/her into it.
Pull wheelchairs backwards up steps, curbs, etc.
Adjust the height of the foot pedals so that the person is sitting at a 90 degree angle at the hip and knee unless he/she is in a "Posture 90" chair.
Place one arm around the person and under his/her arm at the armpit. Place your other arm under the person's knees. OR
Face the person in the chair, secure a hold under each arm, lift out of the chair making sure you have put up the foot pedals or moved them out of the way.
Moving from Bed to Wheelchair:
Place the chair at a close angle to the bed.
Move the person to the edge of the bed, moving upper trunk first, then the legs, one at a time.
Remember to bend from the knees, not from the waist.
Position yourself near the person's head and trunk.
Slide one arm under the person's upper trunk (under the arms) and raise to a sitting position.
Place your other arm in a cradle position under the person's hips. Straighten your knees, lift and hold the person close to your body.
Turn one half circle to face the chair and lower the person into it while bending your knees.
From Wheelchair to Bed:
Place the chair at an angle close to the bed.
Face the person, assume a slight squatting position (knees bent), place one foot in front of the other and encircle the person at the waist or upper chest.
Shift your weight onto your back foot, straighten the knees, and lift the person out of the chair.
Swing one-half circle, and sit the person on the bed.
Place the legs on the bed and move him/her to the center of the bed.
4. Dressing:For most people undressing is easier than dressing. It is important for you to understand how much independent dressing an individual may do and how much assistance will be needed. In order for an individual to dress independently he/she needs to be able to maintain a sitting balance and have adequate trunk control so that arm motions will not affect balance. The individual must be able to move the arms purposefully in a desired direction to reach necessary garments, and to lift up in order to remove slacks, pants, etc. Grasping and releasing article of clothing requires finger dexterity, as does shoe lacing, tying and buttoning.
Some individuals may find it easier to dress while sitting on a floor, in a chair, on the bed, lying down or in a kneeling position. When assisting with dressing, do not try to stretch the limbs too quickly. Talk in a calm, soft voice and guide the individual through the clothing. If braces must be used always have the parent show you the correct procedure for taking them on and off.
5. Bathing:It is important to provide a comfortable and safe position for bathing. If a person is unable to sit in a tub independently, a special bathtub seat with suction cups and a seat belt can be used. An inflatable "doughnut" tube may also provide sufficient support. Bathtubs and showers should have slip-resistant strip to prevent falling.
Bathing is a good time to inspect the person's skin for pressure areas. These areas will develop in individuals with sensory and motor problems as a result of remaining in one position for too long. Skin breakdown can be a serious problem if it is not cared for immediately. Should you notice any early warning signs, such as reddened areas on the person's skin, notify the parent/guardian immediately. Be sure to position the individual in positions which relieve pressure on the affected area and move frequently to minimize additional injury.
6. Toilet Care:Toileting is the most personal activity of daily living that may require assistance. In order to protect the person's self-esteem it is very important that toileting issues be handled in a positive and supportive manner. Some of the individuals you will assist will be in the process of learning to toilet themselves. You may be asked to maintain a toileting program. Make sure that parent/guardian has thoroughly explained all steps of this program and how it is to be documented. Schedules may be strict, ranging from attempts to toilet every few minutes to various times throughout the day. Make sure you adhere to any toileting schedule that is in place.
Catheters or urine collection devices may be worn either internally or externally. A catheter is a tube-like medical appliance which is surgically inserted into the bladder to help drain urine. Urine drains into a container which may be attached to the individual's leg or a wheelchair. Tubes on these devices can become obstructed. It is important to check the tube to make sure it is draining from time to time, especially after a major change in positioning has been made.
It is always necessary to wear protective gloves when assisting individuals with toileting or when emptying and cleaning catheter containers.
The information outlined in this module is meant to be an overview, and may need to be supplemented by another source. The parent/guardian should always be asked for information and direction before any assistance is attempted in areas of daily living.