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Wheelchair service training package: basic level

31 décembre 2012 Organisation mondiale de la santé

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r i a h c Wheel g Package ants ip ic t r a P r fo l a u n a Reference M Basic Level

n i n i a r T e c i v r e S

r i a h c Wheel g Package ants ip ic t r a P r fo l a u n a Reference M Basic Level

n i n i a r T e c i v r e S

Contributors: Editors: Authors: Peer reviewers: Chapal Khasnabis and Kylie Mines Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, and Isabelle Urseau Melissa Puust Chapal Khasnabis and Jesse Moss Chapal Khasnabis, Amanda McBaine, and Jesse Moss Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT)

Illustrator: Photo credits: Video credits: Pilot trainers:

Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations:

WHO Library Cataloguing-in-Publication Data Wheelchair service training package / edited by Chapal Khasnabis and Kylie Mines. Contents: Trainer’s manual, basic level–Reference manual for participants, basic level – Participant’s workbook, basic level – Posters and slides, basic level. Trainer’s manual and slides available on DVD only. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150347 1 (package) ISBN 978 92 4 150348 8 (DVD) (NLM classification: WB 320) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/ licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cover photo credits (clockwise, from top): Mile End Films /Jesse Moss; WHO /Chapal Khasnabis; Mile End Films / Jesse Moss; Panos /Dieter Telemans; WHO /Chapal Khasnabis. Printed in Malta Design by Inís Communication – www.iniscommunication.com

Terminology The following terms used throughout the training package are defined below. Appropriate wheelchair A wheelchair that meets the user’s needs and environmental conditions; provides proper fit and postural support and is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at the most economical and affordable price. A wheelchair that is propelled by the user or pushed by another person. A device providing wheeled mobility and seating support for a person who has difficulty in walking or moving around. An overall term for wheelchair design, production, supply and service delivery. That part of wheelchair provision concerned with ensuring that each user receives an appropriate wheelchair. Persons skilled in the provision of an appropriate wheelchair. A person who has difficulty in walking or moving around and uses a wheelchair for mobility.

Manual wheelchair Wheelchair

Wheelchair provision Wheelchair service

Wheelchair service personnel Wheelchair user

CONTENTS

VII Preface 1 About the Wheelchair Service Training Package: Basic Level 5 A. Core knowledge 6 A.1: Wheelchair users 6 7 7 What are the benefits of a wheelchair? What is an “appropriate wheelchair”? The United Nations Convention on the Rights of Persons with Disabilities

8 A.2: Wheelchair services

10 A.3: Wheelchair mobility

13 A.4: Sitting upright

16 A.5: Pressure sores Meeting the wheelchair user’s needs Meeting the wheelchair user’s environment Providing proper fit and postural support

21 A.6: Appropriate wheelchair

29 A.7: Cushions 34 A.8 Transfers

B. Wheelchair service steps

39 Step 1: Referral and appointment 41 Step 2: Assessment 50 Step 3: Prescription (selection) 52 Step 4: Funding and ordering 54 Step 5: Product (wheelchair) preparation 62 Step 6: Fitting 74 Step 7: User training 76 Step 8: Maintenance, repairs and follow up

Preface The wheelchair is one of the most commonly used assistive devices for enhancing personal mobility, which is a precondition for enjoying human rights and living in dignity and assists people with disabilities to become more productive members of their communities. For many people, an appropriate, well designed and well fitted wheelchair can be the first step towards inclusion and participation in society. The United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities, the Convention on the Rights of Persons with Disabilities and World Health Assembly resolution WHA58.23, which deals with disability including prevention, management and rehabilitation, all emphasize the importance of wheelchairs and other assistive devices. To ensure that people with disabilities can access an appropriate wheelchair, especially in less resourced parts of the world, WHO developed the Guidelines on the provision of manual wheelchairs in less resourced settings, in partnership with the United States Agency for International Development (USAID) and the International Society for Prosthetics and Orthotics (ISPO). In order to train human resources appropriately and provide a good wheelchair delivery system based on the Wheelchair guidelines, WHO has developed this Wheelchair Service Training Package – Basic Level.

Alana Officer Robert Horvath Coordinator Manager Disability and Rehabilitation Team Programs for Vulnerable Populations Department of Violence and Center of Excellence on Democracy, Injury Prevention and Disability Human Rights, and Governance US Agency for International World Health Organization Development

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About the Wheelchair Service Training Package: Basic Level Introduction Following the release in 2008 of Guidelines on the provision of manual wheelchairs in less resourced settings,1 the World Health Organization has developed the Wheelchair Service Training Package: Basic Level. The wheelchair is one of the most commonly used assistive devices for enabling personal mobility. For people who have difficulties walking, a wheelchair which meets their physical, lifestyle and environmental needs is an essential tool, enabling them to enjoy vastly improved health, social and economic well-being. Mobility opens up opportunities for wheelchair users to study, work, engage in cultural activities and access services such as health care. The importance of mobility is reflected in the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) which advocates for “effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities”. To ensure effective personal mobility, wheelchair users need a wheelchair which fits them correctly and meets their specific needs. This requires an approach which is responsive to individual needs. An effective way of meeting the individual needs of wheelchair users is the provision of wheelchairs through wheelchair services. However, statistics show that less than 5% of those in need actually have access to a properly fitted wheelchair. In addition, there are limited training opportunities for personnel to gain the skills needed to prescribe a wheelchair effectively. The Wheelchair Service Training Package: Basic Level is intended to support the training of personnel fulfilling clinical and technical roles in a wheelchair service (see Guidelines on the provision of manual wheelchairs in less resourced settings, Table 4.2) at basic level. The training package supports the delivery of the theory and practice needed to begin working with wheelchair users who are able to sit upright without additional postural support. The training package includes: how to assess individual needs; assist in selecting and setting up the most appropriate wheelchair from those available; train users and caregivers how to use and maintain the wheelchair; and carry out follow up. 1 World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings.

Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, accessed 15 December 2011).

The training package can be delivered in 35– 40 hours, although this period may be extended or reduced according to the specific needs and resources available in each context. Further practice with a mentor is encouraged to build competencies and enhanced capacity for independent work. WHO hopes to see the Wheelchair Service Training Package both delivered as a stand-alone short training programme for personnel already working in the field, and integrated into the curriculums of training programmes for rehabilitation personnel.

Target audience This training package is for all personnel or volunteers who are expected to carry out wheelchair service delivery in their place of work. This may include health, rehabilitation or technical personnel, community health care workers, community-based rehabilitation workers, occupational therapists, physiotherapists, prosthetists, orthotists, local craftsmen, technicians and wheelchair users.

Purpose The Basic Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who have mobility impairments but can sit upright without additional postural support. The main purpose of the training package is to develop the skills and knowledge of personnel involved in wheelchair service delivery. Delivery of this training package will help to: • increase the number of wheelchair users who receive a wheelchair which meets their needs; • increase the number of wheelchair users who receive training in the use and maintenance of wheelchairs and how to stay healthy in a wheelchair; • increase the number of personnel trained in basic level wheelchair service delivery; • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery; and • achieve greater integration of wheelchair service delivery within rehabilitation services.

Scope The training package covers: • an overview of the eight steps of wheelchair service delivery described in the WHO guidelines on the provision of manual wheelchairs in less resourced settings (Table 1); 2

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• working with wheelchair users to assess their mobility needs and identify the best possible mobility solution; • providing an appropriate manual wheelchair with an appropriate cushion; • problem solving to find simple modifications to the wheelchair that can help ensure the best fit for the user; • wheelchair repairs and maintenance; • training of wheelchair users to make the best use of their wheelchair; and • fabrication of a foam contoured cushion. The inclusion of simple wheelchair modifications is particularly relevant in contexts where there are limitations in the range and sizes of available manual wheelchairs. It is often necessary to make simple modifications to ensure a wheelchair fits correctly. The provision of tricycles is not covered in detail in this training package, although the value of a tricycle for wheelchair users who need to travel longer distances is noted.

Table 1. Key steps of wheelchair service delivery: Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Referral and appointment Assessment Prescription (selection) Funding and ordering Product (wheelchair) preparation Fitting User training Maintenance, repairs and follow up

Required knowledge and skills Previous experience in wheelchair service delivery is not required. However, the training programme has been designed assuming that participants will have the following knowledge and skills: • participants will be able to read and write in the language of the training programme; • participants will have a basic knowledge of the common health conditions; or physical impairments which may affect people who can benefit from wheelchairs, including cerebral palsy, lower-limb amputation, poliomyelitis (polio), spinal cord injury and stroke.

Where participants do not already have information about these health conditions or physical impairments, trainers should include this information as an additional core knowledge session.

Structure The Wheelchair Service Training Package: Basic Level is designed to be delivered by trainers who are skilled in basic wheelchair service delivery and can confidently demonstrate the competencies taught in this training programme. There are a range of teaching resources, including: • Trainer’s Manual and trainer’s tools; • Reference Manual for Participants (hereafter referred to as Reference Manual); • Participant’s Workbook; • Wheelchair service forms; • Wheelchair service checklists; • Visual aids, including PowerPoint slides, videos and posters.

Development process Following the release of the Guidelines on the provision of manual wheelchairs in less resourced settings (WHO, 2008), WHO formed a working group to develop the Wheelchair Service Training Package. The first working group meeting was convened by WHO in October 2008 to determine the scope and content of the Training Package. Following circulation and receipt of feedback from over 20 experts in the field on the proposed Training Package content, a core group of contributors worked to prepare each training package for field piloting. In 2010, the Basic Level training package was piloted in India, Solomon Islands and Kenya. Each pilot was observed by members of the WHO Wheelchair Training Package working group. Feedback from trainers, trainee participants and wheelchair users participating in the practical sessions has been incorporated into the final documents. In addition to the pilots, the Basic Level training package was circulated for peer review, with valuable feedback gained from a range of experts in the field. All the authors involved in the development of the training package completed a Declaration of Interest (DOI) and none declared any conflict of interest related to the subject matter.

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A. Core knowledge

A.1: Wheelchair users Wheelchair users are people who already have a wheelchair or who can benefit from using a wheelchair because their ability to walk is limited. Wheelchair users include: • children, adults and the elderly; men, women, girls and boys; • people with different mobility impairments, lifestyles, life roles and backgrounds; • people living and working in different environments including rural, semi-urban and urban. The needs of each wheelchair user will vary. However, they all need an appropriate wheelchair.

What are the benefits of a wheelchair?

• Mobility: Wheelchairs help people to get around with the greatest possible independence and do the things they want to do. • Health: A wheelchair can improve the user’s health in many ways. A well fitting wheelchair with a cushion can reduce common problems, such as pressure sores or poor posture. A wheelchair that works well, fits well and can be propelled easily can increase the physical activity of the user, thus improving health. • Independence: Wheelchair users can be more independent and more in control of their own life. • Self-esteem and confidence: Wheelchair users may become more confident and have more self-esteem when they have a wheelchair which fits them and which they can use well. • Access to community life: With a wheelchair, wheelchair users can be more involved in community life. For example, it enables the user to go to work or school; visit friends; attend places of worship or other community activities.

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What is an “appropriate wheelchair”? An “Appropriate Wheelchair” is a wheelchair that: • meets the user’s needs; • meets the user’s environment; • is the right match for the user; • ensures postural support (helps the user to sit upright); • can be maintained and repaired locally.

The United Nations Convention on the Rights of Persons with Disabilities The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) entered into force on 3 May 2008. There are human rights that apply to everybody. The UNCRPD focuses on ensuring that everybody recognizes that these rights also apply to people with disabilities. There are 50 different articles in the Convention. One of the articles, article 20, is about “personal mobility”. Personal mobility means the ability to move in a manner and at the time of one’s own choice. Article 20 says: “States Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities”. Wheelchairs and wheelchair services are very important for assisting most people with mobility impairments to gain personal mobility. Wheelchair service personnel can help to implement article 20 of the UNCRPD by: • providing an appropriate wheelchair for wheelchair users who visit their service; • assisting wheelchair users in learning how to get in and out of their wheelchair themselves; • supporting wheelchair users in learning how to propel themselves; • encouraging family members to support wheelchair users to be as independent as they can be. There are other human rights that people with mobility impairments can enjoy more easily if they have an appropriate wheelchair. These are: • living independently and being included in the community (article 19); • right to education (article 24); • right to the enjoyment of the highest attainable standard of health (article 25); • right to work and employment (article 27); • right to participate in political and public life (article 29); • right to participate in cultural life, recreation, leisure and sport (article 30).

The UNCRPD (Article 20–Personal mobility): States Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities, including by: a) Facilitating the personal mobility of persons with disabilities in the manner and at the time of their choice, and at affordable cost; b) Facilitating access by persons with disabilities to quality mobility aids, devices, assistive technologies and forms of live assistance and intermediaries, including by making them available at affordable cost; c) Providing training in mobility skills to persons with disabilities and to specialist staff working with persons with disabilities; d) Encouraging entities that produce mobility aids, devices and assistive technologies to take into account all aspects of mobility for persons with disabilities.

Which means:2 Countries should make sure disabled people can get about independently as much as possible. They should: • Assist people get about. • Assist people to get a quality wheelchair at an affordable cost. • Give training on how to get about. • Get entities/companies that make aids to think about all different needs of disabled people.

A.2: Wheelchair services Wheelchair services work with wheelchair users to find the most suitable wheelchair among those available for that user. The WHO Wheelchair guidelines outline eight steps that wheelchair service personnel need to carry out to provide a wheelchair. These steps are summarized below. Each step is covered in more detail in Section B of this manual.

2 International agreement on the rights of disabled people (easy-read version of the CRPD), prepared for the United Kingdom Department for Work and Pensions by the ”easy read” service @ Inspired Services.IS164/07. Newmarket, Inspired Services, 2007 http://odi.dwp.gov.uk/docs/wor/uncon/un-agree.pdf (accessed 15 December 2011).

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Step 1. Referral and appointment

Summary The way that wheelchair users are referred will vary. Users may refer themselves or be referred through networks made up of governmental or nongovernmental health and rehabilitation workers or volunteers working at community, district or regional level. Some wheelchair services may need to identify potential users actively if they are not already receiving any social or health care services or participating in school, work or community activities. Each user needs an individual assessment, taking into account lifestyle, work, environment and physical condition.

2. Assessment

3. Prescription (selection)

Using the information from the assessment, a wheelchair prescription is developed together with the user and family members or caregivers. The prescription (selection) details the selected wheelchair type and size, special features and modifications. It also describes the training the user needs in order to use and maintain the wheelchair properly. A funding source is identified, and the wheelchair is ordered from stock held by the service or from the supplier. Trained personnel prepare the wheelchair for the initial fitting. Depending on the available product and service facilities, this may include assembly, and possible modification, of products supplied by manufacturers or manufacture of products in the service workshop.

4. Funding and ordering 5. Product (wheelchair) preparation

Continues..

Continued

Step 6. Fitting

Summary The user tries the wheelchair. Final adjustments are made to ensure the wheelchair is correctly assembled and set up. If modifications or postural support components are required, additional fittings may be necessary.

7. User training

The user and caregivers are trained how to use and maintain the wheelchair safely and effectively.

8. Maintenance, repairs and follow up

The wheelchair service provides maintenance and repair services for technical problems that cannot be solved in the community. It is appropriate to carry out follow up activities at the community level as much as possible. Follow up appointments are an opportunity to check wheelchair fit and provide further training and support. The timing depends on the needs of the user and the other services that are available to them. If the wheelchair is found to be no longer appropriate, a new wheelchair needs to be supplied starting again from step one.

Source: World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings, Table 3.2. Geneva, 2008:76.

A.3: Wheelchair mobility Many wheelchair users live and work in places where it is difficult for them to get around, for example areas where the ground is rough, sandy or muddy, or where there are steps, kerbs or small cramped spaces. Training in wheelchair mobility skills can help wheelchair users to tackle some of these obstacles, either independently or with assistance. Various wheelchair mobility skills are described below.

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Wheelchair Mobility Skills: • Pushing correctly requires less effort. • Push from 10 o’clock to 2 o’clock position. • Use long smooth action to push.

Pushing

Turning

• Hold one push rim towards the front and the other towards the back. • Pull the forwards hand backwards and push the backward hand forwards at the same time.

Up slopes

• Lean forward – this helps to stop the wheelchair tipping. • When practising, have an assistant stand behind for safety. • To stop or rest – park the wheelchair sideways on.

Down slopes

• Lean backwards. • Let the push rim slide slowly through the hands. • Experienced wheelchair users who are able to do a “wheelie” (i.e. balance the wheelchair on the rear wheels only) may roll down a slope on their back wheels. This is very efficient.

• Go up backwards. • Tilt wheelchair on to back wheels, positioned against the first step. • Assistant pulls backwards and upwards – rolling the wheelchair up. • Wheelchair user can assist by pushing the push rim backwards. • A second assistant can assist by holding on to the wheelchair frame from the front (not footrests).

Up steps with assistance

• Go down forwards. • Tilt the wheelchair on to back wheels. • Assistant lets the back wheels roll down slowly, one step at a time. • Wheelchair user can assist by controlling the wheelchair with the push rims. • A second assistant can help by steadying the wheelchair from the front, holding on to the wheelchair frame (not footrests). • Being able to do a partial wheelie is very useful for a wheelchair user. • The wheelchair user can lift the front wheels to clear small kerbs, stones and bumps. • Roll the wheelchair backwards until hands are in the 10 o’clock position. Then push forwards quickly. • The castor wheels should come up. • With practice, it is possible to lift the castor wheels at the right time to clear small obstacles. • Always make sure that there is an assistant standing behind the wheelchair user when he/she begins to practise this skill.

How to make wheelchair mobility skills training safe • Do not stand on footrests when getting in and out of the wheelchair. • Keep fingers clear of the wheel spokes and brakes. • When learning how to go up hills, or doing a partial wheelie, ALWAYS have an assistant stand behind the person in the wheelchair. • Do not assist a wheelchair user up and down steps unless you feel very sure that you are able to control the wheelchair safely. If unsure, get help.

Partial wheelie

Down steps with assistance

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A.4: Sitting upright Most wheelchair users spend many hours sitting. This means that their wheelchair is not just a mobility aid. It also helps to support them in sitting upright comfortably.

Sitting upright/neutral sitting posture What is posture? Posture is the way a person’s body parts are arranged. Wherever possible, a well fitting wheelchair should support wheelchair users in sitting in an upright posture. Sometimes “sitting upright” is described as a neutral sitting posture.

Why is it important to sit upright? Sitting upright helps wheelchair users in many ways. Sitting upright is good for: • health: an upright posture helps with digestion of food and breathing; • stability: an upright posture is more stable; • weight distribution: when sitting upright body weight is evenly distributed – this helps to reduce the risk of pressure sores; • comfort: when body weight is distributed evenly, it is more comfortable for the user; • preventing problems with posture: sitting upright will help to reduce the chance of developing deformities of the spine in the future; • self-esteem and confidence: sitting upright can help wheelchair users feel better about themselves. Even though sitting upright has many benefits, without postural support it can be hard to stay in this posture all day. This is why people without a disability use different postures throughout the day. For a wheelchair user who sits in a wheelchair all day, the wheelchair needs to provide enough support to help the user to sit upright comfortably.

How to tell if a person is sitting upright Look from the side and check:  Pelvis upright;  Trunk upright, back following the three natural curves;  Hips flexed near 90 degrees;  Knees and ankles flexed near 90 degrees;  Heels directly below the knees or slightly forward or back;  Feet flat on the floor or footrests.

Look from the front and check:  Pelvis level;  Shoulders level, relaxed and arms free to move;  Legs slightly open (abducted);  Head upright and balanced over the body.

How the pelvis affects the way we sit The pelvis is the base for sitting upright. To be strong and stable, a building needs a solid foundation. In the same way, to be stable when sitting the pelvis must be strong and stable. When the wheelchair user is sitting upright, the pelvis is: • level (viewed from the front); and • upright or slightly tilted forward (viewed from the side). Front view of pelvis Side view of pelvis

Any changes in the pelvis will cause a change in the other parts of the body. If the pelvis is not upright, it is difficult to sit upright.

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The pelvis moves in different ways. The table below shows four different pelvic movements and how the body changes when each movement is made. Movement Rolling forward: (forward pelvic tilt).

Illustration

Changes in the body • The body straightens out with the shoulders pulled back. • There is an increase in the curve of the spine above the pelvis.

Side view of pelvis Rolling backwards: (backward pelvic tilt). • The body becomes rounded with the shoulders forward.

Side view of pelvis Tilting sideways: (lateral tilt). • The body bends sideways.

Back view of pelvis Rotation. • The rest of the body also rotates.

View from above

A.5: Pressure sores A pressure sore is an area of damaged skin and flesh. A pressure sore can develop in a few hours, but the results can last for many months and even cause death.

What causes pressure sores? The three main causes of pressure sores are the following. Pressure: Pressure sores can be caused by pressure on skin from sitting or lying in the same position for too long without moving. Wheelchair users are particularly at risk, because they may spend a long time each day sitting in their wheelchair. Unless the pressure is relieved, a pressure sore can quickly develop. Friction: Friction is constant rubbing on the skin. For example, an arm rubbing on a wheel/armrest as a wheelchair is moved can cause a pressure sore.

Shear: Shear is when the skin stays still and is stretched or pinched as muscles or bones move. For example, when a wheelchair user sits “slumped” in the wheelchair, skin may be damaged by shear by the seat bones as the pelvis rocks backwards, or by bones in the back squeezing the skin against the backrest.

Pressure sore risk factors As well as the three main causes of pressure sores, there are a number of things that make it more likely that someone will get a pressure sore. All these are called pressure sore risk factors. Pressure sore risk factors include the following.

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• Person cannot feel (decreased sensation): Anyone who cannot feel, or has difficulty feeling touch on their buttocks (like most paraplegics or quadriplegics), seat or legs is at risk of developing a pressure sore. • Person cannot move: When a person cannot move, he/she is unable to relieve the pressure. • Moisture from sweat, water or incontinence: Moisture makes the skin soft and more easily damaged. If the user does not have a way to manage bladder and bowel function, urine and faeces can burn and damage the skin. • Poor posture: Not sitting upright can cause an increase in pressure in one area. • Previous or current pressure sore. • Poor diet and not drinking enough water: A good diet, including drinking enough water, is important to ensure the body has fluid and nutrients to maintain healthy skin and heal wounds. • Ageing: Elderly people often have thin, frail skin which can damage easily. • Weight (underweight or overweight): People who are overweight may have poor blood flow in their skin, which can then damage easily and heal poorly. Wheelchair users who are underweight are at risk of developing a pressure sore because their bones are not well protected. The skin over the bony areas can be damaged quickly. Common pressure sensitive areas: Side view Back view

The four stages of a pressure sore3 1 A red or dark mark on the person’s skin. The redness or change in colour does not fade within 30 minutes after pressure is removed. What to do • Remove pressure from that area immediately. • Keep pressure off until the skin has fully healed. This may mean bed-rest. • Identify the cause and address this. • Teach the wheelchair user how pressure sores are formed and how to prevent them in future. Continues..

3 Spinal Injury Network. Pressure sore stages (http://www.spinal-injury.net/pressure-sore-stages-sci.htm, accessed 13 December 2011).

Continued

The four stages of a pressure sore 2 3 4 A shallow wound. The top layer of skin may start to peel away or blister. A deep wound; the whole layer of skin is lost. A very deep wound, extending through the muscle and possibly right down to the bone.

What to do Follow the actions for stage 1. Refer for treatment of the pressure sore to an experienced health care worker. Open pressure sores will need cleaning, dressing and close monitoring to ensure they are healing and do not become infected. Stage 4 wounds may require surgery.

How can pressure sores be prevented? Use a pressure relief cushion: A pressure relief cushion will help to reduce pressure. Anyone at risk of developing a pressure sore should be given a pressure relief cushion.

Sit upright: Sitting upright helps to distribute weight evenly. This reduces pressure under bony parts and helps to reduce sores caused by pressure. Sitting upright also helps to avoid pressure sores caused by shear. Wheelchair service personnel can help wheelchair users to sit upright by making sure the wheelchair fits correctly and explaining why it is important to sit upright.

Use pressure relief techniques: Regular pressure relief can be effective in preventing pressure sores. See below for more information about how to relieve pressure.

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Eat well and drink lots of water: A well balanced diet with fresh vegetables, fruits and meat can help to prevent pressure sores. Drinking lots of water will help to keep the skin healthy and prevent pressure sores. If you are concerned about a wheelchair user’s diet – consider referring him/her to a service that can help. Avoid friction: Make sure the wheelchair fits correctly and has no rough edges. Teach wheelchair users who cannot feel to check that no parts of their body are being rubbed by the wheelchair. Teach wheelchair users to take care when getting in and out of the wheelchair. Avoid moisture: Wheelchair users need to be advised to change wet or soiled clothing straight away, and not to use a wet cushion. A bowel and bladder management programme can reduce problems with moisture. Refer wheelchair users who have a problem with incontinence to a service that can help them. Check skin every day: Pressure sores can develop quickly. It is important to identify a pressure sore quickly and take action. Encourage wheelchair users who are at risk to check their skin every day. They can check themselves using a mirror, or ask a family member to check. If they see a red or dark area of the skin (stage 1 pressure sore), they should take all necessary measures to relieve pressure on that spot immediately.

While lying or sitting, change positions regularly: Changing position regularly helps to relieve pressure. For example, change position from sitting to lying. This is particularly important for someone who has a number of pressure sore risk factors, or has a recently healed pressure sore. People who cannot change position by themselves are at risk.

Pressure relief techniques Wheelchair users can relieve pressure from the seat bones while in their wheelchair. How they do this will vary, depending on how much strength and balance they have. Wheelchair service personnel need to teach all wheelchair users who are at risk of developing a pressure sore at least one way to relieve pressure. Bending forward: A method suitable for most wheelchair users. Independent: for people with good balance and strength. With assistance: For people with poor balance and strength.

Side to side leaning: A method suitable for wheelchair users with limited strength and balance.

Some wheelchair users may hook their arm over the push handle for support.

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A.6: Appropriate wheelchair Parts of a wheelchair Push handle Backrest

Armrest Rear wheel

Cushion Seat Seat rail Brake Footrests hanger Push rim Castor wheel Footrest Calf strap

Definition of an “appropriate wheelchair” Please refer to session A.1 Wheelchair users.

Meeting the wheelchair user’s needs An appropriate wheelchair should make it easier for wheelchair users to carry out the things they need to do. Wheelchair users need to be able to get in and out of their wheelchair, to push their wheelchair, to fold the wheelchair for transport and storage and carry out their daily activities. The right type of wheelchair can make it easier for the wheelchair user to do all these things. See the examples below. 21

Transfers Getting in and out of the wheelchair Wheelchair users get in and out of the wheelchair in different ways, depending on their physical ability. Different wheelchair features can make their transfers easier. Three features that make transfers easier are: armrests, footrests, and brakes. Removable armrests, or armrests which follow the line of the rear wheels, are easier for people who get in and out of their wheelchair sideways. People who stand up to get in and out of the wheelchair may need armrests to help them stand up.

Footrests which can be moved out of the way are helpful for people who stand up to get in and out of the wheelchair. People who want to transfer to the floor may prefer a wheelchair with removable footrests.

Brakes are important for all wheelchair users. They are essential for keeping the wheelchair still while the person gets in and out of the wheelchair.

Pushing the wheelchair Wheelchair users propel their wheelchair in different ways. Many wheelchair users propel the wheelchair with their arms. Some wheelchair users push the wheelchair with their feet – or with one arm and one foot. Some wheelchair users need someone to push the wheelchair for them some or all of the time. Pushing the wheelchair by hand propelling is easier when the armrests and backrest are the right height.

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Backrest is too high. The wheelchair user cannot comfortably move the arms and shoulders to push.

Armrests are too high. The wheelchair user cannot comfortably reach the wheels to push.

When the backrest is lower, the wheelchair user has freedom to move the shoulders to push. For a wheelchair user who can sit upright and has good balance, this is a good height for the backrest.

Pushing the wheelchair is easier if the wheelchair user can reach the push rims comfortably. The rear wheel should be positioned so that when the wheelchair user holds the top of the push rim the elbow is bent at 90 degrees. This is a good pushing position. If the wheel is further back, it is more tiring for the wheelchair user to push.

Some wheelchairs have an adjustable rear wheel position. The position of the rear wheels affects how easy it is to push the wheelchair into a wheelie. Wheelies are useful for going over rough ground, up and down kerbs or down slopes. If the rear wheels move forwards, the wheelchair is easier to push into a wheelie. If the rear wheels move backwards, they become more stable but the wheelchair is harder to push and it is harder to perform a wheelie.

Pushing the wheelchair with the feet is easier if the wheelchair user has enough power in one leg and can sit with the pelvis supported by the wheelchair backrest and the feet flat on the floor.

For wheelchair users who push with their feet, the height of the seat from the floor (including the cushion) is very important. Footrests that swing out of the way are also essential. Some users who push with their feet may like a tray or armrests so that they can lean forward while pushing. The weight of the wheelchair is particularly important in the case of children. If the wheelchair is heavy, this may make the chair hard for the child to control.

A heavy wheelchair takes more energy to push – whether hands, feet or assistant-propelled. However, if the wheelchair is well designed and well balanced, the weight may not be such a problem.

Folding the wheelchair To transport or store the wheelchair, it needs to fold. Wheelchairs fold in two main ways. Wheelchairs with a cross-folding frame fold so that both sides come together. Sometimes it is possible to remove the wheels as well. Cross-folding wheelchairs can be helpful for wheelchair users needing to “squeeze” through narrow doorways. For transport, some people prefer a cross-folding wheelchair. For example, it may fit better in the aisle of a bus. A disadvantage with some cross-folding frames is that the folding mechanism can weaken, making the wheelchair feel unstable. It then becomes harder to push. 24

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Some rigid frame wheelchairs also fold. However, instead of the two sides folding together, the backrest folds down and the rear wheels come off. One advantage of rigid frames is that they can be more durable, as there are fewer moving parts.

Carrying out activities There are several features of a wheelchair which affect how easily a wheelchair user can carry out the activities of daily life. For example, the features that help a wheelchair user to push (described above) will dictate how easily he/she can participate in activities. Here are some other examples. Wheelchair frame length: The overall length of a wheelchair can affect how easy or difficult it is to use in small spaces. For someone who spends a lot of time indoors, a wheelchair with a short length may be the best choice. The frame length is measured from the furthest back part of the wheelchair to the furthest front part. Frame length Armrests: High armrests may make it difficult for the user to get close to a table or desk.

Remember: An appropriate wheelchair helps to meet users’ needs. This includes making it easier for them to do the things they need and want to do.

Meeting the wheelchair user’s environment Different types of wheelchair are suited to different environments. The main features which affect how a wheelchair works in a different environment are: • distance between the front and rear wheels (wheelbase); • the size and width of the wheels. Distance between the front and rear wheels (wheelbase). The distance between the front and rear wheels is important. When the wheels are further apart, this is called a “long-wheelbase”. When the wheels are closer together, this is a “short-wheelbase”. Long-wheelbase wheelchairs are more stable and less likely to tip forward. They can be a good choice for a person who will spend most of the time outdoors and moving over rough or uneven surfaces. There are three-wheel and four-wheel long-wheelbase wheelchairs. Three-wheel long-wheelbase wheelchairs are usually very stable and suitable for outdoors on rough terrain. Wheelbase Wheelbase

Wheelbase

The four-wheel long-wheelbase wheelchairs have the front castor wheels under the footrests instead of behind. This gives the wheelchairs a longer wheelbase.

Shorter-wheelbase wheelchairs are more suited to use in places where the ground is flat or the space is confined – indoors, for example. Short-wheelbase wheelchairs are more likely to tip forward if going downhill, or if the front wheels hit a bump.

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This is an example of an orthopaedic-style wheelchair with a short wheelbase. This chair would not be easy to push over rough terrain.

Wheelchair users with good mobility skills may use a short-wheelbase wheelchair outdoors by balancing on the back wheels to go down hills and over rough ground.

Size and width of wheels The larger the wheel, the easier it is to push over uneven ground. Wide rear wheels and large and wide front castors help prevent the wheelchair from sinking into sandy or muddy ground.

Remember: An appropriate wheelchair will suit the user’s environment – which means the area where he/she spends most time.

Providing proper fit and postural support All wheelchair users are different sizes. The wheelchair must fit the user correctly to provide proper fit and support. Fortunately, many wheelchairs come in a range of different sizes, or have size adjustments. It is easier to make sure these wheelchairs fit the user than if there is only one size available. The following components or features of a wheelchair will affect how well the wheelchair fits and how well it helps the user to sit upright.

Seats Seats: Wheelchair seats may be either solid or slung. The picture on the left shows a solid seat. Solid seats may be made from wood or plastic. Solid seats should always have a cushion over the top. Slung seats are usually made from canvas. Slung seats are made from fabric attached to each side of the frame. Poor-quality slung seats can sometimes stretch and sag so they fail to provide good support. The man pictured on the left is sitting in a wheelchair with a slung seat which has become loose and saggy. It does not provide him with support. This makes it difficult for him to sit upright. Backrests: Backrests may be slung or solid. All solid backrests should have some padding/ cushioning. Backrest Armrest Cushion

Wheelchairs come with different backrest heights. Some wheelchairs have adjustable backrest heights. The correct backrest height needs to be selected for each user. Armrests: Armrests can also provide support. Some armrests are height-adjustable. If they are not, they can sometimes be modified to give more support for a user who needs it. Cushions: The cushion provides comfort, helps to relieve pressure, and also provides support and helps to stop the user from sliding. Footrests: Footrests help to support the user. It is very important that footrests are adjusted correctly. For this reason, the height of the footrests is usually adjustable. Some footrests can also be adjusted by angle, and the distance away from the wheelchair.

Footrest

Remember: An appropriate wheelchair provides proper fit and support for the user.

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A.7: Cushions What are cushions for? A cushion is a very important part of every wheelchair. Cushions provide: • comfort; • posture support (help people to sit more upright); • pressure relief. All wheelchair users should be comfortable in their wheelchair, and a good cushion helps them to sit upright easily and comfortably. That is why every wheelchair user should have a cushion. It is not necessary for every wheelchair user to have a pressure relief cushion.

Different types of cushions Cushions can be described in different ways, including: • the material they are made from (for example foam, coir); • the material they are filled with (for example air, fluid or gel); • their main function (for example pressure relief, comfort, posture support); • their shape (for example flat or contoured); • how they are made (for example foam cushions may be “moulded” from one piece of foam or “layered” – made from a number of layers of foam). The most commonly available cushion is a foam cushion. Foam cushions are also usually the least expensive. They are easy to make where foam is available and easy to modify to suit individual wheelchair users. Who needs a cushion?

Every wheelchair user should have a cushion. Wheelchair users at risk of developing a pressure sore should use a pressure relief cushion.

Pressure relief cushions There are different types of pressure relief cushions including: • foam contoured pressure relief cushions; • air/fluid/gel filled cushions.

Foam pressure relief cushions The key features of a foam pressure relief cushion are the following: Firm stable base: The base of a pressure relief cushion should be firm. This will make sure the cushion provides good support for the user and does not move when the user moves. Top layer: Over the base layer there should be a “comfort layer”. This is a layer (or more than one layer) of softer foam. The top layer should be soft enough to allow the seat bones to sink into it, but should not be so soft that the seat bones can sink all the way to the bottom and rest on the solid base or seat of the wheelchair. Pressure relief cushions help to reduce pressure by: • distributing a wheelchair user’s weight as evenly as possible across the seat surface; • reducing pressure under high-pressure risk areas (seat bones, hip bones, coccyx/tail bone); • reducing shear by assisting the wheelchair user to sit upright.

Shaping on a pressure relief cushion

Pressure relief cushions vary. Shaping that you may see on a pressure relief cushion includes: • a “well” under the seat bones to reduce pressure; • support under the hip bones to help distribute weight; • a shelf in front of the seat bones to keep the pelvis more upright and prevent sliding forward; • grooves or gutters for the legs.

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Air/fluid/gel pressure relief cushions

• Flotation cushions include those filled with air and those that have a fluid or gel pack. • Gel-pack cushions should have a firm foam base very similar to a foam contoured cushion. • Over the base layer there is a gel/fluid pack. • The gel pack automatically matches the shape of the wheelchair user’s body. This helps to distribute the user’s weight evenly and reduces pressure under bony areas.

Which cushion to use? There are advantages and disadvantages of both foam contoured cushions and air/ fluid/gel cushions. Advantages Foam contoured cushion Can be made locally (where there is high-quality foam). Can be modified locally to accommodate different needs. Not subject to”sudden collapse” (a puncture in the air/fluid/gel cushions can cause the release of the materials from the cushion and stop the cushion from relieving pressure, causing “sudden collapse” of the cushion). The top layer of a layered foam cushion can be replaced easily and at a low cost (rather than replacing the whole cushion). Pressure is distributed evenly over the seat surface. The gel pad automatically adapts to the body when the wheelchair user moves or changes position. Disadvantages Foam compresses (becomes flatter and firmer) over time. For this reason, foam cushions should be checked regularly and replaced every 1–2 years. Can take a while to dry out (a problem for people who are incontinent). Foam insulates and can cause an increase in tissue temperature.

Air/ fluid/gel cushions

Air/fluid/gel cushions are often more expensive and less readily available than foam cushions. Some wheelchair users find air/ fluid/gel filled cushions make them feel unstable. Subject to “sudden collapse”. In any context where a wheelchair user is not able to get a replacement cushion quickly, this can be a problem.

Cushion covers A pressure relief cushion should have a cover which can be removed for washing and is water-resistant. The material used for a pressure relief cushion cover should be either stretchy or loose enough to allow the seat bones to sink into the foam. If the cover fabric is not stretchy, a thin fabric is best. Folds in a thin fabric will be less likely to mark the skin and cause a pressure sore. If thin plastic is used under a fabric cover, this also needs to be loose enough to allow the seat bones to sink into the foam. Always advise wheelchair users that if their cushion or cushion cover becomes wet it needs to be dried and replaced only when dry. For wheelchair users who are incontinent and at risk of developing a pressure sore, provide two cushions which may be used in turn. What to do if there is no water-resistant cushion cover

Wherever possible, wheelchair users who are incontinent need a cushion cover which is water-resistant and will keep fluid away from the user’s skin. If there is no water-resistant cover: • investigate what assistance can be provided to reduce incontinence; • provide a second cushion – so that one can be drying while the user sits on the other; • protect the cushion with a very thin plastic bag inside the cover. If using a plastic bag: • check that the plastic bag does not cause the user to “slide” on the cushion; • make sure that there are no creases in the plastic bag that could cause a pressure sore; • the wheelchair user must ensure that fluid does not “pool” over the plastic, as this increases the risk of a pressure sore; • the wheelchair user should ensure that the cover is dried out if it becomes wet and the plastic bag cleaned or replaced.

How to test if a pressure relief cushion is working Whenever you prescribe a pressure relief cushion, carry out this simple manual test to check whether the cushion is reducing pressure under the user’s seat bones. The test requires personnel to place their hands underneath the wheelchair user’s seat bones. Always explain to the wheelchair user what you are going to do and why it is important. Always carry out the test with the same cushion and the wheelchair that has been provided for the user.

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Manual pressure test A Explain to the wheelchair user what you are going to do, and why it is important.

Ask the wheelchair user to push up or lean forward to allow you to place your fingertips under their left or right seat bone (palm up). This is best done from behind the wheelchair by reaching under the back upholstery with one hand.

Ask the wheelchair user to sit back down on your fingers. They should sit normally, face forward, and place their hands on their thighs. This will ensure that they sit in the same position each time you move to check another location. If your fingers are not in a good position to feel the pressure under the seat bone, then ask the user to push up again and reposition your fingers.

Identify the pressure under the first seat bone as either level 1, 2, or 3: Level 1 = safe: Fingertips can wriggle up and down 5 mm or more. Level 2 = warning: Fingertips cannot wriggle, but can easily slide out. Level 3 = unsafe: Fingertips are squeezed firmly. It is difficult to slide fingers out. Repeat under the second seat bone.

How to reduce “warning” or “unsafe” pressure? When level 2 (warning) or level 3 (unsafe) pressures are found under the seat bones, action is needed to reduce the pressure. A simple solution is to add an extra layer of firm foam. This is called a ”lift”. The lift should be approximately 20 mm thick and have holes cut out under the seat bone area. The lift is placed underneath the cushion and inside the cover. Sometimes more than one layer is needed. Personnel should add one layer and test the pressure. If the pressure is still level 2 or 3, add another layer.

A.8 Transfers Getting in and out of the wheelchair The ability to get in and out of the wheelchair easily and safely, with or without assistance, will help a wheelchair user in daily life. Getting in and out of the wheelchair can be called “transferring”.

Why do wheelchair users need to learn how to transfer? Wheelchair users may need to get in and out of their wheelchair several times a day. They need a method which is safe, quick and does not use much energy. Wheelchair users practise different methods, depending on their abilities. Some wheelchair users can get in and out of the chair by themselves, and others need help. Some users can stand up to transfer, while for others this is not possible.

Three ways to get in and out of the wheelchair Before recommending or practising a transfer with a wheelchair user you need to know whether he/she can transfer independently or needs help. • For transferring independently through sitting, check that the wheelchair user can lift his/her weight upwards by pushing with the arms. If the user cannot do this, he/she needs help to transfer. • For transferring independently through standing, check that the wheelchair user can stand up and take his/her own weight through the legs. If he/she cannot do this, he/she needs help to transfer. Some different ways to transfer are shown below.

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Independent transfer through sitting (wheelchair to bed)

• Position the wheelchair close to the bed, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Push up on hands and move to the front of the wheelchair. • With one hand on the bed and the other on the wheelchair, push up and lift on to the bed. • If the user has poor balance or cannot lift high enough or move sideways far enough, he/ she may use a transfer board. If transferring to a bed, some wheelchair users prefer to place their legs on to the bed before transferring.

Assisted transfer through sitting with a transfer board (wheelchair to bed) • Position the wheelchair close to bed, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Assist user to move forward. • Put a transfer board under buttocks across the wheelchair and bed. • User to assist as much as possible by pushing up on wheelchair and bed to take own weight. • Assistant stands behind user, and moves user’s buttocks over to the bed.

Assisted standing transfer (bed to wheelchair) • Position the wheelchair, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Assist the user to move forward on the bed and place feet on the floor. • Support the user’s knees from the side (do not push against knees from the front). • Bring user’s body forwards and upwards by supporting around the shoulder blades. • Twist the user towards the wheelchair and allow him/her to sit down gently.

What is a transfer board? A transfer board is a strong, thin board which can help to bridge the gap between the wheelchair and surface the wheelchair user is transferring to. Transfer boards are useful for wheelchair users who are learning to transfer independently, or who have limited strength in their arms. The wheelchair user can carry out the transfer in a series of small lifts, rather than one big lift. A transfer board can also reduce the assistance a wheelchair user may need. Transfer boards can be made locally from wood or plywood. They should be thin, strong and very smooth. Reduce the thickness at the edges. Suggested dimensions are 300 mm x 600 mm. The thickness of the board depends on the strength of the material, but a typical thickness is between 20 and 25 mm.

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Wheelchair age Service Training Pack

Independent transfer from floor to wheelchair • This transfer requires the wheelchair user to have strong arms and good balance. • Wheelchair users at risk of developing a pressure sore should always sit on their pressure relief cushion when sitting on the floor.

• Sitting in front of the wheelchair, draw the knees up close to the body. • Look down and keep looking down throughout the lift. • Place one hand on the floor and one hand on the front of the wheelchair seat. • Push down with the shoulders and arms to lift buttocks up and on to the front of the wheelchair seat. • Sit back into the wheelchair and reach down to pick up wheelchair cushion. • Shifting your weight to one side, push the wheelchair cushion in place. When transferring from the wheelchair to the floor • Sit at the front of the wheelchair. • Lift feet off the footrests in front of you and slightly to the side (away from the direction you are transferring). • Place your cushion on the floor. • With one hand on the wheelchair seat; reach down to the floor with the other hand. • Using the shoulders and arms, move the buttocks down on to the cushion you have placed on the floor in a controlled movement.

How to make getting in and out of the wheelchair safe For the wheelchair user: • Always put the wheelchair brakes on when getting in and out of the wheelchair. • Check where you are going – make sure there is nothing in the way. • Always lift. Don’t drag – this could cause skin damage and lead to a pressure sore. For people assisting: • Before assisting someone, make sure you can support his/her weight. • Explain to the user what you are going to do. • Use safe lifting techniques. • Do not assist if you are pregnant or have a back problem.

B. Wheelchair service steps

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Step 1: Referral and appointment Referral Referral means: sending or directing a person to the right place for care or assistance. There are different ways in which wheelchair users may be referred to a wheelchair service. For example, wheelchair users may: • hear about the service and come themselves; • be directed to the service by the local hospital, community health centre, community-based rehabilitation service, village/council/church leaders, disabled people’s organizations, other wheelchair users. Wheelchair services can help to increase the number of wheelchair users who are referred to the service by making sure that all possible referral sources know about the service. Providing referral sources with a referral form can help to give the wheelchair service some simple initial information about the wheelchair user. Each wheelchair service needs to decide whether it will find a referral form useful, what information to include and how the form will be used (for example posted to the service, or handed to the wheelchair user to bring along). A sample wheelchair referral form is shown on the next page.

Appointment When a wheelchair user is referred to a wheelchair service, he/she should be given an appointment for an assessment, if he/she cannot be attended to on the same day. The appointment may be for the user to visit the service/centre, or for wheelchair service personnel to visit the user. An appointment system helps wheelchair service personnel organize their time efficiently. It also means that wheelchair users do not have to wait around to see the service personnel. The way an appointment is made depends on how easy it is to get a message to the wheelchair user. For example, messages may be sent by post, by phone or through the original referral source. Sometimes, wheelchair users will arrive without an appointment. If possible, see them on the same day, especially if they have travelled a long way.

Good practice in appointment and referral • Start a file for each wheelchair user when he/she is referred to the service. • Educate referral sources about the wheelchair service and how to refer to the service. • Give referral sources a supply of wheelchair referral forms. • Where there are many wheelchair users, services should work out a way to decide who will be seen first. Consider particularly the needs of children and people with life-threatening conditions, such as pressure sores.

Wheelchair referral form Please complete referral form and post to: Wheelchair Service Name and Address: Name of referral person: Organization you work for: Referral person contact details (the best way to contact you): Wheelchair user’s name: Parent / carer’s name: Address:

A referral form should have clear contact details for the service including service name, postal address and telephone.

Date of Birth: In this referral form the service will contact the wheelchair user to make an appointment. This may not always be possible. In this case, the service may accept referrals without appointment.

How can the wheelchair user be contacted? Post Own Telephone Friend / neighbour’s telephone If by telephone, what is their phone number: Wheelchair user’s disability if known: Reason for referral: • Has no wheelchair • Has a broken wheelchair • Has a wheelchair that does not meet their needs Please add any other information about the wheelchair user that you think it is important the wheelchair service knows:

The person referring should explain to the wheelchair user what the wheelchair service does. The wheelchair user should agree to a referral being made.

Has the wheelchair user agreed to being referred to the wheelchair service? Signature of referring person: Date:

Yes

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Step 2: Assessment Who needs a wheelchair? When someone comes to a wheelchair service for a wheelchair, it is important to be sure that a wheelchair is really what they need. A person usually needs a wheelchair if: • they cannot walk; • they can walk, but with difficulty or only for a short distance.

Why do you need an assessment? A wheelchair assessment is a chance to gather information to help: • choose the most appropriate wheelchair for the wheelchair user from those available; • choose the most appropriate wheelchair components from those available; • find out what training the wheelchair user and/or the family need to make the best use of the wheelchair.

Where to carry out an assessment Assessments should always be carried out in a clean, quiet space. This may be a space within the wheelchair service, at another health care or community facility, or at the user’s home. If it is necessary to check whether a person has a pressure sore – do this in a private space. Respect the dignity and privacy of the wheelchair user irrespective of his/ her age, gender, religion or socioeconomic status.

Two parts of an assessment: • assessment interview; • physical assessment.

1. Assessment interview The best way to gather information about a wheelchair user is to ask questions. The wheelchair assessment form guides wheelchair service personnel to ask the most important questions for a wheelchair assessment. There are four different question headings. These are: • information about the wheelchair user; • physical condition; • lifestyle and environment; • existing wheelchair.

Information about the wheelchair user: Name: Number: Phone no.: Age: Address: Male Female

Goals:

These questions are important so that the wheelchair user can be contacted for the follow up in the future. They also give statistical information about the users seen by the service. Under “goals” write why the wheelchair user wants a wheelchair, and what he/she wants to be able to do in the wheelchair.

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When asking questions remember: • always explain to the wheelchair user why this information is important; • always address the wheelchair user (not their assistant/family member) unless you are dealing with a small child or someone unable to understand or answer your questions; • remember to use good communication methods; • information may not always come in the same order as it appears on the form – make yourself familiar with the form so that the information can be recorded in the correct place.

Physical condition: These questions are important because some of the features of health conditions can affect the choice of a wheelchair. Some examples are given below. Physical condition Cerebral palsy Frail Polio Spinal cord injury Stroke

Spasms or uncontrolled movements R below knee L above knee L below knee

Amputation: R above knee Bladder problems

Bowel problems

If the wheelchair user has bladder or bowel problems, are these managed? Yes No

Others: _______________________________________________________

Different conditions affecting the wheelchair prescription (selection): What you need to know Cerebral palsy Cerebral palsy affects people very differently. For a person with cerebral palsy who can sit upright, it is important to remember that they may have difficulty keeping their sitting position because they get tired. This makes doing things harder and more tiring. Always remember Good support is very important. People with cerebral palsy may need additional postural support in a wheelchair. To do this safely and effectively, intermediate-level training is needed.

Poliomyelitis

People who have poliomyelitis may have weakness or “floppiness” of body parts. Poliomyelitis can affect legs, arms or trunk, but most commonly affects the legs. The muscles and bones become thinner and the limb does not grow so fast and so is shorter. When the trunk is affected, it may appear shorter. People with a spinal cord injury are very likely to be at risk of developing a pressure sore. This is because most people with a spinal cord injury cannot feel below the level of their injury.

Although people with poliomyelitis have sensation, a cushion is important for comfort. A higher cushion may provide a more comfortable pushing position.

Spinal cord injury

Always prescribe a pressure relief cushion.

Stroke

People who have had a stroke are usually affected on one side of their body. This means they may fall to one side in the wheelchair. People who have had a stroke may not be able to feel normally on the affected side of their body. People who have had a stroke may be able to get in and out of the wheelchair by standing up.

Good support is important. Check if the person can feel – he/she may need a pressure relief cushion. A person with a stroke may prefer a wheelchair with footrests which move out of the way so that he/she can do a standing transfer. Continues..

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Continued

What you need to know Lower limb amputation People who are double amputees do not have the weight of their legs to stop their wheelchair from tipping backwards.

Always remember Always be careful when an amputee first tries a wheelchair. Check the wheelchair balance. The rear wheel may need to move backwards to provide extra stability.

Frail

Elderly people may need a wheelchair for different reasons. Usually it is because they are having difficulty walking. The wheelchair will make it easier for them to continue to be a part of family and community life.

Elderly people may be able to do a standing transfer, and will prefer Flip-up or swing-away a wheelchair with flip-up or swing- footrests may be the best away footrests. choice. Spasms or jerky movements Some people have problems with Select a safe back wheel sudden jerking, jumping movements position or a very stable that they cannot control (spasms). wheelchair.

Elderly people should always be given a wheelchair which provides good comfort and support. This will help them to sit well and avoid problems caused by poor posture.

These can throw their weight Straps may help control the backwards, making it more likely for foot position. the wheelchair to tip backwards. Note: whenever straps are The movements can cause the used, it is important that feet to “jump” suddenly off the Velcro is used so that the footrests. This can be dangerous strap can release if the user when propelling. falls out of the wheelchair. Bowel or bladder problems Some people cannot control their bladder or bowels. This problem can often be solved with the right equipment (catheters, for example), medication and a bladder and bowel training programme. People with bladder or bowel problems must not sit on a damp or soiled cushion, as their skin can rapidly break down. In addition, the bugs present in faeces rapidly lead to infected pressure sores. Identify who in your area (for example specialist doctors and nurses) can offer advice and training to avoid these complications. Provide a cushion with a waterproof cover. Teach the user how to wash and dry the cushion. A second cushion may help to enable the user to continue day-to-day activities while the cushion dries.

Lifestyle and environment: These questions gather information about where the wheelchair user lives and the things that he/she needs to do in the wheelchair. Lifestyle and environment Describe where the wheelchair user will use their wheelchair: __________________________________________________________________ Distance travelled per day: Up to 1 km 1–5 km 1–3 More than 5 km 3–5 5–8 more than 8 hours

Hours per day using wheelchair? Less than 1

When out of the wheelchair, where does the user sit or lie down and how (posture and the surface?____________________________________________________________ Transfer: Independent Assisted Standing Non-standing Western Lifted Other

Type of toilet (if transferring to a toilet): Squat

Adapted No

Does the wheelchair user often use public/private transport? Yes If yes, then what kind: Car Taxi Bus

Other ____________________________

Existing wheelchair: These questions help to find out if the wheelchair user’s existing wheelchair is meeting his/her needs, and if not, why not. Existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Does the wheelchair meet the user’s environmental conditions? Does the wheelchair provide proper fit and postural support? Is the wheelchair safe and durable? (Consider whether there is a cushion) Yes Yes Yes Yes No No No No No

Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes

Comments: ________________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications

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2. Physical assessment There are three different question headings. These are: • presence, risk or history of pressure sores; • method of pushing; • taking measurements.

Presence, risk or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore

Can feel normally? Previous pressure sore? Current pressure sore? If yes, is it an open sore (stage 1–4)?

Yes Yes Yes Yes

No No No No

Duration and cause: __________________ _________________________________ Is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous/current pressure sore, poor diet, ageing, under- or over-weight. Yes No

Mark on the body diagram: • areas where the wheelchair user cannot feel; like this: //// • areas where the wheelchair user has had a pressure sore in the past; like this: O • areas where the wheelchair user has a current pressure sore; like this: If a wheelchair user says he/she has a pressure sore, always ask to see it. Make sure this is done in a private area. A wheelchair user is at risk of developing a pressure sore if he/she cannot feel or has other risk factors. The risk factors include: • person cannot feel (decreased sensation); • person cannot move; • moisture from sweat, water or incontinence; • poor posture; • previous or current pressure sore; • poor diet and not drinking enough water; • ageing; • weight (underweight or overweight). Remember: Any wheelchair user at risk of developing a pressure sore needs a pressure relief cushion and education on preventing pressure sores.

Method of pushing How will the wheelchair user push their wheelchair? Both arms Right arm Both legs Left leg Right leg Pushed by a helper Left arm

Comment:__________________________________________________________

It is important to find out how the wheelchair user will push, as this can affect the choice of wheelchair and the way it is set up (please refer to session A.6: Appropriate wheelchair, section ``Pushing the wheelchair``).

Taking measurements Four measurements from the wheelchair user are needed to choose the best available size of wheelchair for that person. Each measurement relates to the wheelchair. Body Measurement A Hip width B Seat depth L R C Calf length L R D Bottom of rib cage E Bottom of shoulder blade

Measurement (mm)

Change body measurement to ideal wheelchair size Hip width = seat width B less 30–60 mm = seat depth (if length is different, use shorter one) = top of seat cushion* to footrests height or = top of seat cushion* to floor for foot propelling = top of seat cushion* to top of backrest (measure D or E – depending on the user’s need)

Wheelchair measurement (mm)

*check the height of the cushion that the wheelchair user will use.

Measuring tools

• Use a retractable metal tape measure (pictured on the right). • Clipboards/books can be used to help measure accurately (see How to take body measurements). • Large callipers are an additional tool that can be very useful. These can be made locally from wood. • Foot-blocks can be used to support the wheelchair user’s feet at the correct height.

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How to take body measurements Ask the wheelchair user to sit as upright as possible. The wheelchair user’s feet should be supported on the floor or on foot-blocks if they cannot reach the floor comfortably. For all measurements, make sure the tape measure is held straight and the wheelchair user is sitting upright. Holding a clipboard/book on either side of the wheelchair user can help in obtaining an accurate measurement. Bend down to ensure you are viewing the tape measure at the correct angle.

• Check there is nothing in wheelchair user’s pockets before measuring. • Measure hips or widest part of thighs. • Holding two clipboards/books against each side of the wheelchair user can help in obtaining an accurate measurement. • Place a clipboard/book at the back of the wheelchair user to help get an accurate measurement. • Measure from the back of the pelvis to the back of the knee in a straight line. • Always measure both legs. If there is a difference between the two legs, check that the wheelchair user is sitting up with the pelvis level. If there is still a difference, make the wheelchair prescription for the shorter side. • Measure from the back of the knee to the base of the heel. • Make sure the wheelchair user’s ankles are bent at 90 degrees (if possible). • Always measure both legs. • The wheelchair user should wear the shoes he/she wears most days (if any). • Measure the seat to the bottom of the rib cage. • To help find the bottom of the rib cage, place hands on both sides of the pelvis. Gently squeeze hands inwards and slide hands upwards. The bottom of the rib cage is just above the waist. • Measure from the seat to the bottom of the shoulder blade in a vertical line. • To help find the bottom of the shoulder blade, ask the user to shrug his/her shoulders.

For more information on the correct fit of a wheelchair, see step 6 session: Fitting.

Step 3: Prescription (selection) What is prescription (selection)? Prescription (selection) means selecting the best match possible between the wheelchairs available and the needs of the user. The prescription (selection) should always be decided with the wheelchair user, including the family member or caregiver if appropriate. Prescription (selection) includes: • selecting the right wheelchair, cushion and wheelchair parts; • selecting the right wheelchair and cushion size; • agreeing with the wheelchair user what training they need to help them use and care for their wheelchair and cushion.

Locally available wheelchairs and cushions Selecting the right size wheelchair is very important. The correct size wheelchair is more comfortable, helps to support upright sitting and is easier for the wheelchair user to use. For more information on the correct fit of a wheelchair, see step 6 session: Fitting. • Frame – for example, whether it is a long or short wheelbase; the frame length; whether it is a cross-folding or rigid frame. • Features – including the type of seat, backrest, footrests, armrests, castor wheels, rear wheels. • Wheelchair size: This is usually described by the wheelchair seat width and sometimes also the depth. The seat height from the floor is also useful to know. • Adjustability options: Which components are adjustable and what is the range of adjustment? Adjustment is usually possible to two or more different positions. For example, most wheelchairs have footrests which can be adjusted to different heights spaced evenly apart. The “range” of adjustment is from the smallest to the largest measurement. • Cushion: What type of cushion (if any) is provided with the wheelchair or is available separately? Some wheelchair suppliers provide: a. brochures or a product summary; b. product (wheelchair) specifications. Wheelchair measurements, weights, features and sometimes optional parts are often listed in this information. Always check whether there is information available about the wheelchairs you are prescribing. Read this information so that you are familiar with the products. If suppliers do not give this information – ask for it.

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Recording the prescription (selection) The prescription (selection) needs to be written down. Below is an example of a wheelchair prescription (selection) form. Adapt this form for your local service by listing the types of wheelchairs and cushions available in your service and in what sizes.

Wheelchair Prescription (selection) Form 1. Wheelchair user information Wheelchair user’s name: Date of assessment: Assessor’s name: Number: Date of fitting:

2. Type of wheelchair and size selected select the type of wheelchair: • Discuss with the wheelchair user; • Think about the most important needs of the wheelchair user; • Check: wheelchair frame, castor and rear wheels, footrests, armrests, backrest height (or adjustability), rear wheels position, support and comfort. Type of wheelchair Size

List the types of wheelchairs available in your service. List the types of cushions available in your service and their sizes. Size

3. Type of cushion selected Type of cushion e.g. Foam pressure relief cushion e.g. Flat foam cushion

4. Agreed with the selection Signature of the user: Signature of the assessor: Signature of the manager:

Step 4: Funding and ordering Funding When the wheelchair has been prescribed, the cost of the recommended product can be accurately estimated. It is essential to know who will fund the wheelchair – it could be funded by an out-of-pocket payment, a subsidy from a government, nongovernmental organization or donor agency, or a payment by an insurance company. In the developing world, many people who need a wheelchair cannot afford to buy one. Nevertheless, everyone who needs a wheelchair is entitled to one, regardless of his/her ability to pay. Thus, funds will need to be made available for users who need financial assistance. For most services, it will be essential to identify the funding source before the wheelchair can be ordered. Often, this responsibility lies with administrative personnel or programme managers rather than clinical or technical personnel.

Ordering When the best wheelchair for the wheelchair user has been selected and the prescription (selection) form prepared, the wheelchair needs to be ordered, if not available within the existing stock. If a wheelchair service keeps wheelchairs in stock, this may mean completing an order form to be authorized by the service manager. The wheelchair may then be prepared by the staff responsible for wheelchair preparation. If the wheelchair service does not keep wheelchairs in stock, this may mean ordering from an external supplier. The system for ordering wheelchairs will vary in different wheelchair services. Write down below the things that you need to remember to order wheelchairs in your local wheelchair service.

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How to order wheelchairs in my local wheelchair service:

Good practice in ordering • Keeping wheelchairs in stock can reduce waiting time for wheelchair users. • An order should always be placed as quickly as possible to avoid delays. • Always let the wheelchair user know when the wheelchair is likely to be available.

Step 5: Product (wheelchair) preparation What is product (wheelchair) preparation? Product (wheelchair) preparation includes: • preparing the wheelchair to match the wheelchair user’s prescription (selection); • checking the wheelchair to make sure that it is safe and ready to be used and all parts are working properly.

Preparing the wheelchair Prepare the wheelchair in the following order: 1. Check that the wheelchair seat width and depth measurements are correct for the prescription (selection). 2. Check that the cushion width and depth match the seat. 3. Adjust (where possible): • • • • • • • Backrest height and angle; Armrests height; Rear wheels position; Brakes position; Footrests height; Push handles height; Any other adjustments.

4. Carry out a “wheelchair safe and ready” check.

Good practice in product preparation • Label each wheelchair being prepared with the wheelchair user’s name. • Any modifications to a wheelchair should always be carried out by someone with the appropriate knowledge and skills. Modifications can affect the strength and function of a wheelchair. • Always check that the wheelchair is safe and ready to be used and that all parts are working before the wheelchair user tries it (see below).

Wheelchair safe and ready checklist Use the checklist below to make sure that the wheelchair is safe to use and all parts are working. Always do this before the wheelchair user tries the wheelchair.

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Checklist: Is the wheelchair safe and ready to use? For the whole wheelchair There are no sharp edges. No parts are damaged or scratched. The wheelchair travels in a straight line. Front castor wheels Spin freely. Spin without touching the fork. Bolts are tight. Front castor barrels Castor fork spins freely. Rear wheels Spin freely. Axle bolts are tight. Tyres (if those are pneumatic) are inflated correctly. Push rims are secure. Brakes Function properly. Footrests Footrests are securely attached. Check. Apply brakes. Check the wheelchair cannot be moved. Tip the wheelchair sideways on to one rear wheel. Spin the other wheel. Check the other side. Check. They should feel firm. Do not over tighten. Press on the tyres with your thumb. The wheel should depress a little, but no more than 5 mm. Check. Tip the wheelchair on to the back wheels. Spin the castor fork around. Tip the wheelchair on to the back wheels. Spin the castor wheels. Check. They should feel firm. Do not over tighten. How to check Check all over the wheelchair with eyes and hands. Push the wheelchair away from you, making sure the castor wheels are in the “trail” position.

Frame Cross-folding wheelchair folds and unfolds easily. Fold-down backrest – the backrest folds and unfolds easily. Cushion The cushion is in the cover correctly. The cushion is sitting on the wheelchair correctly. The cushion cover fabric is tight but not too tight. The cushion fully covers the seat. Usually the cushion cover is done up at the back of the cushion, underneath. If the cushion is contoured, the “well” for the seat bones should be at the back of the seat. The cushion cover should not stretch tightly over any contours of the cushion. Check that no part of the seat is visible from under the cushion. This is particularly important for solid seats. Fold the wheelchair to check that the folding mechanisms are working correctly.

Cushion fabrication If foam is available, wheelchair service personnel can make a foam pressure relief cushion with just a few tools. Personnel need to know what foam to use, and a few important dimensions. Discuss with your trainers the foams that you have available in your location, to find out which ones would be suitable for a pressure relief cushion. The instructions below show how to make a basic foam pressure relief cushion, with two key contours. These are a “well” under the seat bones and a shelf in front of the seat bones.

Cushion features and dimensions The main features of the basic foam contoured cushion are the following. A base layer, made with a firm foam (for example “chip” foam)

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Seat bones well • Relieves pressure under the seat bones and coccyx (tail bone). • Helps to hold the pelvis upright at the back of the cushion. Slung seat base • Cushions used on a slung wheelchair seat have a bevel cut on each side of the base of the cushion. • This allows the cushion to take up the shape of the slung wheelchair seat. The top of the cushion then stays flat. A top layer, made with a soft “comfort” foam Top comfort layer: • Provides comfort over the firm base layer.

How to make a pressure relief cushion base? The following instructions provide a cushion of dimensions 400 mm wide x 400 mm deep x 50 mm high. The seat bones well is 200 mm wide x 200 mm deep x 35 mm high. This cushion would be suitable for a wheelchair user with a seat width of 400 mm. Adapt the dimensions to suit the size of each wheelchair user as described in the box below.

1. Mark out the cut lines on the firm foam.

• Start with a piece of firm foam 400 mm x 400 mm x 50 mm. • The centre of the seat bones well must be on the centre line of the cushion. • For this size cushion, the seat bones well should measure 200 mm x 200 mm x 35 mm. • Draw the cut lines with a dark coloured marker on all six sides of the base foam.

Seat bones well dimensions

Adjust the dimensions of the cushion and the seat bones well to suit individual wheelchair users as follows: c a b

• seat bones well width = ½ the wheelchair user’s seat width or 200 mm (whichever is less) [a]; • seat bones well depth (front to back) = ½ the wheelchair user’s seat width or 200 mm (whichever is less) [b]; • seat bones well height = 35 mm for adults and 20–25 mm for children [c].

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2. Cut out the seat bones well: Use a sharpened hacksaw blade or long knife. Use long slow strokes, cutting mostly when pulling to improve control. • First cut through the back of the cushion to the depth of the seat bones well.

• Then slice out the seat bones well.

• Glue back into place the two “flaps” left on either side of the seat bones well. Allow the glue to set until not completely dried and slightly sticky to touch. Then press the foam together. 3. Cut off (bevel) the corners inside the seat bones well.

15 mm

4. For a slung seat cushion: make an angled cut (bevel) on both sides of the base (under-side). • Mark out as shown and cut. • This cut helps the base of the cushion to match the shape of a slung wheelchair seat.

15 mm

5. Place the top foam layer on top of the cushion. • Both the base and top layer are placed in the cushion cover together. • The two layers do not need to be glued together. • If the top layer becomes soiled or worn, it can be washed and dried, or replaced. • A lift can be added within the cover to increase the depth of the seat bones well.

Frequently asked questions about foam pressure relief cushions: How do you decide which fabric to use for the cushion cover? • Choose a fabric which is stretchy if possible. Water-resistant fabric is very good if available. If the fabric is water-resistant make sure it is not too thick, or the folds may cause marking on the wheelchair user’s skin, which can lead to a pressure sore. • The choice will depend on the fabric available. Sometimes the choice is limited. • If there is a choice and you are not sure, ask wheelchair users to trial different options. • Wheelchair service personnel will develop experience as different fabrics are tried. Does this cushion work for all users? • No – this cushion will not work for all wheelchair users. • However, one advantage of this cushion is that it can be easily adapted. Is this cushion hot or does it cause sweating? • Foam cushions can be hot and can cause sweating. • However, the cushion performs well in many other ways, so putting up with the heat is a compromise. Do all wheelchair users need a pressure relief cushion? • No – not all wheelchair users need a pressure relief cushion. • Consider the pressure risk factors taught in this training programme to decide whether a wheelchair user is at risk of developing a pressure sore. • Although this cushion may not be needed for pressure relief, the cushion can also improve comfort and posture, even for wheelchair users who are not at risk of developing pressure sores.

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What happens if the cushion is used back-to-front or upside down? • It will not work properly and may even increase the risk of developing pressure sores. • Always make sure that wheelchair users, and family members (where relevant), understand how to use and care for the cushion correctly. • Mark the cushion “front” and “back” or “up” and “down” if necessary. Does this cushion work for children? • Yes, this cushion would work for children. However, the seat bone well needs to be smaller. See above for how to work out the dimensions for a child-size cushion. • Many children who use wheelchairs need additional postural support. This cushion may not provide enough postural support. Cushion fit

Always check that the seat bones sit just within the seat bone well and not on the edge or on the high part of the cushion. Always check when fitting a pressure relief cushion for a wheelchair user that: • the pressure under the seat bones is “safe” (see “How to test if a pressure relief cushion is working”, above); and • the seat bones are sitting inside the seat bone well and not on the edge or top layer.

Step 6: Fitting What does fitting involve? During fitting, the wheelchair user and personnel together check that: • the wheelchair is the correct size and all the necessary modifications and adjustments have been made to ensure an optimum fit; • the wheelchair and cushion support the wheelchair user in sitting upright; • if a pressure relief cushion has been prescribed, the cushion really relieves pressure.

Good practice in fitting • Wherever possible, the same person who carried out the assessment should carry out the fitting. • Always check the fit with the wheelchair stationary, and then while the wheelchair user self-propels or is pushed. • Carry out fitting in this order: • • • • check size and adjustments; check posture; check pressure; check fit while the wheelchair user is moving.

• Use the fitting checklist provided to remember each step.

Check size and adjustments Seat width Correct fit: Should fit closely How to check • Run your fingers between the outside of the wheelchair user’s thighs and the sides of the wheelchair. Your fingers should fit comfortably without being pinched. Make sure the sides of the wheelchair do not press into the wheelchair user’s legs. This is particularly important for a wheelchair user who cannot feel pressure on the thighs (does not have normal sensation). Firm pressure on thighs from the side of the wheelchair could cause a pressure sore. Seat depth Correct fit: Two-finger gap (30 mm) between the back of the knee and the cushion. Continues..

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Continued

How to check • Check the wheelchair user is sitting upright. • Slide hand between the cushion and the back of the knee. There should be a gap large enough to admit two fingers (30mm). There may be a bigger gap for wheelchair users with long legs. Up to 60 mm is acceptable. • Slide hand down the back of the calf and make sure it is not touching the seat or cushion. • Always check both sides. Correct fit gives the thigh good support. This will reduce pressure under the seat bones and helps to stop pressure sores. If the seat length is too long, the user will not be able to sit upright. If there is a difference between right and left sides, use the shorter leg measurement to make prescription choices. Footrests height Correct fit: The thighs are fully supported on the cushion with no gaps. The feet are fully supported on the footrests with no gaps. How to check • Slide hand between the thigh and the cushion. There should be even pressure along the thigh and no gaps. • Look at each foot on the footrest. The foot should be supported at the front and the back with no gaps. If there are gaps under the thigh, the footrest may be too high. If there are gaps under the foot, the footrest may be too low. Backrest height Correct fit: How to check • Ask the wheelchair user whether the backrest is comfortable. • Observe whether the trunk is balanced over the hips. • Is the wheelchair user able to push the wheelchair without the backrest interfering? The height of the backrest depends on the needs of the user. Wheelchair users who push themselves need a backrest which allows their shoulders to move freely. Wheelchair users who have difficulty sitting upright may need a higher backrest which gives more support to the spine. There are two backrest height measurements on the wheelchair assessment form (see session Step 2: Assessment under the section ”Taking measurements”). Take both measurements, as sometimes it is not clear in the assessment which height backrest will be most comfortable for the wheelchair user. Continues..

The correct fit should give the wheelchair user the support he/ she needs and allow an active person the freedom to move the shoulders to push.

Continued

A backrest which provides support up to the bottom of the wheelchair user’s rib cage is a good height if the wheelchair user: • is fit and active; • can sit upright easily with good balance; • will be actively propelling himself/herself and needs good freedom of movement. Backrest height D (bottom of rib cage)

A backrest which provides support up to the bottom of the wheelchair user’s shoulder blades is a good height if the wheelchair user: • is likely to get tired quickly, e.g. elderly or with a progressive disease; • has some difficulty sitting upright. This backrest height still allows some freedom of movement around the shoulders for the wheelchair user to propel the wheelchair with the arms. Backrest height E (bottom of shoulder blades)

Rear wheels position – for hand propelling Correct fit: When hands are placed on the push rims, the user’s elbows should be at a right angle. How to check • Ask the wheelchair user to grip the push rims at the top of the wheels. The elbow should be bent at 90 degrees. • Also check with the user if the rear wheels are positioned correctly for balance (forward for active, back for safe). If the wheelchair user needs the rear wheels to be positioned in the “safe” (further back) position, this may mean that the arms are further back and that is ideal for propelling. Explain this compromise to the wheelchair user. If any adjustments are made to the rear wheels position, the brakes will also need to be adjusted and rechecked. Seat height–for foot propelling Correct fit: • With the wheelchair user sitting upright, and the back of the pelvis comfortably supported by the backrest, he/she should be able to rest the feet flat on the floor. Continues..

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Continued

How to check Ask the wheelchair user to sit with the back of their pelvis against the backrest with the pushing foot flat on the floor. Check whether the feet can sit flat on the floor. If the seat height is too high, wheelchair service personnel can try: • reducing the height of the cushion; • attaching a solid seat lower than the original seat (get technical advice or support to do this). For a user who is propelling with only one foot, with the other foot resting on the footrest – check the pressure under the seat bone of the side that is resting on the footrest (please refer to session A. 7: Cushions, section “How to test if a pressure relief cushion is working”).

Check posture Observe how the wheelchair user is sitting in the wheelchair from the side, and from the front. Is the user sitting in an upright posture?

Some wheelchair users like to have their feet tucked in underneath them. Some wheelchair designs allow for this. If the wheelchair user is comfortable and feels balanced, this is fine.

Check pressure For every wheelchair user at risk of developing a pressure sore – check if the pressure under the seat bones is safe.

Check fit while the wheelchair user is moving The final part of fitting is to check how the wheelchair fits when the wheelchair user is moving. If a wheelchair user cannot push the wheelchair independently, ask a family member/caregiver to push the wheelchair.

What to look for: • Does the backrest allow the wheelchair user freedom to move the shoulders to push? • Do the wheelchair user’s feet stay on the footrests? • Is the rear wheel position correct for the user?

Wheelchair fitting checklist 1. Is the wheelchair ready? Has the wheelchair been checked to make sure it is safe to use and all parts are working?

2. Check size and adjustments Seat width Should fit closely. Seat depth Two fingers’ gap between the back of the knee and the seat/cushion.

Footrests height: The thigh is fully supported on the cushion, with no gaps. Each foot is fully supported on the footrest, with no gaps.

Continues..

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Continued

Backrest height: The wheelchair user has the support they need and freedom to move their shoulders to push (if self-propelling). Rear wheels position (for hand propelling): The wheelchair user’s arm should be in line with the rear axle when hanging down. When hands are placed on the push rim, the user’s elbow should be at a right angle. Brakes: Are the brakes working? Seat height (for foot propelling): With the wheelchair user sitting upright, the back should be comfortably supported by the backrest, with feet resting flat on the floor.

3. Check posture Is the wheelchair user able to sit upright comfortably? Check posture from the side. Check posture from front/back.

4. Check pressure Check pressure under seat bones for all wheelchair users at risk of developing a pressure sore. Explain the test to the wheelchair user.

Ask wheelchair user to lean forward or push up. Place fingertips under wheelchair user’s seat bone.

Continues..

Continued

Ask the wheelchair user to sit back down on your fingers. Make sure the user sits upright with hands on thighs.

Identify the pressure: Level 1 = safe: Fingertips can wriggle up and down 5 mm or more. Level 2 = warning: Fingertips cannot wriggle, but can easily slide out. Level 3 = unsafe: Fingertips are squeezed firmly. It is difficult to slide fingers out.

Repeat under the second seat bone.

5. Check fit while the wheelchair is moving Does the backrest allow the wheelchair user freedom to move the shoulders to push? Does the backrest give the wheelchair user enough support? Do the wheelchair user’s feet stay on the footrests? Is the rear wheels position correct for the user?

6. Action? Is any further action necessary? Write any actions in the wheelchair user’s file.

Remember: The next step after fitting is user instruction.

Problem solving Sometimes personnel will find a problem with making the available wheelchair fit the wheelchair user correctly. The problem may be because: • there is a limited range of wheelchairs and sizes available; • the wheelchair user needs extra support to sit upright comfortably. Below are some simple solutions to some common problems. Making modifications and providing more postural support is covered in much greater detail in the intermediate-level training. All of these solutions assume that the closest-size wheelchair for the wheelchair user has already been selected from those available. Always check this before modifying a wheelchair.

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Problem: Seat depth too short If the seat depth (front to back) is more than 100 mm shorter than the wheelchair user’s seat depth (for an adult), this is a problem. The wheelchair user will not have enough support from the seat to be able to sit comfortably. Pressure relief is also reduced. The seat depth needs to be lengthened. Solution: Three different solutions are described below: Solution Caution

1. Lengthen the wheelchair seat depth by extending the seat rails and replacing upholstery. • If the wheelchair is a folding-frame type, check whether the seat rails are “dedicated”. This means the seat rails are not also part of the wheelchair frame. • In this case, an extension can be made to the seat rails and new upholstery made to the correct length. 2. Lengthen the wheelchair seat depth by replacing the upholstery. If the wheelchair is a rigid frame wheelchair with upholstery, check if the seat rail extends beyond the seat. In this case, it may be possible to replace the seat upholstery with new upholstery made to the correct length. 3. Lengthen the wheelchair seat depth by adding a rigid board with a cushion. • A solid seat can be made from wood, • Make sure the new seat is strong enough plastic or any other rigid material which to carry the weight of the user. Check will not flex or crack. that the seat does not flex or crack • The seat can be fixed to the top of the beyond the existing wheelchair seat. seat rails. • Always ensure a rigid seat is provided • Add a cushion that is the same width and with a cushion – for every wheelchair depth as the new seat. user. • Check during fitting that the backrest and footrests are the correct height. The solid seat and the cushion will raise the wheelchair user in the wheelchair.

Problem: Seat depth too long. If the shortest available seat depth is too long, it will be impossible for the wheelchair user to sit upright. The seat depth needs to be shortened.

Solution: One solution is described below. Solution 1. Shorten the wheelchair seat depth. • Mark the seat depth that is needed on the existing seat. • If the seat is upholstered: remove the upholstery, shorten it (using an industrial sewing machine) and replace. • If the seat is rigid: remove the seat, shorten and replace. • Shorten the cushion to match the new seat depth. • When cutting a rigid seat – always ensure that all edges are smooth and splinter-free. • When cutting a cushion – always cut from the front, so that pressure relief at the back of the cushion stays the same. Caution

Problem: Footrests height too low. If the footrests height is too low, the wheelchair user will not be able to rest the feet comfortably on the footrests. This can cause him/her to slide forward in the wheelchair, or to feel unstable. There will not be enough support to sit upright comfortably. The footrests will need to be raised. Solution: Two solutions are described below. Solution • On most four-wheel wheelchairs, the footrests hanger can be cut shorter. • Use wood or another sturdy material to add height to the footrests. Caution Always check that the adjustment mechanism is still working. Check that the build-up does not stop footrests that move out of the way for transfers from working.

1. Raise the footrests height by – shortening the footrests hanger.

2. Raise the footrests by – building up the footrests

Footrest raised by building up the footrest (in this illustration one side only has been built up to accommodate shortening of one leg).

Problem: Footrests height too high. If the footrests height is too high, the wheelchair user’s thighs will not rest comfortably on the seat. Footrests that are too high can increase pressure on the seat bones. The footrests will need to be lowered.

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Solution: Two possible solutions are described below. Solution • Check if the inner extension tube can be replaced with a longer tube. • If so – replace it with a similar tube of the same diameter and strength. 2. Increase the height of the cushion. • Increase the height of the cushion or raise the cushion by adding something solid underneath. Do not use soft foam to increase the height of the cushion. This will compress, and will also feel unstable. Check during fitting that the backrest is the correct height. The higher cushion will raise the wheelchair user in the wheelchair. Check that there are no functional problems with raising the cushion. For example – the wheelchair user may then not be able to fit under tables or desks. Caution Make sure the footrests do not become so low that they catch on the ground. If this happens, try option 2 instead. If this does not work, the wheelchair is not suitable for the wheelchair user. 1. Lower the footrests by – lengthening the inner extension tube.

Problem: Legs tend to roll inwards or outwards. Sometimes the wheelchair user’s legs roll inwards or outwards. This may be because of the way they are used to sitting, or have a physical reason (for example muscle weakness). Simple adjustments to the wheelchair seat or cushion can help to reduce this problem. Solution: Three possible solutions are described below. Solution 1. Double check the footrests height. Make sure the footrests height is supporting the wheelchair user correctly (even pressure should be felt under the feet and under the thighs). 2. Check the seat is properly tensioned. • If the wheelchair has an upholstered seat – make sure that the seat is tensioned firmly. • If the seat is saggy, this will encourage the wheelchair user’s legs to roll inwards. 3. Add wedges to the cushion to support the thighs in neutral (as in DVD and illustration) or provide a contoured cushion, modify cushion if necessary. • Some contoured pressure relief cushions have a rise between the thighs, which will help to keep legs comfortably apart. The rise can be increased to provide additional support if needed. • Some contoured pressure relief cushions have “gutters” for the legs to rest in. The edges of the gutter can be increased to stop legs from rolling outwards.

Wedge added to the centre front of a cushion to help keep a wheelchair user’s legs slightly apart.

Wedges added to the front side of a cushion to help keep a wheelchair user’s legs from falling outwards.

Problem: Feet tend to slide off the footrests Sometimes the wheelchair user’s feet slide off the footrests. This often has a physical reason (for example muscle weakness or muscle spasms). Solution: Three solutions are described below. Solution 1. Double check the footrests height. • Make sure the footrests height is supporting the wheelchair user correctly (even pressure should be felt under the feet and under the thighs). 2. Adjust the footrests angle (if possible). • Check if the footrests angle can be adjusted. • If so – try increasing the angle of the footrests. This may help to hold the wheelchair user’s foot in place. 3. Add a strap. • Attach a strap to the footrests hangers at the level of the ankles. • If the feet tend to slide off backwards, the strap goes behind the legs. • If the feet tend to slide off forwards, the strap goes in front of the legs. Make sure the strap is easy to remove, so that the wheelchair user can get in and out of the wheelchair without effort. Check that the wheelchair user can reach the strap without assistance, and can do it up and undo it easily. Check that there is still even pressure under the foot. Caution

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A calf strap can help to keep a wheelchair user’s legs in place.

Straps at the back of the foot can provide more support, helping to prevent a wheelchair user’s legs from sliding off the back of the footrests.

Problem: Wheelchair is too wide. Sometimes the smallest wheelchair available is still too wide for the wheelchair user. If the wheelchair seat is too wide, the wheelchair user will find it difficult to sit upright, and is likely to collapse to one side. Some simple foam inserts can help to provide the wheelchair user with support to sit upright. Solution: One solution is described below. Solution 1. Add foam inserts on each side of the pelvis. • Measure the space between the wheelchair user (sitting central in the wheelchair with the back against the backrest) and the side of each armrest. • Cut and add foam inserts to fill the space between each side of the wheelchair user and the side of the wheelchair. • Check fit. • Upholster and attach the foam inserts. If the armrests are solid, the inserts may be attached to the armrests. They may also be attached to the top of the cushion. The inserts only need to come as far forward as the user’s trunk. Ensure the cushion matches the seat width. If the wheelchair is very wide, the wheelchair user will also have trouble reaching the push rims. Overreaching for the push rims can cause a shoulder injury. Consider carefully whether the wheelchair is safe for the wheelchair user before prescribing (selecting) it. Caution

Foam inserts can reduce the inside width of the wheelchair.

Step 7: User training Information and training about the wheelchair can help many wheelchair users really benefit from their wheelchair. Without this step, it is possible that the wheelchair will not help the wheelchair user as much as it could.

What are helpful skills for wheelchair users? The six most important things to remember to teach are: • how to handle the wheelchair; • how to get in and out of the wheelchair (transfer); • wheelchair mobility – matched to the user’s needs; • how to prevent pressure sores and what to do if a pressure sore develops; • how to care for the wheelchair and cushion at home; • what to do if there is a problem. The checklist on the next page lists specific skills that a wheelchair user may need to learn. Some wheelchair users will already have these skills; and not all skills are important for all wheelchair users. Personnel can use the checklist to select the training the wheelchair user needs. This is decided through the assessment, and through talking to the wheelchair user. Some services may use this checklist as a form, kept in the wheelchair user’s file. In this case, the checklist can also be used to record the training which has been given. Always check with the wheelchair user whether he/she would like caregivers to learn the skills you are teaching as well. Many wheelchair users are supported by their family or a caregiver, and it is helpful for everyone involved to learn how to use and care for the wheelchair. How to make wheelchair user training successful • Find out what the wheelchair user already knows. • Explain, demonstrate and then allow the wheelchair user to practise. • Use language that everyone can understand. • Have wheelchair users teach other wheelchair users. • Use good communication skills. • Be encouraging.

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Wheelchair age Service Training Pack

Wheelchair user training checklist Skills to teach Wheelchair handling Folding the wheelchair Lifting the wheelchair Using quick-release wheels Using the brakes Using the cushion including positioning correctly Transfers Independent transfer Assisted transfer Other Wheelchair mobility Pushing correctly Up and down a slope Up and down a step On rough ground Partial wheelie Preventing pressure sores Checking for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops Looking after the wheelchair at home Clean the wheelchair; wash and dry the cushion and cushion cover Oil moving parts Pump the tyres if they are pneumatic Tighten nuts and bolts Tighten spokes Check upholstery Check for rust Check the cushion What to do if there is a problem Wheelchair needs repairs The wheelchair does not fit or is not comfortable Skills taught

Step 8: Maintenance, repairs and follow up Regular care of a wheelchair and cushion will save costs for repairs, extend the life of the wheelchair and prevent injuries and long-term damage to the user’s body. A wheelchair which is cared for will be more comfortable, energy-efficient and easier to use. A cushion which is cared for will continue to provide pressure relief and support. Wheelchair service personnel have a responsibility to inform wheelchair users how to care for their wheelchair and cushion at home.

Prevent repairs: home maintenance There are six things that wheelchair users can do at home to look after their wheelchair and cushion. Show wheelchair users how to care for their wheelchair and cushion at home, and explain why it is important. The table on the next page explains what needs to be done, why it is important and how to do it.

Local resources for wheelchair repairs Find out who can help repair wheelchairs in your local area. Possible places or people are: • bicycle repairer; • motorcycle or car mechanic; • workshops – welder, plumber (metal parts), carpenter, furniture maker (wooden parts); • wheelchair user, wheelchair user’s family member, relative or neighbour; • tailor for repairing upholstery; • wheelchair service facilities.

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Wheelchair age Service Training Pack

How to care for a wheelchair at home Why is this important? 1. Clean the wheelchair and cushion Stops metal parts from rusting. Stops wooden parts and upholstery from rotting. Stops damage caused by dirt scraping against moving parts. How to do it Use warm water with a little soap. Rinse and dry. Pay attention to moving parts, and where upholstery joins the frame. Remove cushion from cover and wash separately. Always dry the cushion in the shade – not in direct sun. 2. Oil moving parts Keeps parts moving smoothly. Helps stop rust. Clean and dry the wheelchair first. Use a lubricating oil, for example bearing oil. Apply to all moving parts.

3. Pump up tyres (if pneumatic)

Tyres will last longer. It is easier to propel the wheelchair, taking less energy. Brakes will work correctly.

Press thumb across the tyre to check pressure. It should be possible to depress the tyre very slightly (about 5 mm). Pressure should be the same on each tyre. Pump up using a bicycle pump or similar. Reduce pressure by releasing air through the valve.

4. Tighten nuts and bolts (if loose)

Loose bolts cause unwanted movement in parts. This can be uncomfortable, and cause parts to wear out or be lost.

Check wheelchair for loose bolts or nuts. Tighten loose bolts or nuts with a wrench. Do not overtighten.

Continues..

Continued

Why is this important? 5. Tighten spokes (if loose) Loose spokes can cause wheels to buckle and collapse.

How to do it Squeeze together two spokes all the way around the wheel. If a spoke “gives” when you pull gently, it may be too loose. Tighten with a spoke wrench. Spokes can be overtightened. If the spoke feels very rigid, it is probably too tight and should be loosened.

6. Make regular checks Check for rust and check upholstery Rust reduces the strength of materials. This can cause parts to break and may cause injury to the user. Upholstery needs to be in good condition to support the wheelchair user and provide good comfort. If upholstery rips suddenly, the wheelchair user may be injured. Check painted metal surfaces for rust/corrosion. If rust is found, use sandpaper or steel brush to remove the rust. Clean with a thinner and cloth and repaint. Look for tears, wears, dirt or metal parts sticking out. Check the tension of seat and backrest is correct. If the upholstery is torn or the tension of a slung seat is too loose, repairs are needed. Remove the cover. Check for worn spots, dirt and holes in the cover and foam. If the cushion is worn, it should be checked by the wheelchair service personnel. It may need to be replaced.

Check the cushion

Cushions should be clean and dry to help protect skin. Cushions do not last as long as wheelchairs. A regular check will help wheelchair users to recognize when the cushion needs replacing.

Common wheelchair and cushion repairs Wheelchairs and cushions will sometimes need to be repaired. Wheelchair service personnel need to be able to either carry out a repair, or advise wheelchair users where they can get help. Some wheelchair users will be very good at organizing their own repairs. Other wheelchair users may need help. All wheelchair users will benefit from knowing where they can get their wheelchair and cushion repaired.

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Wheelchair age Service Training Pack

What is follow up and how does it happen? Follow up happens after the wheelchair user has received their wheelchair and has been using it for a while. Follow up appointments are an opportunity to: • gather information from the wheelchair user; • check that the wheelchair is in good working order; • check the fitting of the wheelchair. All users will benefit from a follow up visit. However, follow up is most important for: • children; • wheelchair users at risk of developing a pressure sore; • wheelchair users who have a progressive condition; • wheelchair users who have had difficulty with any of the training or instruction given to them. There is no rule about when follow up should happen though one follow up session within six weeks of the date of delivery is often found to be useful. It will depend on the needs of the user. However, for children, it is ideal if follow up occurs every six months. This is because the needs of children change quickly as they grow. Follow up can be carried out either at a home visit, at a centre or at any other location that suits the user and the wheelchair personnel. This depends on whether the wheelchair user is able to travel to the centre, and whether wheelchair service personnel are able to travel to the user’s home.

Common follow up actions • Check that the wheelchair is in good order; • Provide more tips or training; • If needed, –– re-adjust the wheelchair; –– carry out minor repairs or home maintenance; –– organize major repairs or assist the wheelchair user to arrange for repairs. The form on the next page can be used to guide follow up. Personnel should make a note of any action that is needed after the follow up visit.

Ways to manage follow up appointments • Give wheelchair users a follow up appointment when they receive their wheelchair. • Visit wheelchair users at home for follow up, where possible. • Make follow up visits part of routine visits to communities by community-based rehabilitation (CBR) personnel who have been trained to carry out follow up. • Arrange a follow up phone call if transport is difficult and the wheelchair user has access to a phone. 79

Wheelchair Follow Up Form This form is for recording information from a follow up visit.

1. Wheelchair user information Name: Date of fitting: Name of person carrying out follow up: User’s home Follow up carried out at: Number: Date of follow up: Wheelchair service centre Other: Record action to be taken: Yes Yes Yes Yes Rate: No No No No

2. Interview Are you using your wheelchair as much as you would like? If no – why not? Do you have any problems using your wheelchair? If yes – what are the problems? Do you have any questions about using your wheelchair? If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? If yes – describe (location and grade) How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satisfied and 5 is very satisfied) Comment:

3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Is the cushion in good working order and safe to use? If no for either, what is the problem? Yes Yes No No

4. Fitting check Does the wheelchair fit correctly? If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user is at risk of developing a pressure sore) Is the wheelchair user sitting upright comfortably when still, moving, and through the day? If no – what is the problem? Yes No

Left: Right: Yes No

For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ dar@who.int

ISBN 978 92 4 150347 1

Wheelchair Service Training P ackage Basic LeveL reference Manual for Participants

Wheelchair Service Training P ackage Basic LeveL reference Manual for Participants Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, and Isabelle Urseau Illustrator: Melissa Puust Photo credits: Chapal Khasnabis and Jesse Moss Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) WHO Library Cataloguing-in-Publication Data Wheelchair service training package / edited by Chapal Khasnabis and Kylie Mines. Contents: Trainer’s manual, basic level–Reference manual for participants, basic level – Participant’s workbook, basic level – Posters and slides, basic level. Trainer’s manual and slides available on DVD only. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150347 1 (package) (NLM classification: WB 320) ISBN 978 92 4 150348 8 (DVD) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/ licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cover photo credits (clockwise, from top): Mile End Films /Jesse Moss; WHO /Chapal Khasnabis; Mile End Films / Jesse Moss; Panos /Dieter Telemans; WHO /Chapal Khasnabis. Printed in Malta Design by Inís Communication – www.iniscommunication.com Terminology The following terms used throughout the training package are defined below. appropriate wheelchair A wheelchair that meets the user’s needs and environmental conditions; provides proper fit and postural support and is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at the most economical and affordable price. Manual wheelchair A wheelchair that is propelled by the user or pushed by another person. Wheelchair A device providing wheeled mobility and seating support for a person who has difficulty in walking or moving around. Wheelchair provision An overall term for wheelchair design, production, supply and service delivery. Wheelchair service That part of wheelchair provision concerned with ensuring that each user receives an appropriate wheelchair. Wheelchair service personnel Persons skilled in the provision of an appropriate wheelchair. Wheelchair user A person who has difficulty in walking or moving around and uses a wheelchair for mobility. c O N T eN T s vii Preface 1 about the Wheelchair Service Training Package: Basic level 5 a. core knowledge 6 a.1: Wheelchair users 6 What are the benefits of a wheelchair? 7 What is an “appropriate wheelchair”? 7 The United Nations convention on the Rights of Persons with Disabilities 8 a.2: Wheelchair services 10 a.3: Wheelchair mobility 13 a.4: sitting upright 16 a.5: Pressure sores 21 a.6: appropriate wheelchair 21 Meeting the wheelchair user’s needs 26 Meeting the wheelchair user’s environment 27 Providing proper fit and postural support 29 a.7: cushions 34 a.8 Transfers 38 B. Wheelchair service steps 39 step 1: Referral and appointment 41 step 2: assessment 50 step 3: Prescription (selection) 52 step 4: Funding and ordering 54 step 5: Product (wheelchair) preparation 62 step 6: Fitting 74 step 7: User training 76 step 8: Maintenance, repairs and follow up Preface The wheelchair is one of the most commonly used assistive devices for enhancing personal mobility, which is a precondition for enjoying human rights and living in dignity and assists people with disabilities to become more productive members of their communities. For many people, an appropriate, well designed and well fitted wheelchair can be the first step towards inclusion and participation in society. The United Nations standard Rules on the equalization of Opportunities for Persons with Disabilities, the convention on the Rights of Persons with Disabilities and World Health assembly resolution WHa58.23, which deals with disability including prevention, management and rehabilitation, all emphasize the importance of wheelchairs and other assistive devices. To ensure that people with disabilities can access an appropriate wheelchair, especially in less resourced parts of the world, WHO developed the guidelines on the provision of manual wheelchairs in less resourced settings, in partnership with the United states agency for international Development (UsaiD) and the international society for Prosthetics and Orthotics (isPO). in order to train human resources appropriately and provide a good wheelchair delivery system based on the Wheelchair guidelines, WHO has developed this Wheelchair Service Training Package – Basic level. alana Officer robert horvath coordinator Manager Disability and Rehabilitation Team Programs for vulnerable Populations Department of violence and center of excellence on Democracy, injury Prevention and Disability Human Rights, and Governance World health Organization US agency for international Development Wheelchair Service Training Packag e 1 BASIC LEVEL about the Wheelchair Service Training Package: Basic level introduction Following the release in 2008 of Guidelines on the provision of manual wheelchairs in less resourced settings,1 the World Health Organization has developed the Wheelchair service Training Package: Basic Level. The wheelchair is one of the most commonly used assistive devices for enabling personal mobility. For people who have difficulties walking, a wheelchair which meets their physical, lifestyle and environmental needs is an essential tool, enabling them to enjoy vastly improved health, social and economic well-being. Mobility opens up opportunities for wheelchair users to study, work, engage in cultural activities and access services such as health care. The importance of mobility is reflected in the United Nations convention on the Rights of Persons with Disabilities (UNcRPD) which advocates for “effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities”. To ensure effective personal mobility, wheelchair users need a wheelchair which fits them correctly and meets their specific needs. This requires an approach which is responsive to individual needs. an effective way of meeting the individual needs of wheelchair users is the provision of wheelchairs through wheelchair services. However, statistics show that less than 5% of those in need actually have access to a properly fitted wheelchair. in addition, there are limited training opportunities for personnel to gain the skills needed to prescribe a wheelchair effectively. The Wheelchair service Training Package: Basic Level is intended to support the training of personnel fulfilling clinical and technical roles in a wheelchair service (see Guidelines on the provision of manual wheelchairs in less resourced settings, Table 4.2) at basic level. The training package supports the delivery of the theory and practice needed to begin working with wheelchair users who are able to sit upright without additional postural support. The training package includes: how to assess individual needs; assist in selecting and setting up the most appropriate wheelchair from those available; train users and caregivers how to use and maintain the wheelchair; and carry out follow up. 1 World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings. Geneva, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, accessed 15 December 2011). 2The training package can be delivered in 35–40 hours, although this period may be extended or reduced according to the specific needs and resources available in each context. Further practice with a mentor is encouraged to build competencies and enhanced capacity for independent work. WHO hopes to see the Wheelchair service Training Package both delivered as a stand-alone short training programme for personnel already working in the field, and integrated into the curriculums of training programmes for rehabilitation personnel. Target audience This training package is for all personnel or volunteers who are expected to carry out wheelchair service delivery in their place of work. This may include health, rehabilitation or technical personnel, community health care workers, community-based rehabilitation workers, occupational therapists, physiotherapists, prosthetists, orthotists, local craftsmen, technicians and wheelchair users. Purpose The Basic Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who have mobility impairments but can sit upright without additional postural support. The main purpose of the training package is to develop the skills and knowledge of personnel involved in wheelchair service delivery. Delivery of this training package will help to: • increase the number of wheelchair users who receive a wheelchair which meets their needs; • increase the number of wheelchair users who receive training in the use and maintenance of wheelchairs and how to stay healthy in a wheelchair; • increase the number of personnel trained in basic level wheelchair service delivery; • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery; and • achieve greater integration of wheelchair service delivery within rehabilitation services. Scope The training package covers: • an overview of the eight steps of wheelchair service delivery described in the WHO guidelines on the provision of manual wheelchairs in less resourced settings (Table 1); Wheelchair Service Training Packag e 3 BASIC LEVEL • working with wheelchair users to assess their mobility needs and identify the best possible mobility solution; • providing an appropriate manual wheelchair with an appropriate cushion; • problem solving to find simple modifications to the wheelchair that can help ensure the best fit for the user; • wheelchair repairs and maintenance; • training of wheelchair users to make the best use of their wheelchair; and • fabrication of a foam contoured cushion. The inclusion of simple wheelchair modifications is particularly relevant in contexts where there are limitations in the range and sizes of available manual wheelchairs. it is often necessary to make simple modifications to ensure a wheelchair fits correctly. The provision of tricycles is not covered in detail in this training package, although the value of a tricycle for wheelchair users who need to travel longer distances is noted. Table 1. Key steps of wheelchair service delivery: Step 1 Referral and appointment Step 2 Assessment Step 3 Prescription (selection) Step 4 Funding and ordering Step 5 Product (wheelchair) preparation Step 6 Fitting Step 7 User training Step 8 Maintenance, repairs and follow up required knowledge and skills Previous experience in wheelchair service delivery is not required. However, the training programme has been designed assuming that participants will have the following knowledge and skills: • participants will be able to read and write in the language of the training programme; • participants will have a basic knowledge of the common health conditions; or physical impairments which may affect people who can benefit from wheelchairs, including cerebral palsy, lower-limb amputation, poliomyelitis (polio), spinal cord injury and stroke. 4Where participants do not already have information about these health conditions or physical impairments, trainers should include this information as an additional core knowledge session. Structure The Wheelchair service Training Package: Basic Level is designed to be delivered by trainers who are skilled in basic wheelchair service delivery and can confidently demonstrate the competencies taught in this training programme. There are a range of teaching resources, including: • Trainer’s Manual and trainer’s tools; • Reference Manual for Participants (hereafter referred to as Reference Manual); • Participant’s Workbook; • Wheelchair service forms; • Wheelchair service checklists; • visual aids, including PowerPoint slides, videos and posters. Development process Following the release of the Guidelines on the provision of manual wheelchairs in less resourced settings (WHO, 2008), WHO formed a working group to develop the Wheelchair service Training Package. The first working group meeting was convened by WHO in October 2008 to determine the scope and content of the Training Package. Following circulation and receipt of feedback from over 20 experts in the field on the proposed Training Package content, a core group of contributors worked to prepare each training package for field piloting. in 2010, the Basic Level training package was piloted in india, solomon islands and Kenya. each pilot was observed by members of the WHO Wheelchair Training Package working group. Feedback from trainers, trainee participants and wheelchair users participating in the practical sessions has been incorporated into the final documents. in addition to the pilots, the Basic Level training package was circulated for peer review, with valuable feedback gained from a range of experts in the field. all the authors involved in the development of the training package completed a Declaration of interest (DOi) and none declared any conflict of interest related to the subject matter. Wheelchair Service Training Packag e 5 BASIC LEVEL a. core knowledge 6a.1: Wheelchair users Wheelchair users are people who already have a wheelchair or who can benefit from using a wheelchair because their ability to walk is limited. Wheelchair users include: • children, adults and the elderly; men, women, girls and boys; • people with different mobility impairments, lifestyles, life roles and backgrounds; • people living and working in different environments including rural, semi-urban and urban. The needs of each wheelchair user will vary. However, they all need an appropriate wheelchair. What are the benefits of a wheelchair? • Mobility: Wheelchairs help people to get around with the greatest possible independence and do the things they want to do. • health: a wheelchair can improve the user’s health in many ways. a well fitting wheelchair with a cushion can reduce common problems, such as pressure sores or poor posture. a wheelchair that works well, fits well and can be propelled easily can increase the physical activity of the user, thus improving health. • independence: Wheelchair users can be more independent and more in control of their own life. • Self-esteem and confidence: Wheelchair users may become more confident and have more self-esteem when they have a wheelchair which fits them and which they can use well. • access to community life: With a wheelchair, wheelchair users can be more involved in community life. For example, it enables the user to go to work or school; visit friends; attend places of worship or other community activities. Wheelchair Service Training Packag e 7 BASIC LEVEL What is an “appropriate wheelchair”? an “appropriate Wheelchair” is a wheelchair that: • meets the user’s needs; • meets the user’s environment; • is the right match for the user; • ensures postural support (helps the user to sit upright); • can be maintained and repaired locally. The United nations convention on the rights of Persons with Disabilities The United Nations Convention on the Rights of Persons with Disabilities (UNcRPD) entered into force on 3 May 2008. There are human rights that apply to everybody. The UNcRPD focuses on ensuring that everybody recognizes that these rights also apply to people with disabilities. There are 50 different articles in the convention. One of the articles, article 20, is about “personal mobility”. Personal mobility means the ability to move in a manner and at the time of one’s own choice. article 20 says: “states Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities”. Wheelchairs and wheelchair services are very important for assisting most people with mobility impairments to gain personal mobility. Wheelchair service personnel can help to implement article 20 of the UNcRPD by: • providing an appropriate wheelchair for wheelchair users who visit their service; • assisting wheelchair users in learning how to get in and out of their wheelchair themselves; • supporting wheelchair users in learning how to propel themselves; • encouraging family members to support wheelchair users to be as independent as they can be. There are other human rights that people with mobility impairments can enjoy more easily if they have an appropriate wheelchair. These are: • living independently and being included in the community (article 19); • right to education (article 24); • right to the enjoyment of the highest attainable standard of health (article 25); • right to work and employment (article 27); • right to participate in political and public life (article 29); • right to participate in cultural life, recreation, leisure and sport (article 30). 8The UncrPD (article 20–Personal mobility): states Parties shall take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities, including by: a) Facilitating the personal mobility of persons with disabilities in the manner and at the time of their choice, and at affordable cost; b) Facilitating access by persons with disabilities to quality mobility aids, devices, assistive technologies and forms of live assistance and intermediaries, including by making them available at affordable cost; c) Providing training in mobility skills to persons with disabilities and to specialist staff working with persons with disabilities; d) encouraging entities that produce mobility aids, devices and assistive technologies to take into account all aspects of mobility for persons with disabilities. Which means:2 countries should make sure disabled people can get about independently as much as possible. They should: • assist people get about. • assist people to get a quality wheelchair at an affordable cost. • Give training on how to get about. • Get entities/companies that make aids to think about all different needs of disabled people. a.2: Wheelchair services Wheelchair services work with wheelchair users to find the most suitable wheelchair among those available for that user. The WHO Wheelchair guidelines outline eight steps that wheelchair service personnel need to carry out to provide a wheelchair. These steps are summarized below. each step is covered in more detail in section B of this manual. 2 international agreement on the rights of disabled people (easy-read version of the cRPD), prepared for the United Kingdom Department for Work and Pensions by the ”easy read” service @ inspired services.is164/07. Newmarket, inspired services, 2007 http://odi.dwp.gov.uk/docs/wor/uncon/un-agree.pdf (accessed 15 December 2011). Wheelchair Service Training Packag e 9 BASIC LEVEL Step Summary 1. referral and appointment The way that wheelchair users are referred will vary. Users may refer themselves or be referred through networks made up of governmental or nongovernmental health and rehabilitation workers or volunteers working at community, district or regional level. Some wheelchair services may need to identify potential users actively if they are not already receiving any social or health care services or participating in school, work or community activities. 2. assessment Each user needs an individual assessment, taking into account lifestyle, work, environment and physical condition. 3. Prescription (selection) Using the information from the assessment, a wheelchair prescription is developed together with the user and family members or caregivers. The prescription (selection) details the selected wheelchair type and size, special features and modifications. It also describes the training the user needs in order to use and maintain the wheelchair properly. 4. Funding and ordering A funding source is identified, and the wheelchair is ordered from stock held by the service or from the supplier. 5. Product (wheelchair) preparation Trained personnel prepare the wheelchair for the initial fitting. Depending on the available product and service facilities, this may include assembly, and possible modification, of products supplied by manufacturers or manufacture of products in the service workshop. continues.. 10 Step Summary 6. Fitting The user tries the wheelchair. Final adjustments are made to ensure the wheelchair is correctly assembled and set up. If modifications or postural support components are required, additional fittings may be necessary. 7. User training The user and caregivers are trained how to use and maintain the wheelchair safely and effectively. 8. Maintenance, repairs and follow up The wheelchair service provides maintenance and repair services for technical problems that cannot be solved in the community. It is appropriate to carry out follow up activities at the community level as much as possible. Follow up appointments are an opportunity to check wheelchair fit and provide further training and support. The timing depends on the needs of the user and the other services that are available to them. If the wheelchair is found to be no longer appropriate, a new wheelchair needs to be supplied starting again from step one. source: World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings, Table 3.2. Geneva, 2008:76. a.3: Wheelchair mobility Many wheelchair users live and work in places where it is difficult for them to get around, for example areas where the ground is rough, sandy or muddy, or where there are steps, kerbs or small cramped spaces. Training in wheelchair mobility skills can help wheelchair users to tackle some of these obstacles, either independently or with assistance. various wheelchair mobility skills are described below. continued Wheelchair Service Training Packag e 11 BASIC LEVEL U p st ep s w it h as si st an ce • Go up backwards. • Tilt wheelchair on to back wheels, positioned against the first step. • Assistant pulls backwards and upwards – rolling the wheelchair up. • Wheelchair user can assist by pushing the push rim backwards. • A second assistant can assist by holding on to the wheelchair frame from the front (not footrests). Wheelchair Mobility Skills: P us hi ng • Pushing correctly requires less effort. • Push from 10 o’clock to 2 o’clock position. • Use long smooth action to push. T ur ni ng • Hold one push rim towards the front and the other towards the back. • Pull the forwards hand backwards and push the backward hand forwards at the same time. U p sl o pe s • Lean forward – this helps to stop the wheelchair tipping. • When practising, have an assistant stand behind for safety. • To stop or rest – park the wheelchair sideways on. D ow n sl o pe s • Lean backwards. • Let the push rim slide slowly through the hands. • Experienced wheelchair users who are able to do a “wheelie” (i.e. balance the wheelchair on the rear wheels only) may roll down a slope on their back wheels. This is very efficient. 12 D ow n st ep s w it h as si st an ce • Go down forwards. • Tilt the wheelchair on to back wheels. • Assistant lets the back wheels roll down slowly, one step at a time. • Wheelchair user can assist by controlling the wheelchair with the push rims. • A second assistant can help by steadying the wheelchair from the front, holding on to the wheelchair frame (not footrests). P ar ti al w he el ie • Being able to do a partial wheelie is very useful for a wheelchair user. • The wheelchair user can lift the front wheels to clear small kerbs, stones and bumps. • Roll the wheelchair backwards until hands are in the 10 o’clock position. Then push forwards quickly. • The castor wheels should come up. • With practice, it is possible to lift the castor wheels at the right time to clear small obstacles. • Always make sure that there is an assistant standing behind the wheelchair user when he/she begins to practise this skill. how to make wheelchair mobility skills training safe • Do not stand on footrests when getting in and out of the wheelchair. • Keep fingers clear of the wheel spokes and brakes. • When learning how to go up hills, or doing a partial wheelie, ALWAYS have an assistant stand behind the person in the wheelchair. • Do not assist a wheelchair user up and down steps unless you feel very sure that you are able to control the wheelchair safely. If unsure, get help. Wheelchair Service Training Packag e 13 BASIC LEVEL a.4: Sitting upright Most wheelchair users spend many hours sitting. This means that their wheelchair is not just a mobility aid. it also helps to support them in sitting upright comfortably. Sitting upright/neutral sitting posture What is posture? Posture is the way a person’s body parts are arranged. Wherever possible, a well fitting wheelchair should support wheelchair users in sitting in an upright posture. sometimes “sitting upright” is described as a neutral sitting posture. Why is it important to sit upright? sitting upright helps wheelchair users in many ways. sitting upright is good for: • health: an upright posture helps with digestion of food and breathing; • stability: an upright posture is more stable; • weight distribution: when sitting upright body weight is evenly distributed – this helps to reduce the risk of pressure sores; • comfort: when body weight is distributed evenly, it is more comfortable for the user; • preventing problems with posture: sitting upright will help to reduce the chance of developing deformities of the spine in the future; • self-esteem and confidence: sitting upright can help wheelchair users feel better about themselves. even though sitting upright has many benefits, without postural support it can be hard to stay in this posture all day. This is why people without a disability use different postures throughout the day. For a wheelchair user who sits in a wheelchair all day, the wheelchair needs to provide enough support to help the user to sit upright comfortably. 14 how to tell if a person is sitting upright Look from the side and check:  Pelvis upright;  Trunk upright, back following the three natural curves;  Hips flexed near 90 degrees;  Knees and ankles flexed near 90 degrees;  Heels directly below the knees or slightly forward or back;  Feet flat on the floor or footrests. Look from the front and check:  Pelvis level;  Shoulders level, relaxed and arms free to move;  Legs slightly open (abducted);  Head upright and balanced over the body. how the pelvis affects the way we sit The pelvis is the base for sitting upright. To be strong and stable, a building needs a solid foundation. in the same way, to be stable when sitting the pelvis must be strong and stable. When the wheelchair user is sitting upright, the pelvis is: • level (viewed from the front); and • upright or slightly tilted forward (viewed from the side). Front view of pelvis side view of pelvis any changes in the pelvis will cause a change in the other parts of the body. if the pelvis is not upright, it is difficult to sit upright. Wheelchair Service Training Packag e 15 BASIC LEVEL The pelvis moves in different ways. The table below shows four different pelvic movements and how the body changes when each movement is made. Movement illustration changes in the body rolling forward: (forward pelvic tilt). Side view of pelvis • The body straightens out with the shoulders pulled back. • There is an increase in the curve of the spine above the pelvis. rolling backwards: (backward pelvic tilt). Side view of pelvis • The body becomes rounded with the shoulders forward. Tilting sideways: (lateral tilt). Back view of pelvis • The body bends sideways. rotation. View from above • The rest of the body also rotates. 16 a.5: Pressure sores a pressure sore is an area of damaged skin and flesh. a pressure sore can develop in a few hours, but the results can last for many months and even cause death. What causes pressure sores? The three main causes of pressure sores are the following. Pressure: Pressure sores can be caused by pressure on skin from sitting or lying in the same position for too long without moving. Wheelchair users are particularly at risk, because they may spend a long time each day sitting in their wheelchair. Unless the pressure is relieved, a pressure sore can quickly develop. Friction: Friction is constant rubbing on the skin. For example, an arm rubbing on a wheel/armrest as a wheelchair is moved can cause a pressure sore. Shear: shear is when the skin stays still and is stretched or pinched as muscles or bones move. For example, when a wheelchair user sits “slumped” in the wheelchair, skin may be damaged by shear by the seat bones as the pelvis rocks backwards, or by bones in the back squeezing the skin against the backrest. Pressure sore risk factors as well as the three main causes of pressure sores, there are a number of things that make it more likely that someone will get a pressure sore. all these are called pressure sore risk factors. Pressure sore risk factors include the following. Wheelchair Service Training Packag e 17 BASIC LEVEL • Person cannot feel (decreased sensation): anyone who cannot feel, or has difficulty feeling touch on their buttocks (like most paraplegics or quadriplegics), seat or legs is at risk of developing a pressure sore. • Person cannot move: When a person cannot move, he/she is unable to relieve the pressure. • Moisture from sweat, water or incontinence: Moisture makes the skin soft and more easily damaged. if the user does not have a way to manage bladder and bowel function, urine and faeces can burn and damage the skin. • Poor posture: Not sitting upright can cause an increase in pressure in one area. • Previous or current pressure sore. • Poor diet and not drinking enough water: a good diet, including drinking enough water, is important to ensure the body has fluid and nutrients to maintain healthy skin and heal wounds. • ageing: elderly people often have thin, frail skin which can damage easily. • Weight (underweight or overweight): People who are overweight may have poor blood flow in their skin, which can then damage easily and heal poorly. Wheelchair users who are underweight are at risk of developing a pressure sore because their bones are not well protected. The skin over the bony areas can be damaged quickly. common pressure sensitive areas: side view Back view The four stages of a pressure sore What to do 1 A red or dark mark on the person’s skin. The redness or change in colour does not fade within 30 minutes after pressure is removed. • Remove pressure from that area immediately. • Keep pressure off until the skin has fully healed. This may mean bed-rest. • Identify the cause and address this. • Teach the wheelchair user how pressure sores are formed and how to prevent them in future. 3 spinal injury Network. Pressure sore stages (http://www.spinal-injury.net/pressure-sore-stages-sci.htm, accessed 13 December 2011). continues.. 3 18 The four stages of a pressure sore What to do 2 A shallow wound. The top layer of skin may start to peel away or blister. Follow the actions for stage 1. Refer for treatment of the pressure sore to an experienced health care worker. Open pressure sores will need cleaning, dressing and close monitoring to ensure they are healing and do not become infected. Stage 4 wounds may require surgery. 3 A deep wound; the whole layer of skin is lost. 4 A very deep wound, extending through the muscle and possibly right down to the bone. how can pressure sores be prevented? Use a pressure relief cushion: a pressure relief cushion will help to reduce pressure. anyone at risk of developing a pressure sore should be given a pressure relief cushion. Sit upright: sitting upright helps to distribute weight evenly. This reduces pressure under bony parts and helps to reduce sores caused by pressure. sitting upright also helps to avoid pressure sores caused by shear. Wheelchair service personnel can help wheelchair users to sit upright by making sure the wheelchair fits correctly and explaining why it is important to sit upright. Use pressure relief techniques: Regular pressure relief can be effective in preventing pressure sores. see below for more information about how to relieve pressure. continued Wheelchair Service Training Packag e 19 BASIC LEVEL eat well and drink lots of water: a well balanced diet with fresh vegetables, fruits and meat can help to prevent pressure sores. Drinking lots of water will help to keep the skin healthy and prevent pressure sores. if you are concerned about a wheelchair user’s diet – consider referring him/her to a service that can help. avoid friction: Make sure the wheelchair fits correctly and has no rough edges. Teach wheelchair users who cannot feel to check that no parts of their body are being rubbed by the wheelchair. Teach wheelchair users to take care when getting in and out of the wheelchair. avoid moisture: Wheelchair users need to be advised to change wet or soiled clothing straight away, and not to use a wet cushion. a bowel and bladder management programme can reduce problems with moisture. Refer wheelchair users who have a problem with incontinence to a service that can help them. check skin every day: Pressure sores can develop quickly. it is important to identify a pressure sore quickly and take action. encourage wheelchair users who are at risk to check their skin every day. They can check themselves using a mirror, or ask a family member to check. if they see a red or dark area of the skin (stage 1 pressure sore), they should take all necessary measures to relieve pressure on that spot immediately. 20 While lying or sitting, change positions regularly: changing position regularly helps to relieve pressure. For example, change position from sitting to lying. This is particularly important for someone who has a number of pressure sore risk factors, or has a recently healed pressure sore. People who cannot change position by themselves are at risk. Pressure relief techniques Wheelchair users can relieve pressure from the seat bones while in their wheelchair. How they do this will vary, depending on how much strength and balance they have. Wheelchair service personnel need to teach all wheelchair users who are at risk of developing a pressure sore at least one way to relieve pressure. Bending forward: A method suitable for most wheelchair users. Independent: for people with good balance and strength. With assistance: For people with poor balance and strength. Side to side leaning: A method suitable for wheelchair users with limited strength and balance. Some wheelchair users may hook their arm over the push handle for support. Wheelchair Service Training Packag e 21 BASIC LEVEL a.6: appropriate wheelchair Parts of a wheelchair Definition of an “appropriate wheelchair” Please refer to session a.1 Wheelchair users. Meeting the wheelchair user’s needs an appropriate wheelchair should make it easier for wheelchair users to carry out the things they need to do. Wheelchair users need to be able to get in and out of their wheelchair, to push their wheelchair, to fold the wheelchair for transport and storage and carry out their daily activities. The right type of wheelchair can make it easier for the wheelchair user to do all these things. see the examples below. cushion Push handle Rear wheel seat rail Footrests hanger Push rim castor wheel Brake Backrest seat calf strap Footrest armrest 22 Transfers Getting in and out of the wheelchair Wheelchair users get in and out of the wheelchair in different ways, depending on their physical ability. Different wheelchair features can make their transfers easier. Three features that make transfers easier are: armrests, footrests, and brakes. Removable armrests, or armrests which follow the line of the rear wheels, are easier for people who get in and out of their wheelchair sideways. People who stand up to get in and out of the wheelchair may need armrests to help them stand up. Footrests which can be moved out of the way are helpful for people who stand up to get in and out of the wheelchair. People who want to transfer to the floor may prefer a wheelchair with removable footrests. Brakes are important for all wheelchair users. They are essential for keeping the wheelchair still while the person gets in and out of the wheelchair. Pushing the wheelchair Wheelchair users propel their wheelchair in different ways. Many wheelchair users propel the wheelchair with their arms. some wheelchair users push the wheelchair with their feet – or with one arm and one foot. some wheelchair users need someone to push the wheelchair for them some or all of the time. Pushing the wheelchair by hand propelling is easier when the armrests and backrest are the right height. Wheelchair Service Training Packag e 23 BASIC LEVEL Backrest is too high. The wheelchair user cannot comfortably move the arms and shoulders to push. armrests are too high. The wheelchair user cannot comfortably reach the wheels to push. When the backrest is lower, the wheelchair user has freedom to move the shoulders to push. For a wheelchair user who can sit upright and has good balance, this is a good height for the backrest. Pushing the wheelchair is easier if the wheelchair user can reach the push rims comfortably. The rear wheel should be positioned so that when the wheelchair user holds the top of the push rim the elbow is bent at 90 degrees. This is a good pushing position. if the wheel is further back, it is more tiring for the wheelchair user to push. some wheelchairs have an adjustable rear wheel position. The position of the rear wheels affects how easy it is to push the wheelchair into a wheelie. Wheelies are useful for going over rough ground, up and down kerbs or down slopes. if the rear wheels move forwards, the wheelchair is easier to push into a wheelie. if the rear wheels move backwards, they become more stable but the wheelchair is harder to push and it is harder to perform a wheelie. 24 Pushing the wheelchair with the feet is easier if the wheelchair user has enough power in one leg and can sit with the pelvis supported by the wheelchair backrest and the feet flat on the floor. For wheelchair users who push with their feet, the height of the seat from the floor (including the cushion) is very important. Footrests that swing out of the way are also essential. some users who push with their feet may like a tray or armrests so that they can lean forward while pushing. a heavy wheelchair takes more energy to push – whether hands, feet or assistant-propelled. However, if the wheelchair is well designed and well balanced, the weight may not be such a problem. The weight of the wheelchair is particularly important in the case of children. if the wheelchair is heavy, this may make the chair hard for the child to control. Folding the wheelchair To transport or store the wheelchair, it needs to fold. Wheelchairs fold in two main ways. Wheelchairs with a cross-folding frame fold so that both sides come together. sometimes it is possible to remove the wheels as well. cross-folding wheelchairs can be helpful for wheelchair users needing to “squeeze” through narrow doorways. For transport, some people prefer a cross-folding wheelchair. For example, it may fit better in the aisle of a bus. a disadvantage with some cross-folding frames is that the folding mechanism can weaken, making the wheelchair feel unstable. it then becomes harder to push. Wheelchair Service Training Packag e 25 BASIC LEVEL some rigid frame wheelchairs also fold. However, instead of the two sides folding together, the backrest folds down and the rear wheels come off. One advantage of rigid frames is that they can be more durable, as there are fewer moving parts. Carrying out activities There are several features of a wheelchair which affect how easily a wheelchair user can carry out the activities of daily life. For example, the features that help a wheelchair user to push (described above) will dictate how easily he/she can participate in activities. Here are some other examples. Wheelchair frame length: The overall length of a wheelchair can affect how easy or difficult it is to use in small spaces. For someone who spends a lot of time indoors, a wheelchair with a short length may be the best choice. The frame length is measured from the furthest back part of the wheelchair to the furthest front part. armrests: High armrests may make it difficult for the user to get close to a table or desk. remember: an appropriate wheelchair helps to meet users’ needs. This includes making it easier for them to do the things they need and want to do. Frame length 26 Meeting the wheelchair user’s environment Different types of wheelchair are suited to different environments. The main features which affect how a wheelchair works in a different environment are: • distance between the front and rear wheels (wheelbase); • the size and width of the wheels. Distance between the front and rear wheels (wheelbase). The distance between the front and rear wheels is important. When the wheels are further apart, this is called a “long-wheelbase”. When the wheels are closer together, this is a “short-wheelbase”. Long-wheelbase wheelchairs are more stable and less likely to tip forward. They can be a good choice for a person who will spend most of the time outdoors and moving over rough or uneven surfaces. There are three-wheel and four-wheel long-wheelbase wheelchairs. Three-wheel long-wheelbase wheelchairs are usually very stable and suitable for outdoors on rough terrain. The four-wheel long-wheelbase wheelchairs have the front castor wheels under the footrests instead of behind. This gives the wheelchairs a longer wheelbase. shorter-wheelbase wheelchairs are more suited to use in places where the ground is flat or the space is confined – indoors, for example. short-wheelbase wheelchairs are more likely to tip forward if going downhill, or if the front wheels hit a bump. Wheelbase Wheelbase Wheelbase Wheelchair Service Training Packag e 27 BASIC LEVEL This is an example of an orthopaedic-style wheelchair with a short wheelbase. This chair would not be easy to push over rough terrain. Wheelchair users with good mobility skills may use a short-wheelbase wheelchair outdoors by balancing on the back wheels to go down hills and over rough ground. Size and width of wheels The larger the wheel, the easier it is to push over uneven ground. Wide rear wheels and large and wide front castors help prevent the wheelchair from sinking into sandy or muddy ground. remember: an appropriate wheelchair will suit the user’s environment – which means the area where he/she spends most time. Providing proper fit and postural support all wheelchair users are different sizes. The wheelchair must fit the user correctly to provide proper fit and support. Fortunately, many wheelchairs come in a range of different sizes, or have size adjustments. it is easier to make sure these wheelchairs fit the user than if there is only one size available. The following components or features of a wheelchair will affect how well the wheelchair fits and how well it helps the user to sit upright. 28 Seats Seats: Wheelchair seats may be either solid or slung. The picture on the left shows a solid seat. solid seats may be made from wood or plastic. solid seats should always have a cushion over the top. slung seats are usually made from canvas. slung seats are made from fabric attached to each side of the frame. Poor-quality slung seats can sometimes stretch and sag so they fail to provide good support. The man pictured on the left is sitting in a wheelchair with a slung seat which has become loose and saggy. it does not provide him with support. This makes it difficult for him to sit upright. Backrests: Backrests may be slung or solid. all solid backrests should have some padding/ cushioning. Wheelchairs come with different backrest heights. some wheelchairs have adjustable backrest heights. The correct backrest height needs to be selected for each user. armrests: armrests can also provide support. some armrests are height-adjustable. if they are not, they can sometimes be modified to give more support for a user who needs it. cushions: The cushion provides comfort, helps to relieve pressure, and also provides support and helps to stop the user from sliding. Footrests: Footrests help to support the user. it is very important that footrests are adjusted correctly. For this reason, the height of the footrests is usually adjustable. some footrests can also be adjusted by angle, and the distance away from the wheelchair. remember: an appropriate wheelchair provides proper fit and support for the user. cushion Backrest Footrest armrest Wheelchair Service Training Packag e 29 BASIC LEVEL a.7: cushions What are cushions for? a cushion is a very important part of every wheelchair. cushions provide: • comfort; • posture support (help people to sit more upright); • pressure relief. all wheelchair users should be comfortable in their wheelchair, and a good cushion helps them to sit upright easily and comfortably. That is why every wheelchair user should have a cushion. it is not necessary for every wheelchair user to have a pressure relief cushion. Different types of cushions cushions can be described in different ways, including: • the material they are made from (for example foam, coir); • the material they are filled with (for example air, fluid or gel); • their main function (for example pressure relief, comfort, posture support); • their shape (for example flat or contoured); • how they are made (for example foam cushions may be “moulded” from one piece of foam or “layered” – made from a number of layers of foam). The most commonly available cushion is a foam cushion. Foam cushions are also usually the least expensive. They are easy to make where foam is available and easy to modify to suit individual wheelchair users. Who needs a cushion? every wheelchair user should have a cushion. Wheelchair users at risk of developing a pressure sore should use a pressure relief cushion. 30 Pressure relief cushions There are different types of pressure relief cushions including: • foam contoured pressure relief cushions; • air/fluid/gel filled cushions. Foam pressure relief cushions The key features of a foam pressure relief cushion are the following: Firm stable base: The base of a pressure relief cushion should be firm. This will make sure the cushion provides good support for the user and does not move when the user moves. Top layer: Over the base layer there should be a “comfort layer”. This is a layer (or more than one layer) of softer foam. The top layer should be soft enough to allow the seat bones to sink into it, but should not be so soft that the seat bones can sink all the way to the bottom and rest on the solid base or seat of the wheelchair. Pressure relief cushions help to reduce pressure by: • distributing a wheelchair user’s weight as evenly as possible across the seat surface; • reducing pressure under high-pressure risk areas (seat bones, hip bones, coccyx/tail bone); • reducing shear by assisting the wheelchair user to sit upright. Shaping on a pressure relief cushion Pressure relief cushions vary. shaping that you may see on a pressure relief cushion includes: • a “well” under the seat bones to reduce pressure; • support under the hip bones to help distribute weight; • a shelf in front of the seat bones to keep the pelvis more upright and prevent sliding forward; • grooves or gutters for the legs. Wheelchair Service Training Packag e 31 BASIC LEVEL air/fluid/gel pressure relief cushions • Flotation cushions include those filled with air and those that have a fluid or gel pack. • Gel-pack cushions should have a firm foam base very similar to a foam contoured cushion. • Over the base layer there is a gel/fluid pack. • The gel pack automatically matches the shape of the wheelchair user’s body. This helps to distribute the user’s weight evenly and reduces pressure under bony areas. Which cushion to use? There are advantages and disadvantages of both foam contoured cushions and air/ fluid/gel cushions. advantages Disadvantages Foam contoured cushion Can be made locally (where there is high-quality foam). Can be modified locally to accommodate different needs. Not subject to”sudden collapse” (a puncture in the air/fluid/gel cushions can cause the release of the materials from the cushion and stop the cushion from relieving pressure, causing “sudden collapse” of the cushion). The top layer of a layered foam cushion can be replaced easily and at a low cost (rather than replacing the whole cushion). Foam compresses (becomes flatter and firmer) over time. For this reason, foam cushions should be checked regularly and replaced every 1–2 years. Can take a while to dry out (a problem for people who are incontinent). Foam insulates and can cause an increase in tissue temperature. air/ fluid/gel cushions Pressure is distributed evenly over the seat surface. The gel pad automatically adapts to the body when the wheelchair user moves or changes position. Air/fluid/gel cushions are often more expensive and less readily available than foam cushions. Some wheelchair users find air/ fluid/gel filled cushions make them feel unstable. Subject to “sudden collapse”. In any context where a wheelchair user is not able to get a replacement cushion quickly, this can be a problem. 32 Cushion covers a pressure relief cushion should have a cover which can be removed for washing and is water-resistant. The material used for a pressure relief cushion cover should be either stretchy or loose enough to allow the seat bones to sink into the foam. if the cover fabric is not stretchy, a thin fabric is best. Folds in a thin fabric will be less likely to mark the skin and cause a pressure sore. if thin plastic is used under a fabric cover, this also needs to be loose enough to allow the seat bones to sink into the foam. always advise wheelchair users that if their cushion or cushion cover becomes wet it needs to be dried and replaced only when dry. For wheelchair users who are incontinent and at risk of developing a pressure sore, provide two cushions which may be used in turn. What to do if there is no water-resistant cushion cover Wherever possible, wheelchair users who are incontinent need a cushion cover which is water-resistant and will keep fluid away from the user’s skin. if there is no water-resistant cover: • investigate what assistance can be provided to reduce incontinence; • provide a second cushion – so that one can be drying while the user sits on the other; • protect the cushion with a very thin plastic bag inside the cover. if using a plastic bag: • check that the plastic bag does not cause the user to “slide” on the cushion; • make sure that there are no creases in the plastic bag that could cause a pressure sore; • the wheelchair user must ensure that fluid does not “pool” over the plastic, as this increases the risk of a pressure sore; • the wheelchair user should ensure that the cover is dried out if it becomes wet and the plastic bag cleaned or replaced. how to test if a pressure relief cushion is working Whenever you prescribe a pressure relief cushion, carry out this simple manual test to check whether the cushion is reducing pressure under the user’s seat bones. The test requires personnel to place their hands underneath the wheelchair user’s seat bones. always explain to the wheelchair user what you are going to do and why it is important. always carry out the test with the same cushion and the wheelchair that has been provided for the user. Wheelchair Service Training Packag e 33 BASIC LEVEL Manual pressure test a Explain to the wheelchair user what you are going to do, and why it is important. B Ask the wheelchair user to push up or lean forward to allow you to place your fingertips under their left or right seat bone (palm up). This is best done from behind the wheelchair by reaching under the back upholstery with one hand. c Ask the wheelchair user to sit back down on your fingers. They should sit normally, face forward, and place their hands on their thighs. This will ensure that they sit in the same position each time you move to check another location. If your fingers are not in a good position to feel the pressure under the seat bone, then ask the user to push up again and reposition your fingers. D identify the pressure under the first seat bone as either level 1, 2, or 3: level 1 = safe: Fingertips can wriggle up and down 5 mm or more. level 2 = warning: Fingertips cannot wriggle, but can easily slide out. level 3 = unsafe: Fingertips are squeezed firmly. it is difficult to slide fingers out. e Repeat under the second seat bone. how to reduce “warning” or “unsafe” pressure? When level 2 (warning) or level 3 (unsafe) pressures are found under the seat bones, action is needed to reduce the pressure. a simple solution is to add an extra layer of firm foam. This is called a ”lift”. The lift should be approximately 20 mm thick and have holes cut out under the seat bone area. The lift is placed underneath the cushion and inside the cover. sometimes more than one layer is needed. Personnel should add one layer and test the pressure. if the pressure is still level 2 or 3, add another layer. 34 a.8 Transfers getting in and out of the wheelchair The ability to get in and out of the wheelchair easily and safely, with or without assistance, will help a wheelchair user in daily life. Getting in and out of the wheelchair can be called “transferring”. Why do wheelchair users need to learn how to transfer? Wheelchair users may need to get in and out of their wheelchair several times a day. They need a method which is safe, quick and does not use much energy. Wheelchair users practise different methods, depending on their abilities. some wheelchair users can get in and out of the chair by themselves, and others need help. some users can stand up to transfer, while for others this is not possible. Three ways to get in and out of the wheelchair Before recommending or practising a transfer with a wheelchair user you need to know whether he/she can transfer independently or needs help. • For transferring independently through sitting, check that the wheelchair user can lift his/her weight upwards by pushing with the arms. if the user cannot do this, he/she needs help to transfer. • For transferring independently through standing, check that the wheelchair user can stand up and take his/her own weight through the legs. if he/she cannot do this, he/she needs help to transfer. some different ways to transfer are shown below. Wheelchair Service Training Packag e 35 BASIC LEVEL independent transfer through sitting (wheelchair to bed) • Position the wheelchair close to the bed, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Push up on hands and move to the front of the wheelchair. • With one hand on the bed and the other on the wheelchair, push up and lift on to the bed. • If the user has poor balance or cannot lift high enough or move sideways far enough, he/ she may use a transfer board. If transferring to a bed, some wheelchair users prefer to place their legs on to the bed before transferring. assisted transfer through sitting with a transfer board (wheelchair to bed) • Position the wheelchair close to bed, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Assist user to move forward. • Put a transfer board under buttocks across the wheelchair and bed. • User to assist as much as possible by pushing up on wheelchair and bed to take own weight. • Assistant stands behind user, and moves user’s buttocks over to the bed. 36 assisted standing transfer (bed to wheelchair) • Position the wheelchair, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Assist the user to move forward on the bed and place feet on the floor. • Support the user’s knees from the side (do not push against knees from the front). • Bring user’s body forwards and upwards by supporting around the shoulder blades. • Twist the user towards the wheelchair and allow him/her to sit down gently. What is a transfer board? a transfer board is a strong, thin board which can help to bridge the gap between the wheelchair and surface the wheelchair user is transferring to. Transfer boards are useful for wheelchair users who are learning to transfer independently, or who have limited strength in their arms. The wheelchair user can carry out the transfer in a series of small lifts, rather than one big lift. a transfer board can also reduce the assistance a wheelchair user may need. Transfer boards can be made locally from wood or plywood. They should be thin, strong and very smooth. Reduce the thickness at the edges. suggested dimensions are 300 mm x 600 mm. The thickness of the board depends on the strength of the material, but a typical thickness is between 20 and 25 mm. Wheelchair Service Training Packag e 37 BASIC LEVEL independent transfer from floor to wheelchair • This transfer requires the wheelchair user to have strong arms and good balance. • Wheelchair users at risk of developing a pressure sore should always sit on their pressure relief cushion when sitting on the floor. • Sitting in front of the wheelchair, draw the knees up close to the body. • Look down and keep looking down throughout the lift. • Place one hand on the floor and one hand on the front of the wheelchair seat. • Push down with the shoulders and arms to lift buttocks up and on to the front of the wheelchair seat. • Sit back into the wheelchair and reach down to pick up wheelchair cushion. • Shifting your weight to one side, push the wheelchair cushion in place. When transferring from the wheelchair to the floor • Sit at the front of the wheelchair. • Lift feet off the footrests in front of you and slightly to the side (away from the direction you are transferring). • Place your cushion on the floor. • With one hand on the wheelchair seat; reach down to the floor with the other hand. • Using the shoulders and arms, move the buttocks down on to the cushion you have placed on the floor in a controlled movement. how to make getting in and out of the wheelchair safe For the wheelchair user: • always put the wheelchair brakes on when getting in and out of the wheelchair. • check where you are going – make sure there is nothing in the way. • always lift. Don’t drag – this could cause skin damage and lead to a pressure sore. For people assisting: • Before assisting someone, make sure you can support his/her weight. • explain to the user what you are going to do. • Use safe lifting techniques. • Do not assist if you are pregnant or have a back problem. 38 B. Wheelchair service steps Wheelchair Service Training Packag e 39 BASIC LEVEL Step 1: referral and appointment referral Referral means: sending or directing a person to the right place for care or assistance. There are different ways in which wheelchair users may be referred to a wheelchair service. For example, wheelchair users may: • hear about the service and come themselves; • be directed to the service by the local hospital, community health centre, community-based rehabilitation service, village/council/church leaders, disabled people’s organizations, other wheelchair users. Wheelchair services can help to increase the number of wheelchair users who are referred to the service by making sure that all possible referral sources know about the service. Providing referral sources with a referral form can help to give the wheelchair service some simple initial information about the wheelchair user. each wheelchair service needs to decide whether it will find a referral form useful, what information to include and how the form will be used (for example posted to the service, or handed to the wheelchair user to bring along). a sample wheelchair referral form is shown on the next page. appointment When a wheelchair user is referred to a wheelchair service, he/she should be given an appointment for an assessment, if he/she cannot be attended to on the same day. The appointment may be for the user to visit the service/centre, or for wheelchair service personnel to visit the user. an appointment system helps wheelchair service personnel organize their time efficiently. it also means that wheelchair users do not have to wait around to see the service personnel. The way an appointment is made depends on how easy it is to get a message to the wheelchair user. For example, messages may be sent by post, by phone or through the original referral source. sometimes, wheelchair users will arrive without an appointment. if possible, see them on the same day, especially if they have travelled a long way. 40 good practice in appointment and referral • start a file for each wheelchair user when he/she is referred to the service. • educate referral sources about the wheelchair service and how to refer to the service. • Give referral sources a supply of wheelchair referral forms. • Where there are many wheelchair users, services should work out a way to decide who will be seen first. consider particularly the needs of children and people with life-threatening conditions, such as pressure sores. Wheelchair referral form Please complete referral form and post to: Wheelchair service Name and address: Name of referral person: Organization you work for: Referral person contact details (the best way to contact you): Wheelchair user’s name: Date of Birth: Parent / carer’s name: Address: How can the wheelchair user be contacted? Post Own Telephone Friend / neighbour’s telephone If by telephone, what is their phone number: Wheelchair user’s disability if known: Reason for referral: • Has no wheelchair • Has a broken wheelchair • Has a wheelchair that does not meet their needs Please add any other information about the wheelchair user that you think it is important the wheelchair service knows: Has the wheelchair user agreed to being referred to the wheelchair service? Yes No Signature of referring person: Date: A referral form should have clear contact details for the service including service name, postal address and telephone. In this referral form the service will contact the wheelchair user to make an appointment. This may not always be possible. In this case, the service may accept referrals without appointment. The person referring should explain to the wheelchair user what the wheelchair service does. The wheelchair user should agree to a referral being made. Wheelchair Service Training Packag e 41 BASIC LEVEL Step 2: assessment Who needs a wheelchair? When someone comes to a wheelchair service for a wheelchair, it is important to be sure that a wheelchair is really what they need. a person usually needs a wheelchair if: • they cannot walk; • they can walk, but with difficulty or only for a short distance. Why do you need an assessment? a wheelchair assessment is a chance to gather information to help: • choose the most appropriate wheelchair for the wheelchair user from those available; • choose the most appropriate wheelchair components from those available; • find out what training the wheelchair user and/or the family need to make the best use of the wheelchair. Where to carry out an assessment Assessments should always be carried out in a clean, quiet space. This may be a space within the wheelchair service, at another health care or community facility, or at the user’s home. If it is necessary to check whether a person has a pressure sore – do this in a private space. Respect the dignity and privacy of the wheelchair user irrespective of his/ her age, gender, religion or socioeconomic status. 42 Two parts of an assessment: • assessment interview; • physical assessment. 1. assessment interview The best way to gather information about a wheelchair user is to ask questions. The wheelchair assessment form guides wheelchair service personnel to ask the most important questions for a wheelchair assessment. There are four different question headings. These are: • information about the wheelchair user; • physical condition; • lifestyle and environment; • existing wheelchair. information about the wheelchair user: Name: Number: Age: Male Female Phone no.: Address: Goals: These questions are important so that the wheelchair user can be contacted for the follow up in the future. They also give statistical information about the users seen by the service. Under “goals” write why the wheelchair user wants a wheelchair, and what he/she wants to be able to do in the wheelchair. Wheelchair Service Training Packag e 43 BASIC LEVEL When asking questions remember: • always explain to the wheelchair user why this information is important; • always address the wheelchair user (not their assistant/family member) unless you are dealing with a small child or someone unable to understand or answer your questions; • remember to use good communication methods; • information may not always come in the same order as it appears on the form – make yourself familiar with the form so that the information can be recorded in the correct place. Physical condition: These questions are important because some of the features of health conditions can affect the choice of a wheelchair. some examples are given below. Physical condition Cerebral palsy Polio Spinal cord injury Stroke Frail Spasms or uncontrolled movements Amputation: R above knee R below knee L above knee L below knee Bladder problems Bowel problems If the wheelchair user has bladder or bowel problems, are these managed? Yes No Others: _______________________________________________________ 44 Different conditions affecting the wheelchair prescription (selection): What you need to know always remember Cerebral palsy Cerebral palsy affects people very differently. For a person with cerebral palsy who can sit upright, it is important to remember that they may have difficulty keeping their sitting position because they get tired. This makes doing things harder and more tiring. Good support is very important. People with cerebral palsy may need additional postural support in a wheelchair. To do this safely and effectively, intermediate-level training is needed. Poliomyelitis People who have poliomyelitis may have weakness or “floppiness” of body parts. Poliomyelitis can affect legs, arms or trunk, but most commonly affects the legs. The muscles and bones become thinner and the limb does not grow so fast and so is shorter. When the trunk is affected, it may appear shorter. Although people with poliomyelitis have sensation, a cushion is important for comfort. A higher cushion may provide a more comfortable pushing position. Spinal cord injury People with a spinal cord injury are very likely to be at risk of developing a pressure sore. This is because most people with a spinal cord injury cannot feel below the level of their injury. Always prescribe a pressure relief cushion. Stroke People who have had a stroke are usually affected on one side of their body. This means they may fall to one side in the wheelchair. People who have had a stroke may not be able to feel normally on the affected side of their body. People who have had a stroke may be able to get in and out of the wheelchair by standing up. Good support is important. Check if the person can feel – he/she may need a pressure relief cushion. A person with a stroke may prefer a wheelchair with footrests which move out of the way so that he/she can do a standing transfer. continues.. Wheelchair Service Training Packag e 45 BASIC LEVEL What you need to know always remember Lower limb amputation People who are double amputees do not have the weight of their legs to stop their wheelchair from tipping backwards. Always be careful when an amputee first tries a wheelchair. Check the wheelchair balance. The rear wheel may need to move backwards to provide extra stability. Frail Elderly people may need a wheelchair for different reasons. Usually it is because they are having difficulty walking. The wheelchair will make it easier for them to continue to be a part of family and community life. Elderly people may be able to do a standing transfer, and will prefer a wheelchair with flip-up or swing- away footrests. Elderly people should always be given a wheelchair which provides good comfort and support. This will help them to sit well and avoid problems caused by poor posture. Flip-up or swing-away footrests may be the best choice. Spasms or jerky movements Some people have problems with sudden jerking, jumping movements that they cannot control (spasms). These can throw their weight backwards, making it more likely for the wheelchair to tip backwards. The movements can cause the feet to “jump” suddenly off the footrests. This can be dangerous when propelling. Select a safe back wheel position or a very stable wheelchair. Straps may help control the foot position. Note: whenever straps are used, it is important that Velcro is used so that the strap can release if the user falls out of the wheelchair. Bowel or bladder problems Some people cannot control their bladder or bowels. This problem can often be solved with the right equipment (catheters, for example), medication and a bladder and bowel training programme. People with bladder or bowel problems must not sit on a damp or soiled cushion, as their skin can rapidly break down. In addition, the bugs present in faeces rapidly lead to infected pressure sores. Identify who in your area (for example specialist doctors and nurses) can offer advice and training to avoid these complications. Provide a cushion with a waterproof cover. Teach the user how to wash and dry the cushion. A second cushion may help to enable the user to continue day-to-day activities while the cushion dries. continued 46 lifestyle and environment: These questions gather information about where the wheelchair user lives and the things that he/she needs to do in the wheelchair. lifestyle and environment Describe where the wheelchair user will use their wheelchair: __________________________________________________________________ Distance travelled per day: Up to 1 km 1–5 km More than 5 km Hours per day using wheelchair? Less than 1 1–3 3–5 5–8 more than 8 hours When out of the wheelchair, where does the user sit or lie down and how (posture and the surface?____________________________________________________________ Transfer: Independent Assisted Standing Non-standing Lifted Other Type of toilet (if transferring to a toilet): Squat Western Adapted Does the wheelchair user often use public/private transport? Yes No If yes, then what kind: Car Taxi Bus Other ____________________________ existing wheelchair: These questions help to find out if the wheelchair user’s existing wheelchair is meeting his/her needs, and if not, why not. existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes No Does the wheelchair meet the user’s environmental conditions? Yes No Does the wheelchair provide proper fit and postural support? Yes No Is the wheelchair safe and durable? (Consider whether there is a cushion) Yes No Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes No Comments: ________________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications Wheelchair Service Training Packag e 47 BASIC LEVEL 2. Physical assessment There are three different question headings. These are: • presence, risk or history of pressure sores; • method of pushing; • taking measurements. Presence, risk or history of pressure sores /// = does not feel O = previous pressure sore = existing pressure sore Can feel normally? Yes No Previous pressure sore? Yes No Current pressure sore? Yes No If yes, is it an open sore (stage 1–4)? Yes No Duration and cause: __________________ _________________________________ is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous/current pressure sore, poor diet, ageing, under- or over-weight. Yes No Mark on the body diagram: • areas where the wheelchair user cannot feel; like this: //// • areas where the wheelchair user has had a pressure sore in the past; like this: O • areas where the wheelchair user has a current pressure sore; like this: if a wheelchair user says he/she has a pressure sore, always ask to see it. Make sure this is done in a private area. a wheelchair user is at risk of developing a pressure sore if he/she cannot feel or has other risk factors. The risk factors include: • person cannot feel (decreased sensation); • person cannot move; • moisture from sweat, water or incontinence; • poor posture; • previous or current pressure sore; • poor diet and not drinking enough water; • ageing; • weight (underweight or overweight). remember: any wheelchair user at risk of developing a pressure sore needs a pressure relief cushion and education on preventing pressure sores. 48 Method of pushing How will the wheelchair user push their wheelchair? Both arms Left arm Right arm Both legs Left leg Right leg Pushed by a helper Comment:__________________________________________________________ it is important to find out how the wheelchair user will push, as this can affect the choice of wheelchair and the way it is set up (please refer to session a.6: appropriate wheelchair, section `` Pushing the wheelchair`` ). Taking measurements Four measurements from the wheelchair user are needed to choose the best available size of wheelchair for that person. each measurement relates to the wheelchair. Body Measurement Measurement (mm) Change body measurement to ideal wheelchair size Wheelchair measurement (mm) A Hip width Hip width = seat width B Seat depth L B less 30–60 mm = seat depth (if length is different, use shorter one)R C Calf length L = top of seat cushion* to footrests height or = top of seat cushion* to floor for foot propellingR D Bottom of rib cage = top of seat cushion* to top of backrest (measure D or E – depending on the user’s need) E Bottom of shoulder blade *check the height of the cushion that the wheelchair user will use. Measuring tools • Use a retractable metal tape measure (pictured on the right). • clipboards/books can be used to help measure accurately (see How to take body measurements). • Large callipers are an additional tool that can be very useful. These can be made locally from wood. • Foot-blocks can be used to support the wheelchair user’s feet at the correct height. Wheelchair Service Training Packag e 49 BASIC LEVEL how to take body measurements ask the wheelchair user to sit as upright as possible. The wheelchair user’s feet should be supported on the floor or on foot-blocks if they cannot reach the floor comfortably. For all measurements, make sure the tape measure is held straight and the wheelchair user is sitting upright. Holding a clipboard/book on either side of the wheelchair user can help in obtaining an accurate measurement. Bend down to ensure you are viewing the tape measure at the correct angle. a • Check there is nothing in wheelchair user’s pockets before measuring. • Measure hips or widest part of thighs. • Holding two clipboards/books against each side of the wheelchair user can help in obtaining an accurate measurement. B • Place a clipboard/book at the back of the wheelchair user to help get an accurate measurement. • Measure from the back of the pelvis to the back of the knee in a straight line. • Always measure both legs. If there is a difference between the two legs, check that the wheelchair user is sitting up with the pelvis level. If there is still a difference, make the wheelchair prescription for the shorter side. c • Measure from the back of the knee to the base of the heel. • Make sure the wheelchair user’s ankles are bent at 90 degrees (if possible). • Always measure both legs. • The wheelchair user should wear the shoes he/she wears most days (if any). D • Measure the seat to the bottom of the rib cage. • To help find the bottom of the rib cage, place hands on both sides of the pelvis. Gently squeeze hands inwards and slide hands upwards. The bottom of the rib cage is just above the waist. e • Measure from the seat to the bottom of the shoulder blade in a vertical line. • To help find the bottom of the shoulder blade, ask the user to shrug his/her shoulders. For more information on the correct fit of a wheelchair, see step 6 session: Fitting. 50 Step 3: Prescription (selection) What is prescription (selection)? Prescription (selection) means selecting the best match possible between the wheelchairs available and the needs of the user. The prescription (selection) should always be decided with the wheelchair user, including the family member or caregiver if appropriate. Prescription (selection) includes: • selecting the right wheelchair, cushion and wheelchair parts; • selecting the right wheelchair and cushion size; • agreeing with the wheelchair user what training they need to help them use and care for their wheelchair and cushion. locally available wheelchairs and cushions selecting the right size wheelchair is very important. The correct size wheelchair is more comfortable, helps to support upright sitting and is easier for the wheelchair user to use. For more information on the correct fit of a wheelchair, see step 6 session: Fitting. • Frame – for example, whether it is a long or short wheelbase; the frame length; whether it is a cross-folding or rigid frame. • Features – including the type of seat, backrest, footrests, armrests, castor wheels, rear wheels. • Wheelchair size: This is usually described by the wheelchair seat width and sometimes also the depth. The seat height from the floor is also useful to know. • adjustability options: Which components are adjustable and what is the range of adjustment? adjustment is usually possible to two or more different positions. For example, most wheelchairs have footrests which can be adjusted to different heights spaced evenly apart. The “range” of adjustment is from the smallest to the largest measurement. • cushion: What type of cushion (if any) is provided with the wheelchair or is available separately? some wheelchair suppliers provide: a. brochures or a product summary; b. product (wheelchair) specifications. Wheelchair measurements, weights, features and sometimes optional parts are often listed in this information. always check whether there is information available about the wheelchairs you are prescribing. Read this information so that you are familiar with the products. if suppliers do not give this information – ask for it. Wheelchair Service Training Packag e 51 BASIC LEVEL recording the prescription (selection) The prescription (selection) needs to be written down. Below is an example of a wheelchair prescription (selection) form. adapt this form for your local service by listing the types of wheelchairs and cushions available in your service and in what sizes. Wheelchair Prescription (selection) Form 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of fitting: Assessor’s name: 2. Type of wheelchair and size selected select the type of wheelchair: • Discuss with the wheelchair user; • Think about the most important needs of the wheelchair user; • check: wheelchair frame, castor and rear wheels, footrests, armrests, backrest height (or adjustability), rear wheels position, support and comfort. Type of wheelchair Size 3. Type of cushion selected Type of cushion Size e.g. Foam pressure relief cushion e.g. Flat foam cushion 4. Agreed with the selection Signature of the user: Signature of the assessor: Signature of the manager: List the types of wheelchairs available in your service. List the types of cushions available in your service and their sizes. 52 Step 4: Funding and ordering Funding When the wheelchair has been prescribed, the cost of the recommended product can be accurately estimated. it is essential to know who will fund the wheelchair – it could be funded by an out-of-pocket payment, a subsidy from a government, nongovernmental organization or donor agency, or a payment by an insurance company. in the developing world, many people who need a wheelchair cannot afford to buy one. Nevertheless, everyone who needs a wheelchair is entitled to one, regardless of his/her ability to pay. Thus, funds will need to be made available for users who need financial assistance. For most services, it will be essential to identify the funding source before the wheelchair can be ordered. Often, this responsibility lies with administrative personnel or programme managers rather than clinical or technical personnel. Ordering When the best wheelchair for the wheelchair user has been selected and the prescription (selection) form prepared, the wheelchair needs to be ordered, if not available within the existing stock. if a wheelchair service keeps wheelchairs in stock, this may mean completing an order form to be authorized by the service manager. The wheelchair may then be prepared by the staff responsible for wheelchair preparation. if the wheelchair service does not keep wheelchairs in stock, this may mean ordering from an external supplier. The system for ordering wheelchairs will vary in different wheelchair services. Write down below the things that you need to remember to order wheelchairs in your local wheelchair service. Wheelchair Service Training Packag e 53 BASIC LEVEL how to order wheelchairs in my local wheelchair service: good practice in ordering • Keeping wheelchairs in stock can reduce waiting time for wheelchair users. • an order should always be placed as quickly as possible to avoid delays. • always let the wheelchair user know when the wheelchair is likely to be available. 54 Step 5: Product (wheelchair) preparation What is product (wheelchair) preparation? Product (wheelchair) preparation includes: • preparing the wheelchair to match the wheelchair user’s prescription (selection); • checking the wheelchair to make sure that it is safe and ready to be used and all parts are working properly. Preparing the wheelchair Prepare the wheelchair in the following order: 1. Check that the wheelchair seat width and depth measurements are correct for the prescription (selection). 2. Check that the cushion width and depth match the seat. 3. Adjust (where possible): • Backrest height and angle; • armrests height; • Rear wheels position; • Brakes position; • Footrests height; • Push handles height; • any other adjustments. 4. Carry out a “wheelchair safe and ready” check. good practice in product preparation • Label each wheelchair being prepared with the wheelchair user’s name. • any modifications to a wheelchair should always be carried out by someone with the appropriate knowledge and skills. Modifications can affect the strength and function of a wheelchair. • always check that the wheelchair is safe and ready to be used and that all parts are working before the wheelchair user tries it (see below). Wheelchair safe and ready checklist Use the checklist below to make sure that the wheelchair is safe to use and all parts are working. always do this before the wheelchair user tries the wheelchair. Wheelchair Service Training Packag e 55 BASIC LEVEL Checklist: Is the wheelchair safe and ready to use? For the whole wheelchair how to check There are no sharp edges. Check all over the wheelchair with eyes and hands. No parts are damaged or scratched. The wheelchair travels in a straight line. Push the wheelchair away from you, making sure the castor wheels are in the “trail” position. Front castor wheels Spin freely. Tip the wheelchair on to the back wheels. Spin the castor wheels. Spin without touching the fork. Bolts are tight. Check. They should feel firm. Do not over tighten. Front castor barrels Castor fork spins freely. Tip the wheelchair on to the back wheels. Spin the castor fork around. rear wheels Spin freely. Tip the wheelchair sideways on to one rear wheel. Spin the other wheel. Check the other side. Axle bolts are tight. Check. They should feel firm. Do not over tighten. Tyres (if those are pneumatic) are inflated correctly. Press on the tyres with your thumb. The wheel should depress a little, but no more than 5 mm. Push rims are secure. Check. Brakes Function properly. Apply brakes. Check the wheelchair cannot be moved. Footrests Footrests are securely attached. Check. 56 Frame Cross-folding wheelchair folds and unfolds easily. Fold the wheelchair to check that the folding mechanisms are working correctly.Fold-down backrest – the backrest folds and unfolds easily. cushion The cushion is in the cover correctly. Usually the cushion cover is done up at the back of the cushion, underneath. The cushion is sitting on the wheelchair correctly. If the cushion is contoured, the “well” for the seat bones should be at the back of the seat. The cushion cover fabric is tight but not too tight. The cushion cover should not stretch tightly over any contours of the cushion. The cushion fully covers the seat. Check that no part of the seat is visible from under the cushion. This is particularly important for solid seats. cushion fabrication if foam is available, wheelchair service personnel can make a foam pressure relief cushion with just a few tools. Personnel need to know what foam to use, and a few important dimensions. Discuss with your trainers the foams that you have available in your location, to find out which ones would be suitable for a pressure relief cushion. The instructions below show how to make a basic foam pressure relief cushion, with two key contours. These are a “well” under the seat bones and a shelf in front of the seat bones. cushion features and dimensions The main features of the basic foam contoured cushion are the following. a base layer, made with a firm foam (for example “chip” foam) Wheelchair Service Training Packag e 57 BASIC LEVEL seat bones well • Relieves pressure under the seat bones and coccyx (tail bone). • Helps to hold the pelvis upright at the back of the cushion. slung seat base • cushions used on a slung wheelchair seat have a bevel cut on each side of the base of the cushion. • This allows the cushion to take up the shape of the slung wheelchair seat. The top of the cushion then stays flat. a top layer, made with a soft “comfort” foam Top comfort layer: • Provides comfort over the firm base layer. how to make a pressure relief cushion base? The following instructions provide a cushion of dimensions 400 mm wide x 400 mm deep x 50 mm high. The seat bones well is 200 mm wide x 200 mm deep x 35 mm high. This cushion would be suitable for a wheelchair user with a seat width of 400 mm. adapt the dimensions to suit the size of each wheelchair user as described in the box below. 58 1. Mark out the cut lines on the firm foam. • start with a piece of firm foam 400 mm x 400 mm x 50 mm. • The centre of the seat bones well must be on the centre line of the cushion. • For this size cushion, the seat bones well should measure 200 mm x 200 mm x 35 mm. • Draw the cut lines with a dark coloured marker on all six sides of the base foam. Seat bones well dimensions adjust the dimensions of the cushion and the seat bones well to suit individual wheelchair users as follows: • seat bones well width = ½ the wheelchair user’s seat width or 200 mm (whichever is less) [a]; • seat bones well depth (front to back) = ½ the wheelchair user’s seat width or 200 mm (whichever is less) [b]; • seat bones well height = 35 mm for adults and 20–25 mm for children [c]. b c a Wheelchair Service Training Packag e 59 BASIC LEVEL 2. cut out the seat bones well: Use a sharpened hacksaw blade or long knife. Use long slow strokes, cutting mostly when pulling to improve control. • First cut through the back of the cushion to the depth of the seat bones well. • Then slice out the seat bones well. • Glue back into place the two “flaps” left on either side of the seat bones well. allow the glue to set until not completely dried and slightly sticky to touch. Then press the foam together. 3. cut off (bevel) the corners inside the seat bones well. 4. For a slung seat cushion: make an angled cut (bevel) on both sides of the base (under-side). • Mark out as shown and cut. • This cut helps the base of the cushion to match the shape of a slung wheelchair seat. 15 mm 15 mm 60 5. Place the top foam layer on top of the cushion. • Both the base and top layer are placed in the cushion cover together. • The two layers do not need to be glued together. • if the top layer becomes soiled or worn, it can be washed and dried, or replaced. • a lift can be added within the cover to increase the depth of the seat bones well. Frequently asked questions about foam pressure relief cushions: How do you decide which fabric to use for the cushion cover? • choose a fabric which is stretchy if possible. Water-resistant fabric is very good if available. if the fabric is water-resistant make sure it is not too thick, or the folds may cause marking on the wheelchair user’s skin, which can lead to a pressure sore. • The choice will depend on the fabric available. sometimes the choice is limited. • if there is a choice and you are not sure, ask wheelchair users to trial different options. • Wheelchair service personnel will develop experience as different fabrics are tried. Does this cushion work for all users? • No – this cushion will not work for all wheelchair users. • However, one advantage of this cushion is that it can be easily adapted. Is this cushion hot or does it cause sweating? • Foam cushions can be hot and can cause sweating. • However, the cushion performs well in many other ways, so putting up with the heat is a compromise. Do all wheelchair users need a pressure relief cushion? • No – not all wheelchair users need a pressure relief cushion. • consider the pressure risk factors taught in this training programme to decide whether a wheelchair user is at risk of developing a pressure sore. • although this cushion may not be needed for pressure relief, the cushion can also improve comfort and posture, even for wheelchair users who are not at risk of developing pressure sores. Wheelchair Service Training Packag e 61 BASIC LEVEL What happens if the cushion is used back-to-front or upside down? • it will not work properly and may even increase the risk of developing pressure sores. • always make sure that wheelchair users, and family members (where relevant), understand how to use and care for the cushion correctly. • Mark the cushion “front” and “back” or “up” and “down” if necessary. Does this cushion work for children? • Yes, this cushion would work for children. However, the seat bone well needs to be smaller. see above for how to work out the dimensions for a child-size cushion. • Many children who use wheelchairs need additional postural support. This cushion may not provide enough postural support. cushion fit always check that the seat bones sit just within the seat bone well and not on the edge or on the high part of the cushion. always check when fitting a pressure relief cushion for a wheelchair user that: • the pressure under the seat bones is “safe” (see “How to test if a pressure relief cushion is working”, above); and • the seat bones are sitting inside the seat bone well and not on the edge or top layer. 62 Step 6: Fitting What does fitting involve? During fitting, the wheelchair user and personnel together check that: • the wheelchair is the correct size and all the necessary modifications and adjustments have been made to ensure an optimum fit; • the wheelchair and cushion support the wheelchair user in sitting upright; • if a pressure relief cushion has been prescribed, the cushion really relieves pressure. good practice in fitting • Wherever possible, the same person who carried out the assessment should carry out the fitting. • always check the fit with the wheelchair stationary, and then while the wheelchair user self-propels or is pushed. • carry out fitting in this order: • check size and adjustments; • check posture; • check pressure; • check fit while the wheelchair user is moving. • Use the fitting checklist provided to remember each step. Check size and adjustments Seat width Correct fit: Should fit closely How to check • Run your fingers between the outside of the wheelchair user’s thighs and the sides of the wheelchair. Your fingers should fit comfortably without being pinched. Make sure the sides of the wheelchair do not press into the wheelchair user’s legs. This is particularly important for a wheelchair user who cannot feel pressure on the thighs (does not have normal sensation). Firm pressure on thighs from the side of the wheelchair could cause a pressure sore. Seat depth Correct fit: Two-finger gap (30 mm) between the back of the knee and the cushion. continues.. Wheelchair Service Training Packag e 63 BASIC LEVEL How to check • Check the wheelchair user is sitting upright. • Slide hand between the cushion and the back of the knee. There should be a gap large enough to admit two fingers (30mm). There may be a bigger gap for wheelchair users with long legs. Up to 60 mm is acceptable. • Slide hand down the back of the calf and make sure it is not touching the seat or cushion. • Always check both sides. Correct fit gives the thigh good support. This will reduce pressure under the seat bones and helps to stop pressure sores. If the seat length is too long, the user will not be able to sit upright. If there is a difference between right and left sides, use the shorter leg measurement to make prescription choices. Footrests height Correct fit: The thighs are fully supported on the cushion with no gaps. The feet are fully supported on the footrests with no gaps. How to check • Slide hand between the thigh and the cushion. There should be even pressure along the thigh and no gaps. • Look at each foot on the footrest. The foot should be supported at the front and the back with no gaps. If there are gaps under the thigh, the footrest may be too high. If there are gaps under the foot, the footrest may be too low. Backrest height Correct fit: The correct fit should give the wheelchair user the support he/ she needs and allow an active person the freedom to move the shoulders to push. How to check • Ask the wheelchair user whether the backrest is comfortable. • Observe whether the trunk is balanced over the hips. • Is the wheelchair user able to push the wheelchair without the backrest interfering? The height of the backrest depends on the needs of the user. Wheelchair users who push themselves need a backrest which allows their shoulders to move freely. Wheelchair users who have difficulty sitting upright may need a higher backrest which gives more support to the spine. There are two backrest height measurements on the wheelchair assessment form (see session Step 2: Assessment under the section ”Taking measurements”). Take both measurements, as sometimes it is not clear in the assessment which height backrest will be most comfortable for the wheelchair user. continued continues.. 64 A backrest which provides support up to the bottom of the wheelchair user’s rib cage is a good height if the wheelchair user: • is fit and active; • can sit upright easily with good balance; • will be actively propelling himself/herself and needs good freedom of movement. Backrest height D (bottom of rib cage) A backrest which provides support up to the bottom of the wheelchair user’s shoulder blades is a good height if the wheelchair user: • is likely to get tired quickly, e.g. elderly or with a progressive disease; • has some difficulty sitting upright. This backrest height still allows some freedom of movement around the shoulders for the wheelchair user to propel the wheelchair with the arms. Backrest height E (bottom of shoulder blades) rear wheels position – for hand propelling Correct fit: When hands are placed on the push rims, the user’s elbows should be at a right angle. How to check • Ask the wheelchair user to grip the push rims at the top of the wheels. The elbow should be bent at 90 degrees. • Also check with the user if the rear wheels are positioned correctly for balance (forward for active, back for safe). If the wheelchair user needs the rear wheels to be positioned in the “safe” (further back) position, this may mean that the arms are further back and that is ideal for propelling. Explain this compromise to the wheelchair user. If any adjustments are made to the rear wheels position, the brakes will also need to be adjusted and rechecked. Seat height–for foot propelling Correct fit: • With the wheelchair user sitting upright, and the back of the pelvis comfortably supported by the backrest, he/she should be able to rest the feet flat on the floor. continues.. continued Wheelchair Service Training Packag e 65 BASIC LEVEL How to check Ask the wheelchair user to sit with the back of their pelvis against the backrest with the pushing foot flat on the floor. Check whether the feet can sit flat on the floor. If the seat height is too high, wheelchair service personnel can try: • reducing the height of the cushion; • attaching a solid seat lower than the original seat (get technical advice or support to do this). For a user who is propelling with only one foot, with the other foot resting on the footrest – check the pressure under the seat bone of the side that is resting on the footrest (please refer to session A. 7: Cushions, section “How to test if a pressure relief cushion is working”). Check posture Observe how the wheelchair user is sitting in the wheelchair from the side, and from the front. is the user sitting in an upright posture? some wheelchair users like to have their feet tucked in underneath them. some wheelchair designs allow for this. if the wheelchair user is comfortable and feels balanced, this is fine. Check pressure For every wheelchair user at risk of developing a pressure sore – check if the pressure under the seat bones is safe. continued 66 Check fit while the wheelchair user is moving The final part of fitting is to check how the wheelchair fits when the wheelchair user is moving. if a wheelchair user cannot push the wheelchair independently, ask a family member/caregiver to push the wheelchair. What to look for: • Does the backrest allow the wheelchair user freedom to move the shoulders to push? • Do the wheelchair user’s feet stay on the footrests? • is the rear wheel position correct for the user? Wheelchair fitting checklist 1. is the wheelchair ready? Has the wheelchair been checked to make sure it is safe to use and all parts are working? 2. check size and adjustments Seat width should fit closely. Seat depth Two fingers’ gap between the back of the knee and the seat/cushion. Footrests height: The thigh is fully supported on the cushion, with no gaps. each foot is fully supported on the footrest, with no gaps. continues.. Wheelchair Service Training Packag e 67 BASIC LEVEL Backrest height: The wheelchair user has the support they need and freedom to move their shoulders to push (if self-propelling). rear wheels position (for hand propelling): The wheelchair user’s arm should be in line with the rear axle when hanging down. When hands are placed on the push rim, the user’s elbow should be at a right angle. Brakes: are the brakes working? Seat height (for foot propelling): With the wheelchair user sitting upright, the back should be comfortably supported by the backrest, with feet resting flat on the floor. 3. check posture is the wheelchair user able to sit upright comfortably? check posture from the side. check posture from front/back. 4. check pressure check pressure under seat bones for all wheelchair users at risk of developing a pressure sore. Explain the test to the wheelchair user. B Ask wheelchair user to lean forward or push up. Place fingertips under wheelchair user’s seat bone. continued continues.. 68 C Ask the wheelchair user to sit back down on your fingers. Make sure the user sits upright with hands on thighs. D identify the pressure: level 1 = safe: Fingertips can wriggle up and down 5 mm or more. level 2 = warning: Fingertips cannot wriggle, but can easily slide out. level 3 = unsafe: Fingertips are squeezed firmly. it is difficult to slide fingers out. E Repeat under the second seat bone. 5. check fit while the wheelchair is moving Does the backrest allow the wheelchair user freedom to move the shoulders to push? Does the backrest give the wheelchair user enough support? Do the wheelchair user’s feet stay on the footrests? Is the rear wheels position correct for the user? 6. action? Is any further action necessary? Write any actions in the wheelchair user’s file. remember: The next step after fitting is user instruction. Problem solving sometimes personnel will find a problem with making the available wheelchair fit the wheelchair user correctly. The problem may be because: • there is a limited range of wheelchairs and sizes available; • the wheelchair user needs extra support to sit upright comfortably. Below are some simple solutions to some common problems. Making modifications and providing more postural support is covered in much greater detail in the intermediate-level training. all of these solutions assume that the closest-size wheelchair for the wheelchair user has already been selected from those available. always check this before modifying a wheelchair. continued Wheelchair Service Training Packag e 69 BASIC LEVEL Problem: Seat depth too short if the seat depth (front to back) is more than 100 mm shorter than the wheelchair user’s seat depth (for an adult), this is a problem. The wheelchair user will not have enough support from the seat to be able to sit comfortably. Pressure relief is also reduced. The seat depth needs to be lengthened. Solution: Three different solutions are described below: Solution caution 1. Lengthen the wheelchair seat depth by extending the seat rails and replacing upholstery. • If the wheelchair is a folding-frame type, check whether the seat rails are “dedicated”. This means the seat rails are not also part of the wheelchair frame. • In this case, an extension can be made to the seat rails and new upholstery made to the correct length. 2. Lengthen the wheelchair seat depth by replacing the upholstery. If the wheelchair is a rigid frame wheelchair with upholstery, check if the seat rail extends beyond the seat. In this case, it may be possible to replace the seat upholstery with new upholstery made to the correct length. 3. Lengthen the wheelchair seat depth by adding a rigid board with a cushion. • A solid seat can be made from wood, plastic or any other rigid material which will not flex or crack. • The seat can be fixed to the top of the seat rails. • Add a cushion that is the same width and depth as the new seat. • Make sure the new seat is strong enough to carry the weight of the user. Check that the seat does not flex or crack beyond the existing wheelchair seat. • Always ensure a rigid seat is provided with a cushion – for every wheelchair user. • Check during fitting that the backrest and footrests are the correct height. The solid seat and the cushion will raise the wheelchair user in the wheelchair. Problem: Seat depth too long. if the shortest available seat depth is too long, it will be impossible for the wheelchair user to sit upright. The seat depth needs to be shortened. 70 Solution: One solution is described below. Solution caution 1. Shorten the wheelchair seat depth. • Mark the seat depth that is needed on the existing seat. • If the seat is upholstered: remove the upholstery, shorten it (using an industrial sewing machine) and replace. • If the seat is rigid: remove the seat, shorten and replace. • Shorten the cushion to match the new seat depth. • When cutting a rigid seat – always ensure that all edges are smooth and splinter-free. • When cutting a cushion – always cut from the front, so that pressure relief at the back of the cushion stays the same. Problem: Footrests height too low. if the footrests height is too low, the wheelchair user will not be able to rest the feet comfortably on the footrests. This can cause him/her to slide forward in the wheelchair, or to feel unstable. There will not be enough support to sit upright comfortably. The footrests will need to be raised. Solution: Two solutions are described below. Solution caution 1. Raise the footrests height by – shortening the footrests hanger. • On most four-wheel wheelchairs, the footrests hanger can be cut shorter. Always check that the adjustment mechanism is still working. 2. Raise the footrests by – building up the footrests • Use wood or another sturdy material to add height to the footrests. Check that the build-up does not stop footrests that move out of the way for transfers from working. Footrest raised by building up the footrest (in this illustration one side only has been built up to accommodate shortening of one leg). Problem: Footrests height too high. if the footrests height is too high, the wheelchair user’s thighs will not rest comfortably on the seat. Footrests that are too high can increase pressure on the seat bones. The footrests will need to be lowered. Wheelchair Service Training Packag e 71 BASIC LEVEL Solution: Two possible solutions are described below. Solution caution 1. Lower the footrests by – lengthening the inner extension tube. • Check if the inner extension tube can be replaced with a longer tube. • If so – replace it with a similar tube of the same diameter and strength. Make sure the footrests do not become so low that they catch on the ground. If this happens, try option 2 instead. If this does not work, the wheelchair is not suitable for the wheelchair user. 2. Increase the height of the cushion. • Increase the height of the cushion or raise the cushion by adding something solid underneath. Do not use soft foam to increase the height of the cushion. This will compress, and will also feel unstable. Check during fitting that the backrest is the correct height. The higher cushion will raise the wheelchair user in the wheelchair. Check that there are no functional problems with raising the cushion. For example – the wheelchair user may then not be able to fit under tables or desks. Problem: legs tend to roll inwards or outwards. sometimes the wheelchair user’s legs roll inwards or outwards. This may be because of the way they are used to sitting, or have a physical reason (for example muscle weakness). simple adjustments to the wheelchair seat or cushion can help to reduce this problem. Solution: Three possible solutions are described below. Solution 1. Double check the footrests height. Make sure the footrests height is supporting the wheelchair user correctly (even pressure should be felt under the feet and under the thighs). 2. Check the seat is properly tensioned. • If the wheelchair has an upholstered seat – make sure that the seat is tensioned firmly. • If the seat is saggy, this will encourage the wheelchair user’s legs to roll inwards. 3. Add wedges to the cushion to support the thighs in neutral (as in DVD and illustration) or provide a contoured cushion, modify cushion if necessary. • Some contoured pressure relief cushions have a rise between the thighs, which will help to keep legs comfortably apart. The rise can be increased to provide additional support if needed. • Some contoured pressure relief cushions have “gutters” for the legs to rest in. The edges of the gutter can be increased to stop legs from rolling outwards. 72 Wedge added to the centre front of a cushion to help keep a wheelchair user’s legs slightly apart. Wedges added to the front side of a cushion to help keep a wheelchair user’s legs from falling outwards. Problem: Feet tend to slide off the footrests sometimes the wheelchair user’s feet slide off the footrests. This often has a physical reason (for example muscle weakness or muscle spasms). Solution: Three solutions are described below. Solution caution 1. Double check the footrests height. • Make sure the footrests height is supporting the wheelchair user correctly (even pressure should be felt under the feet and under the thighs). 2. Adjust the footrests angle (if possible). • Check if the footrests angle can be adjusted. • If so – try increasing the angle of the footrests. This may help to hold the wheelchair user’s foot in place. Check that there is still even pressure under the foot. 3. Add a strap. • Attach a strap to the footrests hangers at the level of the ankles. • If the feet tend to slide off backwards, the strap goes behind the legs. • If the feet tend to slide off forwards, the strap goes in front of the legs. Make sure the strap is easy to remove, so that the wheelchair user can get in and out of the wheelchair without effort. Check that the wheelchair user can reach the strap without assistance, and can do it up and undo it easily. Wheelchair Service Training Packag e 73 BASIC LEVEL a calf strap can help to keep a wheelchair user’s legs in place. straps at the back of the foot can provide more support, helping to prevent a wheelchair user’s legs from sliding off the back of the footrests. Problem: Wheelchair is too wide. sometimes the smallest wheelchair available is still too wide for the wheelchair user. if the wheelchair seat is too wide, the wheelchair user will find it difficult to sit upright, and is likely to collapse to one side. some simple foam inserts can help to provide the wheelchair user with support to sit upright. Solution: One solution is described below. Solution caution 1. Add foam inserts on each side of the pelvis. • Measure the space between the wheelchair user (sitting central in the wheelchair with the back against the backrest) and the side of each armrest. • Cut and add foam inserts to fill the space between each side of the wheelchair user and the side of the wheelchair. • Check fit. • Upholster and attach the foam inserts. If the armrests are solid, the inserts may be attached to the armrests. They may also be attached to the top of the cushion. The inserts only need to come as far forward as the user’s trunk. Ensure the cushion matches the seat width. If the wheelchair is very wide, the wheelchair user will also have trouble reaching the push rims. Overreaching for the push rims can cause a shoulder injury. Consider carefully whether the wheelchair is safe for the wheelchair user before prescribing (selecting) it. Foam inserts can reduce the inside width of the wheelchair. 74 Step 7: User training information and training about the wheelchair can help many wheelchair users really benefit from their wheelchair. Without this step, it is possible that the wheelchair will not help the wheelchair user as much as it could. What are helpful skills for wheelchair users? The six most important things to remember to teach are: • how to handle the wheelchair; • how to get in and out of the wheelchair (transfer); • wheelchair mobility – matched to the user’s needs; • how to prevent pressure sores and what to do if a pressure sore develops; • how to care for the wheelchair and cushion at home; • what to do if there is a problem. The checklist on the next page lists specific skills that a wheelchair user may need to learn. some wheelchair users will already have these skills; and not all skills are important for all wheelchair users. Personnel can use the checklist to select the training the wheelchair user needs. This is decided through the assessment, and through talking to the wheelchair user. some services may use this checklist as a form, kept in the wheelchair user’s file. in this case, the checklist can also be used to record the training which has been given. always check with the wheelchair user whether he/she would like caregivers to learn the skills you are teaching as well. Many wheelchair users are supported by their family or a caregiver, and it is helpful for everyone involved to learn how to use and care for the wheelchair. how to make wheelchair user training successful • Find out what the wheelchair user already knows. • explain, demonstrate and then allow the wheelchair user to practise. • Use language that everyone can understand. • Have wheelchair users teach other wheelchair users. • Use good communication skills. • Be encouraging. Wheelchair Service Training Packag e 75 BASIC LEVEL Wheelchair user training checklist Skills to teach Skills taught Wheelchair handling Folding the wheelchair Lifting the wheelchair Using quick-release wheels Using the brakes Using the cushion including positioning correctly Transfers Independent transfer Assisted transfer Other Wheelchair mobility Pushing correctly Up and down a slope Up and down a step On rough ground Partial wheelie Preventing pressure sores Checking for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops looking after the wheelchair at home Clean the wheelchair; wash and dry the cushion and cushion cover Oil moving parts Pump the tyres if they are pneumatic Tighten nuts and bolts Tighten spokes Check upholstery Check for rust Check the cushion What to do if there is a problem Wheelchair needs repairs The wheelchair does not fit or is not comfortable 76 Step 8: Maintenance, repairs and follow up Regular care of a wheelchair and cushion will save costs for repairs, extend the life of the wheelchair and prevent injuries and long-term damage to the user’s body. a wheelchair which is cared for will be more comfortable, energy-efficient and easier to use. a cushion which is cared for will continue to provide pressure relief and support. Wheelchair service personnel have a responsibility to inform wheelchair users how to care for their wheelchair and cushion at home. Prevent repairs: home maintenance There are six things that wheelchair users can do at home to look after their wheelchair and cushion. show wheelchair users how to care for their wheelchair and cushion at home, and explain why it is important. The table on the next page explains what needs to be done, why it is important and how to do it. Local resources for wheelchair repairs Find out who can help repair wheelchairs in your local area. Possible places or people are: • bicycle repairer; • motorcycle or car mechanic; • workshops – welder, plumber (metal parts), carpenter, furniture maker (wooden parts); • wheelchair user, wheelchair user’s family member, relative or neighbour; • tailor for repairing upholstery; • wheelchair service facilities. Wheelchair Service Training Packag e 77 BASIC LEVEL How to care for a wheelchair at home Why is this important? how to do it 1. clean the wheelchair and cushion Stops metal parts from rusting. Stops wooden parts and upholstery from rotting. Stops damage caused by dirt scraping against moving parts. Use warm water with a little soap. Rinse and dry. Pay attention to moving parts, and where upholstery joins the frame. Remove cushion from cover and wash separately. Always dry the cushion in the shade – not in direct sun. 2. Oil moving parts Keeps parts moving smoothly. Helps stop rust. Clean and dry the wheelchair first. Use a lubricating oil, for example bearing oil. Apply to all moving parts. 3. Pump up tyres (if pneumatic) Tyres will last longer. It is easier to propel the wheelchair, taking less energy. Brakes will work correctly. Press thumb across the tyre to check pressure. It should be possible to depress the tyre very slightly (about 5 mm). Pressure should be the same on each tyre. Pump up using a bicycle pump or similar. Reduce pressure by releasing air through the valve. 4. Tighten nuts and bolts (if loose) Loose bolts cause unwanted movement in parts. This can be uncomfortable, and cause parts to wear out or be lost. Check wheelchair for loose bolts or nuts. Tighten loose bolts or nuts with a wrench. Do not overtighten. continues.. 78 Why is this important? how to do it 5. Tighten spokes (if loose) Loose spokes can cause wheels to buckle and collapse. Squeeze together two spokes all the way around the wheel. If a spoke “gives” when you pull gently, it may be too loose. Tighten with a spoke wrench. Spokes can be overtightened. If the spoke feels very rigid, it is probably too tight and should be loosened. 6. Make regular checks check for rust and check upholstery Rust reduces the strength of materials. This can cause parts to break and may cause injury to the user. Upholstery needs to be in good condition to support the wheelchair user and provide good comfort. If upholstery rips suddenly, the wheelchair user may be injured. Check painted metal surfaces for rust/corrosion. If rust is found, use sandpaper or steel brush to remove the rust. Clean with a thinner and cloth and repaint. Look for tears, wears, dirt or metal parts sticking out. Check the tension of seat and backrest is correct. If the upholstery is torn or the tension of a slung seat is too loose, repairs are needed. check the cushion Cushions should be clean and dry to help protect skin. Cushions do not last as long as wheelchairs. A regular check will help wheelchair users to recognize when the cushion needs replacing. Remove the cover. Check for worn spots, dirt and holes in the cover and foam. If the cushion is worn, it should be checked by the wheelchair service personnel. It may need to be replaced. common wheelchair and cushion repairs Wheelchairs and cushions will sometimes need to be repaired. Wheelchair service personnel need to be able to either carry out a repair, or advise wheelchair users where they can get help. some wheelchair users will be very good at organizing their own repairs. Other wheelchair users may need help. all wheelchair users will benefit from knowing where they can get their wheelchair and cushion repaired. continued Wheelchair Service Training Packag e 79 BASIC LEVEL What is follow up and how does it happen? Follow up happens after the wheelchair user has received their wheelchair and has been using it for a while. Follow up appointments are an opportunity to: • gather information from the wheelchair user; • check that the wheelchair is in good working order; • check the fitting of the wheelchair. all users will benefit from a follow up visit. However, follow up is most important for: • children; • wheelchair users at risk of developing a pressure sore; • wheelchair users who have a progressive condition; • wheelchair users who have had difficulty with any of the training or instruction given to them. There is no rule about when follow up should happen though one follow up session within six weeks of the date of delivery is often found to be useful. it will depend on the needs of the user. However, for children, it is ideal if follow up occurs every six months. This is because the needs of children change quickly as they grow. Follow up can be carried out either at a home visit, at a centre or at any other location that suits the user and the wheelchair personnel. This depends on whether the wheelchair user is able to travel to the centre, and whether wheelchair service personnel are able to travel to the user’s home. Common follow up actions • check that the wheelchair is in good order; • Provide more tips or training; • if needed, – re-adjust the wheelchair; – carry out minor repairs or home maintenance; – organize major repairs or assist the wheelchair user to arrange for repairs. The form on the next page can be used to guide follow up. Personnel should make a note of any action that is needed after the follow up visit. Ways to manage follow up appointments • Give wheelchair users a follow up appointment when they receive their wheelchair. • visit wheelchair users at home for follow up, where possible. • Make follow up visits part of routine visits to communities by community-based rehabilitation (cBR) personnel who have been trained to carry out follow up. • arrange a follow up phone call if transport is difficult and the wheelchair user has access to a phone. 80 Wheelchair Follow Up Form This form is for recording information from a follow up visit. 1. Wheelchair user information Name: Number: Date of fitting: Date of follow up: Name of person carrying out follow up: Follow up carried out at: User’s home Wheelchair service centre Other: 2. interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes No If no – why not? Do you have any problems using your wheelchair? Yes No If yes – what are the problems? Do you have any questions about using your wheelchair? Yes No If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? Yes No If yes – describe (location and grade) How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satisfied and 5 is very satisfied) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes No Is the cushion in good working order and safe to use? Yes No If no for either, what is the problem? 4. Fitting check Does the wheelchair fit correctly? Yes No If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user is at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes No If no – what is the problem?

For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ dar@who.int ISBN 978 92 4 150347 1

ز مة ا لتد ر يبية ا لخا صة بخد مة ا لح الكراسي المتحركة المستوى الأساسي الاستمارات والقوائم المرجعية المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة زمة التدريبية الخاصة حال متحرككرسي للحصول على استمارة إحالة وتقديمها إلى مصادر الإحالة ،هذه الاستمارة حسب الحاجة تعديلة متحركخدمة الكراسي الكز امرلنموذج استمارة إحالة: يمكن ة. متحرك خدمة الكراسي المراكز ة إلى متحرك لمساعدتهم في إحالة مستخدمي الكراسي ال الإلكتروني إلى العنوان التالي: لها بالبريد االرجاء ملء الاستمارة وإرس ة وعنوانه:متحركخدمة الكراسي ال مركز اسم اسم صاحب الإحالة: اسم المؤسسة التي تعمل لديها: صاحب الإحالة (أفضل طريقة للاتصال بك):ب بيانات الاتصال : الولادةتاريخ : متحركلاسم مستخدم الكرسي ا مقدم الرعاية: /الوالدة الوالد أواسم العنوان: ؟متحركالتواصل مع مستخدم الكرسي الكيف يمكن ف صديق/ أحد الجيران هات الهاتف الشخصي البريد الإلكتروني: العادي البريد اذكر العنوان:، كترونيلبالبريد الإإذا كان الاتصال اذكر رقم الهاتف: الهاتف، بإذا كان الاتصال ؟ا إذا كان معروف متحركمستخدم الكرسي ال نوع إعاقة الإحالة: سبب ا متحركلا يمتلك كرسيا • مكسور متحركلديه كرسي • تهلا يلبّي احتياجا متحركلديه كرسي • ة متحركخدمة الكراسي المركز در بتعتقد أنها مهمة ويج متحركمستخدم الكرسي الالرجاء إضافة أي معلومات أخرى حول ها: تعرفم إلى تهحالإعلى متحركهل وافق مستخدم الكرسي ال لا نعم ة؟متحركخدمة الكراسي المركز صاحب الإحالة: توقيع التاريخ: المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة يبية الخاصة زمة التدرحال متحرك الكرسي الاستمارة تقييم هذه الاستمارة مخصصة لتقييم مستخدمي الكراسي المتحركة الذين يستطيعون الجلوس في وضع مستقيم بسهولة. قد يحتاج الأشخاص الذين لاستمارة في لا يستطيعون الجلوس في وضع مستقيم بسهولة إلى تقييم على يد شخص حاصل على تدريب "متوسط". الرجاء الاحتفاظ بهذه ا المتحرك.ملف مستخدم الكرسي يم:يتاريخ التق يم:يالتقالمعني باسم لتقييمالمخصصة لمقابلة ال .1 متحرك مستخدم الكرسي البيانات الرقم: الاسم:  أنثى ذكر العمر: :بريد الإلكترونيال رقم الهاتف: العنوان: الأهداف: ديةالحالة الجس  لاإرادية حركات أو تشنجات  وهن  دماغية سكتة  شوكيال نخاعال في إصابة  أطفال شلل  دماغي شلل  الركبة تحت أيسر طرف  الركبة فوق أيسر طرف  الركبة تحت أيمن طرف  الركبة فوق أيمن طرف: بتر  ءمعاالأ في مشاكل  المثانة في مشاكل  لا  نعم لسيطرة؟ا تحت هي هل ،الأمعاء أو المثانة في مشاكل متحركال الكرسي دممستخ لدى كان إذا تفاصيل أخرى: أسلوب الحياة والبيئة : متحركوصف المكان الذي سيستعمل فيه المستخدم كرسيه ال ______________________________________________________________________________ كم 5أكثر من كم 5-1 كم 1 أقل منالتي يقطعها يوميا:ً افة المس  ساعات 5 -3 ساعات 3-1 أقل من ساعة عدد ساعات استعمال الكرسي المتحرك يومياً؟ ساعات 8أكثر من  ساعات 8-5 والسطح)؟ وضعة(ال وكيف أو يستلقي ، أين يجلسمتحركسيه الرك علىيكون المستخدم لا عندما ______________________________________________________________________________ غير ذلك  محمولاً غير واقف واقفا ً  شخص مساعدةب بمفرده الانتقال: طريقة  لحاجته معّدلحاض رم  بيرغ مرحاض ء) القرفصا وضع( شرقيمرحاض : )مرحاض ينتقل إلى(إذا كان مرحاضالنوع لا نعم النقل العام/ الخاص؟ وسائل غالبا ً متحركهل يستعمل مستخدم الكرسي ال غير ذلك ) (باص حافلة سيارة أجرة (تاكسي) نعم، فما نوع وسيلة النقل: سيارة ب إذا كانت الإجابة ) حركتمرسي خص كالش لدى الحالي (إذا كان متحركالكرسي ال  لا نعم احتياجات المستخدم؟ متحركبي الكرسي الليهل  لا نعم ظروف بيئة المستخدم؟مع متحركهل يتناسب الكرسي ال  لا نعم ؟تهدعم وضعيو للمستخدم ملائما ً متحركهل يعتبر الكرسي ال  لا  منع )مثلاً وسادة يشتمل علىآمن ومتين؟ ( متحركهل الكرسي ال  لا نعم ح الضغط)؟ وهل توفّر الوسادة تخفيفا ًمناسبا ًللضغط (إذا كان المستخدم معرضا ًلخطر قر التعليقات: دم لا، فإن المستخبأي من الأسئلة ن أجيب عإذا أما جديد. متحركلا يكون المستخدم بحاجة إلى كرسي فقدالأسئلة، جميعن أجيب بنعم عإذا الحالي أو الوسادة الحالية بحاجة إلى إصلاح أو تعديلات. متحركالكرسي الإن أومختلف أو وسادة مختلفة؛ متحركحتاج إلى كرسي ي المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة يبية الخاصة زمة التدرحال : التقييم الجسدي 2 أو خطر التعّرض لها، أو تاريخ الإصابة بها ضغط،ناجمة عن الح ووجود قر ط سابقة ضغح و= قرO= لا يشعر / // ضغط حالية حو= قر●  لا  نعم لديه إحساس طبيعي؟  لا  نعم ح ضغط سابقة؟وقر  لا  نعم ح ضغط حالية؟وقر إذا كانت الإجابة "نعم"، هل هي )4 – 1درجة ال(ح مفتوحة وقر نعم  لا  المدة والسبب: كان لديه ثلاثة إذا أودر على الإحساس قاالشخص غير ال *ح الضغط؟ وقر معّرض لخطر* هل هذا الشخص عدم القدرة على الحركة، أو الرطوبة، أو الوضعة السيئة، أو : عوامل الخطرعوامل خطر أو أكثر معّرض للخطر. الوزن. قلة/ زيادة، أو التقّدم في العمر (الشيخوخة)، أو ةغذي تالسوء أو الحالية، /ح الضغط السابقةوقر  لا  نعم متحركع الكرسي الدفطريقة الذراع اليمنى الذراع اليسرى ا الذراعينتكرسيّه؟ بواسطة كل متحرككيف سيدفع مستخدم الكرسي ال تاج إلى مساعد ليدفعه يح الرجل اليمنى الرجل اليسرى كلتا الرجلين التعليق: جدول المقاسات مقاسات الجسد إلى المقاس المثالي ر غيّ مم) المقاس ( مقاسات الجسد متحركللكرسي ال مقاس الكرسي متحركال مم 063 عرض الورك = عرض المقعد مم 063 عرض الورك (أ) مم = 05-03ا ًمنه المقاس (ب) مطروح مم 004 يسارال عرض المقعد (ب) (إذا كان الطول مختلفا،ً استعمل عرض المقعد الأقصر) مم 073 مم 004 ينيمال بطن طول (ج) الساق = قمة وسادة المقعد* إلى ارتفاع مسندي القدمين مم 083 يسارال أو = قمة وسادة المقعد* إلى الأرض في حالة دفع الكرسي بالقدمين مم 033 مم 033 مم 083 يمينال الظهر = قمة وسادة المقعد* إلى قمة مسند مم 013 أسفل القفص الصدري (د) المستخدم)حاجة بحسب –أو (هـ) )د لمقاس ((ا مم 063 مم 074 مم 024 أسفل لوح الكتف (هـ) . متحركد ارتفاع الوسادة التي سيستخدمها مستعمل الكرسي الق ّتف* يسار ال مام الأ خلف ال يمين ال المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة زمة التدريبية الخاصة حال متحركلكرسي المعلومات ا لخصم استمارة أدخل الصورة هنا: : متحركاسم الكرسي ال الصانع/ الموّرد: المقاسات المتاحة: الوزن الإجمالي: وصف: ال طول الهيكل: قابل للطي ثابت/ صلب هيكل الكرسي: يمكن تعديل مستوى الشد صلب قماشي /متدل مسند الظهر: تعديل مستوى الشديمكن صلب قماشي /متدل المقعد: حشوة رغويةوسادة لا وسادة الوسادة: مسطحة ذات حشوة رغويةوسادة حواف غير ذلك: إزاحتهما /يمكن فّكهما ثابتان مسندا القدمين: العجلتان الأماميتان الصغيرتان: نصف القطر: العرض: مزودتان بإطار دفع معدني نصف القطر: قابلتان للنفخ العجلتان الخلفيتان: محور قابل مزودتان ب العرض: صلبتان ضبطلل داخلي إطار عجلة صلب يمكن إزالتهما غير ذلك: مقبض طويل ر مقبض قصي : المكابح غير ذلك: إزاحتهمايمكن فّكهما/ ثابتان مسندا الذراعين: دفع الكرسي مقبضا دفع الكرسيمقبضا قضيب منع انقلاب بطن الساق حزام أجزاء/ خيارات إضافية: الوراء الكرسي إلى منضدة غير ذلك: المقاسات، وخيارات التعديل، ونطاق التعديل: متاحا ً متحرك(إذا كان الكرسي الالمقاس مختلفة، ضع قائمة بكل بمقاسات ) المقاسات قابل المقاس هل هذا للتعديل؟ ق التعديل (نطانطاق التعديل الممكن لهذا الكرسي) لا نعم عرض المقعد: عمق المقعد: ارتفاع المقعد: ارتفاع مسند الظهر: زاوية مسند الظهر: ارتفاع مسندي القدمين: مسندي القدمين:زاوية :ارتفاع مقبضي دفع الكرسي طول هيكل الكرسي: :طول قاعدة العجلتين الخلفيتين المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة ي المستوى الأساس - الكراسي المتحركة بخدمة زمة التدريبية الخاصة حال متحركاستمارة وصفة (انتقاء) الكرسي ال وسادة مستخدم الكرسي مواصفات ، وهالمختار، ومكونات متحركتسجيل نوع الكرسي الإلى هدف استمارة الوصفة (الانتقاء) هذه ت . مستقيم وضع ارتياح في بالقادر على الجلوس مستخدم الكرسي المتحركبيانات -1 : رقملا : متحركاسم مستخدم الكرسي ال ضبط الكرسي تاريخ تاريخ التقييم: م: ئالمل في الوضع م: يقي تالالمعني باسم والمقاس الُمنتقى متحركنوع الكرسي ال -2 : متحركلاختيار نوع الكرسي ال ؛متحركناقش الأمر مع مستخدم الكرسي ال o ؛متحرك فّكر في أهم احتياجات مستخدم الكرسي ال o جلتين الأماميتين الصغيرتين، والعجلتين الخلفيتين، ومسندي القدمين، ومسندي الذراعين، علا، وكمتحرتفقّد هيكل الكرسي ال o )، وموقع العجلتين الخلفيتين، والدعم والراحة.ضبطهوارتفاع مسند الظهر (أو إمكانية المقاس متحركنوع الكرسي ال      الُمنتقاةنوع الوسادة -3 المقاس وسادة نوع ال  للتخفيف من الضغطحشوة رغوية مثال: وسادة  مسطحةحشوة رغوية مثال: وسادة  الموافقة -4 توقيع المستخدم: التقييم: المعني بتوقيع المدير: عتوقي المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة زمة التدريبية الخاصة حال آمن وجاهز للاستخدام؟ متحرك: هل الكرسي المرجعيةالقائمة ال بأكمله متحركلكرسي الا  ليست هناك حواف حاّدة  هناك أجزاء متضّررة أو مخدوشة تليس  يسير في خط مستقيم متحركالكرسي ال العجلتان الأماميتان الصغيرتان  ية تدوران بحر ّ  تين عجلل ا تيتثب تيشوكتدوران دون ملامسة  بإحكام مثبتة البراغي العجلة الأمامية الصغيرة شوكة تثبيت  يةدور بحر ّت العجلة الأمامية الصغيرةشوكة تثبيت العجلتان الخلفيتان  ية تدوران بحر ّ  بإحكام مثبتة المحور براغي العجلة الضغط بالإبهام، يمكن ضغط دنعخ) ((إذا كانتا قابلتين للنف على النحو اللازم العجلتان ممتلئتان بالهواء مم) 5بأقل من   لعجلتين الخلفيتين على ا بإحكاممثبّتان المعدنيان الدفع إطارا المكابح  سليمتعمل بشكل مسندا القدمين  بإحكام مسندا القدمين مثبّتان هيكل الكرسي  لة تحه بسهوه وفيمكن طيّ -القابل للطي متحركفي حالة الكرسي ال  يمكن طي مسند الظهر وفتحه بسهولة -ذي مسند الظهر القابل للطي إلى الأسفل متحركالكرسي الفي حالة الوسادة  الوسادة داخل الغطاء بالشكل المناسب  بالشكل الصحيح متحركالوسادة موضوعة على الكرسي ال  بما يكفي دون إفراطقماش غطاء الوسادة مشدود  مقعد صلب: الوسادة تغّطي المقعد بالكامل متحركإذا كان للكرسي ال المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة اصة زمة التدريبية الخحال في الوضع الملائم متحركالكرسي ال لضبط المرجعيةقائمة ال ؟للاستخدام جاهز متحركهل الكرسي ال -1  ؟كما ينبغي للتأكد من أن استعماله آمن وأن جميع أجزائه تعملللفحص متحركالكرسي الخضع هل والتعديلات قاس م د التفق -2 عرض المقعد: على بإحكام ضبطهيجب . مقاس المستخدم  عمق المقعد: يجب أن تكون هناك فجوة تسمح بمرور أصبعين بين لركبة والمقعد/ ا مؤخرة الوسادة.  ارتفاع مسندي القدمين: الفخذان مستندان بالكامل إلى الوسادة دون فجوات. القدمان مستندتان بالكامل على مسندي القدمين دون فجوات.  ارتفاع مسند الظهر: ية تحريك كتفيه لدفع حاصل على الدعم الذي يحتاج إليه ويتمتع بحر متحركسي الرمستخدم الك (إذا كان يدفعه بنفسه). متحرك الكرسي ال  ):في حالة الدفع اليدويالخلفيتين (موقع العجلتين إلى متوافقة مع المحور الخلفي عندما تكون متدلية متحركيجب أن تكون ذراع مستخدم الكرسي ال . سفلالأ إطاري الدفع المعدنيين المثبتين على العجلتين الخلفيتين، فإن مرفق ن على اعندما توضع اليد قائمة.المستخدم يجب أن يكون في زاوية   ؟بشكل جيدمكابح ال تعمل هل: المكابح :في حالة الدفع بالقدم)ارتفاع المقعد ( مستندا ً ، فإن ظهره يجب أن يكون مستقيمع ضو في جالسا ً متحركعندما يكون مستخدم الكرسي ال قدماه منبسطتين على الأرض. تكون يجب أن مسند الظهر، وإلى بشكل مريح  الوضعة د تفق -3  ؟مستقيم وضعارتياح في بقادر على الجلوس متحركهل مستخدم الكرسي ال  تفقد الوضعة من الجانب  تفقد الوضعة من الأمام/ الخلف المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة اصة زمة التدريبية الخحال الضغط دتفق -4 لديهم ضين لخطر حصول قروح الضغط الكراسي المتحركة المعر الضغط تحت عظام الورك الناتئة لدى جميع مستخدمي دتفق (أ) . الغاية من هذا الاختبار متحركاشرح لمستخدم الكرسي ال (ب) رؤوس بوضع فسه أو أن يميل إلى الأمام ليسمح لك من مستخدم الكرسي المتحرك أن يرفع ن اطلب الأيمن أو الأيسر الناتئة (على أن تكون راحة اليد نحو الأعلى) تحت عظام وركه أصابعك (ج) ون قادرا ً. يجب أن يكاء ويجلس على أصابعكمن مستخدم الكرسي المتحرك أن يعود إلى الور طلبا .الأمام، وأن يضع يديه على فخذيه ه إلىعلى الجلوس جلوسا ًطبيعيا،ً ووجه الضغط:مستوى حدد (د) مم أو أكثر. 5صعودا ًوهبوطا ًبمقدار الحركة رؤوس الأصابع قادرة على المستوى الأول = آمن: يمكن سحبها بسهولة. على الحركة ولكنرؤوس الأصابع غير قادرة المستوى الثاني = تحذير: صعب سحبها. يلأصابع محشورة ورؤوس االمستوى الثالث = غير آمن: كر ر العملية تحت العظام الناتئة للورك الثاني (هـ) الحركة أثناء في الوضع الملائم متحركالكرسي الضبط د من تأك -5  كتفيه لدفع الكرسي؟ بتحريك متحركلمستخدم الكرسي الهل يسمح مسند الظهر  ؟ متحركسي الرهل يمنح مسند الظهر الدعم الكافي لمستخدم الك  على مسندي القدمين؟ متحركهل تبقى قدما مستخدم الكرسي ال  بالنسبة للمستخدم؟ سليمهل موقع العجلتين الخلفيتين الإجراءات؟ -6  .متحركإجراء إضافي؟ اكتب أي إجراءات في ملف مستخدم الكرسي الأي يلزم اتخاذهل هي إعطاء تعليمات الاستعمال إلى المستخدم.في الوضع الملائم لمتحرك االكرسي ضبط الخطوة التالية بعد ر:تذك المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة زمة التدريبية الخاصة حال متحركالخاصة بتدريب مستخدم الكرسي الالقائمة المرجعية المهارات الواجب تدريسها المهارات التي ست ُدر متحركالتعامل مع الكرسي ال متحرك طي الكرسي ال متحرك رفع الكرسي ال اللتين يمكن فك هما بسهولةين ين الخلفيتتلاستعمال العج المكابح استعمال استعمال الوسادة بما في ذلك وضعها بالشكل الصحيح الانتقال ةقيطر قلالية)تسالانتقال بمفرده (با شخص مساعدةبالانتقال غير ذلك متحركحركة الكرسي ال دفع الكرسي بالشكل الصحيح وهبوطها صعود المنحدرات صعود الدرجات وهبوطها الأرض الوعرة على الحركة رفع مقدمة الكرسي وموازنته على عجلتيه الخلفيتين ح الضغطووقاية من قرلا ح ضغط وتفقد إمكانية وجود قر طبقات رافعة للتخفيف من الضغط وشرب كميات كبيرة من الماء ة من الطعامجيدتناول كميات قروح الضغط ب الإصابة ةحال ما يجب فعله في في المنزل متحركالعناية بالكرسي ال والوسادة متحركتنظيف الكرسي ال ة متحركتزييت الأجزاء ال بالهواء نفخ العجلات شد البراغي والعزقات (إذا كانت في حالة ارتخاء) شد أسياخ العجلتين الخلفيتين (إذا كانت في حالة ارتخاء) تفقد أقمشة التنجيد تفقد الصدأ تفقد الوسادة مشكلة إذا كانت هناكما يجب فعله بحاجة إلى إصلاح متحرك الكرسي ال مريح م أو غير غير ملائ متحرك الكرسي ال المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمة زمة التدريبية الخاصة حال متحرك استمارة متابعة خاصة بالكرسي ال هذه الاستمارة مخصصة لتسجيل المعلومات خلال زيارة المتابعة. متحركمستخدم الكرسي ال بيانات -1 الرقم: : متحركاسم مستخدم الكرسي ال في المتحرك ضبط الكرسيتاريخ تاريخ المتابعة: : الوضع الملائم المتابعة: المعني باسم الشخص ان إجراء المتابعة:كم ة متحركمركز خدمة الكراسي ال  متحركنزل مستخدم الكرسي الم مكان آخر: تسجيل الإجراء الواجب المقابلة -2 اتخاذه: لا نعم ؟ هر الذي ترغباقد مبال متحركهل تستعمل كرسيك ال لا، لماذا؟ لإجابة إذا كانت ا لا نعم ؟ متحرككرسيك ال لا عماست هل تعاني من أي مشكلة في إذا كانت الإجابة نعم، ما هي المشاكل؟ لا نعم ؟ متحركبخصوص استعمال كرسيك الهل لديك أي أسئلة إذا كانت الإجابة نعم، ما هي الأسئلة؟ هل هناك حاجة إلى المزيد من التدريب؟ لا م عن ؟ قروح ضغط أي متحرك مستعمل الكرسي ال هل لدى إذا كانت الإجابة نعم، الرجاء وصفها (موقعها ودرجتها) 1(؟ 5إلى 1على مقياس من متحركرضاك عن كرسيك ال مستوى مكيف تقي )راٍض جدا تعني 5وعدم الرضا تعني التقييم: ملاحظة: والوسادة متحركتفقد الكرسي ال -3 لا نعم واستعماله آمن؟ بشكل جيدهل الكرسي يعمل لا نعم هل الوسادة في وضع جيد واستعمالها آمن؟ أي من السؤالين، ما هي المشكلة؟ نلا عإذا كانت الإجابة للتأكد من ملاءمته الكرسي المتحرك ضبطتفقد -4 لا نعم ؟ملائم للمستخدم متحركالكرسي ال وضع هل ما هي المشكلة؟لا، إذا كانت الإجابة = غير آمن) 3= تحذير، 2= آمن، 1(وى اختبار الضغط مست ) قروح الضغطب للإصابة معرضا متحرك كان مستخدم الكرسي ال(إذا اليسار: اليمين: عندما يكون ساكنا ، بارتياح مستقيمفي وضع متحركهل يجلس مستخدم الكرسي ال ا ، وطيلة اليوم؟متحركو لا نعم لا، ما هي المشكلة؟لإجابة كانت ا إذا ة م ائ ق ة عي ج ر م ظ ح لا م ب ة ص خا ة ) ء قا نت لا (ا ة صف و ال و م يي تق ال : ى ول لأ ا ي مل لع ا ب ري تد ال ة س جل : ب ّر مد ال : ب ّر مد ال م س ا _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ي: مل ع ال ب ري تد ال ة س جل خ ري تا _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ال ة مد ة دق ب ب اق ر ة س جل ا س ر ما م ال ن ع ة ثل م أ ب كت ت ا ة يد ج ال ت ظا ح لا م م دي تق ل يم قي لت ا ا ن سي ح ت ى إل ج تا ح ت ي لت ا ة س ر ما م ال ن ع ة ثل م أ ب كت يم قي لت ا ت ظا ح لا م م دي تق ل قة قي د  يم قي لت ا 4 5  ء) قا نت لا (ا ة صف و ال 3 0  ت ظا ح لا م ال 1 0  فق ّ ت ي أ ب كت ا ا. ه دي ؤ ت ي ه و ة ع و م ج م لل ك ظت ح لا م ء نا أث ة لي تا ال ت را ها م ال ن م ة ر ها م ل ك د ت قا لي تع م دي تق ل ج أ ن م ك دي ل ك ات ظ ح لا م ة: ع و م ج م لل ة: ع و م ج م ال ى ول لأ ا ة ني ثا ال ة لث ثا ال ن: كي ر شا م ال ء ما س أ ك: ر ح مت ال ي س ر ك ال م خد ست م م س ا  ت قا لي ع لت ا  ت قا لي ع لت ا  ت قا لي ع لت ا ة: م عا ال ت ظا ح لا م ال ته ئل عا و ك ر ح مت ال ي س ر ك ال م خد ست م ع م د جي ل ص وا ت ت را ها م    ة ك ر شا م و ة و ط خ ل ك ي ف ية ال ع بف ك ر ح مت ال ي س ر ك ال م خد ست م ي ف ت را را لق ا ل ك    ل ما ك إ ي ف ية يب ر تد ال ة س جل ال ال ت وق ر ر مق ال    م: يي تق ال ء نا أث ة صل ال ت ذا ة سي سا لأ ا ت ما و عل م ال ع م ج لة اب مق ال    بة اق ر م مة لا س ال ن ما ض ل يم قي لت ا ر ري س ى إل م خد ست م ال ت لا قا نت ا    د دي ح ت بة صا إ ي أ ب و أ ط، غ ض ال ح و ر ق ها ب قة اب س ال ت با صا لإ ا و أ ا، ه ل ض ر ع لت ا ر ط خا م    ح حي ص ال ل ك ش ال ب ك ر ح مت ال ي س ر ك ال ع دف ة يق ر ط د دي ح ت    ت سا قا م ال د خ أ ب ةدق    ك ر ح مت ال ي س ر ك ال م يي تق ة ر ما ست ا ء ل م ب ة دق    ): ء قا نت لا (ا ة صف و ال ة اد س و ال و ك ر ح مت ال ي س ر ك لل س قا م و ع و ن ب س أن ر يا خت ا    د دي ح ت ال ى إل ة ج حا ي أ ل خا إد ة/ يف طف ت لا دي ع ت ل ك شا م ل ح مة ائ ق    دق ب ء) قا نت لا (ا ة صف و ال ة ر ما ست ا ء ل م ة    سي سا الأ ى تو مس ال كة حر مت ال سي را الك ة دم بخ ة ص خا ال ية ريب لتد ة ا زم لح ا ة م ائ ق ة عي ج ر م ظ ح لا م ب ة ص خا ة : ة ني ثا ال ي مل ع ال ب ري تد ال ة س جل : ب ّر مد ال ط ضب ي س ر ك ال ك ر ح مت ال م لائ م ال ع ض و ال ي ف م خد ست م ال ب ري تد و : ب ّر مد ال م س ا _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ي: مل ع ال ب ري تد ال ة س جل خ ري تا _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ال ة مد ة دق ب ب اق ر ة س جل ا س ر ما م ال ن ع ة ثل م أ ب كت ت ا ة يد ج ال ت ظا ح لا م م دي تق ل م يي تق ال ا ن سي ح ت ى إل ج تا ح ت ي لت ا ة س ر ما م ال ن ع ة ثل م أ ب كت م دي تق ل م يي تق ال ت ظا ح لا م ة يق دق  ع ض و ال ي ف ك ر ح مت ال ي س ر ك ال ط ضب ئم لا م ال 4 5  دم خ ست م ال ب ري تد 5 0  يم قي لت ا ت ظا ح لا م 2 0  ت ظا ح لا م ال لا ا تخ ري يا ة دم خ ست م لل 3 0  فق ّ ت ي أ ب كت ا ا. ه دي ؤ ت ي ه و ة ع و م ج م لل ك ظت ح لا م ء نا أث ة لي تا ال ت را ها م ال ن م ة ر ها م ل ك د ت قا لي ع ت م دي تق ل ج أ ن م ك دي ل ك ات ظ ح لا م ة: ع و م ج م لل ة: ع و م ج م ال ى ول لأ ا ة ني ثا ال ة لث ثا ال ن: كي ر شا م ال ء ما س أ م س ا ك: ر ح مت ال ي س ر ك ال م خد ست م  ت قا لي ع لت ا  ت قا لي ع لت ا  ت قا لي ع لت ا ة: م عا ال ت ظا ح لا م ال ه لت ائ ع و ك ر ح مت ال ي س ر ك ال م خد ست م ع م د جي ل ص وا ت ت را ها م    ة ك ر شا م و ة و ط خ ل ك ي ف ة لي عا بف ك ر ح مت ال ي س ر ك ال م خد ست م ي ف ت را را لق ا ل ك    ل ما ك إ ي ف ة بي ري تد ال ة س جل ال ال ت وق ر ر مق ال    م لائ م ال ع ض و ال ي ف ك ر ح مت ال ي س ر ك ال ط ضب ل ك ش ب ام خد ست لا ل ي س ر ك ال ة م ء لا م ن م د ك تأ لل م ز لا ال ط ضب ال ة لي م ع ي ف وة ط خ ل ك ل ما ك ست ا ك ر ح مت ال ي س ر ك ال ط ضب ل ية ع ج ر م ال ة م ائ لق ا ع با ات ي ف قة لد وا ) نة م لآ ا ت لا قا نت لا ا ل مث ( ن م آ    ي ف ل ك شا م ي أ يد حد ت ك ر ح مت ال ي س ر ك ال ة م ء لا م ى مد ا ه جت ال ع م و ل ك ش ب ح حي ص    م ك ل م ع ال م ج ة ع و ى عل ك ر ح مت ال ي س ر ك ال ل دي ع وت ل ك شا م ال ل ح ع ض و ال ي ف ه ط ضب ل لا م ال م ئ    م: خد ست م ال ب ري تد ال ر يا خت ا م م ج و ع ة ا ه م لي ع ت ب ج ي ي لت ا ب س لأن ا ت را ها م لل ل ه لت ائ ع و ك ر ح مت ال ي س ر ك ال م خد ست م ى إل دا ً نا ست ا ال ة م ائ ق ة عي ج ر م ال ي اد ش ر إ ل لي كد ب ري تد ال ب ة ص خا ال    ب لي سا أ ق بي ط ت ة يد ج ة مي لي ع ت ي ف ح ر ش ال ل مث ( ت را ها م ال م لي ع ت ة س ر ما م ال و ح ضي و لت وا )    ة من آ ة يق ر ط ب ب ري تد ال م ما إت لا ً مث ( ف و وق ي لذ ا ك ر ح مت ال ي س ر ك ال م خد ست م ف خل د ع سا م ال ؛ ل نق لت ا ت را ها م ل م ع ست ي ذ في تن ة في كي م لي ع وت ة) من آ ة يق ر ط ب ت لا قا نت لا ا    سي سا الأ ى تو مس ال كة حر مت ال سي را الك ة دم بخ ة ص خا ال ية ريب لتد ة ا زم لح ا ة م ائ ق ة عي ج ر م ظ ح لا م ب ة ص خا ة : ة ني ثا ال ي مل ع ال ب ري تد ال ة س جل : ب ّر مد ال ط ضب ي س ر ك ال ك ر ح مت ال م لائ م ال ع ض و ال ي ف م خد ست م ال ب ري تد و : ب ّر مد ال م س ا _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ي: مل ع ال ب ري تد ال ة س جل خ ري تا _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ال ة مد ة دق ب ب اق ر ة س جل ا س ر ما م ال ن ع ة ثل م أ ب كت ت ا ة يد ج ال ت ظا ح لا م م دي تق ل م يي تق ال ا ن سي ح ت ى إل ج تا ح ت ي لت ا ة س ر ما م ال ن ع ة ثل م أ ب كت م دي تق ل م يي تق ال ت ظا ح لا م ة يق دق  ع ض و ال ي ف ك ر ح مت ال ي س ر ك ال ط ضب ئم لا م ال 4 5  دم خ ست م ال ب ري تد 5 0  يم قي لت ا ت ظا ح لا م 2 0  ت ظا ح لا م ال لا ا تخ ري يا ة دم خ ست م لل 3 0  فق ّ ت ي أ ب كت ا ا. ه دي ؤ ت ي ه و ة ع و م ج م لل ك ظت ح لا م ء نا أث ة لي تا ال ت را ها م ال ن م ة ر ها م ل ك د ت قا لي ع ت م دي تق ل ج أ ن م ك دي ل ك ات ظ ح لا م ة: ع و م ج م لل ة: ع و م ج م ال ى ول لأ ا ة ني ثا ال ة لث ثا ال ن: كي ر شا م ال ء ما س أ م س ا ك: ر ح مت ال ي س ر ك ال م خد ست م  ت قا لي ع لت ا  ت قا لي ع لت ا  ت قا لي ع لت ا ة: م عا ال ت ظا ح لا م ال ه لت ائ ع و ك ر ح مت ال ي س ر ك ال م خد ست م ع م د جي ل ص وا ت ت را ها م    ة ك ر شا م و ة و ط خ ل ك ي ف ة لي عا بف ك ر ح مت ال ي س ر ك ال م خد ست م ي ف ت را را لق ا ل ك    ل ما ك إ ي ف ة بي ري تد ال ة س جل ال ال ت وق ر ر مق ال    م لائ م ال ع ض و ال ي ف ك ر ح مت ال ي س ر ك ال ط ضب ل ك ش ب ام خد ست لا ل ي س ر ك ال ة م ء لا م ن م د ك تأ لل م ز لا ال ط ضب ال ة لي م ع ي ف وة ط خ ل ك ل ما ك ست ا ك ر ح مت ال ي س ر ك ال ط ضب ل ية ع ج ر م ال ة م ائ لق ا ع با ات ي ف قة لد وا ) نة م لآ ا ت لا قا نت لا ا ل مث ( ن م آ    ي ف ل ك شا م ي أ يد حد ت ك ر ح مت ال ي س ر ك ال ة م ء لا م ى مد ا ه جت ال ع م و ل ك ش ب ح حي ص    م ك ل م ع ال م ج ة ع و ى عل ك ر ح مت ال ي س ر ك ال ل دي ع وت ل ك شا م ال ل ح ع ض و ال ي ف ه ط ضب ل لا م ال م ئ    م: خد ست م ال ب ري تد ال ر يا خت ا م م ج و ع ة ا ه م لي ع ت ب ج ي ي لت ا ب س لأن ا ت را ها م لل ل ه لت ائ ع و ك ر ح مت ال ي س ر ك ال م خد ست م ى إل دا ً نا ست ا ال ة م ائ ق ة عي ج ر م ال ي اد ش ر إ ل لي كد ب ري تد ال ب ة ص خا ال    ب لي سا أ ق بي ط ت ة يد ج ة مي لي ع ت ي ف ح ر ش ال ل مث ( ت را ها م ال م لي ع ت ة س ر ما م ال و ح ضي و لت وا )    ة من آ ة يق ر ط ب ب ري تد ال م ما إت لا ً مث ( ف و وق ي لذ ا ك ر ح مت ال ي س ر ك ال م خد ست م ف خل د ع سا م ال ؛ ل نق لت ا ت را ها م ل م ع ست ي ذ في تن ة في كي م لي ع وت ة) من آ ة يق ر ط ب ت لا قا نت لا ا    سي سا الأ ى تو مس ال كة حر مت ال سي را الك ة دم بخ ة ص خا ال ية ريب لتد ة ا زم لح ا ة ئم قا ية جع مر ظ ح لا بم ة ص خا ة عة اب مت ال ة: لث ثا ال ي مل لع ا ب ري تد ال سة جل : ب دّر لم ا : ب دّر لم م ا س ا __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ي: مل لع ب ا ري تد ال سة جل خ ري تا __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ال دة م قة بد ب راق سة جل ا س ار مم ال ن ع ة مثل ب أ كت ت ا ة يد ج ال م دي لتق يم تقي ال ت ظا ح لا م ا ن سي ح ت ى إل ج حتا ت ي الت ة س ار مم ال ن ع ة مثل ب أ كت ت ظا ح لا م يم قد لت يم تقي ال قة قي د  عة تاب لم ا 6 0  ت ظا ح لا م يم قي الت 2 5  فق ّ ت ي أ ب كت ا ا. يه ؤد ت ي وه ة ع مو ج لم ل ك ظت ح لا م اء ثن أ ية تال ال ت را ها لم ا ن م رة ها م كل د ت قا لي تع م دي تق ل ج أ ن م ك دي ل ك ات ظ ح لا م ة: ع مو ج لم ل ة: ع مو ج لم ا ى ول لأ ا ية ثان ال ثة ثال ال ن: كي ر شا لم ء ا ما س أ ك: حر مت ال ي س كر ال دم خ ست م سم ا  ت قا علي الت  ت قا علي الت  ت قا علي الت ة: ام لع ا ت ظا ح لا لم ا ته ائل ع و ك حر مت ال ي س كر ال دم خ ست م مع د جي ل ص وا ت ت را ها م    ة رك شا م و وة ط خ ل ك ي ف ية عال بف ك حر مت ال ي س كر ال دم خ ست م ي ف ل ك ت را را الق    ل ما إك ي ف ية ريب تد ال سة جل ال ال ت وق رر مق ال    ة: بع تا لم ا فق ّ ت ك حر مت ال ي س كر ال لة حا ة ع مو ج لم د ا ليا فع    فق ّ ت ى مد د ط ضب ة ءم لا م ك حر مت ال ي س كر ال يا عل ف مه خد ست لم    جيل س وت ة سب منا ال عة تاب لم ت ا ءا را ج د إ دي ح ت ها    ن مك ي عة تاب م ت ءا را ج ي إ ذ أ في تن ها يق طب ت ة س جل ال ل لا خ    سي سا الأ ى تو مس ال كة حر مت ال سي را الك ة دم بخ ة ص خا ال ية ريب لتد ة ا زم لح ا مة ائ ق ية جع مر ظ ح لا بم ة ص خا ة ، ك حر مت ال ي س كر ال دم خ ست م يم قي ت ة: بع را ال ي مل لع ا ب ري تد ال سة جل : ب دّر لم ا و ، ء) قا نت الا ( فة ص لو ا ئة هي وت ج نت لم ا ، ك) حر مت ال ي س كر (ال ضع لو ا ي ف طه ضب و لا لم ا ،ئم م خد ست لم ا ب ري تد و ب: دّر لم م ا س ا __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ي: مل لع ب ا ري تد ال سة جل خ ري تا __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ ال دة م قة بد ب راق سة جل ا س ار مم ال ن ع ة مثل ب أ كت ت ا ة يد ج ال ت ظا ح لا م يم قد لت يم تقي ال ا ن سي ح ت ى إل ج حتا ت ي الت ة س ار مم ال ن ع ة مثل ب أ كت م دي لتق يم تقي ال ت ظا ح لا م قة قي د 1  يم قي الت 03  ء) قا نت لا (ا ة صف لو ا 02  ئة هي ت ك) حر مت ال ي س كر (ال ج منت ال 06  ئم لا لم ع ا ض لو ي ا ف ي س كر ال ط ضب 03  دم خ ست لم ب ا ري تد 54  ت ظا ح لا م يم قي الت 03  ي أ ب كت ا ا. يه ؤد ت ي وه ة ع مو ج لم ل ك ظت ح لا م اء ثن أ ية تال ال ت را ها لم ا ن م رة ها م كل د فق ت ت قا لي تع م دي تق ل ج أ ن م ك دي ل ك ات ظ ح لا م ة: ع مو ج لم ل ة: ع مو ج لم ا ى ول لأ ا ية ثان ال ثة ثال ال ن: كي ر شا لم ء ا ما س أ ك: حر مت ال ي س كر ال دم خ ست م سم ا  ت قا علي الت  ت قا علي الت  ت قا علي الت ة: ام لع ا ت ظا ح لا لم ا ته ائل ع و ك حر مت ال ي س كر ال دم خ ست م مع د جي ل ص وا ت ت را ها م    ل ك ي ف ية عال بف ك حر مت ال ي س كر ال دم خ ست م كة ار ش م ت را را الق ل ك ي وف ة طو خ    رر مق ال ت وق ال ي ف ية ريب تد ال سة جل ال ل ما إك    __ __ __ __ __ __ __ __ _ 1 : ي ي يل ما ظة ح لا ء م جا لر ا ح سم ة اف ض بإ 02 وة. ط خ ل د ك فق ن ت ن م بي دّر لم ن ا كي تم ول ل اك ش ي م ل أ ح ة ل يق دق سي سا الأ ى تو مس ال كة حر مت ال سي را الك ة دم بخ ة ص خا ال ية ريب لتد ة ا زم لح ا م: يي تق ال ع جم ت ما لو مع ال لة قاب لم ء ا ثنا ة أ صل ال ت ذا ة سي سا لأ ا    د ص ر عة مو ج لم ا لا مة لا س ال ن ما ض م ل قيي الت ر ري س ى إل دم خ ست لم ت ا لا تقا ن    د دي ح ت بة صا ي إ أ ب و ، أ ط ضغ ال ح رو ق ض ر تع ال ر ط خا م ها ب قة ساب ال ت ابا ص لإ و ا ا أ له    د دي ح ت قة ري ط ح حي ص ال ل شك بال ك ر ح مت ال ي س ر لك ع ا دف    ت سا قا لم د ا خ أ ب ةدق    ة ر ما ست ء ا ل م يم قي ت ك ر ح مت ال ي س ر لك ا ق قي د ل شك ب    ): اء تق لان (ا ة صف لو ا ة اد س لو وا ك ر ح مت ال ي س ر لك س ل قا وم ع نو ب س أن ر تيا خ ا    ى إل جة حا ي د أ دي ح ت ل خا إد ة/ يف طف ت لا دي تع ل اك ش م ل ح مة قائ    ق قي د ل شك ب ء) قا لانت (ا ة صف لو ة ا ر ما ست ء ا ل م    ئة هي ت ): ك حر مت ال ي س كر (ال ج نت لم ا ة يئ ته ة ح حي ص ة يق ر ط ب ك ر ح مت ال ي س ر لك ا ت ء) قا نت لا (ا ة صف لو ق ا طاب    ته زي هو ج و ك ر ح مت ال ي س ر لك ن ا ما ق أ قي تد ة ئم قا ل ما تك س ا    ئم لا لم ا ضع لو ا ي ف ك حر مت ال ي س كر ال ط ضب ل شك ب ام خد ست لا ي ل س كر ال مة لاء م ن م كد لتأ م ل ز لا ال ط ضب ال ية مل ع ي ف وة ط خ ل ك ل ما تك س ا ل مث ( ن آم ك حر مت ال ي س كر ال ط ضب ة ل عي ج ر لم ة ا ئم قا ال ع تبا ي ا ف قة لد وا ) نة لآم ت ا لا قا لانت ا    ي ف ل اك ش م ي د أ دي ح ت ك ر ح مت ال ي س ر لك ة ا ءم لا م ى مد ا ته ج عال وم ل شك ب ح حي ص    كم ل عم ال جم عة و ى عل ك حر مت ال ي س ر لك ل ا دي تع و ل اك ش لم ل ا ح ضع لو ي ا ف طه ضب ل لا لم ا م ئ    ب ري تد م: خد ست لم ا ر تيا خ ا عة مو ج لم ا ه ئلت عا و ك حر مت ال ي س كر ال دم خ ست م ها يم عل ت ب ج ي ي الت ب س لأن ت ا را ها لم ل ى ًإل دا تنا س ا ال ة ئم قا ية جع ر لم ا ي اد ش ر ل إ دلي ك ب ري تد بال ة ص خا ال    ب الي س ق أ طبي ت ة يد ج ة مي علي ت ي ف ح شر ال ل مث ( ت را ها لم م ا علي ت سة ار مم وال ح ضي تو وال )    ثلا ً (م نة آم قة ري ط ب ب ري تد ال ام تم إ ف قو و ي لذ ك ا حر مت ال ي س كر ال دم خ ست م ف خل د ع سا لم ا ؛ ل نق الت ت را ها م ل عم ست ي ذ في تن ية يف ك يم عل وت ة) من ة آ يق طر ب ت لا قا لانت ا    سي سا الأ ى تو مس ال كة حر مت ال سي را الك ة دم بخ ة ص خا ال ية ريب لتد ة ا زم لح ا المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمةزمة التدريبية الخاصة حال مشاركيناستمارة تقييم البرنامج التدريبي لل اسم المشارك: المشارك: دور التاريخ: .فهمه في صعوبة الرجاء وصف أي جزء من البرنامج التدريبي وجدت الصعوبات التي واجهتهاالرجاء وصف الجلسة لك في عملك. الأكثر فائدةستكون نها ترى أ الرجاء وصف أي أجزاء من البرنامج التدريبي ولماذا ما وجدته مفيدا الرجاء وصف الجلسة ستدخلها على البرنامج التدريبي. تحسيناتالرجاء وصف أي الرجاء وصف التحسينات الجلسة المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة الأساسي المستوى - الكراسي المتحركة بخدمةزمة التدريبية الخاصة حال استمارة تقييم الدورة للمدّربين اسم المدّرب: التاريخ:الجلسة و .يه تغييرات ليناسب السياق المحليأدخلت علالرجاء وصف أي جزء من البرنامج التدريبي الرجاء وصف التغييرات التي أجريتها الجلسة . تدريسه في صعوبةالرجاء وصف أي جزء من البرنامج التدريبي وجدت صعوباتالرجاء وصف ال الجلسة البرنامج التدريبي. مواد أغفلتهاجوانب أخطاء أو أي ذكرالرجاء نواقص الأخطاء أو ال ذكر الرجاء الجلسة المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة الأساسي المستوى - الكراسي المتحركة بخدمةزمة التدريبية الخاصة حال .المشاركين في البرنامج التدريبي عن صدرتهامة إيجابية أو سلبية ملاحظات أو آراء أي ذكرالرجاء إدراج الملاحظات الرجاء الجلسة ستدخلها على البرنامج التدريبي. تحسيناتالرجاء وصف أي الرجاء وصف التحسينات الجلسة المستوى الأساسي الكراسي المتحركة الحزمة التدريبية الخاصة بخدمة المستوى الأساسي - الكراسي المتحركة بخدمةزمة التدريبية الخاصة حال استمارة تقييم جلسة للمدّربين اسم المدّرب: الجلسة والتاريخ: .يه تغييرات ليناسب السياق المحلي أدخلت علالرجاء وصف أي جزء من الجلسة التي أجريتهاالتغييرات الرجاء وصف .تدريسه في صعوبةالبرنامج التدريبي وجدت الرجاء وصف أي جزء من الجلسة صعوباتلاالرجاء وصف مواد الجلسة. أغفلتها جوانبأخطاء أو الرجاء وصف أي النواقصالأخطاء أو ذكرالرجاء . في البرنامج التدريبي ن المشاركين ع صدرت هامة إيجابية أو سلبية ملاحظات أو آراء الرجاء وصف أي والملاحظاتالآراء إدراج الرجاء على الجلسة. ستدخلها تحسيناتالرجاء وصف أي الرجاء وصف التحسينات

WHEELCHAIR SERVICE TRAINING P ACKAGE BASIC LEVEL Forms and checklists BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 1 Wheelchair Referral Form Sample referral form: This form can be adapted by wheelchair services and provided to referral sources to help them refer wheelchair users to the wheelchair service. Please complete referral form and post to: Wheelchair Service Name and Address: Name of referral person: Organization you work for: Referral person contact details (the best way to contact you): Wheelchair user’s name: Date of Birth: Parent / carer’s name: Address: How can the wheelchair user be contacted? Post Own Telephone Friend / neighbour’s telephone If by telephone, what is their phone number: Wheelchair user’s disability if known: Reason for referral: • Has no wheelchair • Has a broken wheelchair • Has a wheelchair that does not meet their needs Please add any other information about the wheelchair user that you think it is important that the wheelchair service knows: Has the wheelchair user agreed to being referred to the wheelchair service? Yes No Signature of referring person: Date: BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 2 Wheelchair Assessment Form For assessment of wheelchair users who can sit upright easily. Wheelchair users who cannot sit upright easily may need assessment by a person with ‘intermediate’ level training. Keep this form in the wheelchair user’s file. Assessor’s name: Date of assessment: 1: Interview Assessment Information about the wheelchair user Name: Number: Age: Male  Female  Phone no.: Address: Goals: Physical condition Cerebral palsy  Polio  Spinal cord injury  Stroke  Frail  Spasms or uncontrolled movements  Amputation: R above knee  R below knee  L above knee  L below knee Bladder problems Bowel problems If the wheelchair user has bladder or bowel problems, is this managed? Yes  No  Others: __________________________________________________________________ Lifestyle and environment Describe where the wheelchair user will use their wheelchair: ______________________________________________________________________________ Distance travelled per day: Up to 1 km  1 – 5 km  More than 5 km  Hours per day using wheelchair? Less than 1  1-3  3-5  5-8  more than 8 hours  When out of the wheelchair, where does the user sit or lie down and how (posture and the surface? ______________________________________________________________________________ Transfer: Independent  Assisted  Standing  Non Standing  Lifted  Other  Type of toilet (if transferring to a toilet): Squat  Western  Adapted  Does the wheelchair user often use public/private transport? Yes  No  If yes, then what kind: Car  Taxi  Bus  Other _____________________________________ Existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes  No  Does the wheelchair meet the user’s environmental conditions? Yes  No  Does the wheelchair provide proper fit and postural support? Yes  No  Is the wheelchair safe and durable? (Consider whether there is a cushion) Yes  No  Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes  No  Comments: _____________________________________________________________________ Wheelchair Service Training Package: Basic Level. Page 2 of 2 If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications. 2: Physical Assessment Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore  = existing pressure sore Can feel normally? Yes  No  Previous pressure sore? Yes  No  Current pressure sore? Yes  No  If yes, is it an open sore (stage 1 – 4)? Yes  No  Duration and cause: _________________________ _________________________________________ Is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous / current pressure sore, poor diet, ageing, under or over weight. Yes  No  Method of pushing How will the wheelchair user push their wheelchair? Both arms  Left arm  Right arm  Both legs  Left leg  Right leg  Pushed by a helper  Comment: _____________________________________________________________________ Measurements Body Measurement Measurement (mm) Change body measurement to ideal wheelchair size Wheelchair measurement A Hip width 360mm Hip width = seat width 360mm B Seat depth L 400mm B less 30 – 50 mm = seat depth (if length is different, use shorter one) 370mm R 400mm C Calf length L 380mm = top of seat cushion* to footrests heightor = top of seat cushion* to floor for foot propelling 330mm R 380mm 330mm D Bottom of rib cage 310mm = top of seat cushion* to top of backrest (measure D or E – depending on the user’s need) 360mm E Bottom of shoulder blade 420mm 470mm *check the height of the cushion that the wheelchair user will use. BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 2 of 2 If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications. 2: Physical Assessment Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore  = existing pressure sore Can feel normally? Yes  No  Previous pressure sore? Yes  No  Current pressure sore? Yes  No  If yes, is it an open sore (stage 1 – 4)? Yes  No  Duration and cause: _________________________ _________________________________________ Is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous / current pressure sore, poor diet, ageing, under or over weight. Yes  No  Method of pushing How will the wheelchair user push their wheelchair? Both arms  Left arm  Right arm  Both legs  Left leg  Right leg  Pushed by a helper  Comment: _____________________________________________________________________ Measurements Body Measurement Measurement (mm) Change body measurement to ideal wheelchair size Wheelchair measurement A Hip width 360mm Hip width = seat width 360mm B Seat depth L 400mm B less 30 – 50 mm = seat depth (if length is different, use shorter one) 370mm R 400mm C Calf length L 380mm = top of seat cushion* to footrests heightor = top of seat cushion* to floor for foot propelling 330mm R 380mm 330mm D Bottom of rib cage 310mm = top of seat cushion* to top of backrest (measure D or E – depending on the user’s need) 360mm E Bottom of shoulder blade 420mm 470mm *check the height of the cushion that the wheelchair user will use. BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 1. Wheelchair Summary Form Name of Wheelchair: Insert picture here: Manufacturer / Supplier: Sizes available: Overall weight: Description: Frame: Fixed / rigid Folding Frame length: Backrest: Slung / canvas Solid Tension Adjustable Seat: Slung / canvas Solid Tension Adjustable Cushion: No cushion Flat foam Foam Contoured Footrests: Fixed Removable/swing away Other: Castor wheels: Diameter: Width: Rear wheels: Pneumatic Diameter: Push rims Solid Width: Adjustable axle Solid inner tube Removable Brakes: Short lever Long lever Other: Armrests: Fixed Removable/swing away Other: Push handles: Push handles Extra parts / options: Calf strap Anti-tip bars Tray Other: Measurements, adjustment options and range of adjustment: Measurement (if the wheelchair is available in different sizes list all sizes) Is this adjustable? Range of adjustment (adjustment range that is possible for this chair).Yes No Seat width: Seat depth: Seat height: Backrest height: Backrest angle: Footrests height: Footrests angle: Push handles height: Wheelchair Service Training Package: Basic Level. Page 1 of 1. Frame length: Wheel base length: BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 1. Wheelchair Prescription (Selection) Form This prescription (selection) form is for recording the choice of wheelchair, wheelchair components and cushion for a wheelchair user who is able to sit upright comfortably. 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of fitting: Assessor’s name: 2. Type of wheelchair and size selected To select the type of a wheelchair: o Discuss with the wheelchair user; o Think about the most important needs of the wheelchair user; o Check: wheelchair frame, castor and rear wheels, footrests, armrests, backrest height (or adjustability), rear wheels position, support and comfort. Type of wheelchair Size      3. Type of cushion selected Type of cushion Size Eg. Foam pressure relief cushion  Eg. Flat foam cushion   4. Agreed Signature of the user: Signature of the assessor: Signature of the manager: BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 1 Checklist: Is the Wheelchair Safe and Ready to Use? Whole wheelchair There are no sharp edges  No parts are damaged or scratched  The wheelchair travels in a straight line  Front castor wheels Spin freely  Spin without touching the fork  Bolts are tight  Front castor barrels Castor fork spins freely  Rear wheels Spin freely  Axle bolts are tight  Tyres inflated correctly (with thumb pressure, wheel can be depressed less than 5 mm)  Push rims are secure  Brakes Function properly  Footrests Footrests are securely attached  Frame For a folding wheelchair – the wheelchair folds and unfolds easily  For a wheelchair with fold down backrest – the backrest folds and unfolds easily  Cushion The cushion is in the cover correctly  The cushion is sitting on the wheelchair correctly  The cushion cover fabric is tight but not too tight  If the wheelchair has a solid seat: the cushion fully covers the solid seat  BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 2 Wheelchair fitting checklist 1. Is the wheelchair ready? Has the wheelchair been checked to make sure it is safe to use and all parts are working?  2. Check size and adjustments Seat width: Should fit closely.  Seat depth: Two fingers’ gap between the back of the knee and the seat /cushion.  Footrests height: The thighs are fully supported on the cushion with no gaps. The feet are fully supported on the footrests with no gaps.  Backrest height: The wheelchair user has the support they need and freedom to move their shoulders to push (if self propelling).  Rear wheels position (for hand propelling): The wheelchair user’s arm should be in line with the rear axle when hanging down. When hands are placed on the push rims, the user’s elbows should be at a right angle.  Brakes: Are the brakes working?  Seat height (for foot propelling): With the wheelchair user sitting upright, the back should be comfortably supported by the backrest, with feet resting flat on the floor.  3. Check posture Is the wheelchair user able to sit upright comfortably?  Check posture from the side.  Check posture from front /back.  BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 2 of 2 4. Check pressure Check pressure under seat bones for all wheelchair users at risk of developing a pressure sore. Explain the test to the wheelchair user. B Ask wheelchair user to lean forward or push up. Place fingertips under wheelchair user's seat bone. C Ask the wheelchair user to sit back down on your fingers. Make sure they sit upright with hands on thighs. D Identify the pressure: Level one = safe: Finger tips can wriggle up and down 5mm or more. Level two = warning: Finger tips cannot wriggle, but can easily slide out. Level 3 = unsafe: Finger tips are squeezed firmly. It is difficult to slide fingers out. E Repeat under the second seat bone. 5. Check fit while the wheelchair is moving Does the backrest allow the wheelchair user freedom to move their shoulders to push?  Does the backrest give the wheelchair user enough support?  Do the wheelchair user’s feet stay on the footrests?  Is the rear wheels position correct for the user?  6. Action? Is there any further action necessary? Write any actions in the wheelchair user’s file.  Remember: The next step after fitting is user instruction. BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 1 Wheelchair User Training Checklist Skills to Teach Skills Taught Wheelchair handling Folding the wheelchair Lifting the wheelchair Using quick release wheels Using the brakes Using the cushion including positioning correctly Transfers Independent transfer Assisted transfer Other Wheelchair mobility Pushing correctly Up and down slopes Up and down steps On rough ground Partial wheelie Preventing pressure sores Checking for pressure sores Pressure relief lifts Eat well and drink lots of water What to do if a pressure sore develops Looking after the wheelchair at home Clean the wheelchair and cushion Oil moving parts Pump the tyres Tighten nuts and bolts (if loose) Tighten spokes (if loose) Check upholstery Check for rust Check the cushion What to do if there is a problem Wheelchair needs repairs The wheelchair does not fit or is not comfortable BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level. Page 1 of 1 Wheelchair Follow Up Form This form is for recording information from a follow up visit. 1. Wheelchair user information Wheelchair user name: Number: Date of fitting: Date of follow up: Name of person carrying out follow up: Follow up carried out at: Wheelchair user’s home  Wheelchair service centre Other: ________________________________________ 2. Interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes  No  If no – why not? Do you have any problems using your wheelchair? Yes  No  If yes – what are the problems? Do you have any questions about using your wheelchair? Yes  No  If yes – what questions. Is further training needed? Does the wheelchair user have any pressure sores? Yes  No  If yes - describe (location and grade) How would you rate your satisfaction with your wheelchair from 1 - 5? (1 is very satisfied and 5 is not satisfied) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes  No  Is the cushion in good working order and safe to use? Yes  No  If no for either, what is the problem? 4. Fitting check Does the wheelchair fit correctly? Yes  No  If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes  No  If no – what is the problem? Wheelchair Service Training Package: Basic Level: Page 1 of 1 Trainer’s observation checklist: Practical one: Assessment and prescription (selection). Trainer's Name: ________________________________________ Date of Practical: ________________________________________________ Monitor the session time: Write examples of good practice for feedback: Write examples of practice needing improvement for feedback: Min  Assessment 45  Prescription (selection) 30  Feedback 10  Check each skill below as you observe the group demonstrate it. Write any comments you have for group feedback. Group: One Two Three Participants’ names: Wheelchair user’s name:  Comments  Comments  Comments General observations: Good communication skills with wheelchair user and family    Wheelchair user actively involved in each step and decisions    Practical completed on time    Assessment: Key relevant information gathered through interview    Monitors the user’s transfers to assessment bed to ensure safety    Presence, risk of or history of pressure sores identified    Method of pushing correctly identified    Measurements taken accurately    Wheelchair assessment form completed accurately    Prescription (selection): The most appropriate wheelchair and cushion type and size chosen    Any minor modifications / problem solving needed identified    Wheelchair prescription (selection) form completed accurately    BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level: Page 1 of 1 Trainer’s observation checklist: Practical two: Fitting and user training. Trainer's Name: ________________________________________ Date of Practical: ___________________________________________________ Monitor the session time closely: Write examples of good practice for feedback: Write examples of practice needing improvement for feedback: Min  Fitting 45  User training 50  Feedback 20  Optional user feedback 30  Check each skill below as you observe the group demonstrate it. Write any comments you have for group feedback. Group: One Two Three Participants’ names: Wheelchair user’s name:  Comments  Comments  Comments General observations: Good communication skills with wheelchair user and family    Wheelchair user actively involved in each step and all decisions    Practical completed on time    Fitting: Each step of the fitting process completed safely (e.g. safe transfers) and accurately, following the fitting checklist    Any problems with the fit identified and addressed correctly    Group problem solve and adjust the wheelchair to achieve the correct fit    User training: Group selected the most appropriate skills to teach the wheelchair user and their family using    BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level: Page 1 of 1 the training checklist as a guide. Good teaching techniques demonstrated when teaching skills (e.g. explain, demonstrate, practise)    Training carried out safely (e.g. assistant behind wheelchair using mobility skills; transfers taught safely)    Wheelchair Service Training Package: Basic Level: Page 1 of 1 Trainer’s observation checklist: Practical two: Fitting and user training. Trainer's Name: ________________________________________ Date of Practical: ___________________________________________________ Monitor the session time closely: Write examples of good practice for feedback: Write examples of practice needing improvement for feedback: Min  Fitting 45  User training 50  Feedback 20  Optional user feedback 30  Check each skill below as you observe the group demonstrate it. Write any comments you have for group feedback. Group: One Two Three Participants’ names: Wheelchair user’s name:  Comments  Comments  Comments General observations: Good communication skills with wheelchair user and family    Wheelchair user actively involved in each step and all decisions    Practical completed on time    Fitting: Each step of the fitting process completed safely (e.g. safe transfers) and accurately, following the fitting checklist    Any problems with the fit identified and addressed correctly    Group problem solve and adjust the wheelchair to achieve the correct fit    User training: Group selected the most appropriate skills to teach the wheelchair user and their family using    BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level: Page 1 of 1 Trainer’s observation checklist: Practical three: Follow up. Trainer's Name: __________________________________________ Date of Practical: ________________________________________________ Monitor the session time closely: Write examples of good practice for feedback: Write examples of practice needing improvement for feedback: Min  Follow up 60  Feedback 25  Check each skill below as you observe the group demonstrate it. Write any comments you have for group feedback. Group: One Two Three Participants’ names: Wheelchair user’s name:  Comments  Comments  Comments General observations: Good communication skills with wheelchair user and family    Wheelchair user actively involved in each step and all decisions    Practical completed on time    Follow up: The condition of the wheelchair physically checked by the group    How well the wheelchair fits the wheelchair user is physically checked    Appropriate follow up actions are identified and recorded    Any follow up actions that can be carried out during the session are carried out    BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level: Page 1 of 2 Trainer’s observation checklist: Practical four: Wheelchair user assessment, prescription (selection), product (wheelchair) preparation, fitting and user training. Trainer's Name: __________________________________________ Date of Practical: ________________________________________________ Monitor the session time closely: Write examples of good practice for feedback: Write examples of practice needing improvement for feedback: Minutes1  Assessment 30  Prescription (selection) 20  Product (wheelchair) preparation 60  Fitting 30  User training 45  Feedback 30  Check each skill below as you observe the group demonstrate it. Write any comments you have for group feedback. Group: One Two Three Participants’ names: Wheelchair user’s name:  Comments  Comments  Comments General observations: Good communication skills with wheelchair user and family    Wheelchair user actively involved in each step and all decisions    Practical completed on time    Assessment: Key relevant information gathered through interview    1 Please note – an additional 20 minutes is allowed for any problems to be resolved and for trainers to check each step. BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Training Package: Basic Level: Page 1 of 2 Group monitors the wheelchair user’s transfers to assessment bed ensuring safety    Presence, risk of or history of pressure sores correctly identified    Method of pushing correctly identified    Measurements taken accurately    Wheelchair assessment form completed accurately    Prescription (selection): The most appropriate wheelchair and cushion type and size chosen    Any minor modifications / problem solving needed identified    Wheelchair prescription (selection) form completed accurately    Product (wheelchair) preparation: Wheelchair set up correctly, matching the prescription (selection)    Wheelchair safe and ready checklist completed accurately    Fitting: Each step of the fitting process completed safely (e.g. safe transfers) and accurately, following the wheelchair fitting checklist    Any problems with the fit identified and addressed correctly    Group problem solve and adjust the wheelchair to achieve the correct fit    User training: Group selected the most appropriate skills to teach the wheelchair user and their family using the user training checklist as a guide.    Good teaching techniques demonstrated when teaching skills (e.g. explain, demonstrate, practise)    Training carried out safely (e.g. assistant behind wheelchair using mobility skills; transfers taught safely)    BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Delivery Training Package: Basic Module: Pilot 2011 (not for public circulation) Page 1 of 1 Course Evaluation form for Participants Participant’s name: Participant’s role: Date: Please describe any part of the course that you found difficult to understand. Session Describe what was difficult Please describe which parts of the course you think will be most useful in your own work. Session Describe what is useful and why Please describe any improvements you would make to the course. Session Describe improvement BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Delivery Training Package - Basic Module - Page 1 of 1 Course Evaluation form for Trainers Trainer’s name: Session and date: Please describe any part of the course that you changed to fit your local context. Session Describe the change you made Please describe any part of the course that you found difficult to teach. Session Describe what was difficult Please list any mistakes or things missing in the course materials. Session List the mistake or what was missing BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Delivery Training Package - Basic Module - Page 2 of 1 Please describe any significant positive or negative feedback from course participants. Session Describe feedback Please describe any improvements you would make to the course. Session Describe improvement BASIC LEVEL WHEELCHAIR SERVICE TRAIN ING PACKAGE Wheelchair Service Delivery Training Package - Basic Module - Page 1 of 1 Session Evaluation form for Trainers Trainer’s name: Session and date: Please describe any part of the session that you changed to fit your local context. Describe what you changed Please describe any part of the session that you found difficult to teach. Describe what was difficult Please describe any mistakes or missing things in the session materials. List the mistake or missing things Please describe any significant positive or negative feedback from course participants. Describe feedback Please describe any improvements you would make to the session. Describe improvement

Wheelchair Service Training P ackage Basic LeveL reference Manual for Participants

W H O /N M H /V IP /D A R /1 3. 01 D es ig n by In ís C om m un ic at io n – w w w .in is co m m un ic at io n. co m Basic LeveL Wheelchair Service Train ing Package W h e e lc h a ir S e r v ic e S T e P S Appointment and referral ➊ ➋ ➌ ➐ ➍ ➑ ➎ ➏ Assessment Prescription (selection) Funding and ordering Product (wheelchair) preparation Fitting User training Maintenance, repairs and follow up Basic LeveL Wheelchair Service Train ing Package PU SH IN G • To use less effort while pushing, push from 10 o’clock to 2 o’clock position with long smooth action. TU RN IN G • Hold one push rim towards the front and the other towards the back; • Pull the forwards hand backwards and push the backward hand forwards at the same time. U P SL O PE S • Lean forward – this helps stop the wheelchair tipping; • To stop or rest – park the wheelchair side-ways. D OW N S LO PE S • Lean backwards; • Let the push rim slide slowly through the hands. • Experienced wheelchair users who are able to do a ‘wheelie’ may roll down a slope on their back wheels. This is very efficient. UP S TE PS W IT H AS SI ST AN CE • Go up backwards; • Tilt wheelchair onto back wheels; • Assistant pulls backwards and upwards; • Wheelchair user can assist by pulling the push rims backwards. DO W N S TE PS W IT H A SS IS TA N CE • Go down forwards; • Tilt the wheelchair onto back wheels; • Assistant lets the back wheels slowly roll down one step at a time; • Wheelchair user can assist by controlling the push rims. W h e e lc h a ir M O B il iT Y S k il lS Basic LeveL Wheelchair Service Train ing Package P r e S S U r e S O r e S A pressure sore is an area of damaged skin and flesh that is caused by: 1. Pressure 2. Friction 3. Shear People who cannot feel (have no sensation) are most at risk of developing a pressure sore. how can pressure sores be prevented? avoid friction check skin every day While lying or sitting, change positions regularly Use pressure relief cushions Use pressure relief techniques side view Back view common areas where pressure sores might occur: Sit upright avoid moisture ➊ ➋ ➌ ➎ ➏ ➐ ➍ eat well and drink lots of water ➑ Basic LeveL Wheelchair Service Train ing Package ➊ Clean the wheelchair and cushion ➌ Pump up tyres (if pneumatic) ➎ Tighten spokes (if loose) ➋ Oil moving parts ➍ Tighten nuts and bolts (if loose) ➏ Make regular checks: • Rust and upholstery; • Cushion. h O W T O c a r e FO r a W h ee lc h a ir a T h O M e

Wheelchair Service Training P ackage Basic LeveL Trainer’s Manual

Wheelchair Service Training P ackage Trainer's Manual Basic LeveL Wheelchair Service Training Packag e Basic LeveL Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, and Isabelle Urseau Illustrator: Melissa Puust Photo credits: Chapal Khasnabis and Jesse Moss Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) WHO Library Cataloguing-in-Publication Data Wheelchair service training package / edited by Chapal Khasnabis and Kylie Mines. Contents: Trainer’s manual, basic level–Reference manual for participants, basic level – Participant’s workbook, basic level – Posters and slides, basic level. Trainer’s manual and slides available on DVD only. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150347 1 (package) (NLM classification: WB 320) ISBN 978 92 4 150348 8 (DVD) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/ licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cover photo credits (clockwise, from top): Mile End Films /Jesse Moss; WHO /Chapal Khasnabis; Mile End Films / Jesse Moss; Panos /Dieter Telemans; WHO /Chapal Khasnabis. Printed in Malta Design by Inís Communication – www.iniscommunication.com Terminology The following terms used throughout the training package are defined below. appropriate wheelchair A wheelchair that meets the user’s needs and environmental conditions; provides proper fit and postural support and is safe and durable; is available in the country; and can be obtained and maintained and services sustained in the country at the most economical and affordable price. Manual wheelchair A wheelchair that is propelled by the user or pushed by another person. Wheelchair A device providing wheeled mobility and seating support for a person who has difficulty in walking or moving around. Wheelchair provision An overall term for wheelchair design, production, supply and service delivery. Wheelchair service That part of wheelchair provision concerned with ensuring that each user receives an appropriate wheelchair. Wheelchair service personnel Persons skilled in the provision of an appropriate wheelchair. Wheelchair user A person who has difficulty in walking or moving around and uses a wheelchair for mobility. c O N T eN T s 1 about the Wheelchair service Training Package: Basic Level1 introduction 1 Target audience 2 Purpose 2 scope 3 Trainers 4 How to get started 5 1. guidance notes for trainers 5 1.1 Training overview 6 1.2 Training package timetable and duration 6 1.3 session plans 7 1.4 PowerPoint presentations 7 1.5 Observing/monitoring participants’ progress 8 1.6 evaluating the training programme after each delivery 8 1.7 Good practice training tips 10 2. how to prepare to deliver the training package 10 2.1 Know the participants’ wheelchair service network 10 2.2 clarify the participants’ role in wheelchair service delivery 10 2.3 Review each session plan and adjust if necessary 11 2.4 identify the wheelchairs that will be used 11 2.5 invite wheelchair users for practical sessions 13 2.6 Plan groups for practical sessions 13 2.7 Prepare facilities 14 2.8 Prepare the training resources and materials 19 3. Detailed session plans 20 introduction 23 a: core knowledge 1 about the Wheelchair service Training Package: Basic Level 1 introduction 1 Target audience 2 Purpose 2 scope 3 Trainers 4 How to get started 5 1. guidance notes for trainers 5 1.1 Training overview 6 1.2 Training package timetable and duration 6 1.3 session plans 7 1.4 PowerPoint presentations 7 1.5 Observing/monitoring participants’ progress 8 1.6 evaluating the training programme after each delivery 8 1.7 Good practice training tips 10 2. how to prepare to deliver the training package 10 2.1 Know the participants’ wheelchair service network 10 2.2 clarify the participants’ role in wheelchair service delivery 10 2.3 Review each session plan and adjust if necessary 11 2.4 identify the wheelchairs that will be used 11 2.5 invite wheelchair users for practical sessions 13 2.6 Plan groups for practical sessions 13 2.7 Prepare facilities 14 2.8 Prepare the training resources and materials 19 3. Detailed session plans 20 introduction 23 a: core knowledge 24 a.1: Wheelchair users 30 a.2: Wheelchair services 37 a.3: Wheelchair mobility 44 a.4: sitting upright 54 a.5: Pressure sores 67 a.6: appropriate wheelchair 87 a.7: cushions 99 a.8: Transfers 108 B: Wheelchair service steps 109 B.1: Referral and appointment 113 B.2: assessment 118 B.3: assessment interview 131 B.4: Physical assessment 144 B.5: Prescription (selection) 156 B.6: Funding and ordering 159 Practical One: assessment and prescription (selection) 162 B.7: Product (wheelchair) preparation 169 B.8: cushion fabrication 178 B.9: Fitting 185 B.10: Problem solving 195 B.11: User training 201 B.12: Maintenance and repairs 207 Practical Two: Fitting and user training 212 B.13: Follow up 217 Practical Three: Follow up 220 Practical Four: assessment, prescription (selection), product (wheelchair) preparation, fitting and user training VIII 224 B.14: Putting it all together 228 annexes 228 annex 1: Timetable for basic wheelchair service training package 230 annex 2: Wheelchair service referral form 231 annex 3: Wheelchair assessment form 234 annex 4: Wheelchair prescription (selection) form 235 annex 5: Wheelchair summary form 236 annex 6: Wheelchair safe and ready checklist 237 annex 7: Wheelchair fitting checklist 239 annex 8: Wheelchair user training checklist 240 annex 9: Wheelchair follow up form 242 annex 10: Trainer’s observation checklists 1about the Wheelchair Service Training Package: Basic level introduction To ensure better implementation of the guidelines on the provision of manual wheelchairs in less resourced settings, WHO has developed this Wheelchair service Training Package – Basic Level. The need for wheelchair personnel is universal. The wheelchair is one of the most commonly used assistive devices for enabling personal mobility, but there are very few training opportunities for service providers to ensure that wheelchair users can attain personal mobility with the greatest possible independence, be productive and enjoy a high quality of life. This basic level training package is the first part of the wheelchair service training series. The Wheelchair service Training Package – Basic Level comprises a number of documents and presentations for delivering the wheelchair training. The most important of these is this Trainer’s Manual. For practical reasons, the Trainer’s Manual is available only in electronic form (there is no printed version). The disk includes the Trainer’s Manual and all other information materials required to deliver a basic level training programme for wheelchair service provision. Target audience This training package is for all personnel or volunteers who are expected to carry out wheelchair service delivery in their place of work. This may include health, rehabilitation or technical personnel, community health care workers, community- based rehabilitation (cBR) workers, occupational therapists, physiotherapists, prosthetists, orthotists, local craftsmen, technicians and wheelchair users. The training programme has been designed assuming that participants will have the following knowledge and skills: • participants will be able to read and write in the language of the training programme; • participants will have a basic knowledge of the common physical impairments which may affect people who use wheelchairs, including cerebral palsy, lower- limb amputation, poliomyelitis (polio), spinal cord injury, and stroke. Wheelchair Service Training Packag e Basic LeveL Wheelchair Service Training Packag e 2 BASIC LEVEL Where participants do not already have information about common physical impairments, trainers should include this information as an additional core knowledge session. Purpose The Basic Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who have mobility impairments but can sit upright without additional postural support. The main purpose of this training package is to develop the skills and knowledge of personnel involved in the wheelchair service delivery. Delivery of this training package will help to: • increase the number of wheelchair users who receive a wheelchair which meets their needs; • increase the number of wheelchair users who receive training in the use and maintenance of wheelchairs and how to stay healthy in a wheelchair; • increase the number of personnel trained in basic level wheelchair service delivery; • improve the competencies of wheelchair service delivery personnel; • increase the quality of wheelchair service delivery; and • achieve greater integration of wheelchair service delivery within rehabilitation services. Scope The training package includes: • core knowledge required for wheelchair service delivery; • an overview of the key steps of wheelchair service delivery described in the WHO guidelines on the provision of manual wheelchairs in less resourced settings (Table 1); • working with wheelchair users to assess their mobility needs and identify the best possible mobility solution; • providing an appropriate wheelchair with an appropriate cushion; • problem solving to find simple modifications to the wheelchair that can help ensure the best fit for the user; • wheelchair repairs and maintenance; • training of wheelchair users to make the best use of their wheelchair; and • fabrication of a foam contoured cushion. 3The inclusion of simple wheelchair modifications is particularly relevant in contexts where there are limitations in the range and sizes of available manual wheelchairs. it is often necessary to make simple modifications to ensure a wheelchair fits correctly. The provision of tricycles is not covered in detail in this training package, although the value of a tricycle for wheelchair users who need to travel longer distances is noted. Table 1. Key steps of wheelchair service delivery: Step 1 Referral and appointment Step 2 Assessment Step 3 Prescription (selection) Step 4 Funding and ordering Step 5 Product (wheelchair) preparation Step 6 Fitting Step 7 User training Step 8 Maintenance, repairs and follow up Trainers Skills: This training package relies on the availability of trainers who are skilled in basic wheelchair service delivery and can confidently demonstrate the competencies taught in this training programme. Previous experience as a trainer will also be beneficial. Wheelchair users: inclusion of a wheelchair user on the training team is highly recommended. Wheelchair users are able to draw on their own experiences to teach others. Wheelchair users are also able to provide demonstrations of many of the techniques taught during the training programme. Being trained by a wheelchair user will help the participants to appreciate the central role that wheelchair users play in the selection of their own wheelchair. number of trainers: it is recommended that there are two trainers for every 8–10 participants. This ratio is particularly important for practical sessions, so that trainers can give participants good support and feedback and ensure that all involved can practise safely. Having an experienced wheelchair user, who knows the subject and training package well, can be an asset during the training programme. Wheelchair Service Training Packag e 4 BASIC LEVEL how to get started Before carrying out the training programme, you must copy the disc (inside the back of the folder) to your hard drive. You need about 8Gb storage space and a DvD player to make use of this training disc. The simplest way to deliver the training programme is: 1. Open the Trainer’s Manual from the manual folder. 1.1 read sections about the Wheelchair service Training Package and Guidance Notes for Trainers; 1.2 print and bind one copy of the Trainer’s Manual for each trainer; 1.3 print a timetable and trainer’s observation checklists; 1.4 print training programme forms, training programme evaluation forms and wheelchair service forms, including service checklists. 2. Make all the necessary arrangements, as suggested in the section How to Pre- pare to Deliver the Training Package. 3. Give the participants a full set of training materials including: the Reference Manual (1 per participant), Participant’s Workbook (1 per participant) and a set of posters (1 set per participant). if you do not have these in stock, they can be printed from the disc. 4. Open the timetable and click the hyperlinks of each session, which will take you to the exact slides and video location. The best way to deliver the training is to proceed through the lessons in sequential order with respect to the timing allotted for each session, as much as possible. 51. guidance notes for trainers 1.1 Training overview minutes Welcome, introduction and overview. Introduction 60 a: core knowledge Sessions which give participants the background knowledge needed to undertake the wheelchair service steps sessions. A.1 Wheelchair users 45 A.2 Wheelchair services 30 A.3 Wheelchair mobility 90 A.4 Sitting upright 60 A.5 Pressure sores 60 A.6 Appropriate wheelchair 120 A.7 Cushions 75 A.8 Transfers 120 B: Wheelchair service steps Referral and appointment B.1 Referral and appointment 30 Assessment B.2 Assessment 30 B.3 Assessment interview 90 B.4 Physical assessment 90 Prescription (selection) B.5 Prescription (selection) 120 Funding and ordering B.6 Funding and ordering 15 Practical One assessment and prescription (selection) 90 Product (wheelchair) preparation B.7 Product (wheelchair) preparation 75 B.8 Cushion fabrication 120 Fitting B.9 Fitting 60 B.10 Problem solving 45 User training B.11 User training 60 Maintenance, repairs and follow up B.12 Maintenance and repairs 120 Practical Two Fitting and user training 120 Maintenance, repairs and follow up B.13 Follow up 45 Practical Three Follow up 90 Practical Four assessment, prescription (selection), product (wheelchair) preparation, fitting and user training 240 B.14 Putting it all together 105 Wheelchair Service Training Packag e 6 BASIC LEVEL 1.2 Training package timetable and duration This training package may be delivered on consecutive days or in blocks over a period of time. The minimum length of time needed to teach the complete basic level training package is 35–40 hours. an estimate of the time needed to teach each session is included in the session plan. Note – the actual time taken to teach each session will vary depending on the following factors: • the experience and skills of participants; • the overall number of participants; • the number of locally available wheelchairs; • whether there is a need for translation during sessions; • whether additional material is included. Depending on these factors, more or less time may be required to complete the training programme. a sample five day timetable is provided in annex 1. This timetable and a blank timetable template are also available on the DvD. Trainers are strongly encouraged to adapt and modify the timetable to suit the local context and the learning needs of participants. For example: • sessions from the training package may be incorporated into existing health or rehabilitation training programmes; • wherever rehabilitation personnel already have training in some aspects of the training programme, the corresponding sessions may not be required; • where wheelchairs require additional preparation time (for example full assembly is required), it may be necessary to reduce the number of wheelchair users seen in the practical sessions or increase the time allowed. 1.3 Session plans For each session there is a session plan which guides trainers in delivering the session. at the beginning of each session plan is the following information: • Objectives: what the participant should be able to do at the end of the session; • Resources: what resources are needed for the session; • context: how the session may need to be adapted for different contexts or situations; • To prepare: how to prepare for the session; • Outline: an outline of the main parts of the session. 7The rest of the session plan is divided into topics. For each topic, the session plan gives instructions about how to communicate the information for that topic. Note: • words in bold are actions for the trainers (for example: ask, demonstrate, explain, show DvD); • shaded boxes give answers to questions asked by the trainers – but encourage participants to think of the answers themselves. at the end of every session plan is a summary of the key points. instead of reading the key points, trainers may ask participants questions so that they identify the key points themselves. By following the session plans carefully, trainers will be able to teach each session well and on time. session plans provide all the necessary key points and practical skills that should be covered. Trainers are encouraged to bring their own knowledge, skills and style to the session. However, it is important not to move away from the topics and methods provided in the plans. 1.4 PowerPoint presentations There are PowerPoint (PPT) slide presentations for almost every session. Trainers should note that only the key points are written on the slides. Trainers should provide the information given next to each slide in the Trainer’s Manual to make sure that every point is covered. Try to avoid reading out the slides. instead refer to the Trainer’s Manual. 1.5 Observing/monitoring participants’ progress Trainers should observe closely the progress of each participant. The best opportunity to observe progress is during practical sessions. a trainer’s observation checklist for each practical session can be found on the cD. Trainers should use this checklist to: • Help them observe the progress of each group of participants during each practical session. • Record examples of good practice and practice needing improvement – to be discussed during each feedback session. The trainer’s observation checklist may be modified and/or further developed by trainers wishing to gather more detailed information about the progress of each participant. Wheelchair Service Training Packag e 8 BASIC LEVEL 1.6 evaluating the training programme after each delivery it is a good practice to evaluate the training programme after it has been delivered. Trainers can gather feedback from participants regularly throughout the training programme. Trainers may also record their own thoughts about the training programme as it is delivered. This information can help them to evaluate the training programme at the end, including identifying strengths and weaknesses. This will help trainers to improve both the training package itself and their own skills for delivery in their context for the future. a training programme evaluation form is available on the DvD. Trainers may wish to adapt or build on this form in order to meet their needs. 1.7 good practice training tips Be prepared • read each session plan carefully before training starts; • make sure you are confident of the material you are delivering; • gather training resources and prepare the training room well. Model good practice for a wheelchair service • respect participants and wheelchair users; • show care in your work; • be aware at all times of safety in the training room; • be punctual and run sessions according to the timetable. Present information clearly • speak clearly and calmly; • check to make sure everyone in the room can hear you; • ask questions to check that you have been understood; • make sure your writing on the whiteboard can be read by everyone; • repeat important points to reinforce them. Manage session time • note the time allowed for each session and work to keep to time; • if it is likely that additional time will be needed, plan for this at the beginning; • be sure to complete all the sessions planned for a given day. give clear and careful demonstrations • make sure everyone can see clearly; • explain what will happen and describe what you are going to do; • demonstrate slowly and repeat if necessary. Build participants’ skills • always follow demonstrations with an opportunity for participants to practise; • remember that new learners need time to understand new information. 9Build success in the small group activities • observe group activities closely and give help if needed; • ensure that you circulate between the small groups and check the progress of each. Be aware of language differences • if participants are learning in their second language, check they understand -slow down if necessary; • be aware of language differences among wheelchair users and their carers; • use interpreters where necessary. encourage participants to be active and engaged throughout the training • Use the different training styles and methods given in the session plans; • avoid talking too much – encourage participants to speak and discuss themselves; • ask questions to encourage participants to think about the answers themselves, rather than always telling them the answer; • encourage everyone to speak, don’t let one participant dominate; • praise good work from participants and give positive feedback; • let participants know they can ask questions at any time; • link learning to real examples that the participants will recognize; • keep the training fun! Use short “warm up” activities/ games • Use short warm-up activities (5–10 minutes) to help focus attention. Use activities that are inclusive of participants with disabilities. A selection of warm-up games is included in the training programme tools folder. consider the needs of people with different abilities • Think about the needs of any participants with visual, hearing or mobility difficulties. Some activities and teaching approaches may need to be adapted accordingly. Wheelchair Service Training Packag e 10 BASIC LEVEL 2. how to prepare to deliver the training package 2.1 know the participants’ wheelchair service network Trainers need to be familiar with the wheelchair provision system at their place of work. This includes: • the types of wheelchairs available locally and who supplies them; • the wheelchair services in the area, including the level of service they offer; • referral networks in the area; • resource people in the area, including wheelchair users who can assist in delivering the training; • other rehabilitation services to which wheelchair service personnel may refer wheelchair users as required. 2.2 clarify the participants’ role in wheelchair service delivery Find out how wheelchair service delivery fits into the participants’ overall duties at their place of work. For example, will participants be working only in wheelchair service delivery, or do they have other duties as well? Define the role participants will play in wheelchair service delivery. For example, some personnel may be required to carry out only the clinical or the technical aspects covered in the training. Others may fulfil both the clinical and the technical roles. The expected role should be made clear before training begins. Trainers can then relate the training directly to the duties expected of participants. Prior to delivering the training, local trainers may need to adapt the training to fit the role participants will carry out within their wheelchair service. 2.3 review each session plan and adjust if necessary Review each session plan and allocate a lead trainer for each session. a number of the training sessions may need to be adjusted to suit the local context. suggestions for adjusting sessions to different contexts are provided at the beginning of each session plan under the heading “context”. 11 2.4 identify the wheelchairs that will be used identify which wheelchair types will be used for the training. These should be the wheelchairs available at the participants’ place of work. if there is a large range of wheelchairs, select the best examples of different types and those that are most commonly available. Do not include wheelchairs with “intermediate” level features such as adjustable postural support devices (e.g. shoulder harness, spinal supports). Make sure you are very familiar with the features of each wheelchair. complete a wheelchair summary form (see DvD: wheelchair service forms) for each wheelchair and gather product information from the supplier. 2.5 invite wheelchair users for practical sessions To give participants practice in the skills taught in this training package, it is necessary for them to practise with wheelchair users. Before the training programme, trainers need to identify and invite wheelchair users who are willing and able to attend the practical sessions. Below is a checklist to help identify wheelchair users. checklist for wheelchair users for participation in practical sessions: Agree willingly to attend the training to assist in practical sessions  Are able to sit well and do not require modifications or additional postural support in their wheelchair, as this is not covered in this training programme  Are fit and healthy enough to tolerate comfortably attending the training programme  Do not have a pressure sore  Live close enough to attend the practical session without having to travel far  Have time available to attend the practical session  Live close enough for the host organization to follow them up after the training  Equal number of male and female wheelchair users  A range of different physical needs represented  Different ages represented  For wheelchair users attending the follow up session – have used a wheelchair for at least three months  Wheelchair Service Training Packag e 12 BASIC LEVEL how many wheelchair users are needed? The number of wheelchair users needed for the practical sessions depends on the number of participants. However, a minimum of two to four wheelchair users are needed for any size of training programme. Usually participants will work in groups of two or three with one wheelchair user. it is better not to have more than four wheelchair users for any one practical session, as this would become difficult for trainers to manage, monitor and observe. What do wheelchair users attending practical sessions need to know? Wheelchair users attending the practical sessions need to know: • what will happen when they attend the session; • when they will need to attend and for how long; • that they are welcome to attend with a family member/personal assistant; • whether they will receive a wheelchair through their attendance of the training. Trainers and host organizations are encouraged to ensure that all wheelchair users attending practical sessions are offered transport or money to cover transport and participation costs. Meals and refreshments should be available while they are on the training programme. Trainers and host organizations may also provide wheelchair users with a daily allowance for the time that they spend participating in the training. a sample invitation letter and consent form for wheelchair users is available in the training programme forms folder in the DvD. This should be adapted for the specific context, translated and sent to each wheelchair user (volunteer) to help him/her to make an informed choice about participating in the training. Follow up • The trainers or host organization need to plan for immediate follow up for any wheelchair user seen during the training, as it is possible that not everything will be complete by the end of the training programme for each wheelchair user. • any wheelchair users who receive a wheelchair during the training should then be followed up by the host organization/trainers within 6–8 weeks of receiving their wheelchair. 13 2.6 Plan groups for practical sessions each group should consist of no more than three participants. it is better to have two groups of two than one group of four. This ensures that participants have a good opportunity to apply their learning and develop their skills. Trainers need to decide who is in which group. Do not leave this to participants to decide. Depending on the skills of participants and the context, trainers may choose their groups as follows. • Team up more confident participants with less confident participants. The more confident participants may help to guide the less confident participants. Monitor/ observe the groups closely to ensure that everyone is participating. • Team together people who will work together in the future, so that they can develop their skills as a team. For Practicals ‘One and Two’, keep the same participants in the same groups. For Practicals ‘Three and Four’ the groups may be changed around, depending on how well they are working together. For each practical session, appoint a “lead” person from the group. Make sure that every participant has an opportunity to be the lead person. ask the lead person to be responsible for making sure that all steps are carried out. The lead person should be the main person communicating with the wheelchair user and his/her family/carer if needed. 2.7 Prepare facilities To run the training, one large training room (or space) may be used. The space needs to be large enough to allow participants and wheelchair users participating in practical sessions to move around comfortably and to break into small groups. also required is an outdoor area for wheelchair mobility skills practice; a separate space for lunch and refreshments; and clean toilets. all areas, including toilets, must be wheelchair accessible. Wheelchair Service Training Packag e 14 BASIC LEVEL The following checklist can be used to assess and prepare training facilities. Facilities checklist: Training room Lecture area  Chairs for each participant – with facility for participants to write notes  Space for participants to break into small groups of 2–3  Space to display and move around at least three wheelchairs  Screens to provide wheelchair users with privacy during practical sessions  Large tables or benches for cushion fabrication session  Adequate lighting & ventilation  Lockable/secure  Wheelchair mobility training area Smooth flat surfaces  Single step  Short flight of stairs  Rough surface  Sloped surface  lunch/refreshment area Clean area for eating  Tables and chairs  Nearby space for washing hands – clean towels and soap  Toilets Clean toilets supplied with water, toilet paper, hand washing facilities and bins  2.8 Prepare the training resources and materials Printed resources resource Quantity  comment/instructions Manuals, workbook and posters: Trainer’s Manual 1 per trainer  Order from WHO or print and bind. Reference Manual 1 per participant  Order from WHO or print and bind. Participant’s Workbook 1 per participant  Order from WHO or print and bind. Set of posters 1 per participant  Order from WHO or print and bind. 15 Supplementary material: WHO Guidelines on the provision of manual wheelchairs in less resourced settings At least 1 copy per trainer  Provide a soft copy for participants if possible; for soft copies or different language versions, see: http://www.who. int/disabilities/en/ United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) 1 copy per participant  For different language versions: http://www.un.org/disabilities/default. asp?id=150 http://uncrpdindia.org/about/text/ Training programme forms: Participant register form 1 per programme  Use this form to keep a record of participants attending. Name tags 1 per participant & per trainer  Timetable 1 per participant  Samples available on DVD; adjust to suit local context. Photo consent form 1 per participant and 1 per wheelchair user (volunteer)  Adapt this form for the training/ host organization; translate into local language; ensure any person who is photographed signs this form. Invitation letter and consent for wheelchair users 1 per wheelchair user  Adapt the sample letter provided to invite each wheelchair user for the practical sessions. Wheelchair user list for practical sessions 1 per trainer  Use this form to plan wheelchair users’ attendance at practical sessions and to keep a record of who is attending and when. Participant certificate 1 per participant  Prepare participant certificates or adapt the template provided. Training programme evaluation forms: Training programme evaluation form for participants 1 per participant  Sample training programme evaluation forms; these may be adapted by trainers as needed. Training programme session evaluation form for trainers 1 per session  Training programme evaluation form for trainers 1 per trainer  Wheelchair Service Training Packag e 16 BASIC LEVEL Trainer’s observation checklists for practical sessions: Practical One 1 per trainer  Print. Practical Two  Practical Three  Practical Four  Wheelchair service forms: Wheelchair service referral form 1 per participant  Adapt to suit local context or use local referral form if available. Wheelchair assessment form 1 per wheelchair user  Adapt to suit local context – for example add wheelchair service name or additional information required by local service. Wheelchair prescription (selection) form 1 per wheelchair user  Finalize depending on available wheelchair sizes and options. Wheelchair summary form 1 per wheelchair user  Complete one for each locally available wheelchair before the training programme begins. Wheelchair follow up form 1 per wheelchair user  Adapt to suit local context – for example, add wheelchair service name or additional information required by local service. checklists: Wheelchair fitting checklist 1 per participant  Checklists can be found in the printed resources under “Wheelchair service forms”. Wheelchair user training checklist  Wheelchair safe and ready checklist  Posters: Wheelchair service steps 1  1 per participant. Wheelchair mobility skills 1  Pressure sores 1  How to care for a wheelchair at home 1  Optional form (please note this form is not included the package, use only if it is locally available): Wheelchair order form 1 per participant  Trainer to use order form if it is locally available. 17 Materials item Quantity Whiteboard marker pens 3–4  Foam pieces 4–5  Sample pieces for demonstration approximately 100 x 110 x 50 mm). Ankle/calf straps 2–3 sets  If available. equipment item Quantity Large whiteboard 1  Data projector 1  Computer 1  Portable speakers 1 set  To assist with hearing the DVD. Digital camera 1  If available – for different sessions. Assessment bed 1 per wheelchair user for practical sessions  A bench/assessment bed or plinth. The height should be level with average wheelchair seat height. Avoid a hard surface if possible – if using benches provide a thin foam layer and cover, or yoga mat. Set of foot blocks  Wooden blocks to provide support for wheelchair user’s feet when sitting on the assessment bed. A few different heights are needed. Transfer board 1 per 3 participants  If available. Tape measure 1 per participant  ½ anatomical skeleton with spine, pelvis and femurs 1  If available. Wheelchairs and cushions for training At least 1 of each locally available wheelchair and cushion; ideally 1 wheelchair and cushion per 2 participants  Ensure all wheelchairs are in good working order and have a cushion; ensure there is at least one good example of a pressure relief cushion. Wheelchair Service Training Packag e 18 BASIC LEVEL Wheelchairs and cushions for supply to wheelchair user volunteers 1 per wheelchair user attending the practical sessions  There should be enough wheelchairs and cushions for wheelchair users to be prescribed the wheelchair and cushion most appropriate for them. Home maintenance toolkit 1 per 3 participants  Includes: adjustable spanner, Allen keys, screwdriver, tyre pump, lubricating oil, bucket, soap, cloth, sandpaper. Post-it notes or notepaper 1 per participant  cushion fabrication – materials and tools item Quantity Sample contoured foam pressure relief cushion and cover 1  If not already available, trainers will need to make these before the training programme. Sample cushion lift 1  Cushion fabrication toolkit 1 toolkit per 2 participants  Includes: • 1 x sharpened hacksaw blade or long knife; • 1 x black marker pen; • foam glue/contact adhesive and cardboard pieces to spread glue. Cushion materials 1 set per 2 participants  Includes 1 piece each of: • firm foam (e.g. chip foam) – 50 x 400 x 400 mm; • soft foam – 50 x 400 x 400 mm. Sample pieces of available fabric that could be used to make a cushion cover 1 each  See cushion fabrication session for more information about suitable fabrics. 19 3. Detailed session plans Wheelchair Service Training Packag e 20 BASIC LEVEL introduction O B Je c T iv e S By the end of this session, participants will:  know the objectives of the training programme;  know the names of trainers and participants;  have an overview of the training programme timetable;  know any important rules to remember during the training programme. r e S O U r c e S For the session:  PPT slides: Introduction;  Reference Manual for each participant;  Participant’s Workbook for each participant;  DVD: Introduction  copy of the timetable for each participant;  name tags for each trainer and each participant. c O n T e X T Adapt this session to suit the local context in which the training is being given. For example:  include an opening ceremony appropriate to the culture/context;  change or adapt the section “Introduction of trainers and participants” to suit the trainers and participants;  change, adapt and/or add to the list of “housekeeping” and expectations of participants as required – examples are provided in the training programme outline;  change the training programme overview slide if the training programme has been modified (e.g. objectives added or deleted). T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan. O U T l in e 1. Opening ceremony (if any) 2. Introduction of trainers and participants 3. Training programme overview 4. Training programme timetable, Reference Manual and Participant’s Workbook 5. “Housekeeping” and expectations of participants 15 15 10 10 10 Total session time 60 21 VIDEO 1. Opening ceremony (estimated length 15 minutes) 2. introduction of trainers and participants (15 minutes) Trainers: introduce yourself/yourselves. Provide a brief overview of your background and experience of wheelchair provision. ask participants in turn to introduce themselves, stating their name, the organization they come from, and what they hope to learn from the training programme. give out name tags, if these have not already been provided during registration. 3. Training programme overview (10 minutes) explain: The aim of the training programme is to teach each participant how to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who can sit well. • The training package includes: - wheelchair assessment; - selecting, preparing and fitting; - wheelchair user instructions; - maintenance and repairs; - follow up; - how to make a foam pressure relief cushion. introduce DvD: introduction – This short DvD will briefly talk about wheelchair training programme, its purpose, goals and expectations. Show DvD. ask if there are any questions. 4. Training programme timetable, reference Manual and Participant’s Workbook (10 minutes) give a copy of the training programme timetable to each participant. explain: • The training programme will begin with theory/classroom sessions. • Participants will then practise some of the skills they have been taught in the theory sessions with wheelchair users who have volunteered to assist. Th k l d• is training pac age inc u es: – Wheelchair assessment; S l i i d fi i– e ect ng, prepar ng an tt ng; – Wheelchair user instructions; Maintenance and repairs;– – Follow up; How to make a foam pressure – relief cushion. 1. Introduction: 2 BASIC LEVEL OVERVIEW Wheelchair Service Training Packag e 22 BASIC LEVEL give a copy of the Reference Manual to each participant. ask participants to write their name on the manual. explain that they may write any additional notes in this manual. give a copy of the Participant’s Workbook to each participant. ask participants to write their name in the workbook. explain that they will use this Workbook throughout the training and they should bring it to each session. 5. housekeeping and expectations (10 minutes) explain the following, as required: • location of toilets; • who to talk to about accommodation; • who to talk to about return travel for individual participants (do not go into details); • what to do if there is an emergency. explain the expectations placed on training programme participants, as required: • each session will begin on time – participants need to make sure that they arrive on time at the beginning of each day, and return back to sessions on time after breaks; • participants should always ask questions if they are not sure of something; • treat all wheelchair users equally and respect their dignity; • turn off mobile phones during the sessions; • have fun! explain: Throughout the training programme, participants will be riding in and pushing wheelchairs. Whenever using the wheelchairs, remember the following safety rules: • do not stand on footrests when getting in and out of the wheelchair; • keep fingers clear of the wheel spokes and brakes; • when riding the wheelchair up or down slopes, have an assistant behind you in case you tip backwards. 23 a: core knowledge Wheelchair Service Training Packag e 24 BASIC LEVEL a.1: Wheelchair users O B Je c T iv e S By the end of this session, participants will be able to:  list at least seven benefits of an appropriate wheelchair for a wheelchair user ;  explain how wheelchair service personnel can support a wheelchair user’s right to personal mobility;  list at least five ways wheelchair users can be actively involved in wheelchair provision. r e S O U r c e S For the session:  PPT slides A.1 Wheelchair users;  Reference Manual;  DVD: The benefits of an appropriate wheelchair ;  copies of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) if available;  additional reference material (for trainers): • WHO Guidelines on the provision of manual wheelchairs in less resourced settings (page 23). c O n T e X T Adapt this session to suit the context participants come from. For example:  participants may already be familiar with the UNCRPD – in this case, you may ask what they already know about the UNCRPD;  be aware whether the UNCRPD has been signed/ratified in the participants’ country. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan. O U T l in e 1. Introduction 2. What are the benefits of a wheelchair? 3. What is an ``appropriate wheelchair``? 4. The United Nations Convention on the Rights of Persons with Disabilities 5. Wheelchair users are equal partners in wheelchair service delivery 6. Key point summary 2 10 5 5 20 3 Total session time 45 25 VIDEO 1. introduction (2 minutes) explain: in this session, talk about how wheelchair users benefit from an appropriate wheelchair. Think about how participants can actively involve wheelchair users in the process of providing a wheelchair, and why this is important. also we will look briefly at the United Nations convention on the Rights of Persons with Disabilities (cRPD) especially article 1, article 3 and article 20. 2. What are the benefits of a wheelchair? (10 minutes) read the definition of an appropriate wheelchair explain: • This definition comes from the WHO Guidelines on the provision of manual wheelchairs in less resourced settings. in this training programme, we will refer to the Guidelines often. • The “appropriate wheelchair” for each wheelchair user will always depend on his/ her individual needs and the environmental conditions (where he/she lives and works). introduce DvD: The benefits of an appropriate wheelchair – This short DvD will show many different wheelchair users involved in different activities. Watch closely, as afterwards we will talk about how a wheelchair has benefited the different wheelchair users. Show DvD. ask if there are any questions. • In this session participants will: Talk about how wheelchair users benefit from an – appropriate wheelchair; Talk about how wheelchair users can be actively – involved in the process of receiving a wheelchair and why this is important; – Talk about the United Nations Convention on the Rights of Persons with a Disability. A.1. Wheelchair users: 2 BASIC LEVEL INTRODUCTI ON • An appropriate wheelchair: – meets the user’s needs and environmental conditions; provides proper fit and postural support; – – is safe and durable; is available in the country; and – – can be obtained and maintained and services sustained in the country at an affordable cost. A.1. Wheelchair users: 3 BASIC LEVEL WHAT IS AN A PPROPRIATE W HEELCHAIR? Wheelchair Service Training Packag e 26 BASIC LEVEL ask: What are the benefits of having a wheelchair for the wheelchair users pictured in the DvD? encourage answers, and write on the board. answers: • mobility; • health; • help to sit upright; • comfort; • self-esteem and confidence; • dignity; • go to school; • play sport; • work; • be a part of the family and community; • increased independence. explain: • as we can see from the list, there are many benefits of a wheelchair. • Most importantly, remember that wheelchair provision is not only about the wheelchair, which is just a product. • Wheelchair provision is about enabling people with disabilities to become mobile, remain healthy and participate fully in community life. • each wheelchair user in the video is different. However, all have a wheelchair which is “appropriate” for them. 3. What is an appropriate wheelchair? (5 minutes) • an “appropriate Wheelchair” is a wheelchair that: – meets the user’s needs; – meets the user’s environment; – is the right match for the user; – ensures postural support (helps the user to sit upright); – can be maintained and repaired locally. 4. The United nations convention on the rights of Persons with Disabilities (5 minutes) explain: • We all know that many people who need wheelchairs still do not have an appropriate wheelchair. However, there is now an important tool that we can use to advocate for the rights of people who need wheelchairs. • in 2006, the United Nations convention on the Rights of Persons with Disabilities (UNcRPD for short) was signed. in 2008, the UNcRPD became international law. (if the UNcRPD has been signed in the participants’ country/countries, point this out.) 27 ask: Has anyone heard of this convention? acknowledge those who have heard of it. explain: There are human rights that apply to everybody. The focus of the UNcRPD is to make sure that everybody recognizes that these rights also apply to people with a disability. explain: • There are 50 different articles in the convention. • article number 20 is about personal mobility. • Personal mobility means: • the ability to move in a manner and at the time of one’s own choice. ask: How can participants, in their role in a wheelchair service, support a wheelchair user’s right to personal mobility? encourage answers and write on the board. Most important answers: • involve wheelchair users in the decisions about their wheelchair ; • understand the needs of the wheelchair user and help meet those needs; • help to provide an appropriate wheelchair ; • help wheelchair users learn how to get in and out of their wheelchair themselves; • help wheelchair users to learn how to propel themselves; • encourage family members to support the wheelchair user in being more independent; • advocate for increased availability of improved mobility products in the country; • advocate for a barrier-free environment in the country. ask: can anyone think of any other human rights that someone with a mobility impairment can more easily access if they have an appropriate wheelchair? encourage answers and write on the board (give examples of rights if needed). •The United Nations Convention on the Rights of Persons with a Disability (CRPD) says: – All people have a right to personal mobility. •Personal mobility means: – The ability to move in a manner and at the time of one’s own choice. A.1. Wheelchair users: 5 BASIC LEVEL WHAT DOES ‘ PERSONAL M OBILITY’ MEA N? Wheelchair Service Training Packag e 28 BASIC LEVEL answers (it is not necessary to name the articles of the convention): • living independently and being included in the community (article 19); • right to education (article 24); • right to the enjoyment of the highest attainable standard of health (article 25); • right to work and employment (article 27); • right to participate in political and public life (article 29); • right to participate in cultural life, recreation, leisure and sport (article 30). 5. Wheelchair users are equal partners in service delivery (20 minutes) explain: Wheelchair users often know what will be “an appropriate wheelchair” for them. if they have used a wheelchair already, they will have ideas about what works for them, and what they would like to change. Wheelchair users who have not used a wheelchair before will need more information. Wheelchair service personnel should work with the wheelchair user as an equal participant. Small-group activity groups: have 2–3 people in each group. instructions: ask each group to spend five minutes making up a two-minute role-play in which a wheelchair user asks for a wheelchair. One participant will be the wheelchair user, one the wheelchair service personnel, and the other participant is a family member. ask half the groups to role-play a wheelchair service personnel who DOES NOT respect the wheelchair user’s right to have an appropriate wheelchair and DOES NOT treat the wheelchair user as an active par ticipant in wheelchair service delivery. ask the other half of the groups to role play wheelchair service personnel who DOES respect the wheelchair user’s right to have an appropriate wheelchair and DOES treat the wheelchair user as an active participant in wheelchair service delivery. Monitor: Monitor/observe the groups, and assist as needed. Time: 5 minutes to prepare; 10 minutes to perform in front of the other group and 5 minutes for feedback. 29 Feedback: ask at least one group that plays a wheelchair service personnel who DOES NOT respect the wheelchair user’s rights and one group that DOES to perform their role-plays. Feedback discussion: • discuss the differences in the way the wheelchair service personnel communicates with the wheelchair user and his/her family; • ask the wheelchair user in each group how he/she felt; • if there are wheelchair users present in the training, ask if they have had positive or negative experiences similar to those in the role play. ask: From the role play activity, what are some ways that wheelchair service personnel can actively involve wheelchair users in the process of providing a wheelchair? encourage answers. Most important answers: • speak directly to the wheelchair user; • ask the wheelchair user for his/her opinion; • give the wheelchair user choices wherever possible and respect his/her choice; • give the wheelchair user information to help him/her make a choice; • gather information from wheelchair users about their lives, the things they want to do in their wheelchair and the environment in which they live and work. 6. key point summary (3 minutes) read the key points. ask whether there are any questions. • Wheelchair users are all different, and have different needs. • An appropriate wheelchair meets the wheelchair user’s needs and environmental conditions, and provides proper fit and support. • Wheelchairs provide people who have a mobility disability with many benefits including mobility, postural support, comfort, independence, freedom and dignity. • Importantly – personal mobility is a right – and for many people with a mobility disability, a wheelchair is the way that they can have personal mobility. A.1. Wheelchair users: 6 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 30 BASIC LEVEL a.2: Wheelchair services O B Je c T iv e S By the end of this session, participants will be able to:  explain what a wheelchair service is;  identify their role in a basic wheelchair service;  define “basic level service” in wheelchair service delivery. r e S O U r c e S For the session:  PPT slides: A.2: Wheelchair services;  Reference Manual;  poster : Wheelchair service steps. Additional reference material (for trainers):  WHO Guidelines on the provision of manual wheelchairs in less resourced settings (pages 71–72, 76–77). c O n T e X T Adapt this session to suit the context participants will be working in. Think about the following:  The roles of each participant in wheelchair service delivery at his/her place of work. For example, will each participant be responsible for each of the eight steps of wheelchair service delivery? Use this session to clarify for participants what their role will be. T O P r e Pa r e  Gather resources, review slides, read through the session plan.  Prepare information about the role of participants in each service step. O U T l in e 1. Introduction 2. Wheelchair services 3. Wheelchair service personnel roles 4. What does “basic level service” mean? 5. Key point summary 2 10 10 5 3 Total session time 30 31 1. introduction (2 minutes) explain: in this session, we will: • explain what a wheelchair service is and the difference between a “basic” level service and “intermediate” level service; • talk about the key steps in wheelchair service delivery; • discuss the role that each participant will carry out in providing a wheelchair in a basic level wheelchair service. 2. Wheelchair services (10 minutes) explain: a wheelchair service works with wheelchair users to provide the most suitable wheelchair (from those available) for that wheelchair user. ask: What should wheelchair service personnel do to help provide the most appropriate wheelchair for each wheelchair user? encourage answers, and write on the board. Most important answers: • find out what a wheelchair user needs from a wheelchair (assess); • help to select the best wheelchair for the wheelchair user (prescribe); • provide a wheelchair (order, possibly assemble, adjust and fit). ask: What should wheelchair service personnel do to help a wheelchair user benefit as much as possible from his/her wheelchair? encourage answers, and write on the board. Most important answers: • teach wheelchair users how to use their wheelchair and look after it (user training); • help wheelchair users to manage repairs (home maintenance, repairs and follow up); • provide support and follow up to make sure the wheelchair continues to meet the user’s needs; • refer wheelchair users to other services that may help them. • In this session participants will: – Explain what a wheelchair service is and the difference between a ‘basic’ level service and an ‘intermediate’ level service; – Talk about the eight steps in wheelchair service delivery; – Discuss the role that each participant will carry out in providing a wheelchair in a basic level wheelchair service. A.2. Wheelchair services: 2 BASIC LEVEL INTRODUCTI ON Wheelchair Service Training Packag e 32 BASIC LEVEL 3. Wheelchair service personnel roles (10 minutes) Pin up the Wheelchair service steps poster. explain: The role of basic wheelchair service personnel is to provide wheelchair users who can sit upright (without extra postural support) with the best wheelchair available. To do this, the personnel work with each wheelchair user and his/her family, following key wheelchair service steps. explain each step as follows. referral and appointment: • Referral is the way that wheelchair users come to the wheelchair service. • The way that wheelchair users are referred will vary. • Users may refer themselves or be referred through networks made up of governmental or nongovernmental health and rehabilitation workers or volunteers working at community, district or regional level. • each service needs to have a system for managing appointments. assessment: • each user needs an individual assessment. • This includes gathering information about the wheelchair user's lifestyle, the work they do, where they live and their physical condition, and taking their measurements. •Wheelchair personnel: P id h l h i h it i ht– rov e w ee c a r users w o can s upr g (without extra postural support) with the best wheelchair available. •To do this, the wheelchair personnel work h h h l h d h f l wit eac w ee c air user an t eir ami y, following the eight steps. A.2. Wheelchair services: 3 BASIC LEVEL THE ROLE OF A WHEELCHA IR PERSONNE L A.2. Wheelchair services: 4 BASIC LEVEL STEP 1: REFER RAL AND APP OINTMENT A.2. Wheelchair services: 5 BASIC LEVEL STEP 2: ASSES SMENT 33 Prescription (selection): • Using the information from the assessment, a wheelchair prescription (selection) is developed together with the user, family member or caregiver. • The prescription (selection) details the selected wheelchair type, size, special features and modifications. • Prescription (selection) may also include listing the training the user needs to use and maintain the wheelchair well. Funding and ordering: • a funding source is identified and the wheelchair is ordered from stock held by the service or from the supplier. Product (wheelchair) preparation: • service personnel prepare the wheelchair. • Depending on the wheelchair chosen and the facilities available, preparation may include: - assembly of a wheelchair; - full production of a wheelchair; - small modifications to the wheelchair. A.2. Wheelchair services: 6 BASIC LEVEL STEP 3: PRES CRIPTION (SE LECTION) A.2. Wheelchair services: 7 BASIC LEVEL STEP 4: FUND ING AND ORD ERING A.2. Wheelchair services: 8 BASIC LEVEL STEP 5: PROD UCT (WHEELC HAIR) PREPAR ATION Wheelchair Service Training Packag e 34 BASIC LEVEL Fitting: • The user tries the wheelchair. • Final adjustments are made to make sure the wheelchair is correctly assembled and set up. • if modifications or postural support components are required, additional fittings may be needed. User training: • The wheelchair service personnel checks what the wheelchair user and caregivers already know about using and maintaining the wheelchair and finds out what they need to know. • The service personnel provide any instruction needed. some of the key topics include: - how to handle the wheelchair; - how to get in and out of the wheelchair; - wheelchair mobility; - how to maintain the wheelchair; - how to prevent pressure sores; - what to do if there is a problem. • some services may also be able to assist with advice on how to modify the wheelchair user’s home, school or workplace to make wheelchair access easier. This is not covered in this training programme. A.2. Wheelchair services: 9 BASIC LEVEL STEP 6: FITT ING How to handle the wheelchair Getting in and out of the wheelchair Wheelchair mobility Ways to prevent pressure sores Looking after the wheelchair A.2. Wheelchair services: 10 BASIC LEVEL STEP 7: USER TRAINING 35 Maintenance, repairs and follow up: • Provide maintenance and repairs services for technical problems that cannot be solved in the community. • Follow up appointments are an important step in wheelchair service delivery. • During a follow up, service personnel check wheelchair fit and provide further training and support. • if the wheelchair is found to be no longer appropriate, a new wheelchair needs to be supplied, starting again from step 1. explain: Participants will learn in this training programme how to carry out each step. However, in some services, different people may be responsible for different steps. For example, making appointments may be the responsibility of an administrator or user training may be carried out by a peer trainer. ask: Does anyone have a question about their role as a wheelchair service provider? 4. What does “basic level” service mean? (5 minutes) explain • Wheelchair users have different physical needs. it takes more knowledge and skill to provide a wheelchair for someone who has problems with the way that he/she sits, or who has difficulty in balancing, than if the wheelchair user can sit and balance well. • a basic level service can meet the physical needs of wheelchair users who are able to sit up well. in this basic level training programme, participants learn how to provide a wheelchair for a person who can sit well. • in more advanced training, participants learn to provide a wheelchair for a person who cannot sit upright and may have postural problems. • it is very important to have more training before providing a wheelchair for someone with postural problems. This is because it is necessary to understand more about posture, the reasons people have postural problems, and how to provide support safely for a wheelchair user who has postural problems. A.2. Wheelchair services: 11 BASIC LEVEL STEP 8: MAINT ENANCE, REPA IRS AND FOLLO W UP Wheelchair Service Training Packag e 36 BASIC LEVEL explain: clara lives in east Timor. she works in her family’s shop, which is at the front of their house. clara has polio, and needs a wheelchair to move inside the house, to work in the shop, and to move around her village. she can sit upright without any support, and uses a manual wheelchair which has been adjusted and fitted to suit her. clara is an example of someone who can be supplied with a wheelchair through a basic level service. explain: ishade is eight years old and lives in sri Lanka. she has cerebral palsy. For ishade, this means she has trouble controlling her arms, legs, head and neck. she cannot sit upright without support. ishade is an example of someone who needs extra postural support in her wheelchair. This is not taught in this basic wheelchair service training programme. ishade should be supplied with a wheelchair through an intermediate or advanced service. 5. key point summary (3 minutes) read the key points. ask whether there are any questions. A.2. Wheelchair services: 12 BASIC LEVEL CLARA A.2. Wheelchair services: 13 BASIC LEVEL ISHADE Wh l h h l h l h f d h • ee c air services e p w ee c air users in t e most suitable wheelchair from those available. • There are eight steps in wheelchair service delivery. • Wheelchair users have needs for different service levels, depending on their posture and ability to balance. • The role of a basic wheelchair service provider is to provide wheelchair users who can sit well with the best wheelchair available. A.2. Wheelchair services: 14 BASIC LEVEL KEY POINT SU MMARY 37 a.3: Wheelchair mobility O B Je c T iv e S By the end of this session, participants will be able to:  use basic wheelchair mobility skills safely, including pushing, turning, going up and down slopes, going up and down steps with assistance, and a partial wheelie. r e S O U r c e S For the session:  PPT slides A.3: Wheelchair mobility;  Reference Manual;  DVD: Learning to use my wheelchair ;  DVD: Wheelchair mobility skills;  poster : Wheelchair mobility skills;  one wheelchair for each pair of participants. c O n T e X T Adapt this session to suit the context participants will be working in.  Trainers should only teach the partial wheelie included in this session, if the trainer is confident in carrying out this skill and supervising participants as they learn. T O P r e Pa r e  Gather resources, review PPT slides, watch DVDs and read through the session plan.  Select a suitable location for wheelchair mobility skills practice – a flat area, some sloped areas, one or two steps and some rough ground will be needed.  Invite a wheelchair user who has good wheelchair mobility skills to assist in teaching these skills.  Practise the wheelchair mobility skills yourself, using the DVD as a reference, to ensure that you can demonstrate the techniques.  Make sure the wheelchairs are all in good working order with tyres pumped up. O U T l in e 1. Introduction 2. Why are wheelchair mobility skills important? 3. Wheelchair mobility skills – safety 4. Wheelchair mobility skills – demonstration and practice 5. Key point summary 2 15 5 65 3 Total session time 90 Wheelchair Service Training Packag e 38 BASIC LEVEL VIDEO 1. introduction (2 minutes) explain: in this session, participants will learn basic wheelchair mobility skills, which will help them to teach wheelchair users how to be as mobile as possible in their wheelchair. 2. Why are wheelchair mobility skills important? (15 minutes) explain: Many wheelchair users live and work in places where it is difficult for wheelchair users to get around. ask: What are some of the features in the local environment that make it difficult to use a wheelchair? encourage answers and write on the board. Most important answers: • stairs; • muddy ground; • sandy ground; • steep slopes; • small spaces (for example indoors); • rough or uneven ground; • broken or uneven pavements; • cars or other barriers parked on pavements. explain: Training in wheelchair mobility skills can help wheelchair users to tackle some of these obstacles/difficulties, either independently or by asking for assistance. introduce DvD: learning to use my wheelchair in this video, a young girl called sai talks about how learning to use a wheelchair has made a difference in her life. Show DvD. ask if there are any questions. • In this session participants will: Learn basic wheelchair mobility skills– . A.3.Wheelchair Mobility: 2 BASIC LEVEL INTRODUCTI ON 39 ask: What were some of the wheelchair skills that sai learnt? Most important answers: • getting into and out of the wheelchair ; • going over a kerb/bump – to get into and out of her house; • going up and down slopes; • pushing. ask: What difference did having those skills make to sai’s life? Most important answers: • she is more independent; • she has more confidence; • she can go out, go to school, make friends and play. 3. Wheelchair mobility skills – safety (5 minutes) Pin up the Wheelchair Mobility Skills poster. explain: safety is very important when learning and teaching wheelchair mobility skills. ask participants – what are the main safety points we have already talked about when working with wheelchairs? Most important answers: • do not stand on footrests when getting in and out of the wheelchair ; • keep fingers clear of the wheel spokes and brakes; • when learning to go up or down slopes, ALWAYS have an assistant stand behind you in case you tip backwards. explain • in this session, you will be practising different skills, including going up and down slopes and doing a partial wheelie (i.e. balancing the wheelchair on the rear wheels only). Wheelchair Service Training Packag e 40 BASIC LEVEL VIDEO explain • always make sure that you have an assistant standing behind the person in the wheelchair who is learning these skills. • The assistant should stay close to the back of the wheelchair. • The assistant should be ready to steady the wheelchair if it begins to tip backwards. He/she should not hold the push handles. • Do not assist a wheelchair user up and down steps unless you feel very sure that you are able to control the wheelchair safely. if unsure, get help. 4. Wheelchair mobility skills – demonstration and practice (65 minutes) introduce DvD: Wheelchair mobility skills. ask participants to watch the DvD demonstration of the different mobility skills carefully. They should pay attention to the different skills, as they will practise them after watching the DvD. Show DvD. ask if there are any questions. explain • Participants will now practise the wheelchair mobility skills shown in the video, except for the full wheelie. • a full wheelie is a more advanced skill, which takes practice. Once a wheelchair user can balance on the back wheels, he/she can use this skill to roll over rough ground and to roll down slopes, kerbs and steps. Do not try this without an experienced trainer with you. • Learning the mobility skills we are going to practise today is very useful for anyone who works with wheelchair users. it will be easier to teach wheelchair users if you can do these things yourself. •Have an assistant stand behind you when practising: – going up and down slopes; – half wheelies. •Only assist a wheelchair user up and down steps if you are sure you can control the wheelchair safely. A.3.Wheelchair Mobility: 4 BASIC LEVEL SAFETY 41 activity groups: Organize participants into groups of two. Match people who are of a similar height, weight and strength. Give each pair a wheelchair. instructions: ask participants to refer to the wheelchair mobility section of their Reference Manual. explain that they need to work in pairs to practise: 1. pushing and turning; 2. going up and down slopes; 3. going up and down stairs with assistance; 4. partial wheelie. Remind participants: • practise using the techniques shown in the video and described in the Reference Manual; • ALWAYS ensure that they have a person behind them when going up and down slopes, up and down stairs or trying a partial wheelie; • when practising stairs, ensure that only those who feel comfortable with lifting carry out this manoeuvre. Monitor/observe closely to ensure safety. Monitor: Move around the groups and monitor closely to ensure that the techniques are practised safely and correctly. stop the groups to re-explain safety procedures if at any time you see unsafe practice. Demonstrate and correct the techniques as needed (see Techniques below). Time: Allow 50 minutes for practice and 15 minutes for feedback. Feedback: Bring the groups together. correct any common errors in technique that trainers noted during the practice (demonstrate correct technique). ask: What have participants learnt from practising mobility skills? explain: During the training programme, participants are welcome to practise further with the wheelchairs before sessions start or during lunch breaks. They must always ensure that they practise with someone behind them if going up and down slopes or doing a partial wheelie, until they are very confident. Wheelchair Service Training Packag e 42 BASIC LEVEL Notes for trainers – reinforce these points during practice. P us hi ng • Pushing correctly means less effort. • Push from 10 o’clock to 2 o’clock position. • Use a long smooth action to push. Tu rn in g • Hold one push rim towards the front and the other towards the back. • Pull the forward hand backwards and push the backward hand forwards at the same time. U p sl o pe s • Lean forward – this helps stop the wheelchair tipping. • When practising, have an assistant stand behind for safety. • To stop or rest – park the wheelchair sideways. D ow n sl o pe s • Lean backwards. • Let the push rim slide slowly through the hands. • Experienced wheelchair users who are able to do a “wheelie” (i.e. balance the wheelchair on the rear wheels only) may roll down a slope on their back wheels. This is very efficient. U p st ep s w it h as si st an ce • Go up backwards. • Tilt wheelchair on to the back wheels, positioned against the first step. • Assistant pulls backwards and upwards – rolling the wheelchair up. • Wheelchair user can assist by pulling the push rims backwards. • A second assistant can assist by holding on to the wheelchair frame from the front (not footrests). 43 D ow n st ep s w it h as si st an ce • Go down forwards. • Tilt the wheelchair on to the back wheels. • Assistant lets the back wheels slowly roll down one step at a time. • Wheelchair user can assist by controlling the wheelchair with the push rims. • A second assistant can help by steadying the wheelchair from the front, holding on to the wheelchair frame (not footrests). P ar ti al w he el ie • Being able to do a partial wheelie is very useful for a wheelchair user. • The wheelchair user can lift the front wheels to clear small kerbs, stones and bumps. • Roll the wheelchair backwards until hands are at 10 o’clock, then push forwards quickly. • The castor wheels should come up. • With practice, it is possible to lift the castor wheels at the right time to clear small obstacles. • Always make sure there is a person standing behind the wheelchair user when he/she begin to practise this skill. 5. key point summary (3 minutes) read the key points. ask whether there are any questions. •Wheelchair mobility skills help wheelchair users to be more active. • It is particularly important for wheelchair users to know how to manage their wheelchairs in environments where there are no smooth paths and gentle slopes. •When practising wheelchair mobility skills it is important to always remember safety first. A.3.Wheelchair Mobility: 6 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 44 BASIC LEVEL a.4: Sitting upright O B Je c T iv e S By the end of this session, participants will be able to:  list at least 10 features of “sitting upright” (neutral sitting posture);  list at least six benefits of sitting upright;  demonstrate four ways that the pelvis can move;  explain how movement of the pelvis can change sitting posture;  recognize different sitting postures and how these are different from upright sitting. r e S O U r c e S For the session:  PPT: A.4 Sitting upright;  Reference Manual;  Participant’s Workbook;  a half-skeleton with pelvis, spine and femurs (if available). c O n T e X T Adapt this session to suit the context participants will be working in and their learning needs.  This session assumes basic knowledge of the pelvis. If participants do not already know the bony landmarks of the pelvis, include this in the session or before the training programme. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan. O U T l in e 1. Introduction 2. Sitting upright/neutral sitting posture 3. How the pelvis affects the way we sit 4. Different sitting postures 5. Key point summary 2 20 10 25 3 Total session time 60 45 1. introduction (2 minutes) explain: Most wheelchair users spend many hours sitting. Their wheelchair is not just a mobility aid. it also helps to support them in sitting upright comfortably. in this session, we will focus on sitting. We will talk about what “sitting upright” means, and what it looks like. We will think about the benefits of sitting upright. Participants will practise identifying the difference between upright sitting and other postures. We will also discuss problems caused by not sitting upright. 2. Sitting upright/neutral sitting posture (20 minutes) ask: can anyone explain what the word “posture” means? encourage responses. explain: There are many different “sitting postures”. Point out the different ways participants around the room are sitting. explain: • when providing a wheelchair, it is important to encourage wheelchair users to “sit upright”; • “sitting upright” is sometimes called “neutral sitting posture”. ask a volunteer from the group to sit in a chair at the front of the group. ask him/ her to “sit upright”. (ensure that he/she sits with an upright/neutral posture). ask the group to describe the volunteer’s posture. encourage responses. • In this session participants will: Describe what ‘sitting upright’ means and – , what it looks like; L h b f f h– ist t e ene its o sitting uprig t; – Practise identifying the difference between upright sitting and other postures; – Discuss problems caused by not sitting upright. A.4.Sitting upright: 2 BASIC LEVEL INTRODUCTI ON Posture is the way a person's body parts are arranged A.4.Sitting upright: 3 BASIC LEVEL WHAT IS POS TURE? Wheelchair Service Training Packag e 46 BASIC LEVEL Most important answers: • pelvis upright and level; • shoulders level, arms free to move; • trunk upright; • back following the three natural curves; • head upright and balanced over the body; • hips flexed near 90 degrees; • legs slightly open (abducted); • knees and ankles flexed near 90 degrees; • heels directly below the knees or slightly forward or back; • feet flat on the floor. how to tell if a person is sitting upright Look from the side and check:  pelvis upright;  trunk upright, back following the three natural curves;  hips flexed near 90 degrees;  knees and ankles flexed near 90 degrees;  heels directly below the knees or slightly forward or back;  feet flat on the floor or footrests. Look from the front and check:  pelvis level;  shoulders level, relaxed and arms free to move;  legs slightly open (abducted);  head upright and balanced over the body. explain: • Upright sitting is not exactly the same for every person. • The following slides will show the key things to look for – however, these are only a guide. • The most important thing about upright sitting is that the person is relaxed, comfortable and well balanced. 47 click through the slide to show the key points. explain: • Hips, knees and ankles may be a little more open or a little more flexed – this is OK. • The person should feel balanced and comfortable. click through the slide to show the key points. ask all participants to sit upright in a neutral sitting posture. ask: could participants sit like this all day without any support (for example a backrest)? answer for most will be nO. explain: • Without good support in your chair, it would be very hard to sit like this all day. This is why people frequently change the way they are sitting. • a wheelchair user who sits in the wheelchair all day will need good support in the wheelchair seat, cushion, backrest and footrests to maintain an upright sitting posture. ask: What are the benefits of sitting upright? encourage answers and write on the board. Most important answers: • health; • stability; • weight distribution; • comfort; • more active; • can help prevent problems with posture; • self-esteem and confidence. • Pelvis upright; • Trunk upright, back following the three natural curves; • Hips flexed near 90 degrees; • Knees and ankles flexed near 90 degrees; • Heels directly below the knees or slightly forward or back; • Feet flat on the floor or footrests. A.4.Sitting upright: 4 BASIC LEVEL UPRIGHT SITT ING – SIDE VIE W: • P l i l l de v s eve e ; • Shoulders leveled, relaxed and arms free to move; • Legs slightly open (abducted); • Head upright and balanced over the body. A.4.Sitting upright: 5 BASIC LEVEL UPRIGHT SITT ING – FRONT VIEW: Wheelchair Service Training Packag e 48 BASIC LEVEL ask: How can personnel help wheelchair users to sit upright? encourage answers and write on the board. Most important answers: • make sure the wheelchair fits them; • teach wheelchair users why it is important to sit upright if they can; • show wheelchair users how to sit upright in their wheelchair. explain: Not every wheelchair user is able to sit upright. We will talk about this later in the session. 3. how the pelvis affects the way we sit (10 minutes) explain: The pelvis is the base for sitting upright. To be strong and stable, a building needs a solid foundation. in the same way, to be stable when sitting the pelvis must be strong and stable. explain: The pelvis moves in different ways in relation to the trunk and hip joints. The movements are: • rolling forward (forward pelvic tilt). explain: The illustration on the slide shows a view from a side of the pelvis: • rolling backwards (backwards pelvic tilt). Rolling forward: (forward pelvic tilt) A.4.Sitting upright: 6 BASIC LEVEL PELVIS MOVES IN DIFFERENT WAYS – SIDE V IEW: Rolling backwards: (b k d l l )ac war pe vic ti t A.4.Sitting upright: 7 BASIC LEVEL PELVIS MOVES IN DIFFERENT WAYS – SIDE V IEW: 49 explain: The illustration on the slide shows a view from a back of the pelvis: • tilting sideways (lateral tilt). explain: The illustration on the slide shows a view from above the pelvis: • rotation. ask each person to place his/her hands on the top of the pelvis (over the iliac crest). Place your hands on your iliac crest and demonstrate each pelvis movement. ask participants to copy. Tilting sideways: (l l l )atera ti t A.4.Sitting upright: 8 BASIC LEVEL PELVIS MOVES IN DIFFERENT WAYS – BACK V IEW: Rotation A.4.Sitting upright: 9 BASIC LEVEL PELVIS MOVES IN DIFFERENT WAYS – VIEW F ROM ABOVE Wheelchair Service Training Packag e 50 BASIC LEVEL after each movement, ask participants to describe what they feel in their body. Movement illustration changes in the body Rolling forward: (forward pelvic tilt). Side view of pelvis • The body straightens out with the shoulders pulled back; • there is an increase in the curve of the spine above the pelvis. Rolling backwards: (backward pelvic tilt). Side view of pelvis • The body becomes rounded with the shoulders forward. Tilting sideways: (lateral tilt). Back view of pelvis • The body bends sideways. Rotation. View from above • The rest of the body also rotates. ask: How did it feel holding the different postures? if participants are unsure, ask them to repeat the movements, and hold the posture to feel what it is like. encourage answers. 51 Most important answers: • Not comfortable; • hard to move; • uneven weight-bearing; • difficult to use arms to carry out activities; • hard to breathe; • tiring; • pressure on insides; • difficult to balance. explain: When sitting upright, the pelvis is also upright (or slightly tilted forward) and levelled. if the pelvis is not upright, it is not possible to sit upright. 4. Different sitting postures (25 minutes) activity groups: Have 2–3 people in each group. instructions: Ask each group to: • look closely at each example of a different posture in the worksheet in their workbook; • write down how the posture is different from sitting upright; • think about the features of upright sitting from the front and side. Monitor: Monitor the groups, and assist as needed. Time: Allow 10 minutes. Feedback: Project slide of each posture one at a time. ask each group (in turn) to report back the differences between one posture shown and sitting upright. ask participants to add any points they do not already have to their worksheet. notes for trainers – most important answers: • pelvis not level (higher on right side); • shoulders not level (higher on left side); • trunk curved to one side; • right leg turned in; • right ankle turned in; • left ankle turned in.A.4.Sitting upright: 10 BASIC LEVEL POSTURE 1 Wheelchair Service Training Packag e 52 BASIC LEVEL notes for trainers – most important answers: • pelvis tilted backwards; • trunk collapsed (curved forwards, to one side and rotated); • shoulders not level; • head tipped back and chin poking forwards – not balanced over pelvis; • knees not bent to neutral; • ankles not bent to neutral; • one arm between legs and one arm hooked behind push handles – the wheelchair user is not stable in the wheelchair. notes for trainers – most important answers: • pelvis not upright (tilted backwards); • trunk curved forward; • shoulders rounded and forwards; • head not balanced over pelvis; • chin poking forward. explain: • The three examples participants have just looked at show posture which is different to “upright sitting”. These postures may be “fixed”. This means that they cannot be corrected. For others, the posture is flexible. This means that the person can sit upright if given support. • When a person cannot sit upright (even with support), and is fixed in a different posture, this can sometimes be “accommodated” and supported by modifications to a wheelchair. This training programme does not cover how to do this. ask: What are some of the problems that could be caused by not sitting upright? encourage answers. A.4.Sitting upright: 11 BASIC LEVEL POSTURE 2 A.4.Sitting upright: 12 BASIC LEVEL POSTURE 3 53 Most important answers: • can cause pressure sores; • over time, the user’s body may get stuck in a different, non-upright posture, and he/she will never be able to sit upright again; • it is harder to move the head and neck to see, and harder to do things; • can make it harder to breathe and can affect digestion; • increased fatigue; • makes swallowing harder; • can cause discomfort and pain; • makes it harder to balance; • makes it hard to use arms and hands; • can cause more problems like spasms or muscles becoming tight; • poor self-esteem. list the problems that can be caused by not sitting upright, as shown on the slide. 5. key point summary (3 minutes) read the key points. ask whether there are any questions. • Pressure sores; • Development of fixed postures; • Difficulty moving the head and neck to see; • Harder to breathe and can affect digestion; • Makes swallowing harder; • Tiring; C d f d • an cause iscom ort an pain; • Harder to balance; • Hard to se arms and hands;u • Can cause more problems such as spasms; • Poor self-esteem. A.4.Sitting upright: 13 BASIC LEVEL PROBLEMS CA USED BY NOT SITTING UPRIG HT • Encourage wheelchair users who are able to sit in an upright posture to do so. • The benefits of upright posture include: more stability, comfort and function and less risk of pressure sores. An upright posture is also good for self-esteem and confidence. • Poor posture can lead to problems such as: – pressure sores; – becoming stuck in a not upright posture; – increased fatigue; – problems with breathing and digestion. • Not everyone can sit upright. Wheelchair users who cannot sit upright, even when given support, should be referred to a person or service with intermediate level wheelchair service skills. A.4.Sitting upright: 14 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 54 BASIC LEVEL a.5: Pressure sores O B Je c T iv e S By the end of this session, participants will be able to:  list the four stages of a pressure sore;  recognize when a person with a pressure sore should be referred for specialist help;  list local services where wheelchair users can be treated for pressure sores;  list the three main causes of pressure sores;  identify the main pressure sore problem areas for wheelchair users;  list risk factors for pressure sores;  list ways a wheelchair user can prevent pressure sores;  demonstrate two pressure relief techniques. r e S O U r c e S For the session:  PPT slides: A.5 Pressure sores;  Reference Manual;  DVD: Pressure sore testimonial;  Poster : Pressure sores;  one wheelchair (fitted with a cushion) for every two participants (one per pair). c O n T e X T Adapt this session to suit the context in which participants will be working. Think about:  inviting a wheelchair user who has had a pressure sore to share his/her story with the participants. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Prepare a list of local services where wheelchair users can get treatment for a pressure sore. If participants are attending training from distant locations, you may ask participants to bring this information with them.  Invite a wheelchair user who has experienced a pressure sore to share his/her story.  Type the list of resources into slide 6 of the slides for this session. 55 O U T l in e 1. Introduction 2. Pressure sores 3. When and where to get help 4. What causes pressure sores? 5. Pressure sore risk factors 6. How can pressure sores be prevented? 7. Pressure sore testimonial 8. Pressure relief techniques 9. Key point summary 2 5 5 10 10 10 5 10 3 Total session time 60 1. introduction (2 minutes) explain: in this session, we will learn about pressure sores. Not every wheelchair user is at risk of developing a pressure sore. However for people who do develop pressure sores, the consequences are very serious. 2. Pressure sores (5 minutes) Pin up the Pressure Sores poster. ask: Has anyone seen a pressure sore? Discuss briefly. • In this session participants will: • Talk about pressure sores. •Not every wheelchair user is at risk of developing a pressure sore. •However, for people who do develop a pressure sore, the result can be very serious. •Pressure sores can cause death. A.5. Pressure Sores: 2 BASIC LEVEL INTRODUCTI ON Wheelchair Service Training Packag e 56 BASIC LEVEL explain: • The bigger the sore, the greater the problem for the wheelchair user. • Pressure sores can require long periods of bed rest. • if a pressure sore becomes infected, the infection can spread to the blood, heart or bone. This can lead to serious illness and death. explain: There are four stages in the development of a pressure sore. explain: • stage 1 is a red or dark mark on the person’s skin. The redness or change in colour does not fade within 30 minutes after pressure is removed. • stage 2 is a shallow wound, and the top layer of skin may start to peel away or blister. • stage 3 is a deep wound; the whole layer of skin is lost. • stage 4 is very deep, extending through the muscle and possibly right down to the bone. ask: Where are pressure sores most likely to occur? encourage answers. Most important answers: • seat bones; • tail bone (coccyx); • base of spine (sacrum); • hip bones; • shoulder blades; • spine. • A pressure sore is an area of damaged skin and flesh. A d l i f h b h l • pressure sore can eve op n a ew ours, ut t e resu ts can last for many months and may cause death. A.5. Pressure Sores: 3 BASIC LEVEL WHAT IS A PR ESSURE SORE ? Stage 1 Stage 2 Stage 3 Stage 4 A.5. Pressure Sores: 4 BASIC LEVEL STAGES OF PR ESSURE SORE S A.5. Pressure Sores: 5 BASIC LEVEL WHERE ARE PR ESSURE SORES LIKELY TO OC CUR? 57 3. When and where to get help (5 minutes) ask: What advice should personnel give a wheelchair user with a stage 1 pressure sore? encourage answers. reinforce (or give) the correct answer. Most important answers: • Anyone with a stage 1 pressure sore should: - remove pressure from that area immediately; - keep pressure off until the skin has fully recovered. • This may mean bed rest (depending on where the sore is). • Identify the cause and address this. • Teach the wheelchair user how pressure sores are formed and how to prevent them in future. ask: What advice should personnel give a wheelchair user with a stage 2, 3 or 4 pressure sore? encourage answers. reinforce (or give) the correct answer. Most important answers: • Follow the actions for stage 1. and • Refer for treatment of the pressure sore by an experienced health care worker. Open pressure sores will need cleaning, dressing and close monitoring to ensure they are healing and do not become infected. Stage 4 wounds may require surgery. Wheelchair Service Training Packag e 58 BASIC LEVEL 4. What causes pressure sores? (10 minutes) explain: The three main causes of pressure sores are the following. read the slide. explain: We will look at each cause in more detail. explain: • Pressure sores caused by pressure on skin from sitting or lying in the same position for too long without moving. • Pressure sores are a major cause of death for people who have a spinal cord injury. ask participants to sit on their hands and feel the pressure from their seat bones. ask: What would happen if you stayed in this position for a long time without moving? answer: • You would soon become uncomfortable because of always having pressure on the same part of the body. explain: • Friction is constant rubbing on the skin. For example, an arm rubbing on a wheel/ armrest as a wheelchair is moved can cause a pressure sore. • Friction is particularly a problem for wheelchair users who cannot feel. • Bumps can happen when wheelchair users are transferring or moving around in their wheelchair. 1. Pressure 3. Shear 2. Friction A.5. Pressure Sores: 7 BASIC LEVEL WHAT CAUSE S PRESSURE S ORES? 1. Pressure 3. Shear 2. Friction A.5. Pressure Sores: 7 BASIC LEVEL WHAT CAUSE S PRESSURE S ORES? 1. Pressure 3. Shear 2. Friction A.5. Pressure Sores: 7 BASIC LEVEL WHAT CAUSE S PRESSURE S ORES? 59 explain: • shear is when the skin stays still and is stretched or pinched as muscles or bones move. ask participants to sit on their hands again and rock their pelvis backwards. Note the feeling of their seat bones moving over their hand. For example, when a wheelchair user sits “slumped” in the wheelchair, skin may be damaged by shear by the seat bones as the pelvis rocks backwards, or by bones in the back squeezing the skin against the backrest. 5. Pressure sore risk factors (10 minutes) explain: • as well as the three main causes of pressure sores, there are a number of things that increase the chance that a person will get a pressure sore. These are called: pressure sore risk factors. ask: can anyone suggest pressure sore risk factors? encourage answers. Most important answers: • cannot feel (decreased sensation); • cannot move; • moisture from sweat, water or incontinence; • poor diet and not drinking enough water ; • ageing; • weight – underweight or overweight; • poor posture; • previous or current pressure sore; • trauma, bumps or knocks; • heat/fever ; • insect bite. 1. Pressure 3. Shear 2. Friction A.5. Pressure Sores: 7 BASIC LEVEL WHAT CAUSE S PRESSURE S ORES? •What are things that increase the likelihood that someone will get a pressure sore? A.5. Pressure Sores: 8 BASIC LEVEL PRESSURE SO RE RISK FACT ORS: Wheelchair Service Training Packag e 60 BASIC LEVEL explain: The most important risk factors to remember are: • cannot feel (decreased sensation); • cannot move; • moisture from sweat, water or incontinence; • poor posture; • previous or current pressure sore; • poor diet and not drinking enough water; • ageing; • weight – underweight or overweight. explain: • The most important risk factor is not being able to feel. a person who cannot feel does not feel pressure. This means he/she is less likely to change position to relieve pressure. • anyone who cannot feel, or has difficulty feeling touch on his/her buttocks, seat or legs is at risk of developing a pressure sore. • Most people with a spinal cord injury will not be able to feel below the level of their injury. This means they are at risk of developing a pressure sore. People with a spinal cord injury may also not have bowel or bladder control. if they do not have a way of managing incontinence, their risk is increased because of the increase in moisture. explain: • Wheelchair service personnel need to know the pressure sore risk factors so that they can identify wheelchair users who are at risk of developing a pressure sore. • checking for risk factors is part of the wheelchair assessment: - anyone who cannot feel is at risk of developing a pressure sore; - anyone with three or more other risk factors is at risk of developing a pressure sore. •Cannot feel (decreased sensation); •Cannot move; •Moisture from sweat, water or incontinence; •Poor posture; •Previous or current pressure sore; •Poor diet and not drinking enough water; •Ageing; •Weight: underweight or overweight. A.5. Pressure Sores: 9 BASIC LEVEL PRESSURE SO RE RISK FACT ORS: •Checking for risk factors is a part of wheelchair assessment. •Anyone who cannot feel is at risk of developing a pressure sore. •Anyone with three or more other risk factors i i k f d l i s at r s o eve op ng a pressure sore. A.5. Pressure Sores: 10 BASIC LEVEL PRESSURE SO RE RISK FACT ORS: 61 Pressure sore risk factors include the following: • Person cannot feel (decreased sensation): anyone who cannot feel, or has difficulty feeling touch on their buttocks (like most paraplegics or quadriplegics), seat or legs is at risk of developing a pressure sore. • Person cannot move: When a person cannot move, he/she is unable to relieve the pressure. • Moisture from sweat, water or incontinence: Moisture makes the skin soft and more easily damaged. if the user does not have a way to manage bladder and bowel function, urine and faeces can burn and damage the skin. • Poor posture: Not sitting upright can cause an increase in pressure in one area. • Previous or current pressure sore. • Poor diet and not drinking enough water: a good diet, including drinking enough water, is important to ensure the body has fluid and nutrients to maintain healthy skin and heal wounds. • ageing: elderly people often have thin, frail skin which can damage easily. • Weight (underweight or overweight): People who are overweight may have poor blood flow in their skin, which can then damage easily and heal poorly. Wheelchair users who are underweight are at risk of developing a pressure sore because their bones are not well protected. The skin over the bony areas can be damaged quickly. Common pressure sensitive areas: side view Back view 6. how can pressure sores be prevented? (10 minutes) explain: • Wheelchair service personnel can help wheelchair users to prevent pressure sores. • Prevention avoids long hospital stays and wheelchair users being unable to use their wheelchair, and can prevent death. • Different ways that pressure sores can be prevented include the following. Wheelchair Service Training Packag e 62 BASIC LEVEL explain: Use a pressure relief cushion: • a pressure relief cushion will help to reduce pressure. • anyone at risk of developing a pressure sore should be given a pressure relief cushion. explain: sit upright • sitting upright helps to distribute weight evenly. This reduces pressure under bony parts and helps to reduce pressure sores caused by pressure. • sitting upright also helps to avoid pressure sores caused by shear. • Make sure the wheelchair fits correctly. This helps wheelchair users to sit upright. • Teach wheelchair users why it is important to sit upright. explain: Use pressure relief techniques • Regular pressure relief can be effective in preventing pressure sores. • We will cover this in more detail later in this session. A.5. Pressure Sores: 12 BASIC LEVEL USE A PRESSU RE RELIEF CU SHION A.5. Pressure Sores: 13 BASIC LEVEL SIT UPRIGHT BASIC LEVEL A.5. Pressure Sores: 14 USE PRESSUR E RELIEF TECH NIQUES 63 explain: eat well and drink plenty of water • a well balanced diet with fresh vegetables, fruit and meat can help to prevent pressure sores. • Drinking lots of water will help to keep the skin healthy and prevent pressure sores. • if you are concerned about a wheelchair user’s diet – consider referring him/her to a service that can help. explain: avoid friction • Make sure the wheelchair fits correctly and has no rough edges. • Teach wheelchair users who cannot feel to check that no parts of their body are being rubbed by the wheelchair. • Teach wheelchair users to take care when getting in and out of the wheelchair. explain: avoid moisture • Wheelchair users need to be advised to change wet or soiled clothing straight away, and not to use a wet cushion. • a bowel and bladder management programme can reduce problems with moisture. • Refer wheelchair users who have a problem with incontinence to a service that can help them. A.5. Pressure Sores: 15 BASIC LEVEL EAT WELL AN D DRINK LOT S OF WATER BASIC LEVEL A.5. Pressure Sores: 16 AVOID FRICTI ON BASIC LEVEL A.5. Pressure Sores: 17 AVOID MOIST URE Wheelchair Service Training Packag e 64 BASIC LEVEL VIDEO explain: check skin every day • Pressure sores can develop quickly. it is important to identify a pressure sore quickly and take action. • encourage wheelchair users who are at risk to check their skin every day. They can check themselves using a mirror, or ask a family member to check. • if they see a red or dark area of the skin (stage 1), they should relieve pressure on that spot immediately. explain: While lying down or sitting, change positions regularly • changing position regularly helps to relieve pressure. • For example, change position from sitting to lying. • This is particularly important for someone who has a number of pressure sore risk factors, or has a recently healed pressure sore. • People who cannot change position by themselves are at risk. 7. Pressure sore testimonial (5 minutes) introduce DvD Pressure sore testimonial video. Show DvD. ask if there are any questions. 8. Pressure relief techniques (10 minutes) explain: • Wheelchair users can relieve pressure from their seat bones while in their wheelchair. BASIC LEVEL A.5. Pressure Sores: 18 CHECK SKIN E VERYDAY A.5. Pressure Sores: 19 BASIC LEVEL WHILE LYING O R SITTING, CHA NGE POSITION REGULARLY 65 • How the wheelchair user does this will vary, depending on how much strength and balance he/she has. • in this training programme, two safe methods of relieving pressure are taught. These are bending forward and side to side leaning. • Wheelchair service personnel should teach all wheelchair users who are at risk of developing a pressure sore at least one way to relieve pressure. activity groups: ask participants to break into pairs. instructions: Give each pair a wheelchair. ask the pairs to position themselves so that they can see you. Demonstrate each method, and explain that different methods will work for different users. ask participants to practise each method straight after each demonstration. Monitor: Monitor closely and correct techniques as necessary. Time: Allow 10 minutes. Notes for trainers: Some wheelchair users relieve pressure by lifting themselves up with both arms. For enough blood flow to return to the skin, the wheelchair user must hold this position for two minutes. This requires a lot of strength and puts strain on the shoulders. In addition, wheelchair users must be able to control their weight carefully as they sit back down. If they sit down hard, they can cause damage to their skin. For this reason, this method is not taught in this training programme. Bending forward: a method suitable for all wheelchair users. Strongly encourage all wheelchair users to use this method frequently during the day Independent: for people with good balance and strength. With assistance: For people with poor balance and strength. Wheelchair Service Training Packag e 66 BASIC LEVEL Side to side leaning: a method suitable for wheelchair users with limited strength and balance Hook arm over push handle for support. 9. key point summary (3 minutes) read the key points. ask whether there are any questions. P i i If l ft t t d • ressure sores are a ser ous ssue. e un rea e , pressure sores can lead to death. Wh l h i i h 2 • ee c a r users w t a stage or more pressure sore should be referred for specialist help immediately to treat their pressure sore. • The three main causes of pressure sores are pressure, friction or shear . • The main pressure sores risk factors are: inability to move, moisture poor posture previous or current pressure sore , , , poor diet, ageing, underweight or overweight. A.5. Pressure Sores: 21 BASIC LEVEL KEY POINT SUM MARY BASIC LEVEL •Wheelchair personnel can help wheelchair users at risk to avoid pressure sores by: – Providing a pressure relief cushion; – Providing a wheelchair that fits – and helps the user to sit upright; – Teaching wheelchair users simple ways to avoid pressure sores. A.5. Pressure Sores: 22 KEY POINT SUM MARY (CONTIN UED) 67 a.6: appropriate wheelchair O B Je c T iv e S By the end of this session, participants will be able to:  describe at least four things that make a wheelchair “appropriate”;  identify the parts of the wheelchair which affect how the user sits;  explain how different parts of the wheelchair support specific needs of the wheelchair user ;  identify wheelchairs which are more suited to outdoor/rough terrain than others;  suggest the most suitable wheelchair to a wheelchair user, considering his/ her needs. r e S O U r c e S For the session:  PPT slides: A.6: Appropriate wheelchair ;  Reference Manual;  Participant’s Workbook;  DVD: What an appropriate wheelchair means to me;  DVD: Meeting the wheelchair user’s needs;  DVD: Meeting the wheelchair user’s environment;  at least one sample of each of the locally available wheelchairs. c O n T e X T Adapt this session to suit the context participants will be working in.  If there are only one or two different types of wheelchair available in the participants’ location, have a number of wheelchairs of the same type available, so that each small group has a wheelchair to work with. A broader range of wheelchairs may be represented by putting up posters of different wheelchairs.  Adapt the case studies to suit the local context if required. T O P r e Pa r e  Gather resources, review PPT slides, watch DVDs and read through the session plan.  Select an area outside which has some rough terrain (for example gravel, sand, bumps) and enough space for participants to watch one other as they propel themselves along the rough terrain. If it is hot, a shady place is ideal.  Check all wheelchairs are in working condition and each wheelchair has a cushion.  Adjust one wheelchair to fit one of the participants.  Arrange wheelchairs neatly at the front of the training room. O U T l in e 1. Introduction. 2. Definition of an ``appropriate wheelchair``. 3. Meeting the wheelchair user’s needs. 4. Meeting the wheelchair user’s environment. 5. Providing proper fit and postural support. 6. Matching wheelchairs to the needs of wheelchair users. 7. Key point summary. 2 10 30 30 15 30 3 Total session time 120 Wheelchair Service Training Packag e 68 BASIC LEVEL VIDEO 1. introduction (2 minutes) explain: in this session, we will look at the main types of wheelchairs, and some of the different features that can be found on wheelchairs. We will have a better understanding of an “appropriate wheelchair”. a wheelchair that: • meets the user’s needs; • meets the user’s environment; • is the right match for the user; • ensures postural support (helps the user to sit upright); • can be maintained and repaired locally. 2. Definition of the ``appropriate wheelchair`` (10 minutes) introduce DvD: What an appropriate wheelchair means to me. in this short DvD, experienced wheelchair user Faustina explains what an appropriate wheelchair means to her. Show DvD. ask if there are any questions. 3. Meeting the wheelchair users’ needs (30 minutes) ask: What are the things that wheelchair users need to do in their wheelchair? encourage answers Most important answers: • get in and out of the wheelchair (transferring); • push their wheelchair ; • fold the wheelchair to store or transport; • carry out activities (for example: work, house-work, spend time with friends, go to the toilet, wash, get dressed, go through doorways, get under tables or desks). • In this session participants will look at the main types of wheelchairs, and some of the different features the wheelchairs have. • Participants will have a better understanding of an ‘appropriate wheelchair’. A wheelchair that: – meets the user’s needs; – meets the user’s environment; – is the right match for the user; – ensures postural support (helps the user to sit upright); – can be maintained and repaired locally. A.6. Appropriate wheelchair: 2 BASIC LEVEL INTRODUCTI ON 69 explain: an appropriate wheelchair should make it easy for a wheelchair user to do the things they want to do. Let’s look at some of the features of a wheelchair that affect how easily a wheelchair user can do the things they want to do. 3.1 Transfers getting in and out of the wheelchair explain: Wheelchair users get in and out of the wheelchair in different ways. Three parts of the wheelchair which affect how people get in and out of the wheelchair are: explain: (click to show arrow on each component) • brakes; • footrests; • armrests. explain: • Removable armrests or armrests which follow the line of the rear wheels are easier for people who get in and out of the wheelchair sideways. Three important components: 1 b k 3 . ra es; 2. footrests; 3. armrests. 1 2 A.6. Appropriate wheelchair: 5 BASIC LEVEL TRANSFERS Armrest A.6. Appropriate wheelchair: 6 BASIC LEVEL TRANSFERS Wheelchair Service Training Packag e 70 BASIC LEVEL explain: • People who stand up to get in and out of the wheelchair may need armrests to help them stand up. • Footrests which can be moved out of the way are helpful for people who stand up to get in and out of the wheelchair. • People who want to transfer to the floor may prefer a wheelchair with removable footrests. explain: • Brakes are important for all wheelchair users. They are essential for keeping wheelchair still while the person gets in and out. 3.2 Pushing the wheelchair explain: The parts of the wheelchair which affect how well the user can push are the: explain: (click to show arrow on each component) • armrests; • backrest; • push rims; • push handles; • the overall weight of the wheelchair may also affect how well the user can push it. Armrest Footrest A.6. Appropriate wheelchair: 7 BASIC LEVEL TRANSFERS Brakes A.6. Appropriate wheelchair: 8 BASIC LEVEL TRANSFERS Push handles Backrest Armrest Push rim A.6. Appropriate wheelchair: 9 BASIC LEVEL PUSHING THE WHEELCHAIR 71 explain: • To reach the push rim to push comfortably, the wheelchair user needs to be able to reach over the armrests comfortably. • The wheelchair user in this slide cannot easily reach the push rims because the armrests are too high. explain: • The height of the backrest can affect how easy it is to push the wheelchair. • if the backrest is too high it is difficult for a wheelchair user to move their arms and shoulders to push. • The wheelchair user in this slide will find it difficult to push himself because the backrest is high. explain: • When the backrest is lower, the wheelchair user has freedom to move their shoulders to push. • For a wheelchair user who can sit well and has good balance, this is a good height backrest. explain: • For wheelchair users who push with their arms – how easy it is for them to reach the wheels (push rims) affects how easy it is for them to push. • This woman is shown mid-push. Notice how easily she can reach the wheels (push rims). To reach the push rim to push comfortably, the wheelchair user needs to be able to reach over the armrests comfortably. A.6. Appropriate wheelchair: 10 BASIC LEVEL PUSHING THE WHEELCHAIR The height of the backrest can affect how easy it is to push the wheelchair. A.6. Appropriate wheelchair: 11 BASIC LEVEL PUSHING TH E WHEELCHA IR When the backrest is lower , the wheelchair user has a freedom to move their shoulders to push. A.6. Appropriate wheelchair: 12 BASIC LEVEL PUSHING THE WHEELCHAIR For wheelchair users who push with their arms - how easy it is for them to reach the wheels affects how easy it is for them to push. A.6. Appropriate wheelchair: 13 BASIC LEVEL PUSHING THE WHEELCHAIR Wheelchair Service Training Packag e 72 BASIC LEVEL explain: • as a general guide, the rear wheel should be positioned so that when the wheelchair user holds the top of the push rim their elbow is bent at 90 degrees. • if the wheels are further back it is difficult to reach the push rims. it is then more tiring for the wheelchair user to push. explain: • some wheelchairs have an adjustable rear wheels position. • The position of the rear wheels affects how easy it is to push the wheelchair into a wheelie. • Wheelies are useful for going over rough ground or up and down kerbs. • if the rear wheels are placed forwards the wheelchair is easier to push into a wheelie. if the rear wheels are moved backwards, it is harder to push into a wheelie. it is then more stable. explain: • some wheelchair users push with their feet. • To push effectively in this way, the user needs to be able to sit with their pelvis well supported by the backrest, and their feet flat on the floor. • For these users the height of the seat from the floor (with the cushion taken into account) is very important. • Footrests that move out of the way are also essential. • some users who push with their feet may like a tray or armrests so that they can lean forward while pushing. As a general guide, the rear h l h ld b iti d w ee s ou e pos one so that when the wheelchair user holds the to of the sh rim p pu their elbow is bent at 90 degrees . A.6. Appropriate wheelchair: 14 BASIC LEVEL PUSHING THE WHEELCHAIR The position of the rear wheels affects how easy it is to push the wheelchair into a wheelie. A.6. Appropriate wheelchair: 15 BASIC LEVEL PUSHING THE WHEELCHAIR To push with the feet, the d t b bl t it user nee s o e a e o s with their pelvis well s orted b the backrest upp y , and their feet flat on the floor. A.6. Appropriate wheelchair: 16 BASIC LEVEL PUSHING THE WHEELCHAIR 73 explain: • a heavy wheelchair takes more energy to push. if the wheelchair is well designed, and well balanced, the effect of the weight may not be so bad. • The weight of the wheelchair is particularly important for children. if the wheelchair is heavy this may make the chair hard for the child to control. explain: • some wheelchair users are unable to push themselves, and need to be assisted. • Other wheelchair users may push themselves most of the time, needing help occasionally. For example to go up and down steps, or to go over rough ground. • strong push handles will help others to assist the user. For child users, high push handles will be easier for adults who are helping the child. 3.3 Folding the wheelchair explain: a folding wheelchair is useful for storage or transport. Wheelchairs fold in two main ways. explain: • Wheelchairs with a cross-folding frame fold so that both sides come together. sometimes it is possible to remove the wheels as well. • cross-folding wheelchairs can be helpful for wheelchair users needing to ‘squeeze’ through narrow doorways. • For transporting the wheelchair, some people prefer a cross-folding wheelchair. • a disadvantage with some cross-folding frames is that the folding mechanism can weaken, making the wheelchair feel unstable. it then becomes harder to push. Some wheelchair users are unable to push themselves and need to be assisted . A.6. Appropriate wheelchair: 17 BASIC LEVEL PUSHING THE WHEELCHAIR Wheelchairs with a cross folding frame fold so that both sides come together . Sometimes it is possible to remove the wheels as well . A.6. Appropriate wheelchair: 18 BASIC LEVEL FOLDING THE WHEELCHAIR Wheelchair Service Training Packag e 74 BASIC LEVEL explain: • some rigid frame wheelchairs also fold. The backrest folds down towards the seat and the rear wheels come off. • Both rigid frame and cross-folding wheelchairs have advantages and disadvantages. The best choice will depend on the wheelchair users lifestyle, how they transfer in and out of transport and their personal preference. activity groups: Have 3 people in each group. instructions: Ask each group to work out how each of the different wheelchairs in the room fold. Monitor: Check that everyone is able fold and unfold the different wheelchairs. Correct methods if necessary. Time: Allow 5 minutes. 3.4 Carrying out activities explain: There are several features of a wheelchair which affect how easily a wheelchair user can carry out activities. We have talked about some already. For example how easy a wheelchair is for the user to push will affect how easily they can participate in activities. Here are some other examples. explain: • The overall length of a wheelchair can affect how easy or difficult it is to use in small spaces. • The length is from the furthest back part of the wheelchair to the furthest front part. ask participants: What is the wheelchair with the longest overall length in the room? Some rigid frame wheelchairs also fold The backrest folds . down towards the seat and the rear wheels come off. A.6. Appropriate wheelchair: 19 BASIC LEVEL FOLDING THE WHEELCHAIR The overall length of a h l h ff h w ee c air can a ect ow easy or difficult it is to use ll in sma spaces. Overall length A.6. Appropriate wheelchair: 20 BASIC LEVEL CARRYING OU T ACTIVITIES 75 VIDEO explain: • High armrests may make it difficult for the user to pull up close to a table or desk. explain: The main thing to remember is that it is important to think about what the user needs to do when choosing the most appropriate wheelchair. introduce the DvD: Meeting the wheelchair user’s needs. ask participants to watch closely, to see the different features of wheelchairs that help the people in the DvD carry out their work or activities. explain that we will discuss this after the DvD. Show DvD. explain: in the DvD there were many different wheelchair users, using different types of wheelchairs, to carry out different activities. ask: What were some of the activities? answers include: • working (in an office, supermarket, upholstery workshop); • dancing; • getting in and out of a car ; • walking (with Mum and dog); • playing basketball. ask: What were some of the wheelchair features that helped Roger carry out his work in the supermarket? encourage answers (see Notes for trainers below). ask: can someone give another example from the video of how the features of a wheelchair were well suited to the needs of the wheelchair user? encourage answers – remind people of the different people in the clips and re-show if necessary. ask: can someone give one more example? encourage answers. High armrests may make it difficult for the user to pull up close to a table or a desk. High armrest A.6. Appropriate wheelchair: 21 BASIC LEVEL CARRYING OU T ACTIVITIES Wheelchair Service Training Packag e 76 BASIC LEVEL notes for trainers: • it is not necessary to review every wheelchair user; • notes are provided below for each wheelchair user in the clip to assist trainers to answer any questions that participants may have; Wheelchair user activity he/she was carrying out Wheelchair features that helped Roger Working in a supermarket; stocking shelves. • Short wheelbase – helped him to get closer to the shelves and manoeuvre his wheelchair in smaller spaces. • Rear wheels positioned well for propelling and low backrest (Roger does not need support any higher) makes it easier for Roger to propel efficiently. • No armrests – easier for Roger to place things on his lap and to move actively. Ruan Walking with his Mum and dog. • Push handles – at a good height for Mum to push. • Ruan’s wheelchair has extra postural support (do not go into details) which helps him to sit more comfortably and securely. James (number 14) and team mates Playing wheelchair basketball. James and his team mates are using specialized Sports Wheelchairs. Features include: • Rear wheels angled apart (which increases stability); • thin rear wheels (which help to increase speed); • small front castors (reduces weight and increase speed); • calf and or thigh straps – help to provide the wheelchair users with stability and security; • low backrest – allows for lots of freedom of movement while playing sport; • rear wheels positioned well for propelling. Mark Working in an upholstery workshop. Mark can propel with one foot – which means he does not have to use both arms. In the workshop, this can free up one arm to carry things. • The wheelchair enables this by having swing away footrests. 77 Dawid and Pinky Working as security guards in a supermarket. • Both have a relatively short wheelbase – which helps them to move around the store. • Both move their wheelchair independently – however Dawid uses rear wheels; Pinky uses an electric wheelchair. Faizel Works in an office. • Rear wheels positioned well for propelling. • Backrest low enough to allow shoulder movement however high enough to provide correct support. • Uses pushing gloves – which help him to push on the rear wheels and push rims more easily. • No armrests – which makes it easier for Faizel to pull his wheelchair under the desk. Keith (three-wheel wheelchair) and Ralph (four-wheel wheelchair) Work in a wheelchair assembly workshop. • Ralph and Keith: No arm rests – easy to work with tools and at work bench, easy to carry things on their lap. • Keith’s three-wheel wheelchair allows him to get close to objects he needs to pick up as the boom fits easily between other items and equipment. • Ralph has a wheelchair with a short wheelbase, which allows him to get close to the working surface. • Ralph and Keith: Rear wheels positioned well for propelling and low backrest allowing freedom of movement. Ryan Getting in and out of a car. • Ryan’s wheelchair folds and the rear wheels come off (quick release wheels) – which enable him to lift the wheelchair into the car himself. Without this feature he would not be able to get in and out of the car independently. Jenee Dancing. • Short overall wheelchair length – enables very small turning circle. • Short overall wheelbase – improves manoeuvrability. • Low backrest allows for good freedom of movement. • Anti-tip bar – prevents wheelchair from tipping back (which is more likely with such a short wheelbase). Wheelchair Service Training Packag e 78 BASIC LEVEL 4. Meeting the wheelchair user’s environment (30 minutes) explain: Different types of wheelchairs are suited to different environments. The main features which affect how a wheelchair works in a different environment are: • the distance between the front and rear wheels; • the diameter and width of the wheels. Here are some examples: explain: • The distance between the front and rear wheels is important. • When the wheels are further apart, this is called ‘long wheelbase’. • When the wheels are closer together, this is called ‘short wheelbase’. explain: • Long wheelbase wheelchairs are more stable and less likely to tip forward. • Long wheelbase wheelchairs are good for a person who will spend most of their time outdoors and moving over rough or uneven surfaces. • Three-wheel wheelchairs are an example of a long wheelbase wheelchair. They are usually very stable and suitable for outdoors on rough terrain. • Three-wheel wheelchairs do not suit everyone. • For example a three-wheel wheelchair may not suit a person who wants to stand up to transfer in and out of their wheelchair as the footrest is fixed and the front beam may get in the way. The distance between the front and rear wheels is important. Wheel base A.6. Appropriate wheelchair: 23 BASIC LEVEL THE WHEELC HAIR USER’S E NVIRONMENT BASIC LEVEL As a general guide, the rear h l h ld b iti d w ee s ou e pos one so that when the wheelchair user holds the to of the sh rim p pu their elbow is bent at 90 degrees . A.6. Appropriate wheelchair: 14 PUSHING THE WHEELCHAIR 79 • Four-wheel wheelchairs with a long wheelbase can also be successfully used on uneven surfaces. • in this example the front castor wheels are under the footrests instead of behind the footrests. This gives the wheelchair a longer wheelbase and makes it more stable. explain: • shorter wheelbase wheelchairs are more suitable where the ground is flat and reasonably smooth. • short wheelbase wheelchairs are more likely to tip forward if going downhill, or if the front wheels hit a bump. explain: • This is an example of an orthopaedic style wheelchair with a short wheelbase. • This chair would not be easy to push over rough terrain. explain: • short wheelbase wheelchairs are a good choice for a person who spends a lot of time indoors. This is an example of an orthopaedic style wheelchair with a short wheelbase. Short wheelbase A.6. Appropriate wheelchair: 24 BASIC LEVEL THE WHEELC HAIR USER’S E NVIRONMENT BASIC LEVEL Short wheelbase wheelchairs are good choice for a person who spends a lot of time indoors. A.6. Appropriate wheelchair: 26 THE WHEELC HAIR USER’S E NVIRONMENT Long wheelbase wheelchairs can be successfully used on uneven surfaces. Long wheelbase A.6. Appropriate wheelchair: 25 BASIC LEVEL THE WHEELC HAIR USER’S E NVIRONMENT Wheelchair Service Training Packag e 80 BASIC LEVEL explain: • ‘active’ style four-wheel wheelchairs often have a short wheelbase. • some wheelchair users with good wheelchair mobility skills may successfully use short wheelbase wheelchairs on uneven surfaces – for example by balancing on the back wheels to go down hills and over rough ground. explain: • The larger a wheel, the easier it is to push over uneven ground and over obstacles such as rocks and sticks. • Wide rear wheels and front castors help prevent the wheelchair from sinking into sandy or muddy ground. • standard rear wheels are 24". However in many places 24" wheels are hard to find. For this reason some producers make wheelchairs with 26" wheels. • children’s wheelchairs may have 20" or 22" wheels. • Rear and front wheels may be filled with air (pneumatic tyres) or solid. • Pneumatic tyres must be pumped up to work well. • in some locations punctures are common. People living in such locations need to be able to repair punctures themselves, or be able to easily find someone who can fix puncture repairs. • solid tyres are a possible alternative. solid tyres do not need to be pumped up and do not puncture. However over bumpy ground solid tyres feel ‘hard’ for the wheelchair user. • Not all solid tyres last very long when used outdoors. Poor quality solid tyres may ‘peel off’ the rim of the wheels. • There are two types of solid tyres: – solid rubber tyres – which are heavy, quite hard, and can be very durable if good quality. – Polyurethane (PU) tyres – which are light. However unless very good quality, these tyres wear quickly outdoors and become unusable. ‘Active’ style four wheel h l h f h w ee c airs o ten ave a short wheelbase. A.6. Appropriate wheelchair: 27 BASIC LEVEL THE WHEELC HAIR USER’S E NVIRONMENT Wide rear wheels and front castors help prevent the wheelchair from sinking into sandy or muddy ground. Wid f e ront castor A.6. Appropriate wheelchair: 28 BASIC LEVEL THE WHEELC HAIR USER’S E NVIRONMENT 81 VIDEO introduce the DvD: Meeting the wheelchair user’s environment. ask participants to watch closely, to see the different features of wheelchairs that help the people to be mobile in different environments. explain that we will discuss this after the DvD. Show DvD. ask if there are any questions. explain: in the DvD there are a number of wheelchair users moving around quite different terrain including indoors, outdoors on paths and over rough/muddy ground. ask: Two wheelchair users – venkamarantu and sione travelled over fairly rough and muddy ground. What were the features of their wheelchair that helped them to do this more easily? answers: • Three-wheel wheelchair – which gave them stability over uneven ground. • Wide front castor wheels – which roll over obstacles and are less likely to sink into mud/sand. • Rear wheels in a good position for propelling – making it easier for them to push their wheelchair. ask: Jean, who was cooking in her kitchen and Jacques, the trainer working in the gym – were both indoors. What are the features of their wheelchairs which make it easier for them to move around indoors? answers include: • Short wheelbase and short overall length. • Smaller/thinner front castors – move easily on smooth surfaces. ask: One other wheelchair user (Lalithamma) was propelling outdoors. The paths she was pushing over were smoother; however she did need to go over a drain. What were the features of her wheelchair that made this easier? Wheelchair Service Training Packag e 82 BASIC LEVEL answers include: • Long wheelbase four-wheel wheelchair – long wheelbase gives good stability (which also helped Lalithamma to carry the water). • Wide front castor wheels. • Rear wheels in a good position for propelling – making it easier for them to push their wheelchair. Small group activity groups: Take everyone to the area of rough terrain, with three different types of wheelchair instructions: Remind participants of the safety rules: do not stand on footrests, keep fingers clear of the wheel spokes and brakes; if riding the wheelchair up or down slopes, have an assistant behind you in case you tip backwards. ask for two volunteers: • Ask one volunteer to select a wheelchair they think will be the easiest to propel over the rough terrain; • Ask another volunteer to select the wheelchair they think will be the hardest to propel over the rough terrain; • Ask each volunteer to travel across the rough terrain for 5 metres and return; • Repeat with two more volunteers until everyone has had a turn. Monitor: Ensure this activity is carried out safely. Do not encourage participants to race as this could be dangerous. Time: Allow 20 minutes Feedback: ask: Which wheelchair proved to be the easiest to push over the rough terrain? • Why? encourage participants to think about the wheel size and width; wheelbase length; ease of accessing the wheels to push; backrest height. explain: some participants would have found it easier than others, if they were lucky enough to have a wheelchair which fitted them! 83 5. Providing proper fit and postural support (15 minutes) explain: • Wheelchair users are all different sizes. The wheelchair must fit the user correctly to provide proper support. Fortunately, many wheelchairs come in a range of sizes, or have size adjustments. it is easier to make sure these wheelchairs fit the user than if there is only one size available. • The following components or features of a wheelchair will affect how well the wheelchair fits and how well it helps the user to sit upright. Seat Show slides: also point out features on the wheelchairs in the room. explain: • Wheelchair seats may be either slung or solid. • solid seats may be made from wood or plastic. solid seats should always have a cushion over the top. • slung seats (shown in this slide) are usually made from canvas. • The “size” of a wheelchair is often described by the width of the seat. explain: • slung seats are made from canvas and usually attached to each side of the frame. • Poor-quality slung seats will stretch and sag more quickly. The seat does not then provide good support. • in this slide the wheelchair user cannot sit upright because the seat does not provide good support. This makes it difficult for him to sit upright. Wheelchair seats may Seat be either slung or solid. A.6. Appropriate wheelchair: 30 BASIC LEVEL PROVIDING PR OPER FIT AND POSTURAL SUP PORT Slung seats are made from canvas and usually attached to each side of the frame. Slung seat A.6. Appropriate wheelchair: 31 BASIC LEVEL PROVIDING PR OPER FIT AND POSTURAL SUP PORT Wheelchair Service Training Packag e 84 BASIC LEVEL explain: • The cushion provides comfort and helps to relieve pressure. • cushions also can help to stop a wheelchair user from sliding into a slumped posture. • We will talk about cushions in detail in the next session. explain: • Backrests may be slung or solid. all solid backrests should have some padding/ cushioning. • Wheelchairs come with different backrest heights. some wheelchairs have adjustable backrest heights. The correct backrest height needs to be selected for the user. This is discussed later. • some wheelchairs have adjustable angles on the backrest as well. explain: • Footrests help to support the user. it is very important that footrests are adjusted correctly. For this reason, the height of the footrests is usually adjustable. • some footrests can also be adjusted by the angle and the distance away from the wheelchair. explain: • armrests can also be used to provide support. • some armrests are height-adjustable. • if they are not, they can sometimes be modified to give more support for a user who needs it. The cushion provides comfort and helps to relieve pressure Cushion . A.6. Appropriate wheelchair: 32 BASIC LEVEL PROVIDING PR OPER FIT AND POSTURAL SU PPORT Backrests may be slung Backrestor solid. A.6. Appropriate wheelchair: 33 BASIC LEVEL PROVIDING PR OPER FIT AND POSTURAL SU PPORT Footrests help to support the user. Footrest A.6. Appropriate wheelchair: 34 BASIC LEVEL PROVIDING PR OPER FIT AND POSTURAL SU PPORT Armrests also help to support the user. Armrest A.6. Appropriate wheelchair: 35 BASIC LEVEL PROVIDING PR OPER FIT AND POSTURAL SU PPORT 85 6. Matching wheelchairs to the needs of wheelchair users (30 minutes) activity groups: Have two to three people in each group. instructions: Ask each group to: • read the user’s stories in the worksheet in their workbook; • discuss which available wheelchairs best suit each user’s needs and why; • write down their answers. Monitor: Monitor the groups and assist if necessary. Time: Allow 20 minutes and 10 minutes for feedback. Feedback: One at a time, ask each group to come forward and: • state for one wheelchair user which of the available wheelchairs they think would most suit that user ; • provide at least three reasons why they think this is the most appropriate choice; • ask the rest of the participants if they agree with the group’s decision. • (Allow 2–3 minutes for each feedback). At the end of the feedback, remind participants that their decision is a recommendation to be discussed with the wheelchair user. The final decision should be the wheelchair user’s. User’s story learning points Bao lives in a rural village. He is a bilateral above- knee amputee. Before his accident, he ran a shop on the road which runs past his village, selling general groceries. Now he can only reach the shop with help, as the pathway leading from his village to the road is long (almost 1 km), bumpy and often muddy. This has made it difficult for him and his family to keep the shop going. A long time ago, he received a donated orthopaedic-style wheelchair. The chair is rusted and the seat upholstery has ripped. The front castor wheels are small, and the rear wheel tyres are very thin and worn. He cannot push this wheelchair along the track from his hut to the village, as the wheels dig into the path. He would like to be able to get to the shop on his own, so that he is not relying on his wife or others to help him. • Bao needs a wheelchair which can be independently pushed over rough, soft ground. • Good access to the wheels to push is important. • Good postural support will help him, as he will spend a long time in his wheelchair each day at his shop. • Where tricycles are available, trainers may point out that a tricycle can be a very efficient means of mobility for wheelchair users who have good strength and need to travel longer distances. Wheelchair Service Training Packag e 86 BASIC LEVEL User’s story learning points amanthi is 24 and lives with her family in a small town. She was involved in a car accident when she was 18, and became a paraplegic. Amanthi recently had a pressure ulcer, which took six months to heal. She has an orthopaedic wheelchair, but it does not give her good support and she gets very tired in it. It does not have a cushion. Amanthi thinks this is probably why she developed a pressure sore. Amanthi has been invited to attend a secretarial course and wants to go. However, she is worried that she will not be able to sit up all day in her current wheelchair. • Amanthi needs a wheelchair which allows her to transfer easily, gives good postural support and has a pressure relief cushion. • A wheelchair that can fit under a desk is important. • The size of the front castor depends on the type of roads she will travel on. Phillip is 62 years old and lives in a small island community. Six months ago, he had a stroke. He returned to his home after one month in hospital without a wheelchair. He has been lying in bed or sitting on a chair on the veranda of his home. Phillip cannot move his left arm or left leg. However, he is getting stronger each day and can now stand upright with help from a family member. He is exercising his right arm, and is very keen to have a wheelchair so that he can be more mobile and less reliant on his family. He wants to be able to move around his small home, which is all on one level, and around his local community. The terrain is very sandy. One of his grandsons owns a car and says that he will take him out if he has a wheelchair. • Philip needs a wheelchair which allows him to do a standing transfer. Flip-up footrests would make this easier. • Larger front castor wheels and thick rear wheels would make pushing around his community easier. • He may be able to propel himself short distances with his right arm and leg – so the height of the wheelchair seat (with cushion) should allow him to sit with his feet flat on the floor. • A wheelchair that cross-folds, or one in which the backrest folds down and rear wheels come off, will make it easier for him to travel in his grandson’s car. sabina is 56 years old and lives in a small island community. After the birth of her fourth child many years ago, she lost most of the use of her legs. She can stand a little, but she cannot walk. She has never had a wheelchair. Sabina lives in a small village near the sea – and the surface around her home and the village is rough and sandy. She spends her time helping to care for her grandchildren, cooking and weaving. There is no room inside her home for a wheelchair, but it can be stored underneath, as her home is raised on stilts (columns). • Sabina needs a wheelchair she can propel easily over rough and sandy soil. Large front castor wheels will be important. A long wheelbase will help with wheelchair stability. • Because she can stand, she may prefer footrests that move out of the way so that she can stand up to transfer in and out of the wheelchair. • The chair should be strong and robust to suit her outdoor lifestyle. 87 7. key point summary (3 minutes) read the key points. ask whether there are any questions. a.7: cushions O B Je c T iv e S By the end of this session, participants will be able to:  list benefits of cushions for wheelchair users;  name the different types of cushions available locally;  explain what a “pressure relief cushion” is;  demonstrate how to check that a pressure relief cushion is reducing pressure;  explain that adding a foam “lift” to a pressure relief cushion can reduce pressure. r e S O U r c e S For the session:  PPT slides: A.7 Cushions;  Reference Manual (Page no, 29);  Participant’s Workbook (Page no, 21);  DVD: Pressure test demonstration;  one sample of each of the different locally available cushions, one pressure relief cushion fitted in a wheelchair for every three participants, one pressure relief cushion with a “lift” added. c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  the available cushions in the participants’ location – this session provides information on foam and fluid/gel cushions – if there are other types of cushions available in your participant’s location, include these cushions in this session;  if there is no pressure relief cushion available, it will be difficult to teach this session – it will also be difficult for participants to prescribe wheelchairs safely after the training – explore ways to introduce low-cost pressure relief cushions before the training, including local production or contacting external organizations for assistance. Th i t h l h i t th t ill t th d f • ere s no one w ee c a r ype a w mee e nee s o every wheelchair user. Wh l h i d h l h i h h i d • ee c a r users nee a w ee c a r t at meets t e r nee s, suits their environment and is safe and durable. T b bl h l h l h i l h • o e a e to e p w ee c a r users to se ect t e most appropriate wheelchair for them, wheelchair service personnel need: – to be familiar with the different types of wheelchairs available; t k th diff t f t f th h l h i– o now e eren ea ures o ese w ee c a rs; – to have a better understanding of the user's environment. A.6. Appropriate wheelchair: 36 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 88 BASIC LEVEL T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Ensure some of the available wheelchairs are fitted with a pressure relief cushion.  Have one of each locally available cushion and a cushion lift ready at the front of the training room. O U T l in e 1. Introduction. 2. What are cushions for? 3. Different types of cushions. 4. Pressure relief cushions. 5. How to test if a pressure relief cushion is working. 6. What action can be taken to reduce pressure? 7. Key point summary. 2 5 5 25 30 5 3 Total session time 75 1. introduction (2 minutes) explain: in this session, we will talk about wheelchair cushions. We will learn why cushions are important, the different types of cushions, and how to check whether a cushion is fitting correctly. 2. What are cushions for? (5 minutes) ask: What are the benefits of a wheelchair cushion for wheelchair users? encourage answers. Most important answers: • pressure relief; • posture support; • comfort. I thi i ti i t ill• n s sess on par c pan s w : – Discuss why cushions are important; – Look at the different types of cushions; Practise how to check whether a cushion is – fitting correctly. A.7. Cushions: 2 BASIC LEVEL INTRODUCTI ON 89 explain: • a cushion is a very essential part of every wheelchair, for every wheelchair user. • The type of cushion best suited to the user will depend on his/her needs. • People who are at risk of developing a pressure sore should always use a pressure relief cushion. • Not every wheelchair user needs a pressure relief cushion. • However, all wheelchair users should be comfortable in the wheelchair, and all wheelchair users will benefit from support to help them to sit upright easily. 3. Different types of cushions (5 minutes) explain: There are many different wheelchair cushion types. ask: What are the different cushions participants have seen, or heard of? encourage answers and write on the board. answers may include: • foam cushions; • cushions made from coconut fibre (coir); • cushions filled with air ; • cushions filled with fluid or gel; • flat cushions; • contoured cushions; • moulded cushions; • layered cushions. • Wheelchair cushions can provide: – comfort; – postural support (help people to sit more upright); – pressure relief. • Every wheelchair user should use a cushion. • The type of cushion best suited to the user will depend on their needs. • Any person at risk of developing a pressure sore needs a pressure relief cushion. A.7. Cushions: 3 BASIC LEVEL THE BENEFIT S OF A WHEEL CHAIR CUSHI ON Wheelchair Service Training Packag e 90 BASIC LEVEL explain: There are many different types of cushion. cushions can be described in different ways, including: • the material they are made from (for example foam, coir); • the material they are filled with (for example air, fluid or gel); • their main function (for example pressure relief, comfort, posture support); • their shape (for example flat or contoured); • how they are made (for example foam cushions may be “moulded” from one piece of foam or “layered” – made from different layers of foam). hold up the locally available cushions one by one. Describe each cushion by the material, main function, shape and whether the cushion is moulded or layered. Pass each example cushion around the group. 4. Pressure relief cushions (25 minutes) explain: in the session on pressure sores, we talked about making sure that any wheelchair user who is at risk of developing a pressure sore has a pressure relief cushion. in this session, we will look at what a pressure relief cushion is. ask: Which of the sample cushions could act as a pressure relief cushion? answer: • any contoured foam cushions; • any air-filled or fluid-filled cushions. C h b d b d • us ions may e escri e in different ways including: – the material they are made from or filled with; – the main function of the cushion; the cushion’s shape;– – how the cushion is made. A.7. Cushions: 4 BASIC LEVEL THERE ARE MA NY DIFFERENT TYPES OF CUS HIONS 91 Pressure relief cushions help to reduce pressure by: • distributing a wheelchair user’s weight as evenly as possible across the seat surface; • reducing pressure under high-pressure risk areas (seat bones, hip bones, coccyx/tail bone); • reducing shear by assisting the wheelchair user to sit upright. Foam pressure relief cushions explain: We will talk first about foam pressure relief cushions. explain: Firm stable base: • The base of a pressure relief cushion should be firm. • This will make sure the cushion provides good support for the user and does not move when the user moves. explain: Top layer • This is a layer (or more than one layer) of softer foam. • The top layer should be soft enough to allow the seat bones to sink into it, but should not be so soft that the seat bones can sink all the way to the bottom and rest on the solid base or seat of the wheelchair. explain: Many foam pressure relief cushions have some shaping (contours) in the seat. shaping can: • help to support the user; • help to distribute the user’s weight more evenly across the seat surface; • help to relieve pressure under the seat bones and at the coccyx. • Distributing the user’s weight evenly across the seat surface. • Reducing pressure under high pressure risk areas. P ti h b ti • reven ng s ear y crea ng a shelf in front of the seat bones and it can assist users to sit upright. A.7. Cushions: 5 BASIC LEVEL PRESSURE RELI EF CUSHIONS R EDUCE PRESSU RE BY: A.7. Cushions: 6 BASIC LEVEL FOAM PRESSU RE RELIEF CU SHION: BASE LAYER A.7. Cushions: 7 BASIC LEVEL FOAM PRESSUR E RELIEF CUSH ION: WITH TOP LAYER Wheelchair Service Training Packag e 92 BASIC LEVEL shaping that you may see on a pressure relief cushion may include the following (click to show arrows on the slide): • a “well” under the seat bones – to reduce pressure; • a shelf in front of the seat bones – to keep the pelvis more upright and prevent sliding forward; • support under the upper part of the thigh bones to help distribute weight; • grooves or gutters for the rest of the thighs. air/fluid/gel pressure relief cushions explain: Now we will look at air/fluid/gel cushions. explain: • Flotation cushions include those filled with air and those that have a fluid or gel pack. • Gel pack cushions should have a firm foam base, very similar to a foam contoured cushion. • Over the base layer there is a gel/fluid pack. • The gel pack automatically matches the shape of the wheelchair user’s body. This helps to distribute the wheelchair user’s weight evenly and reduces pressure under bony areas. Which cushion to use? explain: There are advantages and disadvantages of both foam contoured cushions and air/gel/fluid cushions. Draw the table below on the board (without the answers). ask: What are some of the advantages and disadvantages? Write in the advantages and disadvantages that participants suggest. ensure that all in the list below are covered. A.7. Cushions: 8 BASIC LEVEL FOAM PRESSU RE RELIEF CU SHION: CONT OURS A.7. Cushions: 9 BASIC LEVEL AIR/FLUID/GE L PRESSURE R ELIEF CUSHIO N 93 advantages Disadvantages Foam contoured cushion • Can be made locally (where there is high-quality foam). • Can be modified locally to accommodate different needs. • Not subject to “sudden collapse” (a puncture which releases the air or fluid can stop the cushion from relieving pressure, causing “sudden collapse” of the cushion). • The top layer of a layered foam cushion can be replaced easily and at a low cost (rather than replacing the whole cushion). • Foam compresses (becomes flatter and firmer) over time. For this reason, foam cushions should be checked regularly and replaced every 1–2 years. • Can take a while to dry out (a problem for people who are incontinent). • Foam insulates and can cause an increase in tissue temperature. air/ fluid/gel cushions • Pressure is distributed evenly over the seat surface. • The gel pad automatically adapts to the body when the wheelchair user moves or changes position. • Air/fluid/gel cushions are often more expensive and less readily available than foam cushions. • Some wheelchair users find air/ fluid/gel -filled cushions make them feel unstable. • Subject to “sudden collapse”. In any context where a wheelchair user is not able to get a replacement cushion quickly, this can be a problem. cushion covers explain: all cushions should have a cushion cover. The type of cover is important. Pass around one of each different cushion cover available. ask participants to look closely at the covers and consider the questions on the slide. • is the cover water-resistant or waterproof? • is the cover likely to be durable (long-lasting)? • is the cover stretchy? • is the cover made of thin material or thick material? • can the cover be easily removed and replaced for washing? I th s e cover: • water resistant or waterproof ? • likely to be durable (long lasting)? h ?• stretc y • made of thin material or thick material? A.7. Cushions:10 BASIC LEVEL CUSHION CO VER QUESTIO NS: Wheelchair Service Training Packag e 94 BASIC LEVEL ask: • Which (if any) of the cushion covers is water-resistant or waterproof? • When would this be a useful feature? answer: • for wheelchair users who are incontinent; • for wheelchair users who may need to leave their wheelchair outdoors, or who are outdoors themselves a lot. explain: • Moisture is one risk factor that can increase the chance of a wheelchair user developing a pressure sore. So keeping a cushion dry is very important. • Always advise wheelchair users to dry their cushion immediately if it becomes wet. Dry the cushion away from direct sunlight, with the cover off. • Consider providing two cushions if a wheelchair user is incontinent. Notes for trainers: Participants may ask what to do if there is no water-resistant or waterproof cushion cover available and a wheelchair user is incontinent. Options include: • investigate what help can be given to help the wheelchair user reduce incontinence; • provide a second cushion – so that one can be drying while the user sits on the other; • protect the cushion with a very thin plastic bag inside the cover; If using a plastic bag: – check that the plastic bag does not cause the user to “slide” on the cushion; – the wheelchair user must ensure that fluid does not “pool” over the plastic – this increases the risk of a pressure sore. – the wheelchair user should ensure that the cover is dried out if it becomes wet and the plastic bag cleaned or replaced. ask: • Which (if any) of the cushion covers is likely to be durable (long-lasting)? explain: a durable cover is an important feature of any cushion. ask: • Which (if any) of the cushion covers is stretchy? • Why would this be a useful feature? 95 VIDEO answer: • a stretchy cover is more likely to follow the contours of a cushion – if a cover is not stretchy, there needs to be more “room” for the cover to fit into the contours. ask: • Which is the thinnest fabric? Which is the thickest fabric? • Why is the thickness/thinness of the fabric important? answer: • thick fabrics may last a long time, but they may not follow the contours of the cushion easily –folds in thick fabric can potentially cause a pressure sore; • thin fabrics are more likely to follow the contours of the cushion and are less likely to cause a pressure sore, but they may not last as long – this depends on the quality of the fabric. ask: Which covers are designed to come on and off for washing? explain: This is an important feature for any wheelchair user who may be incontinent, spends a lot of time outdoors, or has to store their wheelchair outdoors. explain: as for wheelchairs, cushions come in different sizes. it is important that the cushion which is selected for each wheelchair user matches the size of the wheelchair seat, which should be the right size for the wheelchair user. 5. how to test if a pressure relief cushion is working (30 minutes) explain: Whenever a wheelchair user is provided with a pressure relief cushion, it is essential to check whether the cushion is actually working to relieve pressure. ask: What is the part of the wheelchair user’s body which is most at risk of developing a pressure sore when sitting? encourage answers. Most important answers: • seat bones; • tail bone – particularly if the wheelchair user is sitting in a slumped posture. introduce DvD: Pressure test demonstration. The DvD shows a simple test to check if a pressure relief cushion is reducing pressure under the user’s seat bones. Watch closely as you will practise this after the DvD. Show DvD. ask if there are any questions. Wheelchair Service Training Packag e 96 BASIC LEVEL explain the levels of pressure: level 1: • Finger tips can wriggle up and down. There is some compression of tissue but the bones in your finger tips are able to move 5 mm or more. level 2: • Finger tips cannot wriggle, but can easily slide out from under the seat bones. level 3: • Finger tips are squeezed firmly. It is difficult to slide fingers out of position. explain: always check one seat bone at a time. level Pressure action 1 Safe No 2 Warning Yes, if several pressure risk factors 3 Unsafe Yes explain: We will talk about the action needed later in the session. activity groups: Have 2–3 people in each group. Try to pair people of the same gender. Give each group a wheelchair with a pressure relief cushion. instructions: Ask each group to: • practise checking the pressure under each seat bone; • record the level of pressure for each person in the group in their workbook. Make sure everyone gets to practise being the “tester” and the “wheelchair user”. Monitor: • Move around the groups and monitor/observe closely. • Correct techniques if needed. Time: Allow 15 minutes plus 5 minutes for feedback. Feedback: ask: What did it feel like being the wheelchair user? explain: It is important to explain clearly to the user what you are doing, why it is important, and to check he/she is OK with doing this test. ask: Does anyone have any questions about this technique? 97 notes for trainers: When monitoring the small groups – ensure the following steps are followed a • Explain simply to the wheelchair user what you are going to do, and why it is important. B • Ask the wheelchair user to push up or lean forward to allow you to place your finger tips under their left or right seat bone (palm up). • This is best done from behind the wheelchair by reaching under the back upholstery with one hand. c • Ask the wheelchair user to sit back down on your fingers. • He/she should sit upright, face forward, and place the hands on the thighs. This will ensure that he/she sits in the same position each time you move to check another location. • If your fingers are not in a good position to feel the pressure under the bone, then ask the user to push up again and reposition your fingers. D • Identify the pressure under the first seat bone as level 1, 2 or 3. Level 1 = safe: Fingertips can wriggle up and down 5 mm or more. Level 2 = warning: Fingertips cannot wriggle, but can easily slide out. Level 3 = unsafe: Fingertips are squeezed firmly. It is difficult to slide fingers out. e Repeat under the second seat bone. Wheelchair Service Training Packag e 98 BASIC LEVEL 6. What action can be taken to reduce pressure? (5 minutes) explain: • When unsafe pressure is identified under the seat bones, action is needed to reduce the pressure. • a simple solution for high pressure under the seat bones is to add an extra layer of firm foam. This is called a “lift”. • The lift should be approximately 20 mm thick and have a hole cut out under the seat bones area. • The lift is placed on top of the base layer and under the comfort foam layer. explain: sometimes more than one layer is needed. Personnel should add one layer and test the pressure. if the pressure is still level 2 or 3, add another layer. Pass around a lift and an example of a cushion which has had a lift added to reduce pressure. explain: We will practise addition of an extra layer of foam during the practical sessions later in the training. 7. key point summary (3 minutes) read the key points. ask whether there are any questions. • To reduce unsafe pressure add a ‘lift’ on top of the base layer and under the comfort foam layer. A.7. Cushions:12 BASIC LEVEL CUSHION LIFT – TO REDUCE UNSAFE PRESS URE • There are many different types of cushions . • Depending on the type of a cushion, it can provide comfort, help users to sit upright and relieve pressure, . • Every wheelchair user should have a cushion. Wh l h h k f d l • ee c air users w o are at ris o eve oping a pressure sore should have a pressure relief cushion. Wh li f hi i ib d ( l d) • en a pressure re e cus on s prescr e se ecte always test if the cushion is reducing pressure. If the pressure is unsafe, add a ‘lift’. Always re-test the pressure after making any changes. A.7. Cushions:13 BASIC LEVEL KEY POINT SU MMARY 99 a.8: Transfers Getting in and out of the wheelchair O B Je c T iv e S By the end of this session, participants will be able to:  list safety points to think about when getting in and out of a wheelchair ;  demonstrate different ways to get in and out of a wheelchair ;  select at least one transfer method that is best suited for a particular wheelchair user. r e S O U r c e S For the session:  PPT slides: A.8: Transfers;  Reference Manual;  Participant’s Workbook;  DVD: Transfer demonstration;  wheelchairs – one for each group of three.  assessment bed for transfer practice – one for each group of three;  transfer sliding board (if available); c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  the wheelchairs available locally, which may affect the transfer techniques taught – for example, a standing transfer with a three-wheel wheelchair instead of a four-wheel wheelchair with flip-up footrests requires changes to the method;  what transfer methods are most commonly used in the participants’ location – trainers may choose to change the methods taught or add more methods;  if teaching more than three transfer methods, allow 20–25 minutes for each additional transfer to be taught. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Practise each method of getting in and out of the wheelchair so that you are comfortable demonstrating it.  If possible, invite a wheelchair user who can demonstrate the transfers and assist in practice. Wheelchair Service Training Packag e 100 BASIC LEVEL O U T l in e 1. Introduction 2. Why do wheelchair users need to learn how to transfer? 3. Getting in and out of a wheelchair safely 4. Three ways to get in and out of a wheelchair and individual feedback 5. Independent transfer from floor to wheelchair 6. Selecting transfers 7. Key point summary 2 5 10 60 20 20 3 Total session time 120 1. introduction (2 minutes) explain: • The ability to get in and out of the wheelchair easily and safely, with or without assistance, will help a wheelchair user in daily life. • Getting in and out of the wheelchair can sometimes be called “transferring”. • in this session, participants will practise four different ways wheelchair users may transfer in and out of their wheelchair. 2. Why do wheelchair users need to learn how to transfer? (5 minutes) ask: What are some examples of times when wheelchair users have to transfer in and out of their wheelchair? encourage answers and write on the board. answers may include: • getting in and out of bed; • going to the toilet; • moving to and from a chair/bed/tricycle/the floor, etc.; • getting in and out of a car/bus/taxi/mini-cab/rickshaw, etc. I thi i ti i t ill• n s sess on par c pan s w : – Talk about why knowing how to get in and out of a wheelchair easily is important for users; – Practise four different ways that wheelchair users may transfer in and out of their wheelchair. A.8. Transfers: 2 BASIC LEVEL INTRODUCTI ON 101 explain: • Wheelchair users may need to get in and out of their wheelchair several times a day. • For this reason, wheelchair users need a method which is safe, quick and does not use much energy. • Wheelchair users use different methods, depending on their abilities. some wheelchair users can get in and out of the chair themselves, and others need help. some users can stand up to transfer, and for others this is not possible. • Personnel can help wheelchair users learn a method which suits them. 3. getting in and out of a wheelchair safely (10 minutes) explain: safety when transferring is important. ask: What are some of the safety points that should be considered when transferring? encourage answers and write on the board. Most important answers: • put the brakes on; • check where you are going – make sure there is nothing in the way; • always lift – don’t bump or drag – this could cause skin damage and lead to a pressure sore; • before assisting someone, make sure you can support his/her weight; • do not assist if you are pregnant or have a back problem. reinforce the three main safety points: • put the brakes on; • check where you are going; • always lift – do not bump or drag. • Wheelchair users may get in and out of their wheelchair several times a day. • Wheelchair users need a method which is: – safe; – quick; and – does not use much energy. • Different methods suit different wheelchair users. • Wheelchair personnel can help wheelchair users to learn a method that suits them best. A.8. Transfers: 3 BASIC LEVEL TRANSFERS A RE IMPORTAN T • Put the brakes on. • Check where you are going. • Always lift – do not bump or drag. A.8. Transfers: 4 BASIC LEVEL SAFETY WHE N TRANSFERR ING Wheelchair Service Training Packag e 102 BASIC LEVEL 4. Three ways to get in and out of the wheelchair and individual feedback (60 minutes) explain: • We will now watch and practise three different ways to get in and out of a wheelchair. • One transfer is an “independent” transfer, and the other two transfers are “assisted”. Before recommending or practising a transfer with a wheelchair user, you need to know whether he/she can transfer independently or needs help. if you are not sure, check or test with the wheelchair user. • To transfer independently through sitting, check that the wheelchair user can lift his/her weight upwards by pushing with the arms. if he/she cannot do this, he/she needs assistance to transfer. • To transfer independently through standing, check that the wheelchair user can stand up and take his/her own weight through the legs. if he/she cannot do this, he/she needs assistance to transfer. explain: For every transfer, participants should always remember the following: • check if the wheelchair user can transfer independently or needs assistance; • position the wheelchair close to the bed/ surface the wheelchair user is transferring to; • apply brakes; • if the wheelchair has armrests which are in the way – check if they are removable. • For standing transfers, move footrests out of the way (if possible). • always lift – do not drag. Dragging can cause skin damage which may lead to a pressure sore. • During assisted transfers, encourage the wheelchair user to do as much of the transfer independently as possible. • When assisting to lift a wheelchair user – do not grip clothes or belt loops. Pulling on clothes can be very uncomfortable for the wheelchair user. • Check whether the wheelchair user can transfer alone or needs help; • To transfer independently through sitting – check that the user can lift their weight upwards with their arms by pushing; • To transfer independently through standing – check that the user can stand up and take their weight through their legs. A.8. Transfers: 5 BASIC LEVEL BEFORE PRAC TISING A TRA NSFER – CHEC K: Ch k if h h l h i f l d h l• ec t e w ee c a r user can trans er a one or nee s e p. • Position the wheelchair. • Apply brakes. • Remove armrests if they are in the way (if armrests are removable). • For standing transfers – move footrests out of the way (if possible). • Always lift do not drag– . • During assisted transfers, encourage the wheelchair user to do as much of the transfer themselves as they are able to. • When helping to lift a wheelchair user – do not grip clothes or belt loops. A.8. Transfers: 6 BASIC LEVEL FOR EVERY TR ANSFER REME MBER: 103 activity groups: Have three people in each group. Give each group a wheelchair and a bed. instructions: explain – participants will watch the DVD demonstration of three different transfers. After each transfer demonstration, the video will be paused. Participants will practise the transfer they have just seen in pairs. They may refer to their Reference Manual if they like. show DvD ask if there are any questions. Monitor: After each part of DVD demonstration highlight the key points outlined below. Monitor and correct techniques if needed. Make sure everyone has a chance both to transfer and to assist. Time: Allow 60 minutes. Feedback: ask whether anyone has any questions. clarify any common problems or mistakes that groups may have made in their practice. 1. independent transfer through sitting (wheelchair to bed) Highlight these key points after the DVD demonstration and before practice. • Position wheelchair close to the bed, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Push up on hands and move to the front of the wheelchair. • With one hand on the bed and the other on the wheelchair, push up and lift on to the bed. • If the user has poor balance or cannot lift high enough or move sideways far enough, he/ she may use a transfer board, if necessary. explain: • If transferring to a bed, some wheelchair users prefer to place their legs on to the bed before transferring. VIDEO Wheelchair Service Training Packag e 104 BASIC LEVEL 2. assisted transfer through sitting with a transfer board (wheelchair to bed) highlight these key points after the DvD demonstration and before practice • Position the wheelchair close to bed, apply brakes. • Take feet off and swing or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Assist user to move forward. • Put a transfer board under the buttocks across the wheelchair and bed. • User to assist as much as possible by pushing up on the wheelchair and bed to take own weight. • Assistant stands behind user, and moves user’s pelvis over to the bed. 3. assisted standing transfer (bed to wheelchair) highlight these key points after the DvD demonstration and before practice • Position the wheelchair close to bed, apply brakes. • Take feet off and swing away or remove (where applicable) the footrests. • Remove armrest closest to the bed. • Assist user to move forward on the bed and place feet on the floor. • Support the user’s knees from the side (do not push against knees from the front). • Bring user’s body forwards and upwards by supporting around the shoulder blades. • Twist the user towards the wheelchair and allow him/her to sit down gently. 5. independent transfer from floor to wheelchair (20 minutes) explain: • This transfer requires the wheelchair user to have strong arms and good balance. Wheelchair users at risk of developing a pressure sore should always sit on their pressure relief cushion when sitting on the floor. 105 activity groups: Have two people in each group. Give each pair a wheelchair. instructions: Demonstrate the transfer if you are able (or ask a wheelchair user who can do this transfer to demonstrate). Highlight the key points outlined below. ask participants to practise in pairs. Monitor: Monitor and correct techniques if needed. Make sure everyone has a chance to practise. Time: Allow 10 minutes. Feedback: ask: How many people were able to do this transfer? acknowledge that it takes good upper body strength. For active and fit wheelchair users with good arm strength, it is a skill worth practising. independent transfer from floor to wheelchair explain: When transferring from the floor to the wheelchair : • sit in front of the wheelchair and draw knees up close to the body; • look down and keep looking down throughout the lift; • place one hand on the floor and one hand on the front of the wheelchair seat; • push down with shoulders and arms to lift buttocks up and on to the front of the wheelchair seat; • sit back into the wheelchair and reach down to pick up wheelchair cushion; • shifting your weight to one side, push the wheelchair cushion into place. explain: When transferring from the wheelchair to the floor: • sit at the front of the wheelchair ; • lift feet off the footrests in front of you and slightly to the side (away from the direction you are transferring); • place your cushion on the floor; • with one hand on the wheelchair seat, reach down to the floor with the other hand; • using shoulders and arms, control the buttocks down on to the cushion placed on the floor in a controlled movement. Wheelchair Service Training Packag e 106 BASIC LEVEL 6. Selecting transfers (20 minutes) explain: • When wheelchair service personnel provide a wheelchair user with a wheelchair, it is part of their role to make sure the wheelchair user is able to transfer safely and easily. • Many users will already have a way of transferring. • always ask users to demonstrate how they usually get in and out of the wheelchair. • if the transfer method they are using is safe and effective, no further action is necessary. • if not, wheelchair service personnel can teach wheelchair users how to get in and out of the wheelchair more safely and easily. • The first step is to decide which transfer method will best suit the user. This next activity is to help participants practise thinking about the method of transfer which will best suit different users. activity groups: Have three people in each group. instructions: Ask each group to: • read the user stories in their workbook; • decide for each wheelchair user which transfer method will best suit them. Monitor: Monitor the groups and assist if necessary. Time: Allow 10 minutes. Feedback: Ask each group to feed back which transfer method they selected for each wheelchair user, and briefly explain why. 107 User’s story learning points Faridah is 60 years old. She was referred to the wheelchair service by the local hospital. She has recently had a stroke, and needs a wheelchair as she cannot walk. She can stand up a little and take her own weight. However she is very unsteady on her feet. Faridah lives with her daughter and her family. Her daughter does not work and is able to help her mother at home. She has a four-wheel wheelchair with swing-away footrests. • Faridah should be able to transfer through standing with assistance. • Her daughter is at home and able to assist. She should be involved in transfer education. Jose is 45 years old and has been using a wheelchair for 10 years. He is a double above-knee amputee, and works in a radio repair workshop in the local market. Jose has come to the wheelchair service to get a new wheelchair, as his old one is very worn. • Jose should be able to transfer through sitting independently. Tahir is 14 years old and has recently been referred to the wheelchair service for a wheelchair after falling from a tree and suffering a spinal cord injury. Tahir has good use of his arms but he is not yet very strong. He cannot use his legs at all. • Tahir should be able to transfer through sitting with assistance or a transfer board. With practice, he may be able to transfer on his own. 7. key point summary (3 minutes) read the key points. ask whether there are any questions. • Wheelchair users need to be able to get in and out of their wheelchair safely, quickly and without too much effort. • When getting in and out of a wheelchair, users need to remember three main safety points: – use the brakes; – check the area; – lift – do not bump or drag. • Wheelchair personnel play an important role in helping wheelchair users to learn a safe and effective way to get in and out of their wheelchair. A.8. Transfers: 8 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 108 BASIC LEVEL B: Wheelchair service steps 109 B.1: referral and appointment O B Je c T iv e S By the end of this session, participants will be able to:  describe how wheelchair users may be referred to a wheelchair service;  describe the appointment system used in the local wheelchair service. r e S O U r c e S For the session:  PPT slides: B.1 Referral and appointment;  Reference Manual;  Wheelchair service referral form (if available). c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  how wheelchair users are referred to services in the participants’ area;  if the wheelchair services that participants come from have a defined method of referral and an appointment system, teach this as a part of this session – introduce any forms in use and give participants a chance to practise using them. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan.  Prepare OR ask participants to bring a list of the different ways that wheelchair users are referred to their wheelchair service. O U T l in e 1. Introduction. 2. Referral. 3. Appointment. 4. Key point summary. 2 12 13 3 Total session time 30 Wheelchair Service Training Packag e 110 BASIC LEVEL 1. introduction (2 minutes) explain: Referral and appointment is the first step in wheelchair service delivery. in this session, we will discuss the different ways that wheelchair users may be referred to a wheelchair service, and different appointment systems. 2. referral (12 minutes) ask: What does “referral” mean? encourage answers. Most important answer: • sending or directing a person to the right place for care or help. Show slide. explain: There are different ways that wheelchair users may be referred to a wheelchair service. For example, wheelchair users may: • hear about the service and come themselves; • be directed to the service by the local hospital, community health centre, community-based rehabilitation service, village/council/church leaders, disabled people’s organizations, other wheelchair users. ask: What other organizations, services or people may refer wheelchair users to a wheelchair service? encourage answers. Step 1 Referral and appointment • In this session participants will: – Discuss the different ways that the wheelchair users may be referred to a wheelchair service; – Discuss different appointment systems. B.1. Referral and appointment: 2 BASIC LEVEL INTRODUCTI ON •Referral means: Sending or directing a person to the right place for care or assistance. B.1. Referral and appointment: 3 BASIC LEVEL WHAT IS REFE RRAL? 111 answers may include: • doctors; • village/council/church leaders; • rehabilitation centres; • disabled people’s organizations; • other wheelchair users; • nongovernmental organizations. explain: These organizations, services or people are all “referral sources”. Wheelchair services can help increase the number of wheelchair users who are referred to the service by making sure that all possible referral sources know about the service. ask participants to look at the sample wheelchair service referral form in the participant’s Reference Manual Or hand out local wheelchair service referral form, if there is one. explain: • Providing referral sources with a wheelchair service referral form can help to give the wheelchair service some simple initial information about the wheelchair user. • each wheelchair service needs to decide whether a wheelchair service referral form is useful for that service, what information to include and how the form will be used (for example, posted to the service or handed to the wheelchair user to bring). • Different ways that wheelchair users may be referred to a wheelchair service are: d / / h l h l / h b l – octors nurses ea t c inics re a i itation centres; – village / council / church leaders; – disabled persons organizations; – other wheelchair users; – nongovernmental organizations. • Increase the number of wheelchair users referred to a service by telling referral sources about the service. B.1. Referral and appointment: 4 BASIC LEVEL REFERRAL SO URCES B.1. Referral and appointment: 5 BASIC LEVEL SAMPLE REFE RRAL FORM Wheelchair Service Training Packag e 112 BASIC LEVEL 3. appointment (13 minutes) explain: • When a wheelchair user is referred to a wheelchair service, he/she should be given an appointment for an assessment. The appointment may be for the wheelchair user to visit the service/ centre, or for wheelchair service personnel to visit the user. • an appointment system helps wheelchair service personnel organize their time. it also helps wheelchair users avoid having to wait around to see wheelchair service personnel. • The way the appointment is made depends on how easy it is to get a message to the wheelchair user. ask: What are some of the ways that a wheelchair service could get a message to a wheelchair user? encourage answers. answers may include: • telephone; • post; • send a message with a community worker; • radio; • send a message back to the referral source, asking it to contact the wheelchair user ; • send a message through a friend/family member. explain: sometimes wheelchair users will arrive without an appointment. if the wheelchair user has travelled a long way, it is important to try and arrange a way to see him/her. if there is a specific appointment system in the participant’s local wheelchair service, explain the system. • When a wheelchair user is referred to a wheelchair service, he or she should be given an appointment for an assessment. • An appointment system helps: – wheelchair personnel to organize their time; – wheelchair users to avoid having to wait around for wheelchair personnel to see them. • Appointment systems need to be practical for wheelchair users and the wheelchair service personnel. B.1. Referral and appointment: 6 BASIC LEVEL APPOINTMEN T 113 4. key point summary (3 minutes) read the key points. ask whether there are any questions. B.2: assessment O B Je c T iv e S By the end of this session, participants will be able to:  explain the purpose of assessment;  list the two parts of a wheelchair assessment;  list information that is gathered during an assessment. r e S O U r c e S For the session:  PPT slides: B.2 Assessment;  Reference Manual. c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  how assessment is carried out in the participants’ service. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan. • It is important to tell referral sources about the service. • A wheelchair referral form can help to give a wheelchair service some initial information about the wheelchair user. • An appointment system can help wheelchair personnel organize their time; and reduces waiting times for wheelchair users. • Referral systems and appointment systems need to be practical for the wheelchair users and wheelchair services. This includes considering how easily people can travel and the different ways that messages can be send. B.1. Referral and appointment: 7 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 114 BASIC LEVEL O U T l in e 1. Introduction. 2. Who needs a wheelchair? 3. Why do you need an assessment? 4. Where to carry out assessment. 5. Two parts of basic assessment. 6. Key point summary. 2 5 10 5 5 3 Total session time 30 1. introduction (2 minutes) explain: • assessment is the second step in wheelchair service delivery. • in this session, we will explain why assessment is important and introduce the two parts of the assessment. • During the assessment sessions, remember that wheelchair users need to be actively involved in the assessment – ask and listen to their answers and opinions. 2. Who needs a wheelchair? (5 minutes) explain: When someone comes to a wheelchair service for a wheelchair, it is important to be sure that a wheelchair is really what they need. ask: How do you know if someone needs a wheelchair? encourage answers and write on the board. Most important answers: • the person cannot walk; • the person can walk – however, walking is difficult or he/she can walk only for a short distance. Step 2 Assessment • In this session participants will: – Explain why assessment is important; – Introduce the two parts of a basic wheelchair assessment. B.2. Assessment: 2 BASIC LEVEL INTRODUCTI ON 115 explain: • even if a person can walk for a short distance, he/she may need a wheelchair for longer distances. • Using a wheelchair will not usually stop someone from using his/her ability to walk. • The right choice is the one that helps the user to be as mobile as possible and have the best quality of life. it is the user’s right to choose. 3. Why do you need an assessment? (10 minutes) ask: Why do you need an assessment? encourage answers and write on the board. Most important answers: • to help choose the most appropriate wheelchair for the wheelchair user from those available; • to help choose the most appropriate wheelchair components from those available ; • to find out what training the wheelchair user and/or the family need to make the most of the wheelchair. ask: What information do participants think should be gathered in an assessment? encourage answers and write on the board. answers may include: • name, age, address; • where the user lives – type of ground, size of house, steps, etc.; • where the user works or goes to school; • the things the wheelchair user does, or wants to do (lifestyle); • how far the wheelchair user may need to travel each day; • how the wheelchair user gets in and out of the wheelchair (transfers); • who the person lives with; • the wheelchair user’s impairment or disability; • his/her physical abilities; • how long the wheelchair user spends in the wheelchair every day; • health – including risk of pressure sores; • physical dimension; • whether the user already has a wheelchair and whether it meets his/her needs; • how the wheelchair user travels around – for example, does he/she use public transport? • People usually need a wheelchair because: – they cannot walk; – they can walk, but with difficulty or only for a short distances. • E if lk f h t di t th d ven a person can wa or a s or s ance ey may nee a wheelchair for longer distances. • Using a wheelchair will not usually stop someone from using their ability to walk. • The right choice is the one that assists the user to be as mobile as possible and have the best quality of life. B.2. Assessment: 3 BASIC LEVEL WHO NEEDS A WHEELCHA IR? Wheelchair Service Training Packag e 116 BASIC LEVEL explain: • all of this information helps the wheelchair user and personnel to: - choose the most appropriate wheelchair and cushion; - choose the most appropriate wheelchair parts/features and; - identify what training or support the wheelchair user may need. • For example: - a wheelchair user who spends all day in the wheelchair and travels long distances will need a wheelchair that is comfortable, supports him/her well, and is strong and good for pushing outdoors; - a wheelchair user who does not have an efficient way of getting in and out of the wheelchair may need help to learn ways to transfer. 4. Where to carry out assessment (5 minutes) explain: • assessments should always be carried out in a quiet and clean space. • This may be a space within the wheelchair service, at another health- care or community facility, or at the user’s home. ask: Where will participants carry out assessments in their wheelchair service? acknowledge answers. if participants do not know, remind them that they will need to make sure there is a quiet and clean space they can use to carry out wheelchair assessments. • The information gained from an assessment helps the wheelchair user and wheelchair personnel to: – choose the most appropriate wheelchair for the wheelchair user from those available; – choose the most appropriate wheelchair components from those available; – find out what training the wheelchair user and/or the family need to make the best use of the wheelchair. B.2. Assessment: 4 BASIC LEVEL WHY DO YOU NEED AN ASS ESSMENT? A t h ld l b • ssessmen s s ou a ways e carried out in a quiet and clean space. •This may be a space within the wheelchair service, at another health care or community facility, or at the user's home. B.2. Assessment: 5 BASIC LEVEL WHERE TO CA RRY OUT AN A SSESSMENT? 117 5. Two parts of basic assessment (5 minutes) explain: assessment is carried out in two parts: • assessment interview; • physical assessment. information is recorded on a wheelchair assessment form. in the next few sessions, participants will begin practising carrying out a wheelchair assessment. 6. key point summary (3 minutes) read the key points. ask whether there are any questions. •Assessment is carried out in two parts: – interview assessment; – physical assessment. B.2. Assessment: 6 BASIC LEVEL TWO PARTS O F A BASIC ASS ESSMENT • Wheelchair users should be an equal participants in their wheelchair assessment. • Assessment means gathering information to help choose the most appropriate wheelchair for the wheelchair user from those available. • Assessment also helps to identify what type of training the wheelchair user may need. • Assessment should be done in a quiet and clean space. • Assessment is carried out in two parts – interview assessment and physical assessment. B.2. Assessment: 7 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 118 BASIC LEVEL B.3: assessment interview O B Je c T iv e S By the end of this session, participants will be able to:  demonstrate an assessment interview;  record information from an assessment interview on a wheelchair assessment form;  explain how questions in the assessment interview help to choose the most appropriate wheelchair and to identify what a wheelchair user may need to learn. r e S O U r c e S For the session:  PPT slides: B.3 Assessment interview;  Reference Manual;  Participant’s Workbook;  one wheelchair for each group of three. c O n T e X T Adapt this session to suit the context participants will be working in.  If there is a disability type which is very common in the local context, and is not covered in the wheelchair assessment form, add this to the wheelchair assessment form and include in the session.  Change the user’s stories if these do not suit the local context. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan. O U T l in e 1. Introduction. 2. Information about the wheelchair user. 3. Physical condition. 4. Lifestyle and environment. 5. Existing wheelchair. 6. Assessment interview practice. 7. Key point summary. 2 10 15 15 5 40 3 Total session time 90 119 1. introduction (2 minutes) explain: in this session, participants will: • learn how to carry out the first part of the assessment – the interview; • look at each part of the assessment interview and learn how the answers to the questions in the assessment interview affect the choice of wheelchair. each participant will have a chance to practise being the interviewer. 2. information about the wheelchair user (10 minutes) explain: Before we begin looking at the interview questions, there are a few things to remember when asking questions. • always explain to the wheelchair user before you begin that the questions you are going to ask will help you and the wheelchair user choose the most appropriate wheelchair. • always address the wheelchair user (not the assistant/family member) unless he/ she is a small child or unable to understand or answer your questions. • Use good communication techniques. ask: What are some examples of good communication techniques? encourage answers and write on the board. Most important answers: • speak clearly; • use straightforward terms; • explain what is going to happen before it happens; • after explaining something, check that the wheelchair user understands; • listen carefully and check to make sure you have understood the wheelchair user correctly; • make eye contact (where appropriate); • be respectful; • don’t assume you know best; • show you are interested. Step 2 Assessment • In this session participants will: – Learn how to carry out the first part of the assessment – the interview. – Look at each part of the interview and learn how the answers to the questions in the assessment interview affect the choice of the type of the wheelchair. B.3. Assessment interview: 2 BASIC LEVEL INTRODUCTI ON Wheelchair Service Training Packag e 120 BASIC LEVEL Give a wheelchair assessment form to each participant. Start PPT slides B.3 assessment interview. explain: • information from four areas is collected in the assessment interview. • We will look at each area now, and explain how the answers to the questions in the assessment interview affect the choice of wheelchair. • Questions do not need to be asked in the order given on the form. sometimes wheelchair users will volunteer information before they are asked, or it may be more natural to ask questions in a different order. explain: • The “information about the wheelchair user” questions ensure that the wheelchair user can be contacted for follow up in the future. • They also help the service to gather statistics about wheelchair users seen at the service. 3. Physical condition (15 minutes) explain: • Under the heading “physical condition”, personnel will name the wheelchair user’s condition if this is known, and note whether the wheelchair user has any physical conditions which will affect the choice of a wheelchair. • some of the most common conditions are listed with a tick box. These are: cerebral palsy, polio, spinal cord injury and stroke. • There is also a tick box for “others”. if you tick “others”, you can write the condition next to the tick box. • information about the wheelchair user; •physical condition; • lifestyle and environment; •existing wheelchair. •Questions do not need to be asked in the order shown on the assessment form. B.3. Assessment interview: 3 BASIC LEVEL ASSESSMENT INTERVIEW Information about the wheelchair user Number:Name: Male  Female Age: Address:Phone no.: Goals: B.3. Assessment interview: 4 BASIC LEVEL INFORMATION ABOUT THE W HEELCHAIR U SER Physical condition Cerebral palsy  Polio  Spinal cord injury  Stroke  Frail  Spasms or uncontrolled movements  Amputation: R above knee  R below knee  L above knee  L below knee  Bladder problems  Bowel problems  If h h l h i h bl dd b l bl i hi d? Y  N t e w ee c a r user as a er or owe pro ems, s t s manage es o Others: ________________________________________________________________ B.3. Assessment interview: 5 BASIC LEVEL PHYSICAL CO NDITION 121 explain: • it is helpful (although not always necessary) to know which condition a wheelchair user has. • This is because some of the features of different conditions can affect the choice of wheelchair. • We will now look at the most important things to remember for the different conditions when prescribing (selecting) a wheelchair. • This information is in the reference manual. explain: • cerebral palsy affects people very differently. • For a person with cerebral palsy who can sit upright, it is important to remember that they may have difficulty keeping their sitting position because they get tired. This makes doing things harder and more tiring. • Good support is very important. • People with cerebral palsy may need additional postural support in a wheelchair. To do this safely and effectively, intermediate-level training is needed. click through the slide to emphasize the key points to remember. •Remember: People with cerebral palsy – usually need very good support in their wheelchair; Refer an erson who – y p needs extra support to sit upright to an intermediate level training. B.3. Assessment interview: 6 BASIC LEVEL CEREBRAL PA LSY Wheelchair Service Training Packag e 122 BASIC LEVEL explain: • People who have poliomyelitis may have weakness or “floppiness” of body parts. Poliomyelitis can affect legs, arms or trunk, but most commonly it affects the legs. • The muscles and bones become thinner and the limb does not grow so fast and so is shorter. • When the trunk is affected, it may appear shorter. • although people with poliomyelitis have sensation, a cushion is important for comfort. • a higher cushion may provide a more comfortable pushing position. click through the slide to emphasize the key points to remember. explain: • People with a spinal cord injury are very likely to be at risk of developing a pressure sore. • This is because most people with a spinal cord injury cannot feel below the level of their injury. • always prescribe a pressure relief cushion. click through the slide to emphasize the key points to remember. •Remember: A cushion can be important – for comfort; C k – ontractures can ma e sitting upright difficult; – Work out an individual solution for each person; – A higher/thicker cushion may provide a more comfortable pushing position. B.3. Assessment interview: 7 BASIC LEVEL POLIOMYELIT IS •Remember: – Always prescribe a pressure relief cushion. B.3. Assessment interview: 8 BASIC LEVEL SPINAL CORD INJURY 123 explain: • People who have had a stroke are usually affected on one side of their body. This means they may fall to one side in the wheelchair. • People who have had a stroke may not be able to feel normally on the affected side of their body. • People who have had a stroke may be able to get in and out of the wheelchair by standing up. • Good support is important. • check if the person can feel – he/she may need a pressure relief cushion. • a person with a stroke may prefer a wheelchair with footrests which move out of the way so that he/she can do a standing transfer. click through the slide to emphasize the key points to remember. explain: • We will now look at how other conditions may affect the choice of wheelchair. explain: • People who are double amputees do not have the weight of their legs to stop their wheelchair from tipping backwards. • always be careful when an amputee first tries a wheelchair. • check the wheelchair balance. The rear wheel may need to move backwards to provide extra stability. click through the slide to emphasize the key points to remember. •Remember: Good support is important;– – Footrests that move away for d f b a stan ing trans er may e important; – Think about how the wheelchair user will propel themselves. B.3. Assessment interview: 9 BASIC LEVEL STROKE •Remember: Check wheelchair balance;– – Teach mobility skills carefully; – Always be careful when an amputee first tries a wheelchair; – The rear wheels may need to move backwards to provide extra stability. B.3. Assessment interview: 10 BASIC LEVEL LOWER LIMB AMPUTATION Wheelchair Service Training Packag e 124 BASIC LEVEL explain: • elderly people may need a wheelchair for different reasons. Usually it is because they are having difficulty walking. The wheelchair will make it easier for them to continue to be a part of family and community life. • elderly people may be able to do a standing transfer, and will prefer a wheelchair with flip- up or swing-away footrests. • elderly people should always be given a wheelchair which provides good comfort and support. This will help them to sit well and avoid problems caused by poor posture. • Flip-up or swing-away footrests may be the best choice. click through the slide to emphasize the key points to remember. explain: • some people have problems with sudden, jerking movements that they cannot control (spasms). • spasms can throw the person’s weight backwards, which could cause the wheelchair to tip over. in this case, a safe back wheel position should be considered. • spasms can cause feet to “jump” off the footrests. This can be dangerous when propelling. a calf strap may help keep the foot in position. a lap strap may also help. • straps should fasten with velcro so the strap will release if the user falls out of the wheelchair. click through the slide to emphasize the key points to remember. •Remember: – Provide good comfort and support; – Flip-up or swing-away footrests may be the best choice. B.3. Assessment interview: 11 BASIC LEVEL FRAIL •Remember: Safe back wheel position;– – Straps may be helpful. B.3. Assessment interview: 12 BASIC LEVEL SPASMS OR JE RKY MOVEME NTS 125 explain: • some people have difficulty controlling their bladder or bowels. This is very commonly a problem for people with a spinal cord injury. • These problems can be overcome with the right equipment, medication and a bladder and bowel training programme. identify who in your area, e.g. specialist doctors and nurses, can offer advice and training on bowel and bladder management. • People with bladder or bowel problems must not sit on a damp or soiled cushion, as the skin can rapidly break down. in addition, the bugs present in faeces rapidly lead to infected pressure sores. • Provide a cushion with a waterproof cover. Teach the user how to wash and dry the cushion. • a second cushion is often needed to enable the wheelchair user to continue with day-to-day activities while waiting for the cushion to dry. click through the slide to emphasize the key points to remember. 4. lifestyle and environment (15 minutes) explain: • The lifestyle and environment questions gather information about where the wheelchair user lives and the things that he/she needs to do in the wheelchair. read out each question/point and ask: How will answers to this question help in choosing the most appropriate wheelchair, or identify what the wheelchair user may need to learn? acknowledge answers and give examples if necessary. •Remember: – Refer wheelchair user to someone who can help resolve bowel or bladder problems; – Prescribe a waterproof cushion cover if available; – Teach how to wash and dry the cushion, – Prescribe two cushions if possible. B.3. Assessment interview: 13 BASIC LEVEL LIFESTYLE AN D ENVIRONM ENT Describe where the wheelchair user will use their wheelchair: ____________________________________________________________________________ D ll d d U 1 k  1 5 k  M h 5 k istance trave e per ay: p to m – m ore t an m Hours per day using wheelchair? Less than 1  1-3  3-5  5-8  more than 8 hours  When out of the wheelchair where does the user sit or lie down and how (posture and the surface? , ____________________________________________________________________________ Transfer: Independent  Assisted  Standing  Non Standing  Lifted  Other  Type of toilet (if transferring to a toilet): Squat  Western  Adapted  Does the wheelchair user often use public/private transport? Yes  No  If yes, then what kind: Car  Taxi  Bus  Other _____________________________ B.3. Assessment interview: 14 BASIC LEVEL LIFESTYLE AN D ENVIRONM ENT Wheelchair Service Training Packag e 126 BASIC LEVEL Question: Most important answers Describe where the wheelchair user will use their wheelchair • The wheelchair needs to be practical for the wheelchair user’s home, work or school. For example: - if the wheelchair will be used at home, the wheelchair user needs to be able to move about the home easily to carry out important day-to-day activities; - a wheelchair user who works in an office will need a wheelchair which can fit easily into the office space; - a wheelchair user who goes to school will need the wheelchair to fit comfortably in the classroom and under a desk, or will need a tray built on to the wheelchair ; - a wheelchair user who needs to travel to the market to work on a rough track needs a wheelchair which works well on rough terrain. Distance travelled per day? • Just as someone may walk if going a shor t distance, but use a bicycle for longer distances, a wheelchair user may use a wheelchair for shor ter distances and a tricycle for longer distances. • A tricycle takes less energy to cover the same distance and is faster. hours per day using wheelchair? • The longer the person sits in the wheelchair, the greater the risk of fatigue or a pressure sore. Think about how much support the person needs and whether the cushion provides enough pressure relief and comfort. • For any person who is “active” in their wheelchair during the day, the wheelchair should be set up to make pushing and other activities as efficient as possible. The wheels position is impor tant. It is also impor tant to check that the backrest suppor ts the user, but does not restrict freedom of movement of the shoulders. Transfer used • Armrests and footrests can affect how a wheelchair user gets in and out of the wheelchair : - for standing transfers, it is helpful to have footrests which move out of the way and armrests that the user can use to push up; - for non-standing transfers, removable armrests or armrests which follow the profile of the wheels can make the transfer easier. Type of toilet The type of toilet and physical access to the toilet will affect how easy it is for the wheelchair user to use it. It may not be possible to use the toilet because of the design. For example, most wheelchair users find it very difficult to use squat toilets. By asking about the toilet and where the toilet is, the personnel can offer advice on how to transfer to and from the toilet. Personnel may also offer advice on how to adapt the toilet. 127 Does the wheelchair user often use public/ private transport? If a wheelchair user frequently uses transport, he/she will need to be able to transport the wheelchair easily. Different features of a wheelchair which make transporting it easier include the following: • lighter wheelchairs are easier to lift in and out; • removable wheels and folding frame/backrest make a wheelchair easier to transport. If using public transport, removable parts can be an advantage, as this makes the wheelchair easier to load. However, removable parts can also be a disadvantage, as parts may become separated and lost or stolen. 5. existing wheelchair (5 minutes) explain: • if a wheelchair user already has a wheelchair, it is important that this wheelchair is assessed to see why it is not meeting his/her needs. • Read each of the questions on the wheelchair assessment form “existing wheelchair”. if the answer to any of these questions is “no”, wheelchair personnel should describe the problem under “comments”. Depending on the resources available, a way to modify or repair the existing wheelchair may be considered during prescription. if the answer to every question is “yes”, it is very likely that the wheelchair user does not need a new wheelchair. This should be discussed with the wheelchair user. 6. assessment interview practice (40 minutes) activity groups: Have three people in each group. instructions: Ask each group to role-play carrying out the assessment interview – using the wheelchair user stories in their workbook. Emphasize – if possible only the person role-playing the wheelchair user should read that story. Each time, a different person should take the role of the wheelchair user and use the information from their user story to answer the interview questions. The wheelchair user should not read the story out loud. The other two participants work together to carry out the interview and record the information on the wheelchair assessment interview forms in the workbook. • Existing wheelchair (if a person already has a wheelchair) – Does the wheelchair meet the user’s needs? Yes � No � Does the wheelchair meet the user’s environmental conditions? Yes � No �– – Does the wheelchair provide proper fit and postural support? Yes � No � – Is the wheelchair safe and durable? (Consider whether there is a cushion) Yes � No � – Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes � No � – Comments: _____________________________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications. B.3. Assessment interview: 15 BASIC LEVEL EXISTING WH EELCHAIR Wheelchair Service Training Packag e 128 BASIC LEVEL Monitor: Monitor the groups and assist if necessary. Time: Allow 10 minutes for each interview and 10 minutes for whole group feedback. Feedback: Briefly discuss each wheelchair user represented in the stories. show the slide for each user and ask participants the questions on the slide. • What did interviewers find out that would help choose the most appropriate wheelchair for Felicia/Anton/Chantou? • What did interviewers find out that would help identify things that Felicia/Anton/Chantou may need to learn to be able to use the wheelchair? • Are Anton’s and Chantou’s existing wheelchairs meeting their needs? Why/why not? Trainers may refer to the suggested learning points below. User’s story Suggested learning points Felicia is an elderly woman with severe arthritis. She has pain in her arms, hands and legs. She is unable to walk more than a few steps because of the pain and finds it difficult to look after herself. Felicia has attended the assessment with her daughter who also helps her at home. She lives in a small town and her house has three steps at the front entrance. She does not have any health problems apart from the arthritis. She used to go to church regularly, but is no longer able to do so. Her family do not own a car, and rely on public transport. To come to the assessment, the family hired a taxi. However, this is expensive for them. She does not currently have a wheelchair. Information to help choose the most appropriate wheelchair. • Felicia is in a lot of pain – she is likely to need to be attendant-propelled because of her pain. • Felicia can walk a few steps – she is likely to use a standing transfer and would benefit from a wheelchair with footrests that swing away. • Felicia’s family does not own a car – she may need to take the wheelchair on public transport, so folding capacity could be helpful. Information to help identify what Felicia needs to learn. • Felicia’s daughter helps her at home – both Felicia and her daughter need to learn safe transfer techniques and how to go up and down steps in a wheelchair. 129 User’s story Suggested learning points anton has polio. He is 26 years old and lives in a small town. He is studying computer skills and wants very much to start his own business in the future. He has attended the assessment with his wife. A long time ago he received a donated orthopaedic-style wheelchair. The chair is rusted and the seat upholstery has ripped. The front castor wheels are small and thin. The rear wheel tyres are very thin and worn. The wheelchair is uncomfortable and difficult to push. The paths in the town are very rough and his wheelchair gets stuck often. However, he would like to be able to travel from his home to the vocational training centre on his own. The distance is about 1½ km. At present, he needs help from his younger brother – who cannot always take him on time. Information to help choose the most appropriate wheelchair. • Anton lives in a place where the paths are rough and he wants to be able to travel between his home and where he studies – he needs a wheelchair which he can push himself over rough ground. • Anton spends a lot of time in his wheelchair – good postural support is important, as he will spend a long time in his wheelchair each day while training. Information to help identify what Anton needs to learn. • Anton needs to be very mobile over difficult terrain – training in wheelchair mobility skills could really help him. • Anton uses his wheelchair a lot over rough ground – learning how to maintain his wheelchair to keep it working well would be very helpful. Anton’s existing wheelchair. • Anton’s existing wheelchair is in poor repair and is not meeting his environmental or physical needs. Special note: Where tricycles are available, trainers may point out that a tricycle could be a good solution for this wheelchair user to help him travel the distance to the training centre each day. Wheelchair Service Training Packag e 130 BASIC LEVEL User’s story Suggested learning points chantou is 13 years old. She lost both of her legs (above the knee) during an earthquake. She lives with her family in an apartment in a nearby town. She has attended the assessment with her mother and older sister. She has a wheelchair which was donated to her. It is an adult size orthopaedic-style wheelchair. The wheelchair is too big for Chantou. She has to reach up over the armrests to reach the push rims. This is difficult for her. The backrest is also very high and there is no cushion. chantou would like to go back to school, but she feels physically uncomfor table in the wheelchair. She also feels embarrassed that she cannot move herself around. She would like a wheelchair that she can push herself, and which gives her more suppor t. She says she would use the school bus if her wheelchair could travel with her. Information to help choose the most appropriate wheelchair. • Chantou is uncomfortable in her current chair and needs to spend a lot of time in her chair – Chantou needs a wheelchair which fits her correctly so that she is well supported – good postural support will help her to have more stamina during the day, which she will need to attend school. • Chantou needs to go on the school bus – she needs a wheelchair which can travel with her. Chantou’s existing wheelchair. • Her existing wheelchair is too large, and does not help her to move around on her own; a lightweight wheelchair with good postural support would be more suited to her needs than her current wheelchair. 7. key point summary (3 minutes) read the key points. ask whether there are any questions. • The assessment interview is an opportunity to gather information about: – the wheelchair user; physical condition;– – lifestyle and environment; – existing wheelchair. • Relevant information gathered in the assessment interview should be accurately recorded in the wheelchair assessment form. B.3. Assessment interview: 19 BASIC LEVEL KEY POINT SU MMARY 131 B.4: Physical assessment O B Je c T iv e S By the end of this session, participants will be able to:  record the presence, risk of or history of pressure sores;  explain what action should be taken if a wheelchair user has a pressure sore or is at risk of developing a pressure sore;  identify and record how a wheelchair user will push the wheelchair ;  demonstrate the correct way to take measurements from a wheelchair user for a wheelchair (seat width, seat depth, calf length, back height);  describe how body measurements relate to wheelchair size. r e S O U r c e S For the session:  PPT slides B.4: Physical assessment;  Reference Manual;  Participant’s Workbook;  DVD: Measurement demonstration;  wheelchairs with footrests that move out of the way (if available) – 1 per 3 participants;  wheelchair assessment forms – 1 per wheelchair user ;  tape measures for measurement practice – 1 per participant. c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  where participants are most likely to carry out assessment – for example in wheelchair users’ homes, community clinics or a dedicated wheelchair service space. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Arrange the wheelchairs around the room.  Ensure at least one wheelchair has flip-up or swing away footrests (for the foot propulsion exercise). O U T l in e 1. Introduction. 2. Prepare. 3. Presence, risk of or history of pressure sores. 4. Method of pushing. 5. Taking measurements. 6. How to take body measurements. 7. Key point summary. 2 5 10 20 30 20 3 Total session time 90 Wheelchair Service Training Packag e 132 BASIC LEVEL 1. introduction (2 minutes) explain: in this session, we will practise the physical part of a wheelchair assessment. We will: • learn how to record the presence, risk of, or history of, pressure sores for a wheelchair user; • discuss the different ways that wheelchair users may propel their wheelchairs and practise foot propelling; • learn how to take the most important body measurements to help choose the correct size wheelchair for a wheelchair user. 2. Prepare (5 minutes) explain: For the physical assessment, ask the wheelchair user to transfer from the wheelchair (if sitting in one) to an assessment bed. This will make it easier to observe the wheelchair user’s posture and carry out measurements. it is also a chance to see how the wheelchair user transfers. some things to remember are listed below. Step 2 Assessment • In this session participants will practise the physical part of an assessment. Participants will: Learn how to record the presence risk of or history of – , pressure sores for a wheelchair user; Di th diff t th t h l h i l – scuss e eren ways a w ee c a r users may prope their wheelchairs and practise foot propelling; L h k h i b d – earn ow to ta e t e most mportant o y measurements to help select the correct size wheelchair for a wheelchair user. B.4. Physical assessment: 2 BASIC LEVEL INTRODUCTI ON 133 explain: • as with the interview, the assessment should be carried out in a clean and quiet space. • Privacy is important if it is necessary to assess for pressure sores. • always explain to the wheelchair user what you are going to do, and why. • When the wheelchair user does transfer, be ready to offer assistance if you can see that he/she is not able to transfer safely and easily alone. • When the wheelchair user is on the assessment bed: - provide foot blocks if the feet do not comfortably reach the floor; - always stay close by until you are sure that the wheelchair use is safe and comfortable sitting upright alone. 3. Presence, risk of, or history of, pressure sores (10 minutes) explain: We have already talked in detail about the importance of preventing pressure sores. ask: can anyone recall the most important risk factors – those things that make it more likely that a person may develop a pressure sore? encourage answers. Try to elicit all the pressure sore risks listed below. Most important answers: • cannot feel (decreased sensation); • cannot move; • moisture from sweat, water or incontinence; • poor diet and not drinking enough water ; • ageing; • poor posture; • previous or current pressure sore; • weight – underweight or overweight. •Carry out assessment in a clean and quiet space. • Explain what you are going to do and why. •Make sure the wheelchair user is safe: – when they transfer; h h – w en sitting on t e assessment bed/plinth. B.4. Physical assessment: 3 BASIC LEVEL PREPARE Wheelchair Service Training Packag e 134 BASIC LEVEL explain: The assessment form will help participants to assess pressure sore risk. Show slide and click through to explain the following points: • a person who cannot feel is at risk of developing a pressure sore; • a person who has three or more of any other risk factors is at risk of developing a pressure sore. ask participants to look at their copy of the wheelchair assessment form. explain: Participants should ask wheelchair users the questions on the form. • can they feel normally? • Have they ever had a pressure sore? if so – ask the user where. Mark this on the body on the form. • Do they currently have a pressure sore? - if so – ask if you can see it so that you can be sure where the sore is and how serious it is; - be sensitive when you ask to see a person’s pressure sore; - ensure the wheelchair user’s privacy by drawing a screen around the assessment area; - state whether the sore is an open sore or not, and mark where the pressure sore is on the body on the form; - ask the wheelchair user how he/she thinks the sore was caused, and how long he/she has had it. • circle any risk factors. • Tick whether the wheelchair user is or is not at risk of developing a pressure sore. • cannot feel (decreased sensation); • cannot move; •moisture from sweat, water or incontinence; •poor posture; •previous or current pressure sore; •poor diet and not drinking enough water; • ageing; •weight: underweight or overweight. B.4. Physical assessment: 4 BASIC LEVEL PRESSURE SO RE RISK FACT ORS INCLUDE : B.4. Physical assessment: 5 BASIC LEVEL PRESENCE, RIS K OR HISTORY OF PRESSURE SORES 135 ask: What action should be taken if the wheelchair user has an open pressure sore of stage 2 or higher? encourage answers. Most important answers: • refer for treatment; • advise the wheelchair user to take pressure off the sore – this may mean not using the wheelchair. ask: What action should be taken if a wheelchair user is at risk of developing a pressure sore? encourage answers. Most important answers: • provide pressure relief cushion – check whether the cushion is effective by carrying out the seat bones test; • provide education on prevention – teach pressure relief techniques and importance of being active and changing position regularly; check skin daily for marks. Notes for trainers: This question relates to whether a person is “at risk” of developing a pressure sore. If someone actually has a pressure sore, the actions are different. 4. Method of pushing (20 minutes) explain: • it is important to find out how the wheelchair user will push. This can affect the choice of wheelchair. • Wheelchair users push their wheelchairs in different ways. • some push with their arms, some with their legs, and some have a helper to push them. ask: What physical abilities will affect how a wheelchair user pushes? encourage answers. B.4. Physical assessment: 6 BASIC LEVEL METHOD OF P USHING Wheelchair Service Training Packag e 136 BASIC LEVEL answers: • strength and control of arms; • strength and control of legs; • ability to sit upright; • overall stability and control – if someone is not stable or has poor balance they may need to use their arms to “hold on”, then they cannot push. • strength and control over arms and legs is important as well as overall stability. a wheelchair which fits correctly and gives good postural support can make it easier for a person with poor balance or stability to push the wheelchair. ask: What is the ideal position of the rear wheel in relation to the wheelchair user for pushing with arms? answer: • When the wheelchair user holds the top of the push rim, the elbow should be bent at around 90 degrees. explain: • To propel with the feet, the wheelchair needs to be set up so that the wheelchair user’s heels comfortably reach the floor, while the pelvis is supported by the backrest. • it is important to have footrests that move out of the way. The wheelchair user may still need footrests for being pushed by someone else over a longer distance. • armrests can also be useful, as the wheelchair user may lean on these when bending forward to propel. • if a wheelchair user needs to push with the feet and the wheelchair is not set up correctly for foot propelling, the wheelchair user will have to change posture in order to push. This will be very tiring, and may cause long-term postural problems. B.4. Physical assessment: 7 BASIC LEVEL PUSHING WIT H ARMS • People who push with their feet need: – their pelvis to be well supported by the backrest; – their feet to be able to sit flat h flon t e oor. B.4. Physical assessment: 8 BASIC LEVEL PUSHING WIT H FEET 137 explain: We have practised pushing with arms during the wheelchair mobility session. Now everyone will have an opportunity to experience pushing with the legs. activity groups: Have three people in each group (ideally of varied height, as this will bring up issues of being able to reach the ground). Give one wheelchair to each group. instructions: ask each group to take it in turns to try moving the wheelchair with the feet. Ideally, they should sit with the pelvis touching the backrest. If this is not possible, they should experiment to see how they can reach the floor to propel. This will help them to feel what happens if the wheelchair is not correctly set up for pushing with feet. ask participants to experiment pushing with their feet while leaning forwards, while leaning backwards, with their heel and with their toe. Monitor: Monitor the groups. Ensure the activity is carried out safely. Time: Allow 10 minutes for practice and 5 minutes for feedback. Feedback: Ask the groups: • for those who could not easily reach the floor – what did they have to do to get their foot on the floor? (Answer: either slouch, or sit further forward); • was it easier to propel while leaning forwards or backwards? (Answer: leaning forwards – ideally with pelvis against the backrest); • what would encourage someone to lean forwards? (Answer: armrests or a tray which provide a surface to lean forward on); • was it easier to propel with the toe or heel? (Answer: with the heel). explain: • Through the activity, participants will have seen how pushing with feet can be difficult and tiring if the wheelchair is not set up to be pushed with the feet. • setting the wheelchair up correctly means ensuring that the height of the seat from the ground is correct for the wheelchair user. some ways to do this include: – selecting a wheelchair which has the correct seat-to-floor height for the user (take into account the cushion height); – making the cushion thinner – which can reduce the overall height; – attaching a solid seat lower than the original seat. • if the user is going to push with the feet, wheelchair personnel should show him/her how to sit with the pelvis against the backrest, lean forward, and “pull” forward by placing the heel down first. • always teach pushing forwards, not backwards. Wheelchair Service Training Packag e 138 BASIC LEVEL VIDEO ask: if a wheelchair user is going to be pushed all the time or some of the time by an assistant, how will this affect the choice of wheelchair? answer: • strong push handles are important; • for children – high push handles will make it easier for adults to push the child. explain: The method of pushing will also impact on the training needed by the user and (if appropriate) his/her family or carers. 5. Taking measurements (30 minutes) explain: • During assessment, the wheelchair service personnel measure the wheelchair user. The wheelchair service personnel can then check the measurements of the available wheelchairs to see which will provide the best fit. • Measurements are recorded on the assessment form. • a description of how to take each measurement can be found in the Reference Manual. introduce DvD: Measurement demonstration. This DvD will show you how to take five basic wheelchair user measurements. ask participants to watch carefully, as they will practise this skill themselves afterwards. Show DvD. ask if there are any questions. B.4. Physical assessment: 9 BASIC LEVEL BEING PUSHE D BY AN ASSIS TANT Wh l h i Ch b d t t id l M t B d ee c a r measurement ange o y measuremen o ea wheelchair size easuremen (mm) o y measurement Hip width = seat widthHip widthA B less 30-50 mm = seat depth (if length is different, use shortest) LSeat depthB R = top of seat cushion* to footrests height or LCalf lengthC = top of seat cushion* to floor for foot propelling R = top of seat cushion* to top of Bottom of rib D backrest (measure D or E – depending on the user’s need) cage Bottom of shoulder blade E B.4. Physical assessment: 10 BASIC LEVEL MEASUREMEN T TABLE 139 activity groups: Have three people in each group. instructions: Ask each group to: • measure each person and record the measurements; • every member of the group should measure every other person – so that the measurements can be compared at the end of the exercise; • record the measurements in the space provided in the workbook. Monitor: Move around the groups and monitor closely. Use the guide below to check that the participants use the correct techniques. check measurements to assess how accurately participants are taking the measurements. Trainer may record measurements on a whiteboard so that any differences are highlighted. Time: Allow 15 minutes (5 minutes per person) for practice and 15 minutes for feedback. Feedback: • ask: Were all measurements of the same person the same? • ask: What may cause differences? (Answer: not using the correct technique – for example not asking the wheelchair user to sit upright, not placing the tape measure in the correct position, not reading the tape measure correctly). • ask: What problems might be caused if the wrong measurement is taken? (Answer: the wheelchair may not fit the user). Trainers – use this guide to check that participants are using correct techniques For all measurements, make sure the tape measure is held straight and the wheelchair user is sitting upright. The feet should be supported on the floor or on foot blocks if he/she cannot reach the floor comfortably. A Check there is nothing in wheelchair user’s pockets before measuring. Measure hips or widest part of thighs. Holding two clipboards/books against each side of the wheelchair user can help to get an accurate measurement. B Place a clipboard/book at the back of the wheelchair user to help get an accurate measurement. Measure from the back of the pelvis to the back of the knee in a straight line. Always measure both legs. If there is a difference between the two legs, check that the wheelchair user is sitting up with their pelvis level. If there is still a difference, make the wheelchair prescription for the shorter side. Wheelchair Service Training Packag e 140 BASIC LEVEL C Measure from the back of the knee to the base of the heel. Make sure the wheelchair user’s ankles are bent at 90 degrees (if possible). Always measure both legs. If the wheelchair user wears shoes, measure with the shoes they wear most days (if any). D Measure the seat to the bottom of the rib cage. To help find the bottom of the rib cage, place hands on both sides of the pelvis. Gently squeeze hands inwards and slide hands upwards. The bottom of the rib cage is just above the waist. E Measure from the seat to the bottom of the shoulder blade in a vertical line. To help find the bottom of the shoulder blade, ask the wheelchair user to shrug his/ her shoulders. 6. how to take body measurements (20 minutes) explain: We have now practised taking measurements from the wheelchair user. Now we will see how these measurements relate to the wheelchair. ask participants to look at their copy of the wheelchair assessment form. Point out the third column on the measurement table. explain: This explains how the body measurement relates to the wheelchair. We will look at each one now. explain: • Measurement a: Hip width equals the width of the wheelchair seat. • The wheelchair seat width should be as close to the user’s hip width as possible, but should never be smaller. • if a wheelchair user has no sensation, it is important to make sure that the sides of the wheelchair are not pressing on the pelvis or thighs. Wh l h i Ch b d M B d ee c a r measurement ange o y measurement to ideal wheelchair size easurement (mm) o y measurement Hip width = seat widthHip widthA B less 30-50 mm = seat depth (if length is different, use shortest) LSeat depthB R = top of seat cushion* to footrests height or LCalf lengthC = top of seat cushion* to floor for foot propelling R = top of seat cushion* to top of Bottom of rib D backrest (measure D or E – depending on the user’s need) cage Bottom of shoulder blade E B.4. Physical assessment: 12 BASIC LEVEL MEASUREMEN T TABLE H d h d h• ip wi t = seat ept . •Correct fit: – should fit closely. B.4. Physical assessment: 13 BASIC LEVEL HIP WIDTH 141 explain: • Measurement B: seat depth less approximately 30-55 mm is the ideal wheelchair seat depth. • correct fit gives the thigh good support. This will reduce pressure under the seat bones and help to stop pressure sores. • For wheelchair users with long legs, there may be a bigger gap. Up to 60 mm is acceptable. • if the seat length is too long, the user will not be able to sit upright. The back of the calf may also rub on the front edge of the seat, causing discomfort and/or a pressure sore. • if there is a difference between right and left sides, use the shorter leg measurement to make prescription choices. explain: • Measurement c equals either: - the measurement from the top of the seat cushion to the footrests; or - the measurement from the top of the cushion to the floor (for foot propelling). • The correct footrests height is important as this ensures that the thighs are well supported and the feet are fully supported by the footrests. • The footrests height almost always needs final adjustment at fitting, as it is hard to estimate how much the cushion will compress when the user sits on it. • The correct seat height for someone propelling with their feet is important to ensure they are well supported in the wheelchair and can reach the floor comfortably to propel efficiently. •The user’s seat depth = Measurement B minus 30 50 mm- . – Up to 60 mm is acceptable for users with long legs. • Correct fit: – Check the wheelchair user is sitting upright, their hips are all the way back and their back is touching the backrest; – Two fingers (at least) clearance between the seat and the back of the knee. B.4. Physical assessment: 14 BASIC LEVEL SEAT DEPTH • Measurement C = either: – The top of the seat cushion to the footrests; OR – The top of the cushion to the floor (for foot propelling). • Correct fit: – The thigh fully supported on the cushion with no gaps; – The foot fully supported on the footrests with no gaps. • Always re-check at fitting and adjust as necessary. B.4. Physical assessment: 15 BASIC LEVEL CALF LENGTH Wheelchair Service Training Packag e 142 BASIC LEVEL explain: • Measurement D or e equals the distance between the top of the seat cushion and the top of the backrest. • The correct fit should give the wheelchair user the support he/she needs and allow an active wheelchair user the freedom to move the shoulders to push. explain: • Measurement D – will give a backrest height which comes level with the bottom of the wheelchair user’s rib cage. • This is a good height if the wheelchair user: - is fit and active; - can sit upright easily with good balance. • Measurement e – will give a backrest height level with the bottom of the wheelchair user’s shoulder blades. • This is a good height if the wheelchair user: - is likely to get tired quickly; - has difficulty sitting upright. • explain: always take both back height measurements, as sometimes it is not clear during the assessment which height backrest will be most comfortable for the user. • Measurement D or E = the top of the seat cushion to the top of the backrest. • Correct fit: – Depends on the needs of the user; – Should give the wheelchair user the support they need; – Should allow an active wheelchair user the freedom to move their shoulders to push. B.4. Physical assessment: 16 BASIC LEVEL BACKREST HE IGHT • This is a good height if the wheelchair user: i fit d ti– s an ac ve; – can sit upright easily with good balance. B.4. Physical assessment: 17 BASIC LEVEL BACKREST LEV EL AT THE BOT TOM OF THE RI B CAGE • This is a good height if the wheelchair user: i lik l t t ti d i kl– s e y o ge re qu c y; – has difficulty sitting upright. B.4. Physical assessment: 18 BASIC LEVEL BACKREST LEV EL AT THE BOT TOM OF SHOU LDER BLADES 143 explain: We will now look at how to complete the measurement table. Show measurement table with measurements completed for the user. ask: for this person, what would be the: • wheelchair seat width? (click to show answer); • wheelchair seat depth? (click to show answer); • footrests height? (click to show answer); • backrest height for bottom of rib cage (click to show answer); • backrest height for bottom of shoulder blade (click to show answer). ask: What would participants do if the wheelchair user had a different seat depth on the left and right? encourage answers. Most important answers: • when there is a difference in seat depth on one side, the wheelchair seat depth should be as needed for the shortest side. explain: Remember – these are all ideal measurements. Personnel need to know the measurements of the wheelchairs available so that they can select the size that matches the user most closely. We will talk about this more in the next session. 7. key point summary (3 minutes) read the key points. ask whether there are any questions. Wheelchair Change body measurement to Measurement Body measurementideal wheelchair size(mm)measurement 360mmHip width = seat width360mmHip widthA 370mmB less 30-50 mm = seat depth400mmLSeat depthB (if length is different, use shortest)400mmR 330mm= top of seat cushion* to footrests height or = top of seat cushion* to floor for foot propelling 380mmLCalf lengthC 330mm 380mmR 360mm= top of seat cushion* to top of backrest (measure D or E – depending 310mmBottom of rib cage D 420B f E on the user’s need) mmottom o shoulder blade 470mm * Cushion in this case is 50mm high B.4. Physical assessment: 19 BASIC LEVEL BODY MEASU REMENT TO W HEELCHAIR S IZE • Physical assessment includes finding out: – If the wheelchair user is at risk of developing a pressure sore; – How the wheelchair user will be pushing the wheelchair; – Taking the wheelchair user’s measurements. • Wheelchair users push in different ways. The choice of wheelchair and wheelchair set up will change depending on whether the user pushes with their arms, feet or is assisted. • Accurate measuring is essential to ensure a good fitted, comfortable wheelchair. Mistakes in measuring can cause delays in providing the wheelchair. B.4. Physical assessment: 20 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 144 BASIC LEVEL B.5: Prescription (selection) O B Je c T iv e S By the end of this session, participants will be able to:  list what is included in the prescription (selection) process;  describe the main features of the wheelchairs that are available locally;  match wheelchair user needs with the most suitable locally available wheelchair;  select the correct size of wheelchair for a wheelchair user ;  write down prescription decisions on a wheelchair prescription (selection) form. r e S O U r c e S For the session:  PPT slides: B.5 Prescription (selection);  Reference Manual;  Participant’s Workbook, please note there are two B5 sections in the Participant’s Workbook);  at least one example of each locally available wheelchair, with cushion, and the wheelchair brochure or specification summary, if available;  tape measures and any tools needed to loosen adjustable parts (e.g. footrests). c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  adjusting the time depending on the number of locally available wheelchairs;  preparing and including any wheelchair-specific prescription (selection) forms – a wheelchair-specific prescription (selection) form is helpful for any wheelchair which offers a range of options or adjustments. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan.  Complete a wheelchair summary form for each available wheelchair as a reference.  Go over each available wheelchair and be fully familiar with features, adjustment range, options and how the chair is adjusted.  Adapt the wheelchair prescription (selection) form to include any options or adjustments for locally available wheelchairs (unless there is a specific wheelchair prescription (selection) form for that product).  Arrange the wheelchairs around the room, with any material about that wheelchair which is provided by the manufacturer (for example, brochure or product information). 145 O U T l in e 1. Introduction. 2. What is ‘prescription/selection’? 3. Locally available wheelchairs and cushions. 4. Selecting the right wheelchair and wheelchair parts. 5. Selecting the right wheelchair size. 6. Recording the prescription. 7. Key point summary. 2 5 60 15 25 10 3 Total session time 120 1. introduction (2 minutes) explain: • Prescription (selection) is the third step in the eight steps of service delivery. • in this session, participants will learn how to prescribe (select) a wheelchair, using the information gained in the assessment. 2. What is prescription (selection)? (5 minutes) explain: • Prescription (selection) means finding the best match possible between the wheelchairs and cushions available and the needs of the user. • The prescription (selection) should always be decided with the wheelchair user, including the family member or caregiver if appropriate. • Prescription (selection) includes: - selecting the right wheelchair and cushion size; - selecting the right wheelchair, cushion and wheelchair parts; - agreeing with the wheelchair user what training they need to help them use and care for their wheelchair and cushion. Step 3 Prescription (selection) • In this session participants will: – Learn how to prescribe (select) a wheelchair, using the i f i i d i h n ormat on ga ne n t e assessment. B.5. Prescription (Selection): 2 BASIC LEVEL INTRODUCTI ON P i ti ( l ti ) • rescr p on se ec on means: – Selecting the best match possible between the wheelchairs available and the needs of the user. • Prescription (selection) includes: Selecting the right wheelchair cushion and – , wheelchair parts; – Selecting the right wheelchair and cushion size; – Agreeing with the wheelchair user what training they need to help them use and care for their wheelchair and cushion. B.5. Prescription (Selection): 3 BASIC LEVEL WHAT IS ‘PRE SCRIPTION/SE LECTION’? Wheelchair Service Training Packag e 146 BASIC LEVEL explain: To do this, personnel first need to: • understand the wheelchair user’s needs – by carrying out a wheelchair assessment and listening carefully to what the user says; • know about the different wheelchairs and cushions available; • discuss options with the wheelchair user. 3. locally available wheelchairs and cushions (60 minutes) explain: Personnel need to be very knowledgeable about the locally available wheelchairs and cushions. They need to know about the following: • Frame – for example, whether it is a long or short wheelbase; the frame length; whether it is a cross-folding or rigid frame. • Features – including the type of seat, backrest, footrests, armrests, castor wheels, rear wheels. • Wheelchair size: This is usually described by the wheelchair seat width and sometimes also the depth. The seat height from the floor is also useful to know. • adjustability options: Which components are adjustable and what is the range of adjustment? adjustment is usually possible to two or more different positions. For example, most wheelchairs have footrests which can be adjusted to different heights spaced evenly apart. The “range” of adjustment is from the smallest to the largest measurement. • cushion: What type of cushion (if any) is provided with the wheelchair or is available separately? Wh l h l d k h d l • ee c air personne nee to now t e etai s and features of each locally available wheelchair d hian cus on. • Wheelchair personnel need to know about wheelchair: – frame; – features; – cushion; – size range; – adjustability options. B.5. Prescription (Selection): 4 BASIC LEVEL LOCALLY AVAI LABLE WHEEL CHAIRS AND C USHIONS 147 • some wheelchair suppliers provide: a. brochures or a product summary; b. product (wheelchair) specifications. • Wheelchair measurements, weights, features and sometimes optional parts are often listed in this information. • always check whether there is information available about the wheelchairs you are prescribing (selecting). Read this information so that you are familiar with the products. • if suppliers do not give this information – ask for it. explain: in this session, participants will be able to look very closely at some of the locally available wheelchairs. Participants will complete the wheelchair summary form in their workbook. This will include measuring the wheelchairs. This is how to measure a wheelchair. explain • Measure the seat width from the outside of one seat rail to the outside of the other. • if the armrests sit on top of the seat rail, measure between the armrests. • Measure seat depth from the base of the backrest to the front of the seat. S h l h l d• ome w ee c air supp iers provi e: – brochures; – product specifications; – product summaries. • Wheelchair measurements, weights, features and sometimes optional parts are often listed in this information. • If suppliers do not give this information ask for , it. B.5. Prescription (Selection): 5 BASIC LEVEL CHECK WHEEL CHAIR BROCH URES OR INFO RMATION B.5. Prescription (Selection): 6 BASIC LEVEL WHEELCHAIR MEASUREME NTS – SEAT W IDTH B.5. Prescription (Selection): 7 BASIC LEVEL WHEELCHAIR MEASUREME NTS – SEAT D EPTH Wheelchair Service Training Packag e 148 BASIC LEVEL • Measure seat height from the front of the seat directly down to the floor. • Measure backrest height (without the cushion) from the middle of the back of the seat to the top of the backrest. • Measure footrests height by measuring from the back of the footrests directly up to the seat. • To measure the footrests height range, measure with the footrests set at the lowest point and again with them set at the highest point. • Measure the overall wheelchair frame length by measuring from the back of the rear wheels to the front of the footrests (or castor wheels if they are in front of the footrests). B.5. Prescription (Selection): 8 BASIC LEVEL WHEELCHAIR MEASUREMEN TS – SEAT HEI GHT B.5. Prescription (Selection): 9 BASIC LEVEL WHEELCHAIR MEASUREMEN TS – BACKRES T HEIGHT B.5. Prescription (Selection): 10 BASIC LEVEL WHEELCHAIR MEASUREME NTS – FOOTR ESTS HEIGHT B.5. Prescription (Selection): 11 BASIC LEVEL WHEELCHAIR MEASUREME NTS – FRAME LENGTH 149 • Measure the wheelbase by measuring from the middle of the rear wheel to the middle of the front wheel. explain: • Wheelchair measurements and adjustment ranges can often be found on the printed material about the products. • it is still good to know how to measure yourself though, as the information is not always available. • always check whether a particular wheelchair is available from the supplier in different sizes. activity groups: Have three people in each group. Assign each group one of the locally available wheelchairs. If there are not enough different types of wheelchairs, some groups may have the same type of wheelchair. instructions: ask each group to: • study carefully the wheelchair they have been given; • complete the wheelchair summary form in their workbook for that wheelchair (this will include measuring the wheelchair); • find out the adjustment ranges they will need to adjust the wheelchair to the largest setting and then the smallest setting for each adjustable part. Monitor: Move around the groups and monitor closely. Point out any features/components participants have not noticed. Ensure participants work out the range of adjustments. Answer any questions. Time: Allow 20 minutes, plus 20 minutes for whole group feedback. If there are only one or two available wheelchairs, this session will not require so much time. B.5. Prescription (Selection): 12 BASIC LEVEL WHEELCHAIR MEASUREME NTS – WHEEL BASE •Remember: Wheelchair measurements and adjustment – ranges can often be found on the printed material about the products . – Always check whether a particular wheelchair is available from the supplier in different sizes. B.5. Prescription (Selection): 13 BASIC LEVEL CHECK THE P RODUCT INFO RMATION Wheelchair Service Training Packag e 150 BASIC LEVEL Feedback: • Ask each group to present the wheelchair they have reviewed (5 minutes maximum). Ensure they point out the key features, components, size options, the components which are adjustable and their range. It is not necessary to give the actual measurements. • Reinforce the advantages and disadvantages of different features, and add any information not covered by the group. • For example – if a wheelchair has a canvas slung seat and no cushion – explain that this wheelchair is not suitable for a person with a spinal cord injury, although it may be suitable for a temporary or short-term user. explain: Participants may wish to complete a wheelchair summary form for each wheelchair in their workbook (three summary forms are provided in total). Notes for trainers: It is a good idea to pin up a copy of a completed summary form for each wheelchair after this session. This can then be referred to during the practical sessions with wheelchair users. 4. Selecting the right wheelchair and wheelchair parts (15 minutes) explain: • Participants have now practised finding out information about the wheelchair user, and have information about the wheelchairs available locally. it is now time to practise matching the best wheelchair to the wheelchair user. • There are two wheelchair user stories that we will look at now. We will work together to match the best wheelchair and components to each wheelchair user. • Remember – in a real situation, the wheelchair user would be a part of the team choosing the wheelchair. read the first wheelchair user story (and project the slide of this story if you wish). ask: What type of wheelchair and what components will best suit Peter? Why? encourage answers. 151 Peter Wheelchair and components reason Peter lives in a rural village. He is very active and strong. He has good balance. Every day Peter travels nearly 1 km on a dirt path to get to and from work. When it rains, the path is very muddy. Long wheelbase (front and rear wheels far apart) Where available: tricycle Good for outdoors Tricycles are a good option for longer distances Wide front castor wheels Good for dirt/mud/sand Active rear wheel position Easier to lift front wheels over rough ground/small obstacles He has good balance Low backrest Will not restrict propelling read the second wheelchair user story (and project the slide of this story if you wish). ask: What type of wheelchair and what components will best suit Natasha? Why? encourage answers. natasha Wheelchair and components reason Natasha lives in an apartment in a town. She has had a stroke, and is able to stand up to transfer. She is unable to push a wheelchair herself as her arms are very weak. Natasha sometimes slides to the side of the seat and her family members are worried that she is uncomfortable. Footrests which move out of the way To allow standing transfer May allow/encourage foot propelling Seat height from floor – not too high To allow Natasha to reach the floor comfortably when sitting forwards in the seat, ready to stand Pressure relief cushion Relieve pressure, provide comfort and postural support Firm backrest To give good postural support High armrests May help posture Push handles To make it easier for family/ carer to push •Peter lives in a rural village. He is very active and strong. He has good balance. •Every day Peter travels nearly 1 km on a dirt path to get to and from work When it rains the path is . very muddy. B.5. Prescription (Selection): 15 BASIC LEVEL PETER •Natasha lives in an apartment in a town. She has had a stroke, and is able to stand up to transfer. • She is unable to push a wheelchair herself as her arms are very weak . •Natasha sometimes slides to the side of the seat and her family members are worried that she is uncomfortable. B.5. Prescription (Selection): 16 BASIC LEVEL NATASHA Wheelchair Service Training Packag e 152 BASIC LEVEL explain: sometimes it is not possible to find a wheelchair which meets all the wheelchair user’s needs. in this case, discuss with the wheelchair user and try to meet the most important needs. 5. Selecting the right wheelchair size (25 minutes) ask: Why is it important that the wheelchair is the correct size? encourage answers. Most important answers: • the correct size allows the wheelchair user to sit correctly in the wheelchair ; • with the correct size wheelchair, the wheelchair user’s weight is evenly distributed; • the wheelchair will be more comfortable and easier for the wheelchair user to push. activity groups: Have two to three people in each group. instructions: Ask each group to: • look at the wheelchair user measurements on the worksheet in their workbook; • decide what would be the ideal wheelchair size for each user and then; • select the best fit from the available wheelchairs. Explain: • They can use 50 mm as the height of the cushion. • They should assume that the wheelchair user is propelling with his/ her arms, not feet. Monitor: Monitor the groups, and assist as needed. Time: Allow 25 minutes. Feedback: Check with each group that they selected the correct “ideal size”, and the best size match of wheelchair from the wheelchairs available. ask: If the second wheelchair user wanted to propel the wheelchair with his/her feet; what would be the ideal height of the wheelchair seat from the floor? (Answer: 310 mm.) ask: If the wheelchairs available have a larger seat-to-floor height than that, what can they do? (Answer: reduce the height of the cushion.) 153 explain: as well as checking the seat depth, seat width and backrest height, personnel must check the range of adjustment in the footrests height to fit the wheelchair user. sometimes a wheelchair user may have particularly long or particularly short calves. if these are outside the range within which the wheelchair can be adjusted, a modification may be necessary and possible. This is discussed in the next section. Answers for the trainers: 1 Body measurement Measurement (mm) change body measurement to ideal wheelchair size Wheelchair measurement A Hip width 380 mm Hip width = seat width 380 mm B Seat depth L 400 mm B less 30-60 mm = seat depth (if lengths are different, use shorter) 370 mmR 400 mm C Calf length L 420 mm = top of seat cushion to footrests height or = top of seat cushion to floor for foot propelling 370 mm (50 mm cushion)R 420 mm D Bottom of ribcage - = top of seat cushion to top of backrest (measure D or E – depending on the user’s needs) - E Bottom of shoulder blade 380 mm 430 mm (50 mm cushion) Ideal wheelchair size for this wheelchair user : Seat width: 380 mm Seat depth: 370 mm Backrest height: 430 mm From the available wheelchairs, which wheelchair and size best fits the user? Wheelchair Service Training Packag e 154 BASIC LEVEL 2 Body measurement Measurement (mm) change body measurement to ideal wheelchair size Wheelchair measurement A Hip width 420 mm Hip width = seat width 420 mm B Seat depth L 460 mm B less 30–60 mm = seat depth (if lengths are different, use shorter) 430 mmR 460 mm C Calf length L 360 mm = top of seat cushion to footrests height or = top of seat cushion to floor for foot propelling 310 mm (50 mm cushion)R 360 mm D Bottom of ribcage 260 mm = top of seat cushion to top of backrest (measure D or E – depending on the user’s needs) 310 mm (50 mm cushion) E Bottom of shoulder blade – – Ideal wheelchair size for this wheelchair user : Seat width: 420 mm Seat depth: 430 mm Backrest height: 310 mm From the available wheelchairs, which wheelchair and size best fits the user? 6. recording the prescription (selection) (10 minutes) explain: The wheelchair prescription (selection) needs to be written down. Wheelchair services need a form for writing down prescription (selection) decisions. The wheelchair prescription (selection) form used in this training package is an example, which may need to be adapted for different wheelchair services. 155 explain: • The wheelchair prescription (selection) form is in four parts. • The first part is information about the wheelchair user. This information can be taken from the assessment form. • There is also space to write the planned date of the fitting. explain: • The second part records the type of the wheelchair and size selected. • When a wheelchair has options (for example adjustable backrest or different types of footrests), the option chosen should be recorded. • some wheelchair suppliers have a detailed wheelchair prescription (selection) form for their wheelchair. This should be completed as well, and attached to the general prescription form. explain: • The third part records the type of cushion selected. B.5. Prescription (Selection): 17 BASIC LEVEL WHEELCHAIR USER INFORM ATION 2 Type of wheelchair and size selected. To select the type of a wheelchair: •Discuss with the wheelchair user; •Think about the most important needs of the wheelchair user; •Check: wheelchair frame, castor and rear wheels, footrests, armrests, backrest height (or adjustability), rear wheels position, support and comfort. SizeType of wheelchair      B.5. Prescription (Selection): 18 BASIC LEVEL TYPE OF WHE ELCHAIR AND SIZE B.5. Prescription (Selection): 19 BASIC LEVEL TYPE OF CUS HION Wheelchair Service Training Packag e 156 BASIC LEVEL explain: • Finally, there is space for everyone involved to sign that they have agreed to the prescription (selection) of wheelchair. • The list of people who sign will depend on the service. However, it is very important that the wheelchair user signs, and the person who has made the assessment. ask: Does anyone have any questions about filling in the wheelchair prescription (selection) form? answer any questions. explain: Prescription (selection) also includes agreeing with the wheelchair user what training or advice he/she needs to use and care for their wheelchair. 7. key point summary (3 minutes) read the key points. ask whether there are any questions. B.6: Funding and ordering O B Je c T iv e S By the end of this session, participants will be able to:  order the prescribed wheelchair according to the ordering system of their service. 4. Agreed Signature of the user: _____________ Signature of the assessor: _____________ Signature of the manager: _____________ B.5. Prescription (Selection): 20 BASIC LEVEL AGREEMENT • Prescription (selection) means finding the best match possible between the wheelchairs available and the needs of the user. • Prescription (selection) includes: – Selecting the right wheelchair, cushion and wheelchair parts; – Selecting the right wheelchair and cushion size; – Agreeing with the wheelchair user what training or advice they need to help them use and care for their wheelchair. • The prescription (selection) should always be made with the wheelchair user. B.5. Prescription (Selection): 21 BASIC LEVEL KEY POINT SU MMARY 157 r e S O U r c e S For the session:  Reference Manual;  order form (not included in the training package, use only if one is locally available). c O n T e X T Adapt this session to suit the context participants will be working in.  Use this session to teach participants the steps in ordering a wheelchair in the service they will be working in.  Where there is no clear system for ordering a wheelchair, trainers are encouraged to work with services to establish an ordering process.  Give participants an opportunity to practise ordering. This may include getting them to complete an order form (if there is one locally available). T O P r e Pa r e  Gather resources and read through the session plan. O U T l in e 1. Introduction 2. Funding 3. Ordering 2 3 10 Total session time 15 1. introduction (2 minutes) explain: Funding and ordering is the fourth step in wheelchair service delivery. 2. Funding (3 minutes) explain: When the wheelchair has been prescribed, the cost of the recommended product can be accurately estimated. it is essential to know who will fund the wheelchair – it could be funded by an out-of-pocket payment, a subsidy from a government, nongovernmental organization or donor agency, or a payment by an insurance company. in the developing world, many people who need a wheelchair cannot afford to buy one. Nevertheless, everyone who needs a wheelchair is entitled to one, regardless of his/her ability to pay. Thus, funds will need to be made available Wheelchair Service Training Packag e 158 BASIC LEVEL for users who need financial assistance. For most services, it will be essential to identify the funding source before the wheelchair can be ordered. Often, this responsibility lies with administrative personnel or programme managers rather than clinical or technical personnel. include any system for identifying how the wheelchair will be paid for, if this is part of the role of the wheelchair service personnel. Participants can write down the different possibilities for funding wheelchair services in their programme. 3. Ordering (10 minutes) When the best wheelchair for the wheelchair user has been selected and the prescription (selection) prepared, the wheelchair needs to be ordered. if a wheelchair service keeps wheelchairs in stock, this may mean completing an order form to be authorized by the service manager. The wheelchair may then be prepared by the staff responsible for wheelchair preparation. if the wheelchair service does not keep wheelchairs in stock, this may mean ordering from an external supplier. The system for ordering wheelchairs will vary in different wheelchair services. Write down below the things that you need to remember to order wheelchairs in your local wheelchair service. explain: after selecting the best wheelchair for the wheelchair user and preparing a prescription, the wheelchair service personnel should order the wheelchair. an order should always be placed as quickly as possible to avoid delays. explain the different systems for ordering the wheelchair. Participants may write down the ordering system in their referenceManual in the space provided. 159 Practical One: assessment and prescription (selection) O B Je c T iv e S By the end of this session, participants will be able to:  Demonstrate a basic wheelchair assessment working in a group and with assistance.  Demonstrate making a basic level wheelchair prescription (selection) working in a group and with assistance. r e S O U r c e S  trainer’s Observation Checklist: Practical One;  blank wheelchair assessment and wheelchair prescription (selection) forms;  clean and private assessment space with assessment bed for each wheelchair user ;  sample wheelchairs (unless assessment is carried out in the community);  tape measure, foot blocks. c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  cultural factors – for example, whether it is appropriate to have mixed-gender groups doing the assessment;  language factors – for example, whether wheelchair users attending speak a common language with all participants;  any documentation that the service may need when assessing and prescribing a wheelchair – for example, any additional information that services need to collect about wheelchair users accessing their service (e.g. referral source);  how trainers will manage issues that may arise during the assessment that cannot be addressed within the session or training. T O P r e Pa r e  Confirm time and travel arrangements with wheelchair user volunteers. Ensure there are refreshments available for wheelchair users and their family/supporters.  Assign one person to greet wheelchair users as they arrive and show them where they can wait until the session begins.  Prepare an assessment bed with a privacy screen for each pair of participants and wheelchair user volunteer. Place all equipment needed for each assessment, including wheelchair assessment and wheelchair prescription (selection) forms, on the assessment bed.  Ensure that sample wheelchairs and cushions that may be shown to wheelchair users are in good working order.  If there are more than three pairs of participants, ask for another trainer to assist with monitoring the groups.  Decide which participants will work together, and with which wheelchair user. O U T l in e 1. Assessment and prescription practice: • Instructions and set-up • Assessment • Prescription • Feedback 5 45 30 10 Total session time 90 Wheelchair Service Training Packag e 160 BASIC LEVEL 1. assessment and prescription practice (90 minutes) Notes for trainers: Use the “Trainer’s Observation Checklist” for Practical One to ensure that groups perform all the steps in the practical and to note common examples of good or bad practice that should be highlighted in the feedback session on the checklist (box provided). activity groups: • Arrange the participants into groups (no more than three people in each group). • Appoint a leader for each group. • Tell each group the name of the wheelchair user they will be working with. • Assign each group a place to work in. • Explain that all equipment has been laid out for them on the assessment bed. explain all of the following: session aim: • The aim of this practical session is to carry out an assessment and prescribe a wheelchair for a wheelchair user. • Participants will work with the same wheelchair user they work with today, later on in the course, to fit the wheelchair selected today and to give user training. • If it is not possible during the course to complete the wheelchair user’s wheelchair, arrangements will be made with the wheelchair user to ensure that their wheelchair is completed. Participants should try however to get as much of the work done as possible. Lead person: • The lead person is responsible for making sure that all steps are carried out. • The lead person should be the main person talking with the wheelchair user and the family/carer. This is to avoid having too many people speaking at once, which can be confusing for everyone. 161 instructions: service forms: • Hand out an assessment and prescription form to each group’s team leader. Trainer's observation and support: • Participants may ask for assistance or clarification at any time. • Throughout the session, trainers will monitor each group and give as much support and advice as needed. • After completing the assessment, par ticipants should ask one trainer to come and check their assessment and wheelchair assessment form. • After completing the wheelchair prescription (selection), participants should ask one trainer to come and check their prescription (selection) and wheelchair prescription (selection) form. Time allowed: • They should aim to complete the assessment in 40 minutes, and the prescription (selection) in 20 minutes. ask participants: What are the steps for assessment? acknowledge correct answers. ask participants: What are the steps for prescription? acknowledge correct answers. Remind participants that they should actively involve the wheelchair user in every step of the process. ask: Are there any questions? answer any questions. ask each group to prepare the area they are going to work in; then introduce themselves to the wheelchair user they will work with and begin. Monitor and support: closely monitor the groups, ensure safe practice, observe and evaluate the skills of participants. Use the Trainer’s observation checklist to record your observations of each group. Throughout the session: • Give time warnings to help participants manage their time. • Ensure wheelchair users are actively involved. at the end of this session, ask participants to thank the wheelchair users for their participation and explain that the wheelchair prescribed (selected) will now be prepared for them and will be ready for them to try in the next practical session. Wheelchair Service Training Packag e 162 BASIC LEVEL Time: Allow 45 minutes to complete the assessment; 30 minutes to complete the prescription (selection), 10 minutes for feedback. Track time using the Trainer’s Observation Checklist. Feedback: comment on examples of good practice that you saw during the practical sessions. Note any particular areas that participants could improve – do not highlight individuals. ask: Are there any questions? B.7: Product (wheelchair) preparation O B Je c T iv e S By the end of this session, participants will be able to:  adjust a wheelchair to match the wheelchair prescription (selection);  use the “wheelchair safe and ready” checklist to check that a wheelchair is safe to use and all parts are working. r e S O U r c e S For the session:  PPT slides: B.7 Product (wheelchair) preparation;  Reference Manual;  Participant’s Workbook;  DVD: Wheelchair safe and ready checklist demonstration;  the wheelchairs selected for each wheelchair user, as assessed during Practical One;  completed wheelchair prescription (selection) forms (from Practical One);  wheelchair safe and ready checklist (1 copy per participant);  tape measures and any hand tools needed to carry out adjustments (1 per pair). c O n T e X T Adapt this session to suit the context participants will be working in. Think about the following.  The time that is needed to adjust the locally available wheelchairs. If the locally available wheelchairs have few adjustment options, the time needed to set them up is shorter. If there are many adjustment options, the time needed will be longer.  If any locally available wheelchairs require assembly before they can be prepared, time needs to be allowed for the assembly to be carried out, ahead of this session. 163 T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Practise adjusting the locally available wheelchairs so you know how they are adjusted and can demonstrate or assist participants as needed. O U T l in e 1. Introduction. 2. Preparing the wheelchair. 3. Wheelchair safe and ready checklist. 4. Key point summary. 2 40 30 3 Total session time 75 1. introduction (2 minutes) explain: in this session, participants will learn how to prepare the wheelchair for the wheelchair user to try. This is the fifth step in wheelchair service delivery. Wheelchair preparation includes: • preparing the assembled wheelchair to match the wheelchair user’s prescription (selection); • checking the wheelchair to make sure that it is safe and ready to be used and all parts are working properly. 2. Preparing the wheelchair (40 minutes) explain: Participants will prepare the wheelchair that has been prescribed for the wheelchair user with whom they worked in the previous practical. These are the steps to prepare the wheelchair. Step 5 Product (wheelchair) preparation • In this session participants will: – Learn how to prepare the wheelchair for the wheelchair user to try. • Wheelchair preparation includes: – Preparing the assembled wheelchair to match the wheelchair user’s prescription (selection); – Checking the wheelchair to make sure that it is safe to use and all parts are working properly. B.7. Product (wheelchair) preparation: 2 BASIC LEVEL INTRODUCTI ON Wheelchair Service Training Packag e 164 BASIC LEVEL explain: • check that the wheelchair seat width and depth measurements are correct for the prescription (selection). • check that the cushion width and depth match the seat. adjust (where possible): • backrest height; • armrests height; • rear wheels position; • brakes position (always reposition brakes after changing the rear wheels position); • footrests height; • push handles height; • any other adjustments that are possible. •Check the wheelchair seat width and depth measurements are correct for the wheelchair user’s prescription (selection). B.7. Product (wheelchair) preparation: 3 BASIC LEVEL PREPARING T HE WHEELCH AIR •Check that the cushion width and depth match the seat. B.7. Product (wheelchair) preparation: 4 BASIC LEVEL PREPARING T HE WHEELCH AIR •Adjust (where possible): – backrest height and angle; – armrests height; – rear wheels position; – brakes position; – footrests height; – push handles height; – any other adjustments. B.7. Product (wheelchair) preparation: 5 BASIC LEVEL PREPARING T HE WHEELCH AIR 165 activity groups: Ask the same groups that worked together in Practical One to work together now. Give each group: • the wheelchair prescription (selection) form they completed for their wheelchair user ; • a tape measure; • the wheelchair they have prescribed (selected) for their wheelchair user. Ensure that any tools needed to adjust the wheelchairs are available at the front of the training room. instructions: Ask each group to look at the prescription (selection), and prepare the wheelchair. Remind them to follow each step: • check the wheelchair seat width and depth; • check the cushion fits; • make any adjustments to set the wheelchair up for their wheelchair user. Remind them that any tools they need are at the front of the training room. explain: If any group needs to make any small modifications to meet their wheelchair user’s needs, this will be done in a later session. Monitor: Monitor the groups closely. Check that each step is carried out. When each group has finished, check that they have set the wheelchair up as closely as possible to match their wheelchair user’s prescription (selection). If there are any small modifications needed, discuss with the group what is needed. Explain that this will be talked about further in a later session. Time: Allow 20 or more minutes, depending on adjustments that are needed and can be carried out, and 10 minutes for feedback. Feedback: ask: • Was each group able to prepare the wheelchair to match their wheelchair user’s prescription (selection)? • If not – what was the problem? Ask the group what solutions there may be for this problem. Clarify until everyone understands. Wheelchair Service Training Packag e 166 BASIC LEVEL VIDEO 3. Wheelchair safe and ready checklist (30 minutes) explain: The second part of product (wheelchair) preparation is to check that the wheelchair is safe and ready to use and all parts are working properly. give each participant a wheelchair safe and ready checklist. explain: • This checklist helps to make sure nothing is forgotten. • Participants can keep the checklist as an easy reference each time they prepare a wheelchair. • services may choose to use the checklist as a form, to be completed for every wheelchair that is prescribed (selected). This is up to the service personnel. introduce DvD: Wheelchair safe and ready checklist demonstration. This DvD will show how to check a wheelchair to make sure that it is safe and ready for the wheelchair user to try. ask participants to: • watch closely as checks are carried out on the wheelchair; • as they see each check, they should make a tick on the wheelchair safe and ready checklist in their workbook if they think the wheelchair passes. Show DvD. ask if there are any questions. activity groups: Same groups as for Practical One. Assign each group a wheelchair prepared by another group. instructions: Ask each group to check the wheelchair they have been assigned to ensure it is safe and ready for the wheelchair user to try. They should use their checklist to remind them of each check to make. Make a note of any problems and discuss these with trainers. Monitor: Monitor the groups, and assist as needed. Encourage participants to fix any problems that are identified, if possible during the session. If not, any problems need to be noted – and fixed before practical two. •The checklist reminds Whole wheelchair wheelchair personnel what to check for to make sure qThere are no sharp edges qNo parts are damaged or scratched qThe wheelchair travels in a straight line Front castor wheels qSpin freely that a wheelchair is safe and ready to use. qSpin without touching the fork qBolts are tight Front castor barrels qCastor fork spins freely •A copy can be kept as an easy reference. Rear wheels qSpin freely qAxle bolts are tight qTyres inflated correctly (with thumb pressure, wheel can be depressed less than 5 mm) qPush rims are secure • Some services may use the h kli t f t b Brakes qFunction properly Footrests qFootrests is securely attached Frame c ec s as a orm, o e completed for every h l h i qFor a folding wheelchair – the wheelchair folds and un-folds easily qFor a wheelchair with fold down backrest – the backrest folds and un-folds easily Cushion qThe cushion is in the cover correctly qThe cushion is sitting on the wheelchair correctly w ee c a r.qThe cushion cover fabric is tight but not too tight qIf the wheelchair has a solid seat: the cushion fully covers the solid seat B.7. Product (wheelchair) preparation: 6 BASIC LEVEL WHEELCHAIR READY CHEC KLIST 167 Time: Allow 15 minutes. Feedback: Ask each group to report back to the whole group whether their wheelchair was safe and ready for the wheelchair user to use (allow 2–3 minutes per group). ask: if there was a problem, what would they do? encourage answers. Most important answers: • repair/fix the problem; • return the wheelchair to the wheelchair workshop to be fixed; • contact the supplier of the wheelchair and ask for help with fixing the problem. 4. key point summary (3 minutes) read the key points. ask whether there are any questions. Checklist: Is the wheelchair safe and ready to use? For the whole wheelchair: notes for trainers: There are no sharp edges  Check all over the wheelchair with eyes and hands.No parts are damaged or scratched  The wheelchair travels in a straight line  Push the wheelchair away from you, making sure the castor wheels are in the “trail” position. Front castor wheels: Spin freely  Tip the wheelchair on to the back wheels. Spin the castor wheels.Spin without touching the fork  Bolts are tight  Check. They should feel firm. Do not over tighten. • Wheelchair preparation includes: – Adjusting the selected wheelchair to match each wheelchair user’s prescription; Checking the wheelchair to make sure that it is safe to – use and all parts are working properly. Th dj t t ti d f dj t t • e a us men op ons an range o a us men s vary on different wheelchairs. • Participants need to be familiar with the adjustment options and range on the wheelchairs available in their area. B.7. Product (wheelchair) preparation: 8 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 168 BASIC LEVEL Front castor barrels: Castor fork spins freely  Tip the wheelchair on to the back wheels. Spin the castor fork around. rear wheels: Spin freely  Tip the wheelchair sideways on to one rear wheel. Spin the other wheel. Check the other side. Axle bolts are tight  Check. They should feel firm. Do not over tighten. Tyres (if these are pneumatic)are inflated correctly  Press on the tyres with your thumb. The tyre should depress a little, but no more than 5 mm. Push rims are secure  Check. Brakes: Function properly  Apply brakes. Check that the wheelchair cannot be moved. Footrests: Footrests are securely attached  Check. Frame: Cross-folding wheelchair folds and unfolds easily  Fold the wheelchair to check the folding mechanism is working properly.Fold-down backrest – the backrest folds and unfolds easily  cushion: The cushion is in the cover correctly  Usually the cushion cover is done up at the back of the cushion, underneath. The cushion is sitting on the wheelchair correctly.  If the cushion is contoured, the “well” for the seat bones should be at the back of the seat. The cushion cover fabric is tight but not too tight.  The cushion cover should not stretch tightly over any contours of the cushion. The cushion fully covers the seat  Check there is no part of the seat visible from under the cushion. This is particularly important for solid seats. 169 B.8: cushion fabrication O B Je c T iv e S By the end of this session, participants will be able to:  point out features of a basic foam pressure relief cushion.  make a basic foam pressure relief cushion  describe how to insert a cushion “lift” for users with unsafe pressure at the seat bones. r e S O U r c e S  PPT slides: B.8 Cushion fabrication;  Reference Manual;  Participant’s Workbook;  DVD: Cushion fabrication;  sample pressure relief cushion, cushion cover and cushion lift;  cushion fabrication toolkit (see “Cushion fabrication – materials and tools” above for full details);  sample fabrics available locally that are suitable for use as a cushion cover. c O n T e X T Adapt this session to suit the context participants will be working in. For example:  make and fit a cushion for a wheelchair user ;  adapt the dimensions and design of the cushion presented, depending on availability of recommended materials and their performance or based on the average size of people in the local population;  prepare a list of locally available cushions and alternative materials – participants may be asked to bring samples from their home locations. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Set up a workbench/table for each group of three participants, with the materials and tools needed to test the firmness of foam samples; cut and glue a cushion base. O U T l in e 1. Introduction. 2. Cushion features and dimensions. 3. How to make a cushion base – demonstration. 4. How to make a cushion base – practice. 5. Looking after the cushion. 6. Frequently asked questions about foam pressure relief cushions. 7. Key point summary. 5 20 20 60 5 5 5 Total session time 120 Wheelchair Service Training Packag e 170 BASIC LEVEL 1. introduction (5 minutes) explain: • in this session, participants will learn how to make a basic foam pressure relief cushion. if made and fitted correctly, this cushion can help to relieve pressure for many wheelchair users. • it is important to remember that no one cushion is appropriate for all users. • When providing a pressure relief cushion, always check the pressure under the wheelchair user’s seat bones during fitting. some adjustments may be necessary to ensure that the seat bones well is the correct width, depth and height. ask: Has anyone had any previous experience in making and providing pressure relief cushions? encourage and acknowledge answers. 2. cushion features and dimensions (20 minutes) Pass around the sample pressure relief cushion base. Have the top layer and cover close by. For each cushion feature shown on the slides, ask participants: What is the purpose of this feature of the cushion? Remind participants that this was covered in the session “cushions” at the beginning of the training programme. encourage answers. For each feature shown on the slide, point out this feature on the sample cushion. Step 5 Product (wheelchair) preparation • In this session participants will: – Learn how to make a basic foam pressure relief cushion. If made and fitted correctly, this cushion can help to relieve pressure for many wheelchair users. B.8. Cushion fabrication: 2 BASIC LEVEL INTRODUCTI ON 171 Feature Trainer` s notes: What does the feature do? • Gives the cushion its shape. seat bones well • Relieves pressure under the seat bones and coccyx (tail bone). • Helps to hold the pelvis upright at the back of the cushion. explain: • The wheelchair user’s seat bones should sit inside the well – not on the edge or on top of the cushion. • always check that the seat bones well fits correctly during the fitting. Place your hands under the wheelchair user and feel where the seat bones are. check pressure using the pressure test taught in this training programme. • if the cushion is to be used on a slung wheelchair seat, a bevel cut is made on the base of the cushion. • This allows the cushion to take up the shape of a slung wheelchair seat so that the top of the cushion remains flat. • The “bevel” cut is only made when a cushion is to be used on a slung seat. • For solid seats, the base of the cushion is flat. B.8. Cushion fabrication: 3 BASIC LEVEL FIRM FOAM B ASE B.8. Cushion fabrication: 4 BASIC LEVEL SEAT BONES W ELL B.8. Cushion fabrication: 5 BASIC LEVEL SLUNG SEAT BASE Wheelchair Service Training Packag e 172 BASIC LEVEL • The top foam layer provides comfort. • Pass around the sample top layer. • sometimes more pressure relief is needed. • in this case, personnel can make a “lift” from the same foam that is used to make the base. • The lift is placed on top of the base layer of the cushion and under the foam comfort layer. This will increase the pressure relief provided by the seat bones well. • always physically check the pressure after adding a lift, using the seat bones pressure test. • Pass around the sample cushion lift. explain: The final feature of the cushion is the cover. The cover is essential to protect the cushion. ask: What type of fabric could be used to make a cushion cover? encourage answers and write on the board the fabrics which would be “good” and “ok”. explain which ones would be best (good) and which would be used if there is no alternative. Possible answers: • thin nylon/umbrella fabric (good); • stretchy fabric/Lycra (good); • “T” shirt fabric/knit cotton (OK); • neoprene/wet suit (OK); • taffeta (OK); • vinyl/imitation leather (bad); • heavy canvas or nylon (bad); • terry cloth/towels (bad); • linen/sheets (bad); • plastic bag/polyethylene (bad). B.8. Cushion fabrication: 6 BASIC LEVEL TOP FOAM LA YER Pl th lift t f • ace e on op o the base layer of the hi d d th cus on an un er e comfort layer. B.8. Cushion fabrication: 7 BASIC LEVEL LIFT 173 explain: • a good fabric for a pressure relief cushion cover is usually either water-resistant or stretchy. • a water-resistant cover fabric should be very thin (like parachute or umbrella fabric) so that folds will not cause marks on the skin. • if using a stretchy fabric which is not water-resistant, a thin piece of plastic (plastic bag) can be used over the top of the foam and underneath the cushion cover to protect the cushion. • The cover should be looser at the back of the cushion to prevent a “drum” effect across the seat bones well. Pass around the sample cushion cover. explain: • The seat bones well must be the correct width, depth and height to work correctly. To calculate the size of the seat bones well, participants can use the following rules. explain each seat bones well dimension as shown on the slide. • Look for either water resistant or stretchy fabric. • Ensure the fabric is thin (like parachute or umbrella fabric) so that folds will not cause marks on the skin. • If using a fabric that is not water resistant a thin piece of , plastic can be used over the top of the foam and underneath the cushion cover to protect the cushion. • The cover should be looser at the back of the cushion to prevent a “drum” effect across the seat bones well . B.8. Cushion fabrication: 8 BASIC LEVEL CUSHION CO VER FABRIC B.8. Cushion fabrication: 9 BASIC LEVEL SEAT BONES W ELL DIMENSIO NS 1. Width = ½ the user’s seat width or 200mm (whichever is less). 2. Depth = ½ the user’s seat width or 200mm (whichever is less). 3 Height = 35mm for . adults and 20 – 25mm for children. B.8. Cushion fabrication: 10 BASIC LEVEL SEAT BONES W ELL DIMENSIO NS Wheelchair Service Training Packag e 174 BASIC LEVEL VIDEO Small-group activity groups: Have two people in each group. instructions: ask each group to: • complete the table at the beginning of the worksheet in their workbooks. explain they need to calculate the seat bones well width, depth and height for three wheelchair users with different seat widths. Monitor: Monitor the groups, and assist as needed. While they work, draw the table below on the whiteboard – without including the answers. Width Depth Height adult wheelchair user – 360 mm seat width 180 mm 180 mm 35 mm adult wheelchair user – 460 mm seat width 200 mm 200 mm 35 mm child wheelchair user – 280 mm seat width 140 mm 140 mm 20–25 mm Time: 5 minutes. Feedback: Draw the table on the whiteboard. ask: What is the width, depth and height of the seat bones well for each wheelchair user? Write the correct answers into the table on the board. ask: How can participants tell whether the dimension is correct for that wheelchair user? Answer: Always check that the seat bones well fits correctly at the fitting. Place your hands under the wheelchair user and feel where the seat bones are. Check pressure using the pressure test taught in this training programme. Make sure the seat bones are sitting inside the seat bones well, and not on the edge or on top of the cushion. 3. how to make a cushion base – demonstration (20 minutes) introduce DvD: cushion fabrication. it is a short presentation of making a basic foam pressure relief cushion. Show DvD ask if there are any questions. 175 Pass around the sample firm foam and soft foam. ask participants to place the foam on a solid surface (for example a workbench) and feel the different firmness of the two pieces of foam by making a fist and pushing their knuckles into the foam. explain: • Both the base and top layer are placed in the cushion cover together. • The two layers do not need to be glued together. • if the top layer becomes soiled or worn out, it can be washed and dried, or replaced. • show how a lift can be added within the cover to increase the depth of the pelvic well. 4. how to make a cushion base – practice (60 minutes) explain: Participants will now practise cutting the cushion base. activity groups: Have two to three people in each group. Assign each group to a workbench/table with the materials and tools required to cut a foam base. instructions: ask each group to: • work together to cut the cushion base; • use the worksheet in their workbook to remember each step. Highlight safety points: • remind participants that the foam cutting tools are very sharp and must be handled carefully. Monitor: Monitor the groups, and assist as needed. Time: 50 minutes and 10 minutes for feedback. Feedback: Ask groups: • What helpful techniques for cutting or gluing foam did you discover? • What happens if you cut a segment from two directions? (Answer: The two cuts may not meet, leaving a step in the surface.) Wheelchair Service Training Packag e 176 BASIC LEVEL 5. looking after the cushion (5 minutes) explain: Wheelchair users need to know how to look after their cushion. This includes the following. • Keep the cushion clean – the cushion can be washed with warm, slightly soapy water. it should be dried away from direct sunlight before being replaced. • check the top layer – the top layer should “spring back” when pressed. if it does not spring back and has become hard and flat, it needs to be replaced. • check the base layer – check that the base still holds its shape and is not chipped or wearing away. if it is, it may need to be replaced. • The top layer may be replaced two or three times before the base needs replacing. 6. Frequently asked questions about foam pressure relief cushions (5 minutes) ask: are there any questions about this cushion? answer any questions. Possible questions answers how do you decide what fabric to use for the cushion cover? • Choose a fabric which is stretchy if possible. Water-resistant fabric is very good, if available. If the fabric is water-resistant, make sure it is not too thick or the folds may cause marking on the wheelchair user’s skin, which can lead to a pressure sore. • The choice will depend on the fabric available. Sometimes the choice is limited. • If there is a choice and you are not sure, ask wheelchair users to trial different options. • Wheelchair service personnel will develop experience as different fabrics are tried. • Keep the cushion clean and dry: • wash with warm soapy water; • dry away from direct sunlight. • Check the top layer: • replace if it does not spring back when pressed or is hard. • Check the base layer: • replace if it has lost its shape or is chipped. • The top layer may be replaced two or three times before the base needs replacing. B.8. Cushion fabrication: 12 BASIC LEVEL HOW TO LOOK AFTER A FOAM PRESSURE REL IEF CUSHION 177 Does this cushion work for all users? • No – this cushion will not work for all wheelchair users. • However, one advantage of this cushion is that it can be easily adapted. is this cushion hot or does it cause sweating? • Foam cushions can be hot and can cause sweating. However, the cushion performs well in many other ways, so the warmth is a compromise. Do all wheelchair users need a pressure relief cushion? • No – not all wheelchair users need a pressure relief cushion but every hard-seat wheelchair needs a seat cushion. • Consider the pressure risk factors taught in this training programme to decide whether a wheelchair user is at risk of developing a pressure sore. • Although this cushion may not be needed for pressure relief, the cushion can also improve comfort and posture, even for wheelchair users who are not at risk of developing pressure sores. What happens if the cushion is used back-to-front or upside down? • It will not work properly and may even increase the risk of developing pressure sores. • Always make sure that wheelchair users, and family members (where relevant), understand how to use and care for the cushion correctly. • Mark the cushion “front” and “back” or “up” and “down” if necessary. Does this cushion work for children? • Yes, this cushion would work for children who are able to sit well and who are at risk of developing a pressure sore. • Many children who use a wheelchair need extra postural support – which is not provided by this cushion alone. 7. key point summary (5 minutes) read the key points. ask whether there are any questions. If d d f d l h h l l • ma e an itte correct y, cus ions can e p to re ieve pressure for many wheelchair users. • It is important to remember that no one cushion is appropriate for all users. •Whenever providing a pressure relief cushion for a wheelchair user physically check the pressure under the wheelchair user’s seat bones during fitting. Some adjustments may be necessary to ensure that the seat bone well is the correct width, depth and height. B.8. Cushion fabrication: 13 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 178 BASIC LEVEL B.9: Fitting O B Je c T iv e S By the end of this session, participants will be able to:  list the steps of fitting in the correct order;  demonstrate how to check the size and common adjustments of a wheelchair for an individual wheelchair user. r e S O U r c e S For the session:  PPT slides: B.9 Fitting;  Reference Manual;  DVD: Fitting demonstration;  one wheelchair for each group of three;  wheelchair fitting checklist (1 per participant). c O n T e X T Adapt this session to suit the context participants will be working in. Think about the following.  Where fitting will be carried out. If participants will be carrying out fitting in the community, trainers may include advice on tools that should be taken on the fitting visit and any other considerations. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan. O U T l in e 1. Introduction. 2. Good practice in fitting. 3. Fitting practice. 4. Key point summary. 2 30 25 3 Total session time 60 179 1. introduction (2 minutes) explain: • Fitting is the sixth step in the eight steps of wheelchair service delivery. in this session, participants will learn what to do during the fitting. 2. good practice in fitting (30 minutes) explain: During fitting, the wheelchair user and personnel together check that: • the wheelchair is the correct size and has been adjusted correctly; • the wheelchair and cushion support the wheelchair user in sitting upright; • if a pressure relief cushion has been prescribed (selected), the cushion relieves pressure. explain: Good practice in fitting is: • checking size and adjustments; • checking posture; • checking pressure; • checking fit while the wheelchair user is moving. check if the wheelchair is ready explain: • Make sure the wheelchair has been checked, it is safe to use and all parts are working. Step 6 Fitting • In this session participants will: – Learn what to do during the fitting. B.9. Fitting: 2 BASIC LEVEL INTRODUCTI ON •During the fitting the wheelchair user and personnel check that: – The wheelchair is the correct size and all the necessary modifications and adjustments have been made to ensure an optimum fit. – The wheelchair and cushion support the wheelchair user to sit upright. If li f hi h b – a pressure re e cus on as een prescribed – the cushion relieves pressure. B.9. Fitting: 3 BASIC LEVEL FITTING •Fitting is carried out in the following order: – check size and adjustments; – check posture; – check pressure; – check fit while the wheelchair user is moving. B.9. Fitting: 4 BASIC LEVEL GOOD PRACT ICE IN FITTIN G Wheelchair Service Training Packag e 180 BASIC LEVEL Check size and adjustments explain: • We have already talked a little about how the wheelchair should fit. During fitting, you need to check physically that the wheelchair fit is correct. This is how it is done. explain: To check the seat width: • Run your fingers between the outside of the wheelchair user’s thighs and the sides of the wheelchair. Your fingers should fit comfortably without being pinched. To check seat depth: • check the wheelchair user is sitting upright. • slide hand between the cushion and the back of the knee. There should be a gap large enough to admit two fingers (30 mm). There may be a bigger gap for wheelchair users with long legs. Up to 60 mm is acceptable. • slide hand down the back of the calf and make sure it is not touching the seat or cushion. • always check both sides. To check footrests height: • slide the hand between the thigh and the cushion – there should be even pressure along the thigh and no gaps; • look at the foot on the footrests – the foot should be supported at the front and the back with no gaps. •Run your fingers between the outside of the wheelchair user's thighs and the sides of the wheelchair. •Your fingers should fit f t bl ith t b i com or a y w ou e ng pinched. B.9. Fitting: 5 BASIC LEVEL CHECK SEAT W IDTH • Check the wheelchair user is sitting upright, with the back of their pelvis touching the backrest. • Slide hand between the cushion and back of the knee. Count how fi ll i h ld many ngers – usua y t s ou be a two finger gap. Sl d h d d h b k f h • i e an own t e ac o t e calf and make sure it is not touching the seat or cushion. • Check both sides. B.9. Fitting: 6 BASIC LEVEL CHECK SEAT DEPTH • Slide the hand between the thigh and the cushion. There should be even pressure along the thigh and no gaps. L k t th f t th • oo a e oo on e footrest. The foot should be t d t th f t d th suppor e a e ron an e back with no gaps. B.9. Fitting: 7 BASIC LEVEL CHECK FOOT RESTS HEIGH T 181 To check backrest height: • ask the wheelchair user if the backrest is comfortable; • observe whether the trunk is balanced over the hips; • is the wheelchair user able to push the wheelchair without the backrest interfering? To check the rear wheels position for hand propelling: • ask the wheelchair user to grip the push rims at the top of the wheels – the elbow should be bent at 90 degrees; • also check with the user if the rear wheels are positioned correctly for balance (forward for active, back for safe). To check the seat height for foot propelling: • ask the wheelchair user to sit with the back of their pelvis against the backrest with the pushing foot flat on the floor. check whether the feet can sit flat on the floor. • if the seat height is too high, personnel can try: - reducing the height of the cushion; - attaching a solid seat lower than the original seat (get technical advice or support to do this). For a user who is propelling with only one foot, with the other foot resting on the footrest: • check that the pressure under the seat bone of the side that is resting on the footrest is not at level 3. •Ask the wheelchair user if the backrest is comfortable. Ob h th th t k i • serve w e er e run s balanced over the hips. • Is the wheelchair user able to push the wheelchair without the backrest interfering? B.9. Fitting: 8 BASIC LEVEL CHECK BACK REST HEIGHT •Are the wheelchair user’s hands in a comfortable position to push the wheelchair? •Also check the position for b l (f d f ti a ance orwar or ac ve, backwards for safe). •Always re-check the brakes if the rear wheels are moved. B.9. Fitting: 9 BASIC LEVEL CHECK REAR W HEELS POSITIO N (FOR HAND P ROPELLING) •Can the wheelchair user sit with the back of their pelvis against the backrest and the pushing foot flat on the floor? B.9. Fitting: 10 BASIC LEVEL CHECK SEAT H EIGHT (FOR FO OT PROPELLIN G) Wheelchair Service Training Packag e 182 BASIC LEVEL check posture explain: after checking the size and adjustments, personnel should then check that the wheelchair user’s posture is as upright as is possible for them. ask: What are some of the things they would look for to check whether a person is sitting upright? encourage answers. Most important answers: • pelvis upright and level; • shoulders level, arms free to move; • trunk upright; • back following the three natural curves; • head upright and balanced over the body; • hips flexed near 90 degrees; • legs slightly open (abducted); • knees and ankles flexed near 90 degrees; • heels directly below the knees or slightly forward or back; • feet flat on the floor. explain: Remember that not everyone sits in exactly the same way. For example – some wheelchair users like to have their feet tucked back, with their knees bent more than 90 degrees. B.9. Fitting: 11 BASIC LEVEL POSTURE B.9. Fitting: 12 BASIC LEVEL NOT EVERYON E SITS EXACT LY THE SAME WAY 183 VIDEO check pressure explain: • For every wheelchair user at risk of developing a pressure sore – check if the pressure under the seat bones is safe. check fit while the wheelchair user is moving explain: The final part of fitting is to check when the wheelchair user is moving. The things to look for include: • does the backrest allow the wheelchair user freedom to move the shoulders to push? • does the backrest give the wheelchair user enough support? • do the wheelchair user’s feet stay on the footrests? • is the rear wheels position correct for the user? explain: if a wheelchair user cannot push the wheelchair themselves, ask a family member/carer to push them. introduce the DvD: We will now watch the whole fitting sequence. This includes checking the fit, checking posture, and checking while the wheelchair user is moving. hand out the wheelchair fitting checklist. explain: Participants can keep the checklist, and this will help to remind them of the steps in fitting. ask participants to watch the video, and see if they can see each of the fitting checks being carried out as shown on their checklist. Show DvD. ask if there are any questions. check if there are any further actions that need to take place • For every wheelchair user at risk of developing a pressure sore – check if the pressure under the seat bones is safe. B.9. Fitting: 13 BASIC LEVEL FITTING • Finally – check that the wheelchair fits when the wheelchair user is moving. B.9. Fitting: 14 BASIC LEVEL FITTING Wheelchair Service Training Packag e 184 BASIC LEVEL 3. Fitting practice (25 minutes) activity groups: Have two to three people in each group. Give each group a wheelchair and a wheelchair fitting checklist. instructions: • Ask each group to elect one person to be the wheelchair user. The other members of the group work with the wheelchair user to check that the wheelchair fits. • Remind participants to check the wheelchair user at rest and then moving. They should look at the “fit”, user’s posture and check pressure. Monitor: Monitor the groups, and assist as needed. Time: Allow 10 minutes for feedback. Feedback: ask each group to report back briefly to the whole group: • whether the wheelchair fitted or did not fit the wheelchair user ; • if the wheelchair did not fit, ask what part did not fit; • would it be possible to adjust the wheelchair to fit, or would they need to change the wheelchair? explain: if a wheelchair does not fit even after adjustment, there may be simple ways to modify it. This is explained in the next session. 4. key point summary (3 minutes) read the key points. ask whether there are any questions. •Always involve the wheelchair user in the fitting. Ask and listen to their opinion. Discuss and explain any changes or adjustments that you would like to make. •Fitting should check size posture and pressure, . •Check with the wheelchair user both still and moving. B.9. Fitting: 16 BASIC LEVEL KEY POINT S UMMARY 185 B.10: Problem solving O B Je c T iv e S By the end of this session, participants will be able to:  list common wheelchair fit or adjustment problems  describe simple solutions for common wheelchair fit or adjustment problems. r e S O U r c e S For the session:  PPT slides: B.10 Problem solving;  Reference Manual;  DVD: Problem solving fit or adjustment (parts 1 and 2);  one wheelchair ;  two blocks of foam (approximately 100 mm x 100 mm x 50 mm) for demonstration;  ankle/calf straps (if available). c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  the locally available wheelchairs – and any particular solutions that can be applied to these wheelchairs;  the materials and facilities participants have in their workplace. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Prepare photographs or slides of any local examples of the solutions described in this session. O U T l in e 1. Introduction. 2. Seat depth too short or too long. 3. Footrests height too low or too high. 4. Legs tend to roll inwards or outwards. 5. Feet tend to slide off the footrests. 6. Wheelchair is too wide. 7. Key point summary. 3 10 5 10 10 5 2 Total session time 45 Wheelchair Service Training Packag e 186 BASIC LEVEL 1. introduction (3 minutes) explain: sometimes personnel will find a problem with making the available wheelchair fit the wheelchair user correctly. The problem may be because: • there is a limited range of wheelchairs and sizes available; • the wheelchair user needs extra support to sit upright comfortably. • in this session, we will look at some simple solutions to some of the common problems caused by limitation in the sizes and range of wheelchairs available. • Making modifications and providing more postural support is covered in much more detail in the intermediate-level training. all of the solutions we will discuss in this session assume that the closest size wheelchair for the wheelchair user has already been selected. always check this before modifying a wheelchair. ask: What are some common fitting problems personnel have already seen, or think may happen? Most important answers: • seat depth is too long or too short; • footrests height cannot go up high enough or does not go down low enough; • legs tend to roll inwards or outwards; • feet tend to slide off footrests; • wheelchair is too wide. explain: in this session, we will look at five possible problems. Step 6 Fitting • In this session participants will: – Look at some simple solutions to some of the common fitting problems caused by limitations in the sizes and range of wheelchairs available. – Making modifications and providing more postural support is covered in much more detail in the intermediate level training. B.10. Problem solving: 2 BASIC LEVEL INTRODUCTI ON 187 1. Seat depth too short or too long (10 minutes) Problem: Seat depth too short Describe the possible solutions outlined below. Use a wheelchair to demonstrate. • Lengthen the wheelchair seat depth by extending the seat rails and replacing upholstery: - if the wheelchair is a folding-frame wheelchair, check whether the seat rails are “dedicated”. This means the seat rails are not also part of the wheelchair frame. - in this case, an extension can be made to the seat rails and new upholstery made. • Lengthen the wheelchair seat depth by replacing the upholstery: - if the wheelchair is a rigid frame wheelchair with upholstery, check if the seat rail extends beyond the seat. - in this case, it may be possible to replace the seat upholstery with new upholstery made to the correct length and supported by the existing seat rails. • Lengthen the wheelchair seat depth by adding a rigid board with a cushion: - a solid seat can be made from wood, plastic or any other rigid material which will not flex or crack. - The seat can be fixed to the top of the seat rails. - add a cushion that is the same width and depth as the new seat. •Mark the seat depth that is needed on the existing seat and reduce it. • If the seat is upholstered – remove the upholstery, shorten it (using an industrial sewing machine) and replace. • If the seat is rigid – remove the seat shorten , and replace. • Shorten the cushion to match the new seat depth. B.10. Problem solving: 3 BASIC LEVEL PROBLEM: SEA T DEPTH IS TO O SHORT Wheelchair Service Training Packag e 188 BASIC LEVEL explain: When replacing a wheelchair seat, remember the following. • Make sure the new seat is strong enough to carry the weight of the user. • if it is a rigid (solid) seat: - check that the seat does not flex or crack beyond the existing wheelchair seat; - always ensure a rigid seat is provided with a cushion – for every wheelchair user; - check during fitting that the backrest and footrests are the correct height – a solid seat and cushion will raise the wheelchair user in the wheelchair. Problem: Seat depth too long explain: if the shortest available seat depth is too long for the wheelchair user, it will be impossible for him/her to sit upright. The seat depth must be shortened. Describe the possible solutions outlined below. Use a wheelchair to demonstrate. • Mark the seat depth that is needed on the existing seat and reduce it. • if the seat is upholstered – remove the upholstery, shorten it (using an industrial sewing machine) and replace. • if the seat is rigid – remove the seat, shorten and replace. • shorten the cushion to match the new seat depth. explain: When shortening a seat depth, remember: • when cutting a rigid seat – always ensure that all edges are smooth and splinter-free; • when cutting a cushion – always cut from the front so that pressure relief at the back of the cushion stays the same. •Lengthen the wheelchair seat depth by extending the seat rails and replacing upholstery. •Lengthen the wheelchair seat depth by replacing the upholstery. •Lengthen the wheelchair seat depth by adding a rigid board with a cushion. B.10. Problem solving: 5 BASIC LEVEL PROBLEM: SEA T DEPTH IS TO O LONG • When replacing a wheelchair seat make sure the , new seat is strong enough to carry the weight of the user. • If it is a rigid seat: – Check that the seat does not flex or crack beyond where it extends beyond the existing wheelchair seat; Al i id i id d i h – ways ensure a r g seat s prov e w t a cushion for every wheelchair user; Check during fitting that the backrest and – footrests are the correct height. A solid seat and cushion will raise the wheelchair user in the wheelchair . B.10. Problem solving: 6 BASIC LEVEL CAUTION • When replacing a wheelchair seat make sure the , new seat is strong enough to carry the weight of the user. • If it is a rigid seat: – Check that the seat does not flex or crack beyond where it extends beyond the existing wheelchair seat; Al i id i id d i h – ways ensure a r g seat s prov e w t a cushion for every wheelchair user; Check during fitting that the backrest and – footrests are the correct height. A solid seat and cushion will raise the wheelchair user in the wheelchair . B.10. Problem solving: 6 BASIC LEVEL CAUTION 189 explain: if the wheelchair seat depth is more than 60 mm shorter (for an adult) than the wheelchair user’s seat depth, this can be a problem. The wheelchair user will not have enough support from the seat to be able to sit comfortably. There is also an increased risk of pressure on high-risk areas such as the seat bones. 3. Footrests height too low or too high (5 minutes) Problem: Footrests height is too low explain: if the footrests height is too low, the wheelchair user will not be able to rest the feet comfortably on the footrests. This can cause him/her to slide forward in the wheelchair, or to feel unstable. He/she will not have the support needed to sit upright comfortably. Describe the possible solutions outlined below. Use a wheelchair to demonstrate. • Raise the footrests height by shortening the footrests hanger: - on most four-wheel wheelchairs, the footrests hanger may be cut shorter. • Raise the footrests height by building up the footrests: - use wood or another sturdy material to add height to the footrests. explain: • When changing the footrests hanger: – always check that the adjustment mechanism still working. • if building up footrests – check the build- up does not stop footrests that move out of the way from working. •Raise the footrests height by shortening the footrest hangers. •Raise the footrests height by building up the footrests. B.10. Problem solving: 7 BASIC LEVEL PROBLEM: FO OTRESTS ARE TOO LOW •When changing the footrest hangers – always check that the adjustment mechanism still works. • If building up footrests check that the build– - up does not stop footrests that move out of the way from working. B.10. Problem solving: 8 BASIC LEVEL CAUTION Wheelchair Service Training Packag e 190 BASIC LEVEL Problem: Footrests height is too high explain: if the footrests height is too high, the wheelchair user’s thighs will not rest comfortably on the seat. Footrests that are too high can increase pressure on the seat bones. Describe the possible solutions outlined below. Use a wheelchair to demonstrate. 1. Lower the footrests height by lengthening the inner extension tube: - check if the inner extension tube can be replaced with a longer tube; - if so – replace it with a similar tube of the same diameter and strength. 2. increase the height of the cushion: - increase the height of the cushion, or raise the cushion by adding something solid underneath. explain: • if lowering the footrests – make sure the footrests do not become so low that they catch on the ground. if this happens, try option 2 instead. if that does not work, the wheelchair is not suitable for the wheelchair user. • When raising the height of a cushion: - do not use soft foam to increase the height of the cushion – this will compress, and will also feel unstable; - check during fitting that the backrest and armrests are the correct height – the higher cushion will raise the wheelchair user in the wheelchair; - check that there are no functional problems with raising the cushion – for example, the wheelchair user may then not be able to fit under tables or desks. •Lower the footrests by lengthening the inner extension tube. • Increase the height of the cushion. B.10. Problem solving: 9 BASIC LEVEL PROBLEM: FO OTRESTS ARE TOO HIGH If l i h f k h • ower ng t e ootrests - ma e sure t e footrests do not become so low that it catch on the ground . • If raising the height of a cushion: – Do not use soft foam to increase the height of the cushion. – Check during fitting that the backrest and armrests are the correct height. – Check that there are not functional problems with raising the cushion. B.10. Problem solving: 10 BASIC LEVEL CAUTION 191 VIDEO 4. legs tend to roll inwards or outwards (10 minutes) explain: • sometimes the wheelchair user’s legs roll inwards or outwards. This may be because of the way he/she is used to sitting, or have a physical reason (for example muscle weakness). • simple adjustments to the wheelchair seat or cushion can help to reduce this problem. introduce DvD: Problem solving fit or adjustment. This short video shows a wheelchair user called Gary, whose legs tend to roll outwards. Show DvD: (part 1 – gary) after the video ask: What was the solution that the therapist provided? encourage answers. explain that in this example the solution was to add wedges to the cushion to support the thighs in neutral. The rise on the outside of the legs was increased. a contoured cushion could have also been added to solve this problem. if legs were rolling inwards, the rise on the inside could have been increased. Describe the other possible solutions outlined below. Use a wheelchair to demonstrate. • Double check the footrests height: - make sure the footrests height is supporting the wheelchair user correctly (even pressure should be felt under the feet and under the thighs). • check the wheelchair seat is properly tensioned: - if the wheelchair has an upholstered seat – make sure that the seat is tensioned firmly; - if the seat is saggy, this will encourage the wheelchair user’s legs to roll inwards. • add wedges to the cushion to support the thighs in neutral (as in DvD and illustration) or provide a contoured cushion, modify cushion if necessary. •Double check the footrests height. •Check that the wheelchair seat (if canvas/slung) is properly tensioned. •Add wedges to the cushion to support the thighs in neutral (as in DVD and illustration) or provide a contoured cushion, modify if necessary. B.10. Problem solving: 12 BASIC LEVEL PROBLEM: LEG S TEND TO RO LL INWARDS O R OUTWARDS Wheelchair Service Training Packag e 192 BASIC LEVEL 5. Feet tend to slide off the footrests (10 minutes) explain: • sometimes the wheelchair user’s feet slide off the footrests. This often has a physical reason (for example muscle weakness or muscle spasms). • The simple addition of straps can help to reduce this problem. Describe the possible solutions outlined below. Use a wheelchair to demonstrate. • Double check the footrests height: - make sure the footrests height is supporting the wheelchair user correctly (even pressure should be felt under the feet and under the thighs). • adjust the footrests angle (if possible): - check if the footrests angle can be adjusted; - if so – try increasing the angle of the footrests. This may help to hold the wheelchair user’s feet in place. • add a strap: - attach a strap to the footrests hangers at the level of the ankles; - if the feet tend to slide off backwards, the strap goes behind the legs; - if the feet tend to slide off forwards, the strap goes in front of the legs. explain: • Make sure the strap is easy to remove, so that the wheelchair user can get in and out of the wheelchair without effort. • check that the wheelchair user can reach the strap without assistance, and can do it up and undo it easily. D bl h k h f • ou e c ec t e ootrests height. •Adjust the footrests angle (if possible). •Add a strap. B.10. Problem solving: 13 BASIC LEVEL PROBLEM: FEE T TEND TO SL IDE OFF THE F OOTRESTS Wh l h f• enever a tering t e ootrests: – Try to ensure there is even pressure under the foot. •When adding a strap: – Make sure the strap is easy to remove so that th h l h i t i d t f th e w ee c a r user can ge n an ou o e wheelchair without effort. – Check that the wheelchair user can reach the strap without assistance, and can do it up and d i ilun o t eas y. B.10. Problem solving: 14 BASIC LEVEL CAUTION 193 VIDEO explain: another problem can be that the feet are not evenly supported on the footrests. This is often caused by the wheelchair user’s feet not being able to reach a neutral posture. introduce the DvD: Problem solving fit or adjustment. This short DvD shows arun, a wheelchair user whose feet are not evenly supported on the footrest. Show DvD: (part 2 – arun) after the video ask: What was the solution that the therapist provided? encourage answers. 6. Wheelchair is too wide (5 minutes) explain: sometimes the smallest wheelchair available is still too wide for the wheelchair user. if the wheelchair seat is too wide, the wheelchair user will find it difficult to sit upright, and is likely to collapse to one side. some simple foam inserts can help to provide the wheelchair user with support to sit upright. Describe the possible solutions outlined below. Use a wheelchair to demonstrate. • add foam pads on each side of the pelvis: - measure the space between the wheelchair user (when he/she is sitting central in the wheelchair with the back against the backrest) and the side of the armrests; - cut and add foam inserts to fill the space between each side of the wheelchair user and the side of the wheelchair; - check fit; - upholster and attach the foam inserts. if the armrests are solid, the inserts may be attached to the armrests. They may also be attached to the top of the cushion. •To reduce wheelchair idth dd f i t w , a oam nser s on each side of the pelvis. B.10. Problem solving: 16 BASIC LEVEL PROBLEM: WH EELCHAIR IS T OO WIDE Wheelchair Service Training Packag e 194 BASIC LEVEL explain: • The inserts only need to come as far forward as the user’s trunk. • ensure the cushion matches the seat width. • if the wheelchair is very wide, the wheelchair user will also have trouble reaching the push rims. • Over-reaching for the push rims can cause a shoulder injury. consider carefully whether the wheelchair is safe for the wheelchair user before prescribing it. 7. key point summary (2 minutes) read the key points. ask whether there are any questions. If d i h l h i t idth b ddi id d• re uc ng a w ee c a r sea w y a ng s e pa s: – Remember - The pads only need to come as far forward as th ’ t ke user s run . – Ensure the cushion matches the wheelchair seat width. • If the wheelchair is very wide, the wheelchair user will also have trouble reaching the push rims. • Over-reaching for the push rims can cause a shoulder injury. Consider carefully whether the wheelchair is safe for the h l h i b f ibi iw ee c a r user e ore prescr ng t. B.10. Problem solving: 17 BASIC LEVEL CAUTION • Problems with the wheelchair fit may be due to: – Limitations in the sizes and ranges of wheelchairs available; Th h l h i di t t t b bl t it i ht – e w ee c a r user nee ng ex ra suppor o e a e o s upr g comfortably. • Simple solutions can sometimes solve these problems. • Before making any modifications, always check that you have the best size of the wheelchair available for the wheelchair user, and i i dj d ll i b t s a uste as we as t can e. • Whenever making any modifications to a wheelchair: – Re-check the wheelchair to make sure it is safe to use; – Carry out a complete fitting again with the wheelchair user, as changes to one thing can affect others. B.10. Problem solving: 18 BASIC LEVEL KEY POINT SU MMARY 195 B.11: User training O B Je c T iv e S By the end of this session, participants will be able to:  list skills wheelchair service personnel can teach wheelchair users when they receive a new wheelchair ;  list “good practice training methods”;  demonstrate teaching a colleague one wheelchair skill. r e S O U r c e S For the session:  PPT slides: B.11 User training;  Reference Manual;  Participant’s Workbook;  one wheelchair for each group of three;  wheelchair user training checklist (1 per participant). c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  local groups that can offer more training or advice to wheelchair users. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan. O U T l in e 1. Introduction. 2. What are helpful skills for wheelchair users? 3. Wheelchair user training practice. 4. Key point summary. 2 10 45 3 Total session time 60 Wheelchair Service Training Packag e 196 BASIC LEVEL 1. introduction (2 minutes) explain: • User training is the seventh step in wheelchair service delivery. information and training about the wheelchair can help many wheelchair users benefit more fully from their wheelchair. • Without this step, it is possible a wheelchair will not help a wheelchair user as much as it could. • in this session, we will talk about the skills that personnel can teach wheelchair users when they first receive a wheelchair. We will introduce the wheelchair user training checklist and practise giving user training. 2. What are helpful skills for wheelchair users? (10 minutes) ask: What have participants learnt on this training programme that they can teach to wheelchair users? Think about things that will help wheelchair users: • stay healthy; • use their wheelchair inside and outside their home; • care for their wheelchair so that it lasts as long as possible. remind participants of the video of sai, talking about the things that helped her to get to school. encourage answers. Most important answers: • ways to stop pressure sores developing; • how to handle the wheelchair ; • how to get in and out of the wheelchair ; • wheelchair mobility; • what to do if there is a problem; • how to look after the wheelchair and cushion; • what other organizations or services there are that may be helpful to them. Step 7 User training • In this session participants will: – Discuss the skills that wheelchair personnel can teach wheelchair users when they first receive a wheelchair; – Introduce the user instruction checklist; P ti i i i t ti– rac se g v ng user ns ruc ons. B.11. User training: 2 BASIC LEVEL INTRODUCTI ON 197 explain: The six most important things to remember to teach users are: • How to handle the wheelchair. • How to prevent pressure sores and what to do if a pressure sore develops. • How to get in and out of the wheelchair (transfer). • Wheelchair mobility – match the user’s needs. B.11. User training: 3 BASIC LEVEL HOW TO HAN DLE THE WHE ELCHAIR B.11. User training: 4 BASIC LEVEL HOW TO PREV ENT PRESSUR E SORES B.11. User training: 5 BASIC LEVEL HOW TO GET IN AND OUT OF THE WHEE LCHAIR B.11. User training: 6 BASIC LEVEL WHEELCHAIR MOBILITY Wheelchair Service Training Packag e 198 BASIC LEVEL • How to care for a wheelchair and cushion at home. explain: We will talk more about this in the next session. • What to do if there is a problem. give each participant a wheelchair user training checklist. explain: • The checklist lists specific skills that may be helpful for a wheelchair user to learn. However, some wheelchair users will already know how to carry out these skills, and not all skills are important for all wheelchair users. • some services may use this checklist as a form, kept in the wheelchair user’s file. Personnel can record on the checklist what instruction the wheelchair user needs. This is decided through the assessment, and through talking to the wheelchair user. The checklist can also be used to record the training which has been given. • check with the wheelchair user whether he/she would like caregivers to learn the skills you are teaching as well. Many wheelchair users are supported by their family or a carer, and it is helpful for everyone involved to learn the skills involved in using and caring for the wheelchair. 3. Wheelchair user training practice (45 minutes) ask: What are some things that can make training successful? Participants can think about some good teaching methods they have experienced (maybe during the training!). encourage answers. B.11. User training: 7 BASIC LEVEL HOW TO CAR E FOR THE WH EELCHAIR AN D CUSHION •Who the wheelchair user should ask if there is a problem. •How they can contact the wheelchair service if they need help. B.11. User training: 8 BASIC LEVEL WHAT TO DO IF THERE IS A PROBLEM 199 Most important answers: • Find out what the wheelchair user already knows. • Explain, demonstrate and then allow the wheelchair user to practise. • Use language that everyone can understand. • Have wheelchair users teach other wheelchair users. • Use good communication skills. • Be encouraging. explain: Practice is important when learning any new skill. always try to teach a skill first by demonstrating, and then giving the learner an opportunity to practise. Small-group activity groups: Have two to three people in each group. instructions: • ask each group to read the stories in their workbook. They should identify at least three skills that each wheelchair user in the story could benefit from learning. • For each user, the group should practise teaching at least one of those skills. The group should take turns being the wheelchair user, family member and teacher. • Remind participants to think about “good communication” and “good ways to teach”. stress the importance of “demonstration” followed by “practice”. Monitor: • Monitor the groups, assist as needed. Time: Allow 30 minutes and 15 minutes for feedback. Feedback: • ask each group to highlight one good way of teaching they have tried or observed. Moses notes for trainers: Moses is 23 years old. He fell from the back of a truck two years ago and became a paraplegic. He spent one year in hospital and then returned to his home village with an old donated wheelchair. The wheelchair broke very quickly and he was unable to move around. He developed a pressure sore which has now healed. Moses has just received a new wheelchair with a pressure relief cushion through the wheelchair service. This wheelchair is designed to go over rough ground. He is very excited about going home with this wheelchair and is hopeful that he will be more independent. Most important skills: • wheelchair handling and how to use the pressure relief cushion – particularly as Moses is new to having a wheelchair ; • how to prevent pressure sores; • how to get in and out of the wheelchair (transfer); • wheelchair mobility skills; • how to care for a wheelchair and cushion at home; • other organizations or services which may be helpful. Wheelchair Service Training Packag e 200 BASIC LEVEL Sian notes for trainers: sian is 40 years old and is a bilateral above-knee amputee. He has been a wheelchair user for 20 years and has had five wheelchairs over that time. He finds that the wheelchairs he has break down quickly. He is very active and works in a local shop. He travels from his home to the shop every day – on rough, bumpy and often muddy paths. He demonstrated for the wheelchair service personnel how he can do wheelies. He has just been prescribed a new wheelchair. He is hoping that this wheelchair will last longer than his last one, which broke down after six months. Most important skills: • how to care for a wheelchair and cushion at home – regular maintenance may help Sian to keep his wheelchair working for longer. Zoe notes for trainers: Zoe is 16 years old. She had polio as a young girl, and now cannot walk. She is very shy, and has not been to school. Her mother has given her lessons at home and she can read and write well. She has just received a new wheelchair and has shown the wheelchair service personnel how she can transfer easily into and out of the chair. Zoe is interested in attending a local vocational school – however, she does not think that she can manage getting to the school and back. There are a few steps into the school building. She is also worried about how she would go to the toilet while at the school. Most important skills: • wheelchair mobility skills – particularly how to get up and down steps; • transfers – how to transfer to and from the toilet. 4. key point summary (3 minutes) read the key points. ask whether there are any questions. I f i d i i b h d f • n ormat on an tra n ng a out ow to use an care or a wheelchair can help many users benefit from their wheelchair. • When teaching new skills – provide lots of opportunity for the person learning to practise. • The six most important things to teach are: – How to stop pressure sores; – How to get in and out of the wheelchair; – Wheelchair mobility – matched to the user’s needs; – How to care for the wheelchair and cushion; – What to do if there is a problem. B.11. User training: 9 BASIC LEVEL KEY POINT SU MMARY 201 B.12: Maintenance and repairs O B Je c T iv e S By the end of this session, participants will be able to:  demonstrate how to care for a wheelchair at home;  identify common technical problems with a wheelchair and explain how these problems can be solved within the local community/context. r e S O U r c e S For the session:  PPT slides: B.12 Maintenance and repairs;  Reference Manual;  Participant’s Workbook;  DVD: How to care for a wheelchair at home;  poster : How to care for a wheelchair at home;  wheelchairs needing repair including: punctured tyre, brakes not working, damaged cushion, corrosion, loose upholstery, loose bolts, loose or missing spokes, damaged bearings, damaged push rims. More than one repair may be required on any one wheelchair ;  1 home maintenance toolkit (see equipment list above). c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  where wheelchairs can be repaired in the participants’ locations;  any specific repairs or maintenance needs for locally available wheelchairs which should be highlighted;  whether the participants’ wheelchair service provides wheelchair repairs – if so, how wheelchair users can access the repairs service, and whether there is a charge. T O P r e Pa r e  Gather resources, review PPT slides, watch DVD and read through the session plan.  Pin up How to Care for a Wheelchair at Home poster where it can be seen by all participants.  Prepare the wheelchairs for repairs and label them A, B, C, etc. Arrange them around the room.  Arrange to have someone with technical experience join the session to assist in answering detailed questions about wheelchair repairs (if trainers do not feel confident with this). O U T l in e 1. Introduction. 2. Prevent repairs: home maintenance. 3. Common wheelchair and cushion repairs. 4. Key point summary. 2 60 55 3 Total session time 120 Wheelchair Service Training Packag e 202 BASIC LEVEL 1. introduction (2 minutes) explain: • Regular care of a wheelchair and cushion will save repair costs and prevent injuries and long-term damage to the user’s body. • a wheelchair which is cared for will be more comfortable and easier to use. • a cushion which is cared for will continue to provide pressure relief and support. • Wheelchair service personnel have a responsibility to teach wheelchair users how to care for their wheelchair and cushion at home. • in this session, we will learn about what can be done to care for a wheelchair and cushion at home, and what to do when a wheelchair or cushion needs repairs. 2. Prevent repairs: home maintenance (60 minutes) Pin up the how to care for a wheelchair at home poster. Notes for trainers: The slides below explain how to care for a wheelchair at home. Each slide explains why the task is important, how to do it and how often. Trainers should add the additional points listed below. explain: • There are six things that wheelchair users can do at home to maintain their wheelchair and cushion. • list (see slide). Step 8 Maintenance, repairs and follow up • In this session participants will: – Learn about what can be done to care for a wheelchair and cushion at home; – What to do when a wheelchair or cushion needs repairs. B.12. Maintenance and repairs: 2 BASIC LEVEL INTRODUCTI ON •Clean the wheelchair and cushion. Oil i t• mov ng par s. •Pump up the tyres (if pneumatic). •Tighten nuts and bolts (if loose). T h k ( f l )• ig ten spo es i oose . •Make regular checks. B.12. Maintenance and repairs: 3 BASIC LEVEL HOW TO CAR E FOR A WHE ELCHAIR AT H OME 203 explain: • Why, how often and how (see slide). add: • Pay attention to moving parts and places where upholstery joins the frame. explain: • Why, how often and how (see slide). add: • Do not spray lubricants on the bearings, as this may wash away the grease which helps to keep the bearing working well. • Do not use a penetrating oil to oil the wheelchair, as this can cause damage to the wheelchair. ask: What oil is available in participants’ local area? explain: • Why, how often and how (see slide). add: • check if tyres are pneumatic. • When checking pressure – press down firmly on the tyre with your thumb. it should be possible to depress the tyre very slightly (about 5 mm). • Pressure should be the same on each tyre. • Why? St t l t f ti– ops me a par s rom rus ng; – Stops wooden parts and upholstery rotting; – Stops damage caused by dirt scraping against moving parts. • How often? – Monthly. • How? – Use warm water with a little soap; – Rinse and dry; – Always dry the cushion in the shade - not i di n rect sun. B.12. Maintenance and repairs: 4 BASIC LEVEL CLEAN THE W HEELCHAIR A ND CUSHION •Why? – Keeps parts moving smoothly; Helps stop rust– . •How often? – Every three months. •How? – Dry wheelchair thoroughly; Use lubricating oil;– – Apply to all moving parts. B.12. Maintenance and repairs: 5 BASIC LEVEL OIL MOVING P ARTS • Why? T ll l l– yres wi ast onger; – It is easier to push the wheelchair; T k l – a es ess energy; – Brakes will work correctly. • How often? – Once a week or if the tyre is flat. • How? – Check pressure; Pump up using a bicycle pump;– – Reduce pressure by releasing air through the valve. B.12. Maintenance and repairs: 6 BASIC LEVEL PUMP UP TYR ES (IF PNEUM ATIC) Wheelchair Service Training Packag e 204 BASIC LEVEL explain • Why, how often and how (see slide). add: • Do not over tighten. • avoid “cross-threading” nuts. explain • Why, how often and how (see slide). add: • To check spokes – squeeze two spokes together all the way around the wheel. if a spoke “gives” when you pull gently, it may be too loose. • a spoke wrench is an important tool for a wheelchair user. if the user does not have one, most bicycle repair shops sell them. • spokes can be over-tightened. if the spoke feels very rigid, it is probably too tight and should be loosened. explain • Why, how often and how (see slide). add: • if the upholstery has weakened or there are loose stitches, it is better to get this repaired before it becomes worse. • if there is rust, this can be removed with sandpaper or a steel brush. Then repaint or oil the metal part. • Why? – Loose bolts cause unwanted movement in the parts; – This can be uncomfortable and can cause parts to wear out or be lost. • How often? – Once a month. • How? – Check all nuts and bolts; – Tighten any loose nuts and bolts but do not over tighten. B.12. Maintenance and repairs: 7 BASIC LEVEL TIGHTEN NU TS AND BOLT S (IF LOOSE) •Why? – Loose spokes can cause wheels to buckle and collapse. •How often? – Once a month or if the wheels are wobbly. •How? – Check spokes by squeezing together. – Tighten any loose spokes with a spoke wrench. B.12. Maintenance and repairs: 8 BASIC LEVEL TIGHTEN SPO KES (IF LOOS E) • Why? U h l t t b i d – p o s ery mus e n goo condition to support the user; – A sudden rip may cause an injury; – Rust reduces the strength of the wheelchair and may cause parts to b krea . • How often? – Once a month. • How? – Check upholstery including stitching; – Check all metal parts. B.12. Maintenance and repairs: 9 BASIC LEVEL MAKE REGULA R CHECKS: RUS T AND UPHOL STERY 205 VIDEO explain • Why, how often and how (see slide). add: • check for worn spots, dirt and holes in the cover and/or foam. • if the cushion is worn, it should be checked by the wheelchair service personnel. it may need to be replaced. introduce DvD: how to care for a wheelchair at home. This short video will show a wheelchair user carrying out for the wheelchair at home. Teaching wheelchair users how to carry out these tasks is important. Show DvD. ask if there are any questions. activity groups: Have three people in each group. Give each group a wheelchair. Place sufficient tools and equipment for home maintenance in a central location for each group to share. instructions: Ask each group to carry out ``How to care for a wheelchair at home`` tasks. Point out the How to care for a wheelchair at home poster and remind participants to follow each step. Monitor: Monitor the groups. Answer any questions and explain the techniques in more detail as necessary. Time: Allow 30 minutes. Feedback: ask: Does anyone have any questions about the home maintenance tasks? 3. common wheelchair and cushion repairs (55 minutes) explain: Wheelchairs will sometimes need to be repaired. Wheelchair service personnel need to be able either to carry out a repair themselves, or tell wheelchair users where they can get help. some wheelchair users will be very good at organizing their own repairs. Other wheelchair users may need help. all wheelchair users will benefit from knowing where they can get their wheelchairs repaired. ask: Where can wheelchair users get their wheelchairs repaired? • Why? C hi h ld b l d d t – us on s ou e c ean an ry o protect skin; – Cushion do not last as long as the wheelchairs; – A regular check will help wheelchair user to recognize when the cushion needs to be replaced. • How often? – Once a month. • How? – Remove cover and check cushion and cover for worn spots, dirt and holes. B.12. Maintenance and repairs: 10 BASIC LEVEL MAKE REGUL AR CHECKS - CUSHION Wheelchair Service Training Packag e 206 BASIC LEVEL encourage answers and write on the whiteboard. Most important answers: • bicycle repairer ; • motorcycle or car mechanic; • workshops – welder, plumber (metal parts), carpenter, furniture maker (wooden parts); • wheelchair user, wheelchair user’s family member, relative or neighbour; • tailor for repairing upholstery; • wheelchair service facilities. ask: What are the most common things that can go wrong on a wheelchair? encourage answers and write on the board. Most important answers: • compressed or damaged cushion; • stretched or torn upholstery; • corrosion or rust on metal parts; • loose, missing or broken spokes; • loose or missing nuts, bolts or screws; • castor wheels breaking; • punctured/flat tyre; • worn tyres and castor wheels; • dirty, worn or damaged bearings; • damaged push rims; • brakes not working. Small-group activity groups: Have three people in each group. instructions: ask each group to: • assess each of the wheelchairs to find out what is broken and needs repair • remind them to consider the different problems written on the whiteboard • answer the questions in their workbook for each wheelchair. Monitor: Monitor the groups. answer any questions and help participants to identify repair needs if needed. Some people will be better at this than others, depending upon their technical experience. It is not necessary for every person to be able to repair a wheelchair themselves. The most important skill is to be able to identify what is wrong and know what can be done to ensure the wheelchair is repaired. Time: Allow 30 minutes. Feedback: ask the groups to feed back the things that need repairing on each wheelchair. Make sure each group has a chance to feed back on at least one wheelchair. For each repair item, ask: why is this a problem for the wheelchair user? 207 4. key point summary (3 minutes) read the key points. ask whether there are any questions. Practical Two: Fitting and user training O B Je c T iv e S By the end of this session, participants will be able to:  Demonstrate a basic level fitting – with assistance.  Demonstrate providing a wheelchair user with the user training to help him/ her to use and maintain the wheelchair effectively. r e S O U r c e S  trainer’s Observation Checklist: Practical Two;  completed wheelchair assessment and wheelchair prescription (selection) forms from Practical One;  wheelchair fitting and wheelchair user training checklists (provided to participants earlier);  clean and quiet space for each group to work with their wheelchair user ;  wheelchairs ready for first fitting;  tape measure and tools to adjust wheelchairs – one set per group. c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  cultural factors – for example, whether it is appropriate to have mixed-gender groups doing the fitting and user instruction;  language factors – for example, whether wheelchair users attending speak a common language with all participants;  any documentation that the service may require when providing a wheelchair – for example, wheelchair serial number;  how trainers will manage any problems that may arise during the fitting or user training that cannot be addressed within the training context. • Regular care of a wheelchair will save costs for repairs and will prevent injury. • Wheelchair users can do a lot at home to look after their wheelchair and to keep it in good working condition. • Caring for a wheelchair at home tasks are: clean the wheelchair and cushion, oil moving parts, pump up the tyres, tighten nuts and bolts (if loose), tighten spokes (if loose), make regular checks. • Wheelchair personnel should explain to wheelchair users what to do if their wheelchair needs repairs. B.12. Maintenance and repairs: 12 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 208 BASIC LEVEL T O P r e Pa r e  If there are more than three pairs of participants, ask for another trainer to assist with monitoring the groups.  Confirm time and travel arrangements with wheelchair user volunteers. Ensure there are refreshments available for wheelchair users and their family/ supporters.  Assign one person to greet wheelchair users as they arrive and show them where they can wait until the session begins.  Prepare a fitting area for each group (assessment bed and privacy screen). Place all equipment needed for fitting on the assessment bed. (Or make travel arrangements if carried out in the community).  Ensure that the wheelchairs to be fitted are fully prepared (check them against the prescription forms and confirm that wheelchair safe and ready checks have been completed). O U T l in e 1. Fitting and user training: • Instructions and set up • Fitting • User training • Feedback. 5 45 50 20 Total session time 120 2. Wheelchair user feedback (optional – depending on wheelchair users and time availability). 30 1. Fitting and user training including feedback (120 minutes) Notes for trainers: Use the trainer’s observation checklist for Practical Two to guide you as you observe participants during the practical session. Write any common examples of good or bad practice that should be highlighted in the feedback session on the checklist (box provided). activity groups: • Groups should be the same as for Practical One. • Appoint a leader for each group (this may be the same leader as for Practical One or a different leader). • Assign each group a place to work. • Explain where to find materials and tools. • Check that each group has wheelchair fitting and wheelchair user training checklists. 209 instructions: explain all of the following: session aim: • The aim of this practical session is to carry out steps six and seven of the eight steps of wheelchair service delivery – fitting and user training – working with the wheelchair user from the previous practical session. • It is possible that participants may not be able to complete the wheelchair for the wheelchair user during the time available. This will depend on the first fitting, and what modifications / adjustments may be necessary. However, participants should use the session time as well as possible to get as much done as possible. If the wheelchair cannot be completed, arrangements will be made with the wheelchair user to ensure that their wheelchair is completed after the course. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out. • The lead person should be the main person talking with the wheelchair user and his/her family/carer. This is to avoid having too many people speaking at once, which can be confusing for everyone. Trainer's observation and support: • Participants may ask for assistance or clarification at any time. • Throughout the session, trainers will monitor each group and give as much support and advice as needed. • If any problems with the fit are identified, please ask for the trainer to come and check this, and discuss what modifications/ adjustments may be needed. • After completing the fitting, participants should ask one trainer to come and check the fitting. DO NOT BEGIN USER TRAINING until the fit has been checked by one of the trainers. • After completing the user training, participants should ask one trainer to come and discuss with the group and the wheelchair user what training was provided. Wheelchair Service Training Packag e 210 BASIC LEVEL Time allowed: • They should aim to complete the fitting in 45 minutes, and the user training in a further 50 minutes. service forms: • Hand out the wheelchair assessment and wheelchair prescription (selection) forms from Practical One (used in Practical Two) to each group leader. • Check that each group has at least one copy of the wheelchair fitting and wheelchair user training checklists. ask participants: What are the steps for fitting? Acknowledge correct answers. Remind participants: they should only teach the wheelchair user the skills that are relevant to them. For example – it is not necessary to teach pressure relief techniques to a person who is not at risk of developing a pressure sore. Remind participants that they should actively involve the wheelchair user in every step of the process. ask: Are there any questions? Answer any questions. ask each group to prepare the area they are going to work in; then introduce themselves to the wheelchair user they will work with and begin. Monitor and support: closely monitor the groups, ensure safe practice, observe and evaluate the skills of participants. Use the trainer's observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a white board where all participants can see) to help participants manage their time. • Ensure wheelchair users are actively involved. at the end of this session, ask participants to thank the wheelchair users for their participation and ask whether they would like to stay and provide feedback to the whole group about their experiences during assessment, prescription (selection), fitting and user training. 211 Time: Allow 45 minutes to complete the fitting, 50 minutes to complete the user training, 20 minutes for feedback. Feedback: comment on examples of good practice that you saw during the practical session. Note any particular areas that participants could improve – do not highlight individuals. ask each group to summarize briefly any changes they had to make to the wheelchair to ensure it fitted the user correctly (allow 3 minutes for each group). ask: Are there any questions? 2. Wheelchair user feedback (optional – depending on the wheelchair users and time availability) (30 minutes) notes for trainers: If the wheelchair users who have attended Practicals One and Two are willing, invite each one to offer some feedback to participants about the process they have just gone through. This could be done informally – for example with refreshments/cake to celebrate the completion of the first two practicals. Sample questions to ask wheelchair users are shown below. ask wheelchair users to provide feedback in the following areas. • How did they feel during the assessment? (For example – did they feel involved, how did they feel about answering the interview questions, did they feel that the questions would help them to get a better wheelchair?) • are they happy with the wheelchair they have been prescribed? • Have they learnt anything new from the user training? Will they use this at home/work in the future? Wheelchair Service Training Packag e 212 BASIC LEVEL B.13: Follow up O B Je c T iv e S By the end of this session, participants will be able to:  explain what “follow up” means and how it happens;  complete a wheelchair follow up form. r e S O U r c e S For the session:  PPT slides: B.13 Follow up;  Reference Manual;  Participant’s Workbook; c O n T e X T All wheelchair users will benefit from follow up visits, preferably at the place where they live. Adapt this session to suit the context participants will be working in. Think about the following:  How follow up will be managed in the services participants come from (home visits, centre-based, managed by community-based rehabilitation (CBR) personnel) and adapt the training accordingly. For example, if participants come from a wheelchair service which has a follow up plan, this plan should be explained to the participants. T O P r e Pa r e  Gather resources, review PPT slides and read through the session plan. O U T l in e 1. Introduction. 2. What is follow up and how does it happen? 3. Introducing the follow up form. 4. Practising follow up. 5. Key point summary. 2 10 5 25 3 Total session time 45 213 1. introduction (2 minutes) explain: “Follow up” is part of the eighth step in wheelchair service delivery. in this session, we will talk about what follow up includes. We will introduce the wheelchair follow up form and practise using it. 2. What is follow up and how does it happen? (10 minutes) ask: What do participants think “follow up” includes? encourage answers. Most important answers: • gather information from the wheelchair user ; • check that the wheelchair is in good working order; • check the fitting of the wheelchair. explain: • all wheelchair users will benefit from follow up. However, follow up is most important for: - children; - wheelchair users at risk of developing a pressure sore; - wheelchair users who have a progressive condition; - wheelchair users who have had difficulty with any of the training given to them. Step 8 Maintenance, repairs and follow up • In this session participants will: – Talk about what follow up includes; – Introduce the follow up form and practise using it. B.13. Follow up: 2 BASIC LEVEL INTRODUCTI ON • All wheelchair users will benefit from follow up. • Follow up is most important for: – children; – wheelchair users at risk of developing a pressure sore; – wheelchair users who have a progressive condition; – wheelchair users who have had difficulty with training in transfers, mobility, health or wheelchair maintenance. B.13. Follow up: 3 BASIC LEVEL WHO NEEDS FOLLOW UP? Wheelchair Service Training Packag e 214 BASIC LEVEL • There is no rule about when follow up should happen though one follow up session within six weeks of the date of delivery is often found to be useful. it will depend on the needs of the user. However, for children, it is ideal if follow up occurs every six months. This is because the needs of children change quickly as they grow. • Follow up appointments can be: - at the wheelchair user’s home; - at the wheelchair service; - at any other location that suits the user and the wheelchair personnel. ask: How could follow up be managed (or how is it managed) in the participants’ wheelchair service? encourage answers and write on the board. Most important answers: • give wheelchair users a follow up appointment when they receive their wheelchair ; • visit wheelchair users at home for follow up (where possible); • make follow up visits part of routine visits to communities by community-based personnel who have been trained to carry out follow up; • arrange a follow up phone call where transport is difficult and the wheelchair user has access to a phone. 3. introducing the wheelchair follow up form (5 minutes) explain: The knowledge and skills needed to do a follow up visit have already been covered in the training. To do a follow up visit, personnel need to: • gather information from the wheelchair user; • check that the wheelchair is in good working order; • check the fit of the wheelchair. • Follow up frequency depends on the needs of the user. Id ll hild h ld b f ll d t • ea y c ren s ou e o owe up a least once every 6 months. B.13. Follow up: 4 BASIC LEVEL HOW OFTEN SHOULD FOL LOW UP BE? • Follow up visits can be at: – the wheelchair user’s home; – the wheelchair service centre; – any other location that suits the user and the wheelchair personnel. B.13. Follow up: 5 BASIC LEVEL WHERE SHOU LD FOLLOW U P VISITS BE? 215 ask participants to look at the wheelchair follow up form in their workbook. explain: The wheelchair follow up form will help personnel to remember what questions to ask and what to do on a follow up visit. The form also has a place to write down any “actions” that may be needed. some common follow up actions are listed below. • Providing more advice or training. For example, if a wheelchair user is not using the wheelchair as expected, it may be because he/she is not confident about how getting in and out of the chair when alone. More training in transfers could help. • Readjusting the wheelchair. • carrying out minor repairs. For example, pumping the tyres. encourage wheelchair users to maintain the wheelchair by caring for a wheelchair at home. • carrying out repairs or assisting the wheelchair user to arrange for repairs. ask: if a wheelchair user reports having a pressure sore, what action should be taken? Most important answers: • ask to see the pressure sore and record the location and grade of pressure sore; • if the pressure sore is on any part of the body which is touching the wheelchair, the wheelchair user should stop using the wheelchair until the sore has healed; • if the pressure sore is grade 2 or higher, seek specialist help for treatment; • identify why the pressure sore occurred (for example – not using cushion or cushion not relieving pressure, poor transfer method, incontinence, etc.) and try to resolve the problem. • Check that the wheelchair is in good order. • P id ti t i irov e more ps or ra n ng. • If needed: – re-adjust the wheelchair; – carry out minor repairs or home maintenance; – organize major repairs or assist the wheelchair user to arrange for repairs. B.13. Follow up: 6 BASIC LEVEL COMMON FO LLOW UP ACT IONS Wheelchair Service Training Packag e 216 BASIC LEVEL 4. Practising follow up (25 minutes) activity groups: Have three people in each group. instructions: Ask each group to: • read each user’s story in their workbook and discuss what actions should be taken; • complete a wheelchair follow up form for each user (there are three follow up forms in the workbook). Monitor: Monitor the groups and assist as needed. Time: 20 minutes and 5 minutes for feedback. Feedback: ask: What actions did participants suggest for Hala, Daarun and Talha? learning points Hala lives at home with her grown up daughter and her family. She received her wheelchair six months ago. She had a stroke just over a year ago, and is unable to walk. When she received her wheelchair she learnt how to transfer by standing up with help from her daughter. She said she wanted a wheelchair so that she could be more help in the home and be able to go to church. At the follow up visit, Hala said she has not left her house for some months. The path to her house is rough, and there is a step leading up to the house from the path. She is, however, using the wheelchair in her home, and has been able to help her daughter by helping to look after her grandchildren. She sits upright in the wheelchair and the wheelchair has been well cared for. She is now able to transfer from the chair herself. • Find out why Hala is not attending church as she had hoped. • If this is because of the step and rough ground – provide advice and training for Hala and her daughter on how to manage the step and the path safely. Daarun has a spinal cord injury. He works in a radio repair workshop in the local market. He received his wheelchair and pressure relief cushion two years ago. At the follow up visit, he said that he uses his wheelchair every day to get to and from the market. He does not have any pressure sores. He has had two flat tyres and has repaired them himself. When checking the wheelchair, the service personnel notice that the spokes are loose and two bolts are missing on the seat base. The soft foam on his cushion is now flat. He sits well in the wheelchair and says that he is very satisfied with the chair. • Arrange to replace the top soft foam layer of the cushion. • Give advice on caring for a wheelchair at home, including checking spokes and tightening bolts. 217 learning points Talha is 10 years old. He has mild cerebral palsy and goes to the local school. He was prescribed a wheelchair with a postural support cushion one year ago. At the follow up visit, Talha said he uses his wheelchair every day to go to school. His father pushes him as he is not strong enough to push himself. The wheelchair is in good repair. His father says that he has repaired the tyre once. The wheelchair service personnel notice that Talha has grown, and his legs are now not properly supported by the wheelchair seat as the footrests are too high for him. • Follow up visits for children should take place every 3–6 months if at all possible. • Children can grow quickly. It is important to educate parents or carers to bring their child for review if the service cannot visit them. • Talha needs to be reassessed and the wheelchair adjusted or replaced with a larger size. 5. key point summary (3 minutes) read the key points. ask whether there are any questions. Practical Three: Follow up O B Je c T iv e S By the end of this session, participants will be able to:  demonstrate follow up. r e S O U r c e S  clean and private assessment space and assessment bed (unless session is carried out in the community);  previous wheelchair assessment and wheelchair prescription (selection) forms for each wheelchair user ;  wheelchair follow up form (1 per wheelchair user);  wheelchair safe and ready checklist;  trainer’s observation checklist;  tape measure and tools to adjust wheelchairs. • Follow up is a: – review of the wheelchair user’s needs; – review of the wheelchair; – a chance to find out if the wheelchair user has questions or requires more information. •For many wheelchair users a follow up visit can make a big difference in how much benefit they get from their wheelchair. •Follow up may be done at the user’s home or at a centre. •Ideally every wheelchair service will have a plan for how follow up will b i d t e carr e ou . •Use the follow up form to remember the main steps in follow up. B.13. Follow up: 7 BASIC LEVEL KEY POINT SU MMARY Wheelchair Service Training Packag e 218 BASIC LEVEL c O n T e X T Adapt this session to suit the context participants will be working in. Think about:  cultural factors that need to be considered;  language factors – for example, whether wheelchair users attending speak a common language with all participants;  any documentation that the service may require when carrying out follow up;  how trainers will manage any actions identified during the follow up that cannot be addressed within the session, for example if the wheelchair needs to be replaced. T O P r e Pa r e  Consider carrying out this session in the community.  Contact wheelchair users who have received a wheelchair within the last 3–6 months and need follow up. Invite them to schedule a follow up visit either in the user’s home or at the clinic.  Confirm time and travel arrangements. Ensure there are refreshments available for wheelchair users and their family/supporters if they have travelled to the training venue.  If follow up is carried out at the training venue, prepare an assessment bed with a privacy screen for each pair of participants and wheelchair user volunteer. Place all equipment needed on the assessment bed.  If there are more than three pairs of participants, ask for another trainer to assist with monitoring the groups.  Decide which participants will work together, and with which wheelchair user. O U T l in e 1. Follow up: • Instructions. • Follow up. • Feedback. 5 60 25 Total session time 90 1. Follow up (90 minutes) Notes for trainers: Use the Trainer’s Observation Checklist for Practical Three to guide you as you observe participants during the practical session. Write any common examples of good or bad practice that should be highlighted in the feedback session on the checklist (box provided). 219 activity groups: • Arrange the participants into the same groups (no more than 3 people in each group). • Appoint a leader for each group. • Tell participants the name of the wheelchair user they will be working with and provide any relevant notes – for example, previous wheelchair assessment form. • Assign each group a place to work in and explain that all equipment has been laid out for them on the assessment bed (or explain transport arrangements if carried out in the community). instructions: explain all of the following: session aim: • The aim of this session is to carry out a follow up. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out. • The lead person should be the main person talking with the wheelchair user and his/her family/carer. This is to avoid having too many people speaking at once, which can be confusing for everyone. Trainer's observation and support: • Participants may ask for assistance or clarification at any time. Time allowed: • They should aim to complete the follow up in 60 minutes. service forms: • Hand out a wheelchair follow up form to each group leader. • Make sure that each group has at least one copy of the wheelchair safe and ready checklist. Remind participants that they should actively involve the wheelchair user in every step of the process. ask: Are there any questions? answer any questions. ask each group to prepare the area they are going to work in; then introduce themselves to the wheelchair user they will work with and invite them in. Wheelchair Service Training Packag e 220 BASIC LEVEL Monitor and support: closely monitor the groups, ensure safe practice, observe and evaluate the skills of participants. Use the trainer’s observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a white board where all participants can see) to help participants manage their time. • Ensure wheelchair users are actively involved. at the end of this session, ask participants to thank the wheelchair users for their participation and explain how any actions identified (and not yet addressed) will be followed up. Time: Allow 60 minutes to complete the follow up and 25 minutes for feedback. Feedback: comment on examples of good practice that you saw during the practical sessions. Note any particular areas that participants could improve – do not highlight individuals. ask each group to summarize briefly what they found during the follow up appointment, including: • how well the wheelchair has met the wheelchair user’s needs; • any issues/concerns; • any recommended follow up actions (allow 5 minutes for each group). ask: Are there any questions? Practical Four: assessment, prescription (selection), product (wheelchair) preparation, fitting and user training. O B Je c T iv e S By the end of this session, participants will be able to work as a team member to:  demonstrate wheelchair assessment, prescription (selection), product (wheelchair) preparation, fitting and user training at a basic level. r e S O U r c e S  locally available wheelchairs;  clean and private assessment space and assessment bed (1 per wheelchair user);  forms: wheelchair assessment form, wheelchair prescription (selection) form, wheelchair safe and ready checklist, wheelchair fitting checklist, wheelchair user training checklist (1 set per wheelchair user);  trainer’s observation checklist;  digital camera and photo consent forms;  tape measure. 221 c O n T e X T Adapt this session to suit the context participants will be working in. Think about the following:  cultural and language factors;  the types of wheelchairs available – and the length of time taken to prepare them;  any documentation the service requires in addition to information collected on the wheelchair assessment and wheelchair prescription (selection) forms;  how trainers will manage any actions identified during the practical that cannot be addressed within the session;  how follow up will be managed for each wheelchair user after the training programme. T O P r e Pa r e  Invite a new group of wheelchair user volunteers, one for each group. Confirm time and travel arrangements with wheelchair user ; ensure there are refreshments available.  Assign one person to greet wheelchair users as they arrive.  Ensure there is somewhere for wheelchair users and their families to wait after the assessment and prescription (selection), while they wait for their wheelchair to be prepared.  Ensure sample wheelchairs and cushions are in good working order.  Prepare the training room (or make travel arrangements if carried out in the community).  If there are more than three pairs of participants, ask for another trainer to assist with monitoring the groups.  Decide which participants will work together, and with which wheelchair user. O U T l in e 1. Assessment, prescription (selection), product (wheelchair) preparation, fitting and user training: • Instructions and set up. • Assessment. • Prescription (selection). • Product (wheelchair) preparation. • Fitting. • User training. • Feedback. • Additional time. 5 30 20 60 30 45 30 20 Total session time 240 Wheelchair Service Training Packag e 222 BASIC LEVEL 1. assessment, prescription (selection), product (wheelchair) preparation, fitting and user training (240 minutes). Notes for trainers: 1. Photographs: • check that each wheelchair user has been asked for their signed permission to take their photograph. ensure that wheelchair users understand that their permission is voluntary and that the photographs will be used for further training during this course. • Take photographs during the practical of each wheelchair user who has given permission as follows: – in their existing wheelchair (if they have one) (front and the side view); – during assessment (postural observation); – in the wheelchair prescribed after fitting (front and side view). 2. Meeting the needs of the wheelchair users participating in the practical session: • Not all wheelchairs may be completed during the time available in the practical session. • if another appointment is required for any wheelchair users seen during the practical session, the trainer should ensure that an appointment is made by the host organization/service and all assessment, prescription (selection) and fitting information is handed over. 3. Observing participants` practice: Use the “Trainer’s Observation Checklist” for Practical Four to ensure that groups perform all the steps in the practical and to note common examples of good or bad practice that should be highlighted in the feedback session on the checklist (box provided). • These photographs can be used in the final session B.14: Putting it all together (if time permits). activity groups: • Arrange the participants into groups (2 or 3 people in each group). • Appoint a leader for each group. • Tell each group the name of the wheelchair user they will be working with. • Assign each group a place to work in and explain that all equipment has been laid out for them on the assessment bed. 223 instructions: explain all of the following: session aim: • The aim of this practical session is to work with a wheelchair user to carry out an assessment, prescription (selection), product (wheelchair) preparation, fitting and user training. • If it is not possible during the session time to complete the wheelchair user’s wheelchair, arrangements will be made with the wheelchair user to ensure that their wheelchair is completed. Participants should try however to get as much of the work done as possible. Lead person: • The lead person for each group is responsible for making sure that all steps are carried out. • The lead person should be the main person talking with the wheelchair user and his/her family/carer. This is to avoid having too many people speaking at once, which can be confusing for everyone. Trainer’s observation and support: • Participants may ask for assistance or clarification at any time. • Throughout the session trainers will monitor each group and give as much support and advice as needed. • After completing EACH SERVICE STEP participants should ask a trainer to come and check BEFORE beginning the next step. Remind participants that they should actively involve the wheelchair user in every step of the process. ask: Are there any questions? answer any questions. ask each group to prepare the area they are going to work in; then introduce themselves to the wheelchair user they will work with and begin. Monitor and support: closely monitor the groups throughout the whole practical session. Use the trainer’s observation checklist to record your observations of each group. Throughout the session: • Give time warnings (verbally and/or write on a white board where all participants can see) to help participants manage their time. • Ensure wheelchair users are actively involved. • Check participants work at each step. at the end of this session, ask participants to thank the wheelchair user for their participation and explain that the wheelchair prescribed (selected) will now be prepared for them and will be ready for them to try in the next practical session. Wheelchair Service Training Packag e 224 BASIC LEVEL Time: Allow the following time: • assessment – 30 minutes; • prescription (selection) – 20 minutes; • product (wheelchair) preparation – 60 minutes; • fitting – 30 minutes; • user training – 45 minutes; • feedback – 30 minutes. Notes for trainers: It is important to keep a close eye on the clock during the practical session. The times given above are a guide – however, they may vary depending on the experience of participants, the needs of the wheelchair users or the time required setting up products. Trainers may need to make adjustments. • an additional 20 minutes for any problems to be resolved and for trainers to check each step. Feedback: comment on examples of good practice that you saw during the practical sessions. Note any particular areas that participants could improve – do not highlight individuals. ask: Are there any questions? B.14: Putting it all together O B Je c T iv e S By the end of this session, participants will be able to:  Provide a summary of the wheelchair user they worked with in the last practical session (Practical Four) including: assessment, prescription (selection), product (wheelchair) preparation, fitting, user training and maintenance, repairs and follow up. r e S O U r c e S  Participant’s Workbook;  DVD: Take home message  Post-it notes or notepaper. 225 T O P r e Pa r e  Gather resources, watch DVD and read through the session plan. O U T l in e 1. Introduction and instructions. 2. Participants’ questions. 3. Participants’ preparation. 4. Participants’ presentations. 5. Question-and-answer session. 6. Key points. 2 5 25 40 20 13 Total session time 105 1. introduction and instructions (2 minutes) explain: • in this session, participants will have an opportunity to: – share with everyone else what they have learnt through the last practical session; – ask any questions that they still may have about basic wheelchair service delivery. 2. Participants’ questions (5 minutes) Small-group activity groups: Have three people in each group. Give each group a block of “Post-it” notes or a number of small pieces of notepad paper (for example A4 paper cut into four pieces) instructions: ask each group to discuss together whether they have any questions remaining about basic wheelchair service delivery. They should write down any questions that either one person or the whole group has. Monitor: Monitor the groups. Time: Allow 10 minutes in total. Feedback: ask each group to hand their questions to the trainers. Wheelchair Service Training Packag e 226 BASIC LEVEL 3. Participants’ preparation (25 minutes) Small-group activity groups: Ask the groups who worked together for the last two practical sessions to work together again. instructions: Ask each group to prepare a 10-minute presentation about the wheelchair user they worked with and what they learnt. They should aim to answer the questions on the worksheet in their workbook. Explain that pictures of the wheelchair users are on the computer, which they can use to illustrate their story when they present. Notes for trainers: If participants are not comfortable using the computer, explain that the trainers will arrange the pictures for them and show them when needed. Monitor: While the groups prepare, trainers should review the questions that have been written down by the groups. Some questions may be the same. Order the questions in a logical sequence (for example, in order of the service steps they relate to). Prepare answers to the questions. Time: Allow participants 25 minutes to prepare. Feedback: see 4. Participant presentations. 4. Participants` presentations (40 minutes) ask each group to present in turn. encourage the whole group to ask questions at the end of the presentation. allow 10 minutes for each presentation and 5 minutes for questions. Thank each participant for his/her presentation. 5. Questions-and-answers session (20 minutes) read out each participant’s question (see 2. Participants’ questions). DO nOT say who asked the question. either provide an answer or clarification, or ask whether there are others in the group who would like to answer the question. if more than one person/group has asked the same question – explain that this is a question that a few people have asked. 227 VIDEO explain: • Providing a wheelchair which truly meets the wheelchair user’s needs is a skill that requires practice, good teamwork (between personnel and the wheelchair user) and at least some basic resources. • This training programme has given an overview of the steps involved. However, every wheelchair user is different – so it is hard to cover every possibility in a training programme such as this. • Participants will learn something from every new wheelchair user they work with. They will also learn from their mistakes, as well as the things they do well. • They will find that the process becomes quicker for them the more they practise. • The important thing is to keep practising, and keep listening to the wheelchair user! 6. key points (13 minutes) introduce DvD: Take home message. This short video will emphasize the importance of the wheelchair training programme. Show DvD. ask if there are any questions. closing ceremony and presentation of certificates. Wheelchair Service Training Packag e 228 BASIC LEVEL annexes annex 1: Timetable for basic wheelchair service training package Five full days Day 1 Day 2 Day 3 Day 4 Day 5 8:30 a.m. Introduction A.6 Appropriate wheelchair B.4 Physical assessment B.9 Fitting Practical Three: Follow up8:45 9:00 A.7 Cushions B.5 Prescription (selection) 9:15 9:30 A.1 Wheelchair users B.10 Problem solving9:45 10:00 Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, fitting and user training 10:15 A.2 Wheelchair services A.8 Transfers B.11 User training 10:30 10:45 A.3 Wheelchair mobility 11:00 – 11:15: Morning tea (adjust time to suit local context and to fit with session plan) 11:15 A.3 Wheelchair mobility A.8 Transfers B.6 Funding and ordering B.11 User training Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, fitting and user training 11:30 Practical One: Assessment and prescription (selection) B.12 Maintenance and repairs11:45 12:00 12:15 p.m. 12:30 A.4 Sitting upright B.1 Referral and appointment12:45 229 1:00 – 2:00 lunch (adjust time to suit local context and to fit with session plan) 2:00 A.4 Sitting upright B.2 Assessment B.7 Product (wheelchair) preparation B.12 Maintenance and repairs Practical Four: Assessment, prescription (selection), product (wheelchair) preparation, fitting and user training 2:15 2:30 A.5 Pressure sores B.3 Assessment interview Practical Two: Fitting and user training 2:45 3:00 3:15 – 3:30: afternoon tea (adjust time to suit local context and to fit with session plan) 3:30 A.5 Pressure sores B.3 Assessment interview B.8 Cushion fabrication Practical Two: Fitting and user training B.14 Putting it all together 3:45 A.6 Appropriate wheelchair4:00 4:15 B.4 Physical assessment 4:30 4:45 B.13 Follow up 5:00 5:15 Presentation of certificates Wheelchair Service Training Packag e 230 BASIC LEVEL annex 2: Wheelchair service referral form A referral form is needed to run session B.1. Where there is no wheelchair service referral form already, trainers may use or adapt this one. A Word version of this form is available on the training package CD. With this referral form, the service will contact the wheelchair user to make an appointment. This may not always be possible, in which case the service may accept referrals without an appointment. a referral form should have clear contact details for the service, including service name, postal address and telephone. it is important that the wheelchair user has been fully informed about the service, and agrees to a referral being made. 231 annex 3: Wheelchair assessment form For assessment of wheelchair users who can sit upright easily. Wheelchair users who cannot sit upright easily may need assessment by a person with “intermediate” level training. Keep this form in the wheelchair user’s file. assessor’s name: Date of assessment: 1: interview assessment Information about the wheelchair user Name: Number: age: Male  Female  Phone no.: address: Goals: Physical condition cerebral palsy  Polio  spinal cord injury  stroke  Frail  spasms or uncontrolled movements  amputation: R above knee  R below knee  L above knee  L below knee  Bladder problems  Bowel problems  if the wheelchair user has bladder or bowel problems, are these managed? Yes  No  Others: _______________________________________________________ Lifestyle and environment Describe where the wheelchair user will use their wheelchair: _____________________________________________________________ Distance travelled per day: Up to 1 km  1–5 km  More than 5 km  Hours per day using wheelchair? Less than 1  1–3  3–5  5–8  More than 8 hours  Wheelchair Service Training Packag e 232 BASIC LEVEL When out of the wheelchair, where does the user sit or lie down and how (posture and the surface?) _____________________________________________________________ Transfer: independent  assisted  standing  Non-standing  Lifted  Other  Type of toilet (if transferring to a toilet): squat  Western  adapted  Does the wheelchair user often use public/private transport? Yes  No  if yes, then what kind: car  Taxi  Bus  Other _______________________ Existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes  No  Does the wheelchair meet the user’s environmental conditions? Yes  No  Does the wheelchair provide proper fit and postural support? Yes  No  is the wheelchair safe and durable? (consider whether there is a cushion) Yes  No  Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes  No  comments: ____________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications. 2: Physical assessment Presence, risk of or history of pressure sores /// = does not feel O = previous pressure sore • = existing pressure sore can feel normally? Yes  No  Previous pressure sore? Yes  No  current pressure sore? Yes  No  if yes, is it an open sore (stage 1–4)? Yes  No  Duration and cause:________________ _______________________________ 233 is this person at risk* of a pressure sore? *A person who cannot feel or has 3 or more risk factors is at risk. Risk factors: cannot move, moisture, poor posture, previous/current pressure sore, poor diet, ageing, under or over weight. Yes  No  Method of pushing How will the wheelchair user push their wheelchair? Both arms  Left arm  Right arm  Both legs  Left leg  Right leg  Pushed by a helper  comment: _____________________________________________________ Measurements Body Measurement Measurement (mm) change body measurement to ideal wheelchair size Wheelchair measurement A Hip width Hip width = seat width B Seat depth L B less 30–60 mm = seat depth (if lengths are different, use shorter)R C Calf length L = top of seat cushion* to footrests height or = top of seat cushion* to floor for foot propelling R D Bottom of rib cage = top of seat cushion* to top of backrest (measure D or E – depending on the user’s need)E Bottom of shoulder blade *Check the height of the cushion that the wheelchair user will use. Wheelchair Service Training Packag e 234 BASIC LEVEL annex 4: Wheelchair prescription (selection) form This prescription form is for recording the choice of wheelchair, wheelchair components and cushion for a wheelchair user who is able to sit upright comfortably. 1. Wheelchair user information Wheelchair user’s name: Number: Date of assessment: Date of fitting: assessor’s name: 2. Type of wheelchair and size selected To select the type of wheelchair: • Discuss with the wheelchair user. • Think about the most important needs of the wheelchair user. • check: wheelchair frame, castor and rear wheels, footrests, armrests, backrest height (or adjustability), rear wheels position, support and comfort. Type of wheelchair Size      3. Type of cushion selected Type of cushion Size E.g. Foam pressure relief cushion  E.g. Flat foam cushion   4. agreed signature of the user: signature of the assessor: signature of the manager: 235 annex 5: Wheelchair summary form Name of wheelchair : Insert picture here Manufacturer/supplier : Sizes available: Overall weight: Description: Frame: Folding  Fixed/rigid  Frame length Backrest: Slung/canvas  Solid  Tension adjustable  Seat: Slung/canvas  Solid  Tension adjustable  Cushion: No cushion  Flat foam  Foam contoured  Footrests: Swing away  Fixed  Other: Castor wheels: Diameter: Width: Rear wheels: Pneumatic  Diameter: Push rims  Solid  Width: Adjustable axle  Solid inner tube  Removable  Brakes: Short lever  Long lever Other: Armrests: Fixed  Removable  Other: Push handles: Push handles  Extra parts/ options: Calf strap  Anti-tip bars  Tray  Other: Measurements, adjustment options and range of adjustment: Measurement (if the wheelchair is available in different sizes, list all sizes) is this adjustable? range of adjustment (adjustment range that is possible for this chair)Yes no Seat width:   Seat depth:   Seat height:   Backrest height:   Backrest angle:   Footrests height:   Footrests angle:   Push handle height:   Frame length:   Wheelbase length:   Wheelchair Service Training Packag e 236 BASIC LEVEL annex 6: Wheelchair safe and ready checklist name of wheelchair service: name of wheelchair user: Wheelchair type: Wheelchair serial number: Whole wheelchair There are no sharp edges  No parts are damaged or scratched  The wheelchair travels in a straight line  Front castor wheels Spin freely  Spin without touching the fork  Bolts are tight  Front castor barrels Castor fork spins freely  rear wheels Spin freely  Axle bolts are tight  Tyres inflated correctly (with thumb pressure, wheel can be depressed less than 5 mm)  Push rims are secure  Brakes Function properly  Footrests Footrests are securely attached  Frame For a folding wheelchair – the wheelchair folds and unfolds easily  For a wheelchair with fold-down backrest – the backrest folds and unfolds easily  cushion The cushion is in the cover correctly  The cushion is sitting on the wheelchair correctly  The cushion cover fabric is tight but not too tight  If the wheelchair has a solid seat: the cushion fully covers the solid seat  name of person who has checked the wheelchair: Signature: Date: 237 annex 7: Wheelchair fitting checklist 1. is the wheelchair ready? Has the wheelchair been checked to make sure it is safe to use and all parts are working?  2. check size and adjustments seat width: Should fit closely.  seat depth: Two fingers’ gap between the back of the knee and the seat/cushion.  Footrests height: The thighs are fully supported on the cushion with no gaps. The feet are fully supported on the footrests with no gaps.  Backrest height: The wheelchair user has the support they need and freedom to move their shoulders to push (if self-propelling).  Rear wheels position (for hand propelling): The wheelchair user’s arm should be in line with the rear axle when hanging down. When hands are placed on the push rim, the user’s elbow should be at a right angle.  Brakes: Are the brakes working?  seat height (for foot propelling): With the wheelchair user sitting upright, the wheelchair user’s back should be comfortably supported by the backrest, with feet resting flat on the floor.  Wheelchair Service Training Packag e 238 BASIC LEVEL 3. check posture Is the wheelchair user able to sit upright comfortably?  Check posture from the side.  Check posture from front/back.  4. check pressure check pressure under seat bones for all wheelchair users at risk of developing a pressure sore A Explain the test to the wheelchair user. B Ask wheelchair user to lean forward or push up. Place finger tips under wheelchair user’s seat bone. C Ask the wheelchair user to sit back down on your fingers. Make sure they sit upright with hands on thighs. D Identify the pressure: Level 1 = safe: Finger tips can wriggle up and down 5 mm or more. Level 2 = warning: Finger tips cannot wriggle, but can easily slide out. Level 3 = unsafe: Finger tips are squeezed firmly. It is difficult to slide fingers out. E Repeat under the second seat bone. 239 5. check fit while the wheelchair is moving Does the backrest allow the wheelchair user freedom to move shoulders to push?  Does the backrest give the wheelchair user enough support?  Do the wheelchair user’s feet stay on the footrests?  Is the rear wheel position correct for the user?  6. action? Is there any further action necessary? Write any actions in the wheelchair user’s file.  remember: The next step after fitting is user instruction. annex 8: Wheelchair user training checklist Skills to Teach Skills Taught Wheelchair handling Folding the wheelchair   Lifting the wheelchair   Using quick release wheels   Using the brakes   Using the cushion, including positioning correctly   Transfers Independent transfer   Assisted transfer   Other   Wheelchair mobility Pushing correctly   Up and down a slopes   Up and down a steps   On rough ground   Partial wheelie   Preventing pressure sores Checking for pressure sores   Pressure relief lifts   Eat well and drink lots of water   What to do if a pressure sore develops   Wheelchair Service Training Packag e 240 BASIC LEVEL looking after the wheelchair at home Clean the wheelchair ; wash and dry the cushion and cushion cover   Oil moving parts   Pump the tyres   Tighten nuts and bolts (if loose)   Tighten spokes (if loose)   Check upholstery   Check for rust   Check the cushion   What to do if there is a problem Wheelchair needs repair   The wheelchair does not fit or is not comfortable   annex 9: Wheelchair follow up form This form is for recording information from a follow up visit. 1. Wheelchair user information Wheelchair user name: Number: Date of fitting: Date of follow up: Name of person carrying out follow up: Follow up carried out at:Wheelchair user’s home Wheelchair service centre  Other  2. interview Record action to be taken: Are you using your wheelchair as much as you would like? Yes  No  If no – why not? Do you have any problems using your wheelchair? Yes  No  If yes – what are the problems? Do you have any questions about using your wheelchair? Yes  No  If yes – what questions? Is further training needed? Does the wheelchair user have any pressure sores? Yes  No  Describe (location and grade) 241 How would you rate your satisfaction with your wheelchair from 1–5? (1 is not satisfied and 5 is very satisfied) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes  No  Is the cushion in good working order and safe to use? Yes  No  If no for either, what is the problem? 4. Fitting check Does the wheelchair fit correctly? Yes  No  If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes  No  If no – what is the problem? 24 2 a nn ex 1 0: T ra in er ’s o bs er va ti on c he ck lis ts Th es e fo rm s ar e de sig ne d to a ss ist tr ai ne rs in o bs er vin g ea ch p ra ct ica l s es sio n. T ra in er ’s O bs er va ti on c he ck lis t: P ra ct ic al O ne : a ss es sm en t an d P re sc ri pt io n (s el ec ti on ) Tr ai ne r’s N am e: _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ D at e of P ra ct ic al : _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ M o ni to r th e se ss io n ti m e: W ri te e xa m pl es o f g o o d pr ac ti ce fo r fe ed ba ck : W ri te e xa m pl es o f p ra ct ic e ne ed in g im pr ov em en t fo r fe ed ba ck : M in  A ss es sm en t 45  Pr es cr ip tio n (s el ec tio n) 30  Fe ed ba ck 10  c he ck e ac h sk ill b el ow a s yo u ob se rv e th e gr ou p de m on st ra te it . W ri te a ny c om m en ts y ou h av e fo r gr ou p fe ed ba ck . G ro up : O ne Tw o Th re e Pa rt ic ip an ts ’ n am es : W he el ch ai r us er ’s na m e:  c o m m en ts  c o m m en ts  c o m m en ts g en er al o bs er va ti o ns : G oo d co m m un ic at io n sk ills w ith w he el ch ai r us er a nd fa m ily W he el ch ai r us er a ct iv el y in vo lv ed in e ac h st ep a nd d ec isi on s Pr ac tic al c om pl et ed o n tim e          W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL 24 3 a ss es sm en t: Ke y re le va nt in fo rm at io n ga th er ed t hr ou gh in te rv ie w    M on ito rs th e us er ’s tr an sfe rs to a ss es sm en t b ed to e ns ur e sa fe ty    Pr es en ce , r isk o f o r hi st or y of p re ss ur e so re s id en tifi ed    M et ho d of p us hi ng c or re ct ly id en tifi ed    M ea su re m en ts t ak en a cc ur at el y    W he el ch ai r as se ss m en t fo rm c om pl et ed a cc ur at el y    P re sc ri pt io n (s el ec ti o n) : Th e m os t a pp ro pr iat e w he el ch air a nd c us hi on ty pe a nd si ze c ho se n    A ny m in or m od ifi ca tio ns / pr ob le m -s ol vi ng n ee de d id en tifi ed    W he el ch ai r pr es cr ip tio n (s el ec tio n) fo rm c om pl et ed a cc ur at el y    T ra in er ’s O bs er va ti on c he ck lis t: P ra ct ic al T w o: F it ti ng a nd U se r T ra in in g Tr ai ne r’s N am e: _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ D at e of P ra ct ic al : _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ M o ni to r th e se ss io n ti m e cl o se ly : W ri te e xa m pl es o f g o o d pr ac ti ce fo r fe ed ba ck : W ri te e xa m pl es o f p ra ct ic e ne ed in g im pr ov em en t fo r fe ed ba ck : M in  Fi tt in g 45  U se r tr ai ni ng 50  Fe ed ba ck 20  O pt io na l u se r f ee db ac k 30  W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL 24 4 c he ck e ac h sk ill b el ow a s yo u ob se rv e th e gr ou p de m on st ra te it . W ri te a ny c om m en ts y ou h av e fo r gr ou p fe ed ba ck . G ro up : O ne Tw o Th re e Pa rt ic ip an ts ’ n am es : W he el ch ai r us er ’s na m e:  c o m m en ts  c o m m en ts  c o m m en ts g en er al o bs er va ti o ns : G oo d co m m un ic at io n sk ills w ith w he el ch ai r us er a nd fa m ily    W he el ch ai r us er a ct iv el y in vo lv ed in e ac h st ep a nd a ll de ci sio ns    Pr ac tic al c om pl et ed o n tim e    F it ti ng : Ea ch s te p of t he fi tt in g pr oc es s co m pl et ed s af el y (e .g . s af e tr an sf er s) a nd a cc ur at el y, fo llo w in g th e fit tin g ch ec kl ist    A ny p ro bl em s w ith t he fi t id en tifi ed a nd a dd re ss ed c or re ct ly    G ro up p ro bl em -s ol ve a nd a dj us t th e w he el ch ai r to a ch ie ve t he co rr ec t fit    U se r tr ai ni ng : G ro up s el ec te d th e m os t a pp ro pr ia te s ki lls to te ac h th e w he el ch ai r us er a nd th ei r f am ily u sin g th e tr ai ni ng c he ck lis t a s a gu id e.    G oo d te ac hi ng t ec hn iq ue s de m on st ra te d w he n te ac hi ng s ki lls (e .g . e xp la in , d em on st ra te , p ra ct ise )    Tr ai ni ng c ar rie d ou t s af el y (e .g. a ss ist an t b eh in d w he el ch ai r u sin g m ob ilit y sk ills ; t ra ns fe rs ta ug ht s af el y)    W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL 24 5 T ra in er ’s O bs er va ti on c he ck lis t: P ra ct ic al T hr ee : F ol lo w U p Tr ai ne r’s N am e: _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ D at e of P ra ct ic al : _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ M o ni to r th e se ss io n ti m e cl o se ly : W ri te e xa m p le s of g oo d p ra ct ic e fo r fe ed ba ck : W ri te e xa m p le s of p ra ct ic e ne ed in g im p ro ve m en t fo r fe ed ba ck : M in  Fo llo w u p 60  Fe ed ba ck 25  c he ck e ac h sk ill b el ow a s yo u o bs er ve t he g ro up d em o ns tr at e it . W ri te a ny c o m m en ts y o u ha ve fo r gr o up fe ed ba ck . G ro up : O ne Tw o Th re e Pa rt ic ip an ts ’ n am es : W he el ch ai r us er ’s na m e:  c o m m en ts  c o m m en ts  c o m m en ts g en er al o bs er va ti o ns : G oo d co m m un ic at io n sk ills w ith w he el ch ai r us er a nd fa m ily    W he el ch ai r us er a ct iv el y in vo lv ed in e ac h st ep a nd a ll de ci sio ns    Pr ac tic al c om pl et ed o n tim e    W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL 24 6 Fo llo w u p: Th e co nd iti on o f t he w he el ch ai r p hy sic al ly ch ec ke d by th e gr ou p    H ow w el l t he w he el ch ai r fit s th e w he el ch ai r us er is p hy sic al ly ch ec ke d    A pp ro pr ia te fo llo w u p ac tio ns a re id en tifi ed a nd r ec or de d    A ny fo llo w u p ac tio ns t ha t ca n be c ar rie d ou t du rin g th e se ss io n ar e ca rr ie d ou t    T ra in er ’s O bs er va ti on c he ck lis t: P ra ct ic al F ou r: W he el ch ai r U se r a ss es sm en t, P re sc ri pt io n (s el ec ti on ), P ro du ct (w he el ch ai r) P re pa ra ti on , F it ti ng a nd U se r T ra in in g. Tr ai ne r’s N am e: _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ D at e of P ra ct ic al : _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ M o ni to r th e se ss io n ti m e cl o se ly : W ri te e xa m pl es o f g o o d pr ac ti ce fo r fe ed ba ck : W ri te e xa m pl es o f p ra ct ic e ne ed in g im pr ov em en t fo r fe ed ba ck : M in ut es 1  A ss es sm en t 30  Pr es cr ip tio n (s el ec tio n) 20  Pr od uc t (w he el ch ai r) pr ep ar at io n 60  Fi tt in g 30  U se r tr ai ni ng 45  Fe ed ba ck 30  1 Pl ea se n ot e – an a dd iti on al 2 0 m in ut es is a llo w ed fo r an y pr ob le m s to b e re so lv ed a nd fo r tr ai ne rs t o ch ec k ea ch s te p. W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL 24 7 c he ck e ac h sk ill b el ow a s yo u o bs er ve t he g ro up d em o ns tr at e it . W ri te a ny c o m m en ts y o u ha ve fo r gr o up fe ed ba ck . G ro up : O ne Tw o Th re e Pa rt ic ip an ts ’ n am es : W he el ch ai r us er ’s na m e:  c o m m en ts  c o m m en ts  c o m m en ts g en er al o bs er va ti o ns : G oo d co m m un ic at io n sk ills w ith w he el ch ai r us er a nd fa m ily    W he el ch ai r u se r a ct ive ly in vo lve d in e ac h st ep a nd a ll de cis io ns    Pr ac tic al c om pl et ed o n tim e    a ss es sm en t: Ke y re le va nt in fo rm at io n ga th er ed t hr ou gh in te rv ie w    G ro up m on ito rs t he w he el ch ai r us er ’s tr an sf er s to a ss es sm en t be d en su rin g sa fe ty    Pr es en ce , r isk o f o r hi st or y of p re ss ur e so re s co rr ec tly id en tifi ed    M et ho d of p us hi ng c or re ct ly id en tifi ed    M ea su re m en ts t ak en a cc ur at el y    W he el ch ai r as se ss m en t fo rm c om pl et ed a cc ur at el y    P re sc ri pt io n (s el ec ti o n) : Th e m os t ap pr op ria te w he el ch ai r an d cu sh io n ty pe a nd s ize c ho se n    A ny m in or m od ifi ca tio ns / pr ob le m -s ol vi ng n ee de d id en tifi ed    W he el ch ai r pr es cr ip tio n (s el ec tio n) fo rm c om pl et ed a cc ur at el y    W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL 24 8 P ro du ct ( w he el ch ai r) p re pa ra ti o n: W he el ch ai r se t up c or re ct ly, m at ch in g th e pr es cr ip tio n (s el ec tio n)    W he el ch ai r sa fe a nd r ea dy c he ck lis t co m pl et ed a cc ur at el y    F it ti ng : Ea ch s te p of t he fi tt in g pr oc es s co m pl et ed s af el y (e .g . s af e tr an sf er s) a nd ac cu ra te ly, fo llo w in g th e w he el ch ai r fit tin g ch ec kl ist    A ny p ro bl em s w ith t he fi t id en tifi ed a nd a dd re ss ed c or re ct ly    G ro up p ro bl em -s ol ve a nd a dj us t t he w he el ch ai r t o ac hi ev e th e co rr ec t fi t    U se r tr ai ni ng : G ro up s el ec te d th e m os t ap pr op ria te s ki lls t o te ac h th e w he el ch ai r us er an d th ei r fa m ily u sin g th e us er t ra in in g ch ec kl ist a s a gu id e.    G oo d te ac hi ng t ec hn iq ue s de m on st ra te d w he n te ac hi ng s ki lls ( e. g. ex pl ai n, d em on st ra te , p ra ct ise )    Tr ai ni ng c ar rie d ou t sa fe ly ( e. g. as sis ta nt b eh in d w he el ch ai r us in g m ob ilit y sk ills ; t ra ns fe rs t au gh t sa fe ly )    W h e e l c h a ir S e r v ic e T r a in in g P a c k a g e B a si c L ev eL

Wheelchair Service Training P ackage Basic LeveL Participant's Workbook

Wheelchair Service Training P ackage Participant's Workbook Basic LeveL Contributors: Editors: Chapal Khasnabis and Kylie Mines Authors: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Peer reviewers: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, and Isabelle Urseau Illustrator: Melissa Puust Photo credits: Chapal Khasnabis and Jesse Moss Video credits: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Pilot trainers: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri Financial support: US Agency for International Development and Australian Agency for International Development Partner organizations: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania, and Tanzania Training Centre for Orthopaedic Technologists (TATCOT) WHO Library Cataloguing-in-Publication Data Wheelchair service training package / edited by Chapal Khasnabis and Kylie Mines. Contents: Trainer’s manual, basic level–Reference manual for participants, basic level – Participant’s workbook, basic level – Posters and slides, basic level. Trainer’s manual and slides available on DVD only. 1.Wheelchairs – standards. 2.Disabled persons – rehabilitation. 3.Teaching materials. I.Khasnabis, Chapal. II.Mines, Kylie. III.World Health Organization. ISBN 978 92 4 150347 1 (package) (NLM classification: WB 320) ISBN 978 92 4 150348 8 (DVD) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/ licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cover photo credits (clockwise, from top): Mile End Films /Jesse Moss; WHO /Chapal Khasnabis; Mile End Films / Jesse Moss; Panos /Dieter Telemans; WHO /Chapal Khasnabis. Printed in Malta Design by Inís Communication – www.iniscommunication.com c O N T eN T s Name: 1 Purpose 2 a.4: sitting upright 4 a.6: appropriate wheelchair 6 a.7: cushions 7 a.8: Transfers 8 B.3: assessment interview 13 B.4: Physical assessment 14 B.5: Prescription (selection) – wheelchair summaries 18 B.5: Prescription (selection) – selecting the right wheelchair size 20 B.7: Product (wheelchair) preparation 21 B.8: cushion fabrication 23 B.11: User training 24 B.12: Maintenance and repairs 26 B.13: Follow up 30 B.14: Putting it all together Wheelchair Service Training Packag e 1 BASIC LEVEL Purpose The Basic Level training package is designed to support the training of personnel or volunteers to provide an appropriate manual wheelchair and cushion for girls, boys, women and men who have mobility impairments but can sit upright without additional postural support. The purpose of the Participant’s Workbook is to develop the skills and knowledge of personnel involved in wheelchair service delivery. The Participant’s Workbook contains exercises which will help to test and develop participants’ knowledge and skills. The Participant’s Workbook contains material from lectures, slide presentations and the reference manual; it is intended that the participants will keep their copy of the workbook for future reference, if needed. 2a.4: Sitting upright • Look closely at each example of different postures. • Write down how the posture is different from sitting upright. • Think about the features of upright sitting from the front and side. 1. Describe how this person’s posture is different from “sitting upright”. 2. Describe how this person’s posture is different from “sitting upright”. Wheelchair Service Training Packag e 3 BASIC LEVEL 3. Describe how this person’s posture is different from “sitting upright”. 4. What problems could be caused by not sitting upright? 1. 2. 3. 4. 5. 4a.6: appropriate wheelchair • Read all the users’ stories. • Discuss which of the available wheelchairs would best suit each user’s needs. • List at least three reasons why the participants would recommend this wheelchair for the wheelchair user. • consider the wheelchair user’s physical, environmental and lifestyle needs – and the features they need in a wheelchair. • Write down your answers. Bao Which of the available wheelchairs would best suit Bao’s needs? Why? Bao lives in a rural village. He has a bilateral above-knee amputation. Before his accident, he ran a shop on the road which runs past his village, selling general groceries. Now he can only reach the shop with help, as the pathway leading from his village to the road is long (almost 1 km), bumpy and often muddy. This has made it difficult for him and his family to keep the shop going. A long time ago Bao received a donated orthopaedic-style wheelchair. The chair is rusted and the seat upholstery has ripped. The front castor wheels are small and the rear wheel tyres are very thin and worn. He cannot push this wheelchair along the track from his hut to the village as the wheels dig into the path. He would like to be able to get to the shop on his own, so that he is not relying on his wife or others to help him. amanthi Which of the available wheelchairs would best suit amanthi’s needs? Why? Amanthi is 24 and lives with her family in a small town. She was involved in a car accident when she was 18, and became a paraplegic. Amanthi recently had a pressure ulcer, which took six months to heal. Amanthi has an orthopaedic wheelchair, but it does not give her good support and she gets very tired in it. It does not have a cushion. She thinks this is probably why she developed a pressure sore. Amanthi has been invited to attend a secretarial course and wants to go. However, she is worried that she will not be able to sit up all day in her current wheelchair. Wheelchair Service Training Packag e 5 BASIC LEVEL Phillip Which of the available wheelchairs would best suit Phillip’s needs? Why? Phillip is 62 years old and lives in a small island community. Six months ago he had a stroke. He returned to his home after one month in a hospital without a wheelchair. He has been lying in bed or sitting in a chair on the veranda of his home. Phillip cannot move his left arm or left leg. However, he is getting stronger each day and can now stand upright with the help from a family member. He is exercising his right arm, and is very keen to have a wheelchair so that he can be more mobile and less reliant on his family. He wants to be able to move around his small home which is all on one level, and around his local community. The terrain is very sandy. One of his grandsons owns a car and says that he will take him out if he has a wheelchair. Sabina Which of the available wheelchairs would best suit Sabina’s needs? Why? Sabina is 56 years old and lives in a small island community. After the birth of her fourth child many years ago, she lost most of the use of her legs. She can stand a little, but she cannot walk. She has never had a wheelchair. Sabina lives in a small village near the sea – and the surface around her home and the village is rough and sandy. She spends her time helping to care for her grandchildren, cooking and weaving. There is no room inside her home for a wheelchair, but it can be stored underneath, as her home is on stilts (columns). Which of the available wheelchairs would be most suitable for your environment and why? 1. 2. 3. 4. 5. 6a.7: cushions • Practise checking the pressure under each seat bone (left and right) of each person in the group. • Make sure that everyone in the group has a turn being tested, and testing. • Record the level of pressure for each person in the group in the table below. check pressure under seat bones for all wheelchair users at risk of developing a pressure sore. A Before you start, explain the test to the wheelchair user. B Ask the wheelchair user to push up or lean forward to allow you to place your finger tips under their left or right seat bones (palm up). C Ask the wheelchair user to sit back down on your fingers. He/she should sit normally, face forward, and place the hands on the thighs. D Identify the pressure: Level 1 = safe: Finger tips can wriggle up and down 5 mm or more. Level 2 = warning: Finger tips cannot wriggle, but can easily slide out. Level 3 = unsafe: Finger tips are squeezed firmly. It is difficult to slide fingers out. E Repeat under the second seat bone. Record the level of pressure for each person in the group in the table below. left seat bone right seat bone Person 1 Level 1: o Level 2: o Level 3: o Level 1: o Level 2: o Level 3: o Person 2 Level 1: o Level 2: o Level 3: o Level 1: o Level 2: o Level 3: o Person 3 Level 1: o Level 2: o Level 3: o Level 1: o Level 2: o Level 3: o Person 4 Level 1: o Level 2: o Level 3: o Level 1: o Level 2: o Level 3: o Wheelchair Service Training Packag e 7 BASIC LEVEL a.8: Transfers • Read the users’ stories. • Discuss for each wheelchair user the transfer method which will best suit them and why. • Write down your answers. Faridah Which transfer method would be most appropriate for Faridah? Why? Faridah is 60 years old. She was referred to the wheelchair service by the local hospital. She has recently had a stroke, and needs a wheelchair as she cannot walk. Faridah can stand up a little and take her own weight. However she is very unsteady on her feet. Faridah lives with her daughter and her family. Her daughter does not work and is able to help her mother at home. She has a four- wheel wheelchair with swing-away footrests. Jose Which transfer method would be most appropriate for Jose? Why? Jose is 45 years old and has been using a wheelchair for 10 years. He has a bilateral above-knee amputation and works in a radio repair workshop in the local market. Jose has come to the wheelchair service to get a new wheelchair as his old one is very worn. Tahir Which transfer method would be most appropriate for Tahir? Why? Wheelchair user Tahir is 14 years old and has recently been referred for a wheelchair after falling from a tree and having a spinal cord injury. Tahir has good use of his arms but he is not yet very strong. He cannot use his legs at all. 8B.3: assessment interview • each person in the group is to select and read one story – and role play that wheelchair user. When you are interviewed, use the information from the story to answer the interview questions as well as you can. • Do not read the user’s story out loud to the rest of your group and do not read anyone else’s story. • Take it in turns to interview one another and complete the assessment forms on the following pages. Felicia is an elderly woman with severe arthritis. She has pain in her arms, hands and legs. She is unable to walk more than a few steps because of the pain and finds it difficult to look after herself. Felicia has attended the assessment with her daughter. She lives in a small town and her house has three steps at the front entrance. She does not have any health problems apart from the arthritis. She used to go to church regularly but is no longer able to do so. She uses a western-style toilet in her home. Her family do not own a car, and rely on public transport. To come to the assessment, the family hired a taxi. However, this is expensive for them. She does not currently have a wheelchair. anton has polio. He is 26 and lives in a small town. He is studying computer skills and wants very much to start his own business in the future. He has attended the assessment with his wife. A long time ago, Anton received a donated orthopaedic-style wheelchair. The chair is rusted and the seat upholstery has ripped. The front castors wheels are small and thin. The rear wheel tyres are very thin and worn. The wheelchair is uncomfortable and difficult to push. Anton uses the same toilet as his family. The paths in the town are very rough and his wheelchair gets stuck often. However, Anton would like to be able to travel from his home to the vocational training centre on his own. The distance is about 1½ km. Right now he needs help from his younger brother – who cannot always take him on time. chantou is a 13 year old girl. She lost both of her legs (above the knee) during an earthquake. She lives with her family in an apartment in a nearby town. She has attended the assessment with her mother and older sister. She has a wheelchair which was donated to her. It is an adult size orthopaedic-style wheelchair. The wheelchair is too big for Chantou. She has to reach up over the armrests to reach the push rims. This is difficult for her. The backrest is also very high and there is no cushion. Chantou would like to go back to school, but she feels physically uncomfortable in the wheelchair. She is embarrassed that she cannot move herself around. She would like a wheelchair that she can push herself, and which gives her more support. She says she would use the school bus if her wheelchair could go with her. Wheelchair Service Training Packag e 9 BASIC LEVEL interview the person who is role-playing a wheelchair user in your group and complete the assessment form below. assessor’s name:_____________________Date of assessment:_____________ information about the wheelchair user Name:___________________________Number:____________________ age:_______________________________Male o Female o Phone no.:____________________________address:_____________________ _______________________________________________________________ Goals:__________________________________________________________ Physical condition cerebral palsy o Polio o spinal cord injury o stroke o Frail o spasms or uncontrolled movements o amputation: R above knee o R below knee o L above knee o L below knee o Bladder problems o Bowel problems o if the wheelchair user has bladder or bowel problems, are these managed? Yes o No o Others: _______________________________________________________ lifestyle and environment Describe where the wheelchair user will use their wheelchair: ______________________________________________________________ Distance travelled per day: Up to 1km o 1–5km o More than 5km o Hours per day using wheelchair? Less than 1 o 1–3 o 3–5 o 5–8 o More than 8 hours o 10 When out of the wheelchair, where does the user sit or lie down and how (posture and the surface? ______________________________________________________________ Transfer: independent o assisted o standing o Non-standing o Lifted o Other o Type of toilet (if transferring to a toilet): squat o Western o adapted o Does the wheelchair user often use public/private transport? Yes o No o if yes, then what kind: car o Taxi o Bus o Other ______________________ existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes o No o Does the wheelchair meet the user’s environmental conditions? Yes o No o Does the wheelchair provide proper fit and postural support? Yes o No o is the wheelchair safe and durable? (consider whether there is a cushion) Yes o No o Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes o No o comments: ____________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications. Wheelchair Service Training Packag e 11 BASIC LEVEL interview the person who is role-playing a wheelchair user in your group and complete the assessment form below. assessor’s name:_____________________Date of assessment:_____________ information about the wheelchair user Name:___________________________Number:____________________ age:_______________________________Male o Female o Phone no.:____________________________address:_____________________ _______________________________________________________________ Goals:__________________________________________________________ Physical condition cerebral palsy o Polio o spinal cord injury o stroke o Frail o spasms or uncontrolled movements o amputation: R above knee o R below knee o L above knee o L below knee Bladder problems o Bowel problems o if the wheelchair user has bladder or bowel problems, are these managed? Yes o No o Others: ___________________________________________________________ lifestyle and environment Describe where the wheelchair user will use their wheelchair: ______________________________________________________________ Distance travelled per day: Up to 1km o 1–5km o More than 5km o Hours per day using wheelchair? Less than 1 o 1–3 o 3–5 o 5–8 o More than 8 hours o 12 When out of the wheelchair, where does the user sit or lie down and how (posture and the surface? _______________________________________________________________ Transfer: independent o assisted o standing o Non-standing o Lifted o Other o Type of toilet (if transferring to a toilet): squat o Western o adapted o Does the wheelchair user often use public/private transport? Yes o No o if yes, then what kind: car o Taxi o Bus o Other ______________________ existing wheelchair (if a person already has a wheelchair) Does the wheelchair meet the user’s needs? Yes o No o Does the wheelchair meet the user’s environmental conditions? Yes o No o Does the wheelchair provide proper fit and postural support? Yes o No o is the wheelchair safe and durable? (consider whether there is a cushion) Yes o No o Does the cushion provide proper pressure relief (if user has pressure sore risk)? Yes o No o comments: ____________________________________________________ If yes to all questions, the user may not need a new wheelchair. If no to any of these questions, the user needs a different wheelchair or cushion; or the existing wheelchair or cushion needs repair or modifications. Wheelchair Service Training Packag e 13 BASIC LEVEL B.4: Physical assessment each member of your group should measure the others in the group. Record the measurements below. Write the name of the person measuring in the table as well. 1. Name of the wheelchair user: _____________________________________ Measurer 1: Measurer 2: Body Measurement Measurement (mm) Measurement (mm) a hip width B Seat depth l r c calf length l r D Bottom of rib cage e Bottom of shoulder blade 2. Name of the wheelchair user: _____________________________________ Measurer 1: Measurer 2: Body Measurement Measurement (mm) Measurement (mm) a hip width B Seat depth l r c calf length l r D Bottom of rib cage e Bottom of shoulder blade 3. Name of the wheelchair user: _____________________________________ Measurer 1: Measurer 2: Body Measurement Measurement (mm) Measurement (mm) a hip width B Seat depth l r c calf length l r D Bottom of rib cage e Bottom of shoulder blade 14 B.5: Prescription (selection) – wheelchair summaries • complete the wheelchair summary sheet for the wheelchair assigned to you by the trainer. • To complete the form you will need to: – look carefully at the wheelchair; – look at any written information about the chair (if available); – take measurements (if not available in written information), which may require adjusting the wheelchair to the minimum and maximum range of some adjustable features. complete the wheelchair summary for any other locally available wheelchair. name of wheelchair: Manufacturer/supplier: Sizes available: Overall weight: Description: Frame: Folding  Fixed or rigid  Frame length(mm) Backrest: Slung/canvas  Solid  Tension adjustable  Seat: Slung/canvas  Solid  Tension adjustable  cushion: No cushion  Flat foam  Foam-contoured  Footrests: Swing-away  Fixed  Other: castor wheels: Diameter: Width: rear wheels: Pneumatic  Diameter: Push rims  Solid  Width: Adjustable axle  Solid inner tube  Removable  Brakes: Short lever  Long lever  Other: armrests: Fixed  Removable  Other: Push handles: Push handles  extra parts/ options: Calf strap  Anti-tip bars  Tray  Other: Wheelchair Service Training Packag e 15 BASIC LEVEL Measurements, adjustment options and range of adjustment: Measurement (if the wheelchair is available in different sizes, list all sizes) is this adjustable? range of adjustment (adjustment range that is possible for this chair) Yes no Seat width:   Seat depth:   Seat height:   Backrest height:   Backrest angle:   Footrests height:   Footrests angle:   Push handles height:   Frame length:   Wheelbase length:   complete the wheelchair summary for any other locally available wheelchair. name of wheelchair: Manufacturer/supplier: Sizes available: Overall weight: 16 Description: Frame: Folding  Fixed/rigid  Frame length(mm) Backrest: Slung/canvas  Solid  Tension adjustable  Seat: Slung/canvas  Solid  Tension adjustable  cushion: No cushion  Flat foam  Foam-contoured  Footrests: Swing-away  Fixed  Other: castor wheels: Diameter: Width: rear wheels: Pneumatic  Diameter: Push rims  Solid  Width: Adjustable axle  Solid inner tube  Removable  Brakes: Short lever  Long lever  Other: armrests: Fixed  Removable  Other: Push handles: Push handles  extra parts/ options: Calf strap  Anti-tip bars  Tray  Other: Measurements, adjustment options and range of adjustment: Measurement (if the wheelchair is available in different sizes list all sizes) is this adjustable? range of adjustment (adjustment range that is possible for this chair) Yes no Seat width:   Seat depth:   Seat height:   Backrest height:   Backrest angle:   Footrests height:   Footrests angle:   Push handles height:   Frame length:   Wheelbase length:   Wheelchair Service Training Packag e 17 BASIC LEVEL complete the wheelchair summary for any other locally available wheelchair. name of wheelchair: Manufacturer/ supplier: Sizes available: Overall weight: Description: Frame: Folding  Fixed/rigid  Frame length(mm) Backrest: Slung/canvas  Solid  Tension adjustable  Seat: Slung/canvas  Solid  Tension adjustable  cushion: No cushion  Flat foam  Foam-contoured  Footrests: Swing-away  Fixed  Other: castor wheels: Diameter: Width: rear wheels: Pneumatic  Diameter: Push rims  Solid  Width: Adjustable axle  Solid inner tube  Removable  Brakes: Short lever  Long lever  Other: armrests: Fixed  Removable  Other: Push handles: Push handles  extra parts/ options: Calf strap  Anti-tip bars  Tray  Other: 18 Measurements, adjustment options and range of adjustment: Measurement (if the wheelchair is available in different sizes list all sizes) is this adjustable? range of adjustment (adjustment range that is possible for this chair) Yes no Seat width:   Seat depth:   Seat height:   Backrest height:   Backrest angle:   Footrests height:   Footrests angle:   Push handles height:   Frame length:   Wheelbase length:   B.5: Prescription (selection) – selecting the right wheelchair size For each of the examples below: • work out the ideal wheelchair size and • select from the wheelchairs available the best size match for that user. (assume that the wheelchair cushion the user would use in both cases is 50 mm high.) 1 Body Measurement Measurement (mm) change body measurement to ideal wheelchair size Wheelchair measurement a hip width 380 mm Hip width = seat width B Seat depth l 400 mm B less 30–60 mm = seat depth (if lengths are different, use shortest)r 400 mm c calf length l 420 mm = top of seat cushion to footrests height or = top of seat cushion to floor for foot propelling r 420 mm Wheelchair Service Training Packag e 19 BASIC LEVEL D Bottom of rib cage = top of seat cushion to top of backrest (measure D or E – depending on the user’s need) e Bottom of shoulder blade 380 mm Ideal wheelchair size for this wheelchair user : Seat width: Seat depth: Backrest height: From the available wheelchairs, which wheelchair and size best fits the user? 2 Body Measurement Measurement (mm) change body measurement to ideal wheelchair size Wheelchair measurement a hip width 420 mm Hip width = seat width B Seat depth l 460 mm B less 30–60 mm = seat depth (if lengths are different, use shortest)r 460 mm c calf length l 360 mm = top of seat cushion to footrests height or = top of seat cushion to floor for foot propelling r 360 mm D Bottom of ribcage 260 mm = top of seat cushion to top of backrest (measure D or E – depending on the user’s need) e Bottom of shoulder blade – Ideal wheelchair size for this wheelchair user : Seat width: Seat depth: Backrest height: From the available wheelchairs, which wheelchair and size best fits the user? 20 B.7: Product (wheelchair) preparation checklist: is the wheelchair safe and ready to use? name of wheelchair service: name of wheelchair user: Wheelchair type: Wheelchair serial number: Whole wheelchair There are no sharp edges  No parts are damaged or scratched  The wheelchair travels in a straight line  Front castor wheels Spin freely  Spin without touching the fork  Bolts are tight  Front castor barrels Castor fork spins freely  rear wheels Spin freely  Axle bolts are tight  Tyres inflated correctly (with thumb pressure, wheel can be depressed less than 5 mm)  Push rims are secure  Brakes Function properly  Footrests Footrests are securely attached  Frame For a folding wheelchair – the wheelchair folds and unfolds easily  For a wheelchair with fold-down backrest – the backrest folds and unfolds easily  cushion The cushion is in the cover correctly  The cushion is sitting on the wheelchair correctly  The cushion cover fabric is tight but not too tight  If the wheelchair has a solid seat: the cushion fully covers the solid seat  name of person who has checked the wheelchair: Signature: Date: Wheelchair Service Training Packag e 21 BASIC LEVEL B.8: cushion fabrication Seat bones well dimensions calculate the correct seat bones well dimensions for each of the wheelchair users in the table below: Width Depth height adult wheelchair user – 360 mm seat width adult wheelchair user – 460 mm seat width child wheelchair user – 280 mm seat width cushion fabrication • Work with a partner. • Follow the instructions below to make a cushion. ask trainers if you have any questions. 1. Mark out the cut lines • Use a piece of firm foam 400 mm x 400 mm x 50 mm. • The centre of the seat bones well must be on the centre line of the cushion. • For this size cushion, the seat bones well should measure 200 mm x 200 mm x 35 mm. • Draw the cut lines with a dark coloured marker on all six sides of the base foam. 22 2. cut out the well for seat bones: Use a sharpened hacksaw blade or long knife. Use long slow strokes, cutting mostly when pulling to improve control. • First cut through the back of the cushion to the depth of the seat bones well. • Then slice out the “seat bones well”. • Glue back into place the two “flaps” left on either side of the seat bones well. 3. cut off the corners inside the seat bones well 4. For a slung seat cushion: make an angled cut (bevel) on both sides of the base (underside) • Mark out as shown and cut. • This cut helps the base of the cushion to match the shape of a slung wheelchair seat. 5. Place the top foam layer on top of the cushion • Both the base and top layer are placed in the cushion cover together. • The two layers do not need to be glued together. • if the top layer becomes soiled or worn out, it can be washed and dried or replaced. • a lift can be added within the cover (on top of the base layer and under the comfort layer) to increase the depth of the pelvic well. Wheelchair Service Training Packag e 23 BASIC LEVEL B.11: User training • Read the users’ stories. • identify at least three skills from the wheelchair user training checklist that will be very important for the wheelchair user to know before leaving the wheelchair service with the new wheelchair. • Practise teaching one skill to the wheelchair user (take it in turns to be the wheelchair service personnel, instructor and family member). Remember to use the good teaching methods discussed in the session. Moses What skills do you think Moses could benefit from learning? Moses is 23 years old. He fell from the back of a truck two years ago and became paraplegic. He spent one year in the hospital and then returned to his home village with an old donated wheelchair. The wheelchair broke very quickly and he was unable to move around. He developed a pressure sore which has now healed. Moses has just received a new wheelchair with a pressure relief cushion through the wheelchair service. This wheelchair is designed to go over rough ground. He is very excited about going home with this wheelchair and is hopeful that he will be more independent. Sian What skills do you think Sian could benefit from learning? Sian is 40 years old and has a bilateral above knee amputation. He has been a wheelchair user for 20 years and has had five wheelchairs over that time. He finds that the wheelchairs he has break down quickly. He is very active and works in a local shop. He travels from his home to the shop every day – on rough, bumpy and often muddy paths. He demonstrated for the wheelchair service personnel how he can do wheelies. He has just been prescribed a new wheelchair. He is hoping that this wheelchair will last longer than his last one, which broke down after six months. 24 Zoe What skills do you think Zoe could benefit from learning? Zoe is 16 years old. She had polio as a young girl, and now cannot walk. She is very shy, and has not been to school. Her mother has given her lessons at home and she can read and write well. She has just received a new wheelchair and has shown the wheelchair service personnel how she can transfer easily into and out of the chair. Zoe is interested in attending a local vocational school – however, she does not think that she can manage getting to the school and back. There are a few steps into the school building. She is also worried about how she would go to the toilet while at the school. B.12: Maintenance and repairs Maintenance: • identify what can be done to care for a wheelchair and cushion at home 1. _____________________________________________________________ _____________________________________________________________ 2. _____________________________________________________________ _____________________________________________________________ 3. _____________________________________________________________ _____________________________________________________________ 4. _____________________________________________________________ _____________________________________________________________ 5. _____________________________________________________________ _____________________________________________________________ 6. _____________________________________________________________ _____________________________________________________________ Repairs: • Look closely at each wheelchair available for the training purpose. • identify which needs repairing (if any), and suggest how these repairs could be made in your location. Wheelchair Service Training Packag e 25 BASIC LEVEL Wheelchair a What needs repairing? how can this be repaired in your location? Wheelchair B What needs repairing? how can this be repaired in your location? Wheelchair c What needs repairing? how can this be repaired in your location? 26 B.13: Follow up • Read each user’s story. • Discuss what actions should be taken. • complete a follow up form for each user, including noting any actions to be taken. hala Hala lives at home with her grown up daughter and her family. She received a wheelchair through the wheelchair service six months ago. She had a stroke just over a year ago, and is unable to walk. When she received her wheelchair, she learnt how to do a standing transfer with help from her daughter. She said she wanted a wheelchair so that she could be more help in the home, and be able to go to church. At the follow up visit, Hala said that she has not left her house for some months. The path to her house is quite rough, and there is a step leading up to the house from the path. She is, however, using the wheelchair at home, and has been able to help her daughter by helping to look after her grandchildren. She sits upright in the wheelchair and the wheelchair is in good repair. She was able to transfer from the chair herself without her daughter’s help. Daarun Daarun has a spinal cord injury. He works in a radio repair workshop in the local market. He received his wheelchair and pressure relief cushion two years ago. At the follow up visit, he said that he uses his wheelchair every day to get to and from the market. He does not have any pressure sores. Daarun has had two flat tyres and has repaired them himself. When checking the wheelchair, the service worker notices that the spokes are loose and two bolts are missing on the seat base. The soft foam on his cushion has become very flat. He sits well in the wheelchair and says that he is very satisfied with the chair. Talha Talha is 10 years old. He has mild cerebral palsy and goes to the local school. He was prescribed a four wheel wheelchair with a postural support cushion one year ago. At the follow up visit, Talha said that he uses his wheelchair every day to get to school. His father pushes him as he does not have the strength to push himself. The wheelchair is in good repair. His father says that he has repaired the tyre once. The wheelchair service worker notices that Talha has grown, and his legs are now not properly supported by the wheelchair seat as the footrests are too high for him. Wheelchair Service Training Packag e 27 BASIC LEVEL Wheelchair follow up form This form is for recording information from a follow up visit. 1. Wheelchair user information Wheelchair user name:____________________Number:_________________________ Date of fitting:__________________________Date of follow up:__________________ Name of person carrying out follow up:_______________________________________ Follow up carried out at: User’s home  Wheelchair service centre  Other: _________ 2. interview record action to be taken: Are you using your wheelchair as much as you would like? Yes  No  If no – why not? Do you have any problems using your wheelchair? Yes  No  If yes – what are the problems? Do you have any questions about using your wheelchair? Yes  No  If yes – what questions? Is further training needed? Does the wheelchair user have any pressure sores? Yes  No  Describe (location and grade) How would you rate your satisfaction with your wheelchair from 1-5? (1 is not satisfied and 5 is very satisfied) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes  No  Is the cushion in good working order and safe to use? Yes  No  If no for either, what is the problem? 4. Fitting check Does the wheelchair fit correctly? Yes  No  If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes  No  If no – what is the problem? Hala 28 Wheelchair follow up form This form is for recording information from a follow up visit. 1. Wheelchair user information Wheelchair user name:________________Number:____________________________ Date of fitting: ________________Date of follow up:___________________________ Name of person carrying out follow up:______________________________________ Follow up carried out at: User’s home  Wheelchair service centre  Other:_________ 2. interview record action to be taken: Are you using your wheelchair as much as you would like? Yes  No  If no – why not? Do you have any problems using your wheelchair? Yes  No  If yes – what are the problems? Do you have any questions about using your wheelchair? Yes  No  If yes – what questions? Is further training needed? Does the wheelchair user have any pressure sores? Yes  No  Describe (location and grade) How would you rate your satisfaction with your wheelchair from 1-5? (1 is not satisfied and 5 is very satisfied) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes  No  Is the cushion in good working order and safe to use? Yes  No  If no for either, what is the problem? 4. Fitting check Does the wheelchair fit correctly? Yes  No  If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes  No  If no – what is the problem? Daarun Wheelchair Service Training Packag e 29 BASIC LEVEL Wheelchair follow up form This form is for recording information from a follow up visit. 1. Wheelchair user information Wheelchair user name:____________________Number:_________________________ Date of fitting:__________________________Date of follow up:__________________ Name of person carrying out follow up:_______________________________________ Follow up carried out at: User’s home  Wheelchair service centre  Other: ___________ 2. interview record action to be taken: Are you using your wheelchair as much as you would like? Yes  No  If no – why not? Do you have any problems using your wheelchair? Yes  No  If yes – what are the problems? Do you have any questions about using your wheelchair? Yes  No  If yes – what questions? Is further training needed? Does the wheelchair user have any pressure sores? Yes  No  Describe (location and grade) How would you rate your satisfaction with your wheelchair from 1-5? (1 is not satisfied and 5 is very satisfied) Rate: Comment: 3. Wheelchair and cushion check Is the wheelchair in good working order and safe to use? Yes  No  Is the cushion in good working order and safe to use? Yes  No  If no for either, what is the problem? 4. Fitting check Does the wheelchair fit correctly? Yes  No  If no – what is the problem? Pressure test level (1 = safe, 2 = warning, 3 = unsafe) (if user at risk of developing a pressure sore) Left: Right: Is the wheelchair user sitting upright comfortably when still, moving, and through the day? Yes  No  If no – what is the problem? Talha 30 B.14: Putting it all together Prepare a 10 minute presentation for the whole group. The presentation should include the following. 1. information gained from the assessment: • the wheelchair user’s goals (why he/she wants a wheelchair); • his/her physical needs; • his/her lifestyle needs; • whether he/she has an existing wheelchair – and whether this wheelchair is meeting his/her needs; • presence, risk of or history of pressure sores; • method of pushing; • sitting posture without support; • results of the pelvis and hip posture screening; 2. Wheelchair and cushion prescribed: • type of wheelchair • type of cushion • any postural support devices that were prescribed. 3. Fitting: • any problems that were identified at fitting and needed to be resolved – and if so, how these were resolved. 4. User training: • what did the wheelchair user and the group decide should be covered in user training? 5. Wheelchair user’s feedback: • after receiving the wheelchair – did the wheelchair user have any comments/ feedback? 6. Maintenance and repairs: • after receiving the wheelchair – what maintenance needs to be carried out and how often? • what to do when a wheelchair or cushion needs repair? 7. Follow up plan: • what arrangements have been made for follow up? For more information, contact. World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2715 Fax: (+ 41 22) 791-4874 www.who.int/disabilities/en/ dar@who.int ISBN 978 92 4 150347 1

SERVICII PENTRU UTILIZATORII DE SCAUN RUL ANT CAIET DE EXERCIȚII PRACTICE PACHET DE INSTRUIRE - NIVEL DE BAZĂ

SERVICII PENTRU UTILIZATORII DE SCAUN RULANT CAIET DE EXERCIȚII PRAC TICE PACHET DE INSTRUIRE - NIVEL DE BAZĂ Publicat de Organizația Mondială a Sănătății în 2012, cu titlul Wheelchair Service Training Package: Basic Level. Participant’s Workbook ©World Health Organization 2012 Directorul General al Organizației Mondiale a Sănătății a acordat dreptul de a traduce și de a publica ediția în limba română Fundației Motivation România, care este singura responsabilă pentru ediția în limba română. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază. Caiet de exerciții practice 1. Scaune rulante – servicii. 2. Scaune rulante – furnizare și distribuire. 3. Scaune rulante – caracteristici. 4. Persoane cu dizabilități – recuperare. 5 Țări în curs de dezvoltare. 6. Organizația Mondială a Sănătății Editori: Chapal Khasnabis și Kylie Mines Autori: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler și Rebecca Jackson Stoeckle Revizuit de: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif și Isabelle Urseau Ilustrații: Melissa Puust Foto: Chapal Khasnabis și Jesse Moss Video: Chapal Khasnabis, Amanda McBaine și Jesse Moss Formatori: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju și Elsie Taloafiri Realizat cu sprijinul financiar al Agenției Statelor Unite pentru Dezvoltare Internațională și al Agenției Australiene pentru Dezvoltare Internațională. Organizații partenere: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation România și Tanzania Training Centre for Orthopaedic Technologists (TATCOT) ©Fundația Motivation România, 2013 Această publicație a fost produsă cu sprijinul generos al poporului american, prin Agenția Statelor Unite pentru Dezvoltare Internațională (USAID). Conținutul este responsabilitatea Fundației Motivation România și nu reflectă în mod necesar punctul de vedere al USAID sau al Guvernului Statelor Unite. CUPRINS Nume: __________________ Scop: ....................................................................................................4 A.4: Poziția așezat ................................................................................5 A.6: Scaunul rulant corespunzător .......................................................7 A.7: Pernele ..........................................................................................10 A.8: Transferurile ..................................................................................11 B.3: Interviul de evaluare ......................................................................12 B.4: Evaluarea fizică .............................................................................18 B.5: Prescrierea (selecția) – prezentare scaune rulante ......................19 B.5: Prescrierea (selecția) – alegerea mărimii corespunzătoare a scaunului rulant ............................................................................24 B.7: Pregătirea produsului (scaunului rulant) ......................................26 B.8: Confecționarea pernei ...................................................................28 B.11: Instruirea utilizatorului de scaun rulant .......................................30 B.12: Întreținerea și reparațiile ............................................................31 B.13: Monitorizarea ..............................................................................33 Formular de monitorizare a utilizării scaunului rulant ...........................34 Formular de monitorizare a utilizării scaunului rulant ...........................36 Formular monitorizare scaun rulant ......................................................38 B.14: Recapitulare ................................................................................40 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 4 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Scop: Modulul de instruire pentru nivelul de bază a fost creat pentru a oferi suport în procesul de pregătire a personalului sau voluntarilor al căror rol este furnizarea de scaune rulante și perne corespunzătoare către acei copii și adulți care au deficiențe motorii, dar care pot să adopte poziția așezat, fără a avea nevoie de suport postural suplimentar. Scopul Caietului de exerciții practice este dezvoltarea cunoștințelor și abilităților personalului implicat în livrarea de servicii destinate utilizatorilor de scaun rulant. Acesta conține exerciții care vor contribui la testarea și îmbunătățirea cunoștințelor și abilităților participanților. Caietul de exerciții practice include materiale din cadrul cursurilor, din prezentările PPT, precum și din Manualul participantului. Este indicat ca participanții să păstreze acest caiet, pentru a-l putea consulta ulterior, dacă acest lucru este necesar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 5 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.4: Poziția așezat o Priviți cu atenție exemplele de posturi de mai jos. o Notați în ce mod diferă aceste posturi de poziția așezat. o Gândiți-vă la caracteristicile poziției așezat, așa cum este ea văzută din față și din lateral. 1. Descrieți în ce mod diferă postura persoanei din imagine de „poziția așezat”. 2. Descrieți în ce mod diferă postura persoanei din imagine de „poziția așezat”. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 6 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază 3. Descrieți în ce mod diferă postura persoanei din imagine de „poziția așezat”. 4. Care sunt problemele care pot apărea atunci când utilizatorul nu poate menține o poziție așezat corectă? 1. 2. 3. 4. 5. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 7 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.6: Scaunul rulant corespunzător o Citiți cu atenție toate exemplele de mai jos. o Discutați care dintre scaunele rulante disponibile ar răspunde cel mai bine cerințelor fiecărui utilizator. o Notați cel puțin trei motive pentru care participanții ar recomanda un anumit tip de scaun rulant fiecărui utilizator prezentat. o Luați în considerare starea fizică, cerințele impuse de mediul și stilul de viață ale utilizatorului, precum și acele caracteristici ale scaunului rulant care îi sunt necesare. o Notați răspunsurile. Bao Care din scaunele rulante disponibile ar răspunde cel mai bine cerințelor lui Bao? De ce? Bao locuiește într-o așezare rurală. Are o amputație bilaterală, deasupra genunchilor. Înainte de accident, avea o băcănie situată la șoseaua care trece prin sat. Astăzi, Bao poate ajunge la magazin doar dacă este ajutat, deoarece drumul de acasă până la șosea este lung (aproape 1 km), accidentat și deseori plin de noroi. Acest lucru face ca lui Bao și familiei lui să le fie greu să se ocupe de băcănie. Cu multă vreme în urmă, Bao a primit donație un scaun rulant de tip ortopedic. Scaunul este ruginit, iar tapițeria șezutului este ruptă. Roțile frontale sunt mici, iar anvelopele roților din spate sunt subțiri și uzate. Bao nu poate împinge scaunul rulant pe drumul ce leagă casa lui de sat, pentru că roțile se împotmolesc. El își dorește să ajungă singur la băcănie, pentru a nu mai fi nevoit să fie ajutat de soția lui sau de către altcineva. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 8 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Amanthi Care din scaunele rulante disponibile ar răspunde cel mai bine cerințelor lui Amanthi? De ce? Amanthi are 24 de ani și locuiește împreună cu familia ei într-un mic oraș. La vârsta de 18 ani a avut un accident de mașină și a devenit paraplegică. De curând, Amanthi a avut o ulcerație, care a avut nevoie de șase luni pentru a se vindeca. Amanthi are un scaun rulant de tip ortopedic, dar acesta nu îi oferă suportul de care are nevoie și ea obosește stând în acesta. Scaunul rulant nu are pernă. Ea crede că acesta este motivul apariției escarei. Amanthi a fost chemată să participe la un curs de secretariat și își dorește să meargă. Cu toate acestea, este îngrijorată că având acest scaun rulant, ea nu va putea să stea în poziția așezat toată ziua. Phillip Care din scaunele rulante disponibile ar răspunde cel mai bine cerințelor lui Phillip? De ce? Phillip are vârsta de 62 de ani și trăiește într-o comunitate mică, pe o insulă. Cu șase luni în urmă, el a avut un accident vascular- cerebral. După o lună în spital, el s-a întors acasă fără un scaun rulant. De atunci, stă în pat sau într-un scaun, pe veranda casei lui. Phillip nu își poate mișca brațul stâng și nici piciorul stâng. Totuși, pe zi ce trece el este mai puternic și poate sta în picioare, cu ajutorul unui membru de familie. Își folosește mâna dreaptă și își dorește mult un scaun rulant, pentru a avea mai multă libertate de mișcare și pentru a depinde mai puțin de familie. El vrea să se poată deplasa în casa lui, care are dimensiuni reduse și este pe un singur nivel, precum și în comunitatea din care face parte. Terenul este foarte nisipos. Unul din nepoții săi are o mașină și i-a spus lui Phillip că îl va lua cu mașina atunci când va avea un scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 9 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Sabina Care din scaunele rulante disponibile ar răspunde cel mai bine cerințelor Sabinei? De ce? Sabina are 56 de ani și trăiește într-o comunitate mica, pe o insulă. După nașterea celui de-al patrulea copil, în urmă cu mulți ani, și-a pierdut aproape în totalitate capacitatea de a-și folosi picioarele. Poate sta în picioare puțin, dar nu poate merge. Nu a avut niciodată un scaun rulant. Sabina locuiește într-un mic sat aproape de mare - terenul din jurul casei sale și din sat este accidentat și nisipos. Sabina își petrece timpul gătind, cosând și ajutând la îngrijirea nepoților. În casa ei nu există spațiu pentru un scaun rulant, dar acesta poate fi ținut dedesubt, deoarece construcția casei este pe piloni. Care din scaunele rulante disponibile ar corespunde cel mai bine mediului în care vă aflați și de ce? 1. 2. 3. 4. 5. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 10 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază A.7: Pernele o Exersați modalitatea de verificare a presiunii sub oasele bazinului, de fiecare parte (stânga și dreapta), în cazul fiecărei persoane din grup. o Asigurați-vă că toți cursanții au participat și că au avut posibilitatea să testeze nivelul presiunii. o Notați nivelul de presiune pentru fiecare persoană din grup, folosind tabelul de mai jos. Verificați presiunea de sub oasele bazinului în cazul fiecărui utilizator de scaun rulant la care există riscul apariției escarelor. A Înainte de a începe, explicați utilizatorului de scaun rulant în ce constă testul. B Cereți utilizatorului de scaun rulant să își ridice trunchiul sau să se aplece înainte, pentru a putea plasa vârfurile degetelor sub oasele bazinului (cu palma în sus). C Cereți utilizatorului de scaun rulant să se așeze pe degetele voastre. Utilizatorul trebuie să stea în poziția obișnuită, cu privirea îndreptată spre înainte și să își poziționeze mâinile pe coapse. D Stabiliți nivelul de presiune: Nivel 1 = sigur: vârfurile degetelor se pot mișca în sus sau în jos cel puțin 5 mm. Nivel 2 = avertizare: vârfurile degetelor nu se pot mișca în sus sau în jos, dar pot fi retrase cu ușurință. Nivel 3 = pericol: vârfurile degetelor sunt presate cu putere, retragerea lor este dificilă. E Repetați pentru cealaltă parte a oaselor bazinului. În tabelul de mai jos, notați nivelul de presiune identificat în cazul fiecărei persoane din grup. Oase bazin partea stângă Oase bazin partea dreaptă Persoana 1 Nivel 1: Nivel 2: Nivel 3: Nivel 1: Nivel 2: Nivel 3: Persoana 2 Nivel 1: Nivel 2: Nivel 3: Nivel 1: Nivel 2: Nivel 3: Persoana 3 Nivel 1: Nivel 2: Nivel 3: Nivel 1: Nivel 2: Nivel 3: Persoana 4 Nivel 1: Nivel 2: Nivel 3: Nivel 1: Nivel 2: Nivel 3: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 11 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.8: Transferurile o Citiți cu atenție toate exemplele de mai jos. o Discutați care dintre tehnicile de transfer s-ar potrivi cel mai bine cerințelor fiecărui utilizator și de ce. o Notați răspunsurile. Faridah Care tehnică de transfer i se potrivește cel mai bine lui Faridah? De ce? Faridah are vârsta de 60 de ani. Cei de la spitalul din localitate i-au recomandat să apeleze la furnizorul de servicii de scaune rulante. Recent, ea a avut un atac vascular- cerebral și are nevoie de un scaun rulant, deoarece nu mai poate merge. Faridah poate sta în picioare puțin și își poate susține greutatea. Totuși, are mari dificultăți în a-și menține stabilitatea. Faridah locuiește cu fiica ei și cu familia acesteia. Fiica ei nu lucrează și de aceea are posibilitatea de a o ajuta acasă. Faridah are un scaun rulant cu patru roți și cu suport de picioare ce se pliază lateral. Jose Care tehnică de transfer i se potrivește cel mai bine lui Jose? De ce? Jose are 45 de ani și este utilizator de scaun rulant de 10 ani. El are o amputație bilaterală, deasupra nivelului genunchilor, și lucrează într-un atelier de reparații radio, în piața din localitate. Jose a apelat la furnizorul de servicii de scaune rulante pentru că are nevoie de un scaun rulant nou, cel pe care îl are fiind foarte uzat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 12 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Tahir Care tehnică de transfer i se potrivește cel mai bine lui Tahir? De ce? Tahir are vârsta de 14 ani și este utilizator de scaun rulant. Lui Tahir i s-a recomandat să apeleze la un furnizor de servicii de scaune rulante după ce a suferit un traumatism vertebro-medular, în urma unei căzături din copac. Tahir își poate folosi brațele, dar nu este încă foarte puternic. Nu își poate folosi deloc picioarele. B.3: Interviul de evaluare o Fiecare persoană din grup va alege și va citi un exemplu, jucând rolul respectivului utilizator de scaun rulant. În timpul interviului, folosiți informațiile din exemplul selectat pentru a răspunde cât mai exact întrebărilor puse. o Nu citiți cu voce tare exemplul ales și nu citiți nici exemplele alese de celelalte persoane din grup. o Pe rând, realizați interviurile și completați formularele de evaluare prezentate în paginile următoare. Felicia este o femeie în vârstă, cu o formă severă de artrită, având dureri în brațe, mâini și picioare. Nu poate face mai mult de câțiva pași din cauza durerilor și îi este dificil să aibă grijă de ea. Felicia a participat la evaluare împreună cu fiica ei. Locuiește într-un oraș mic, iar casa ei are trei trepte la intrare. Nu are alte probleme de sănătate, cu excepția artritei. Obișnuia să meargă la biserică în mod regulat, dar nu mai poate face asta. Casa în care locuiește are o toaletă tipică. Familia Feliciei nu deține un autoturism și folosește mijloacele de transport în comun. Pentru a veni la evaluare, ele au închiriat un taxi, ceea ce este o cheltuială importantă. La ora actuală, ea nu deține un scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 13 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Anton are poliomielită. Are 26 de ani și locuiește într-un oraș mic. Studiază informatica și își dorește mult ca în viitor să aibă propria lui afacere. El a participat la evaluare împreună cu soția lui. În urmă cu multă vreme, Anton a primit donație un scaun rulant de tip ortopedic. Acesta este ruginit, iar tapițeria este ruptă. Roțile frontale sunt mici și subțiri. Anvelopele roților spate sunt foarte subțiri și uzate. Scaunul rulant este inconfortabil și dificil de împins. Anton folosește aceeași toaletă pe care o folosește și familia sa. Drumurile din oraș sunt accidentate, iar scaunul rulant se împotmolește de multe ori. Cu toate acestea, Anton vrea să se poată deplasa singur de acasă la centrul de pregătire vocațională. Distanța este de 1½ km. La ora actuală, el are nevoie de ajutor din partea fratelui său mai mic, dar acesta nu îl poate duce întotdeauna la timp. Chantou este o fată de 13 ani, care și-a pierdut ambele picioare (de deasupra genunchilor) în timpul unui cutremur. Locuiește împreună cu familia ei într-un apartament dintr-un oraș aflat în apropiere. A venit la evaluare împreună cu mama și cu sora ei mai mare. Are un scaun rulant primit ca donație, care este unul de tip ortopedic, destinat adulților. Scaunul rulant este prea mare pentru Chantou. Trebuie să își întindă brațele peste suporturile de brațe pentru a ajunge la inelele de antrenare, ceea ce este dificil pentru ea. Spătarul este și el prea înalt și nu există o pernă. Chantou ar vrea să se întoarcă la școală, dar se simte fizic inconfortabil în scaunul său rulant. De asemenea, este jenată de faptul că nu se poate deplasa singură. Și-ar dori un scaun rulant pe care să îl poată manevra ea însăși și care să îi ofere mai mult suport. Ea ar merge cu autobuzul școlii, dacă ar putea să își ia scaunul rulant cu ea. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 14 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Realizați interviul cu persoana care joacă rolul utilizatorului de scaun rulant în cadrul grupului și completați formularul de evaluare de mai jos. Nume evaluator: Data evaluării: Informații despre utilizatorul de scaun rulant Nume: Număr: Vârsta: Bărbat o Femeie o Nr. telefon: Adresa: Obiective: Condiția fizică Paralizie cerebrală o Poliomielită o Traumatism vertebro-medular o Accident vascular-cerebral o Constituție fragilă o Spasme sau mișcări involuntare o Amputație: D deasupra genunchiului o D sub genunchi o S deasupra genunchiului o S sub genunchi o Probleme de management urinar o Probleme de management intestinal o Dacă există probleme de management urinar sau intestinal, acestea sunt gestionate? Da o Nu o Altele: ______________________________________________________________ Stilul de viață și mediul Descrieți mediul în care va fi folosit scaunul rulant de către utilizator: __________________________________________________________________________ Distanța parcursă zilnic: Mai puțin de 1 km o 1–5 km o Mai mult de 5 km o Numărul de ore pe zi de utilizare a scaunului rulant? Mai puțin de 1 oră o 1-3 ore o 3-5 ore o 5-8 ore o Mai mult de 8 ore o Când nu folosește scaunul rulant, unde și cum stă utilizatorul (poziția și tipul de suprafață)? __________________________________________________________________________ Transfer: Independent o Asistat o În picioare o Așezat o Ridicat o Altele o Tipul de toaletă (dacă se face transferul pe toaletă): La nivelul podelei o Tipică o Adaptată o Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 15 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Utilizatorul de scaun rulant folosește în mod frecvent mijloace de transport în comun / proprii? Da o Nu o Dacă da, de care: Autoturism o Taxi o Autobuz o Altele __________________________ Scaunul rulant existent (dacă persoana are deja un scaun rulant) Scaunul rulant răspunde cerințelor utilizatorului? Da o Nu o Scaunul rulant corespunde condițiilor din mediul utilizatorului? Da o Nu o Este scaunul rulant potrivit și oferă suport postural corespunzător? Da o Nu o Este scaunul rulant sigur și durabil? (Există pernă sau nu?) Da o Nu o Perna oferă o reducere a presiunii adecvată (previne riscul apariției escarelor)? Da o Nu o Comentarii: ________________________________________________________________ Dacă răspunsul este ”da” la toate întrebările, atunci este posibil ca utilizatorul să nu aibă nevoie de alt scaun rulant. Dacă răspunsul la oricare din aceste întrebări este ”nu”, atunci utilizatorul are nevoie fie de un alt scaun rulant, fie de o altă pernă ori scaunul rulant sau perna au nevoie de reparații, respectiv de modificări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 16 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Realizați interviul cu persoana care joacă rolul utilizatorului de scaun rulant în cadrul grupului și completați formularul de evaluare de mai jos. Nume evaluator: Data evaluării: Informații despre utilizatorul de scaun rulant Nume: Număr: Vârsta: Bărbat o Femeie o Nr. telefon.: Adresa: Obiective: Condiția fizică Paralizie cerebrală o Poliomielită o Traumatism vertebro-medular o Accident vascular-cerebral o Constituție fragilă o Spasme sau mișcări involuntare o Amputație: D deasupra genunchiului o D sub genunchi o S deasupra genunchiului o S sub genunchi o Probleme de management urinar o Probleme de management intestinal o Dacă există probleme de management urinar sau intestinal, acestea sunt gestionate? Da o Nu o Altele: ______________________________________________________________ Stilul de viață și mediul Descrieți mediul în care va fi folosit scaunul rulant de către utilizator: __________________________________________________________________________ Distanța parcursă zilnic: Mai puțin de 1 km o 1–5 km o Mai mult de 5 km o Numărul de ore pe zi de utilizare a scaunului rulant? Mai puțin de 1 oră o 1-3 ore o 3-5 ore o 5-8 ore o Mai mult de 8 ore o Când nu folosește scaunul rulant, unde și cum stă utilizatorul (poziția și tipul de suprafață)? __________________________________________________________________________ Transfer: Independent o Asistat o În picioare o Așezat o Ridicat o Altele o Tipul de toaletă (dacă se face transferul pe toaletă): La nivelul podelei o Tipică o Adaptată o Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 17 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Utilizatorul de scaun rulant folosește în mod frecvent mijloace de transport în comun / proprii? Da o Nu o Dacă da, de care: Autoturism o Taxi o Autobuz o Altele __________________________ Scaunul rulant existent (dacă persoana are deja un scaun rulant) Scaunul rulant răspunde cerințelor utilizatorului? Da o Nu o Scaunul rulant corespunde condițiilor din mediul utilizatorului? Da o Nu o Este scaunul rulant potrivit și oferă suport postural corespunzător? Da o Nu o Este scaunul rulant sigur și durabil? (Există pernă sau nu?) Da o Nu o Perna oferă o reducere a presiunii adecvată (previne riscul apariției escarelor)? Da o Nu o Comentarii: ________________________________________________________________ Dacă răspunsul este ”da” la toate întrebările, atunci este posibil ca utilizatorul să nu aibă nevoie de alt scaun rulant. Dacă răspunsul la oricare din aceste întrebări este ”nu”, atunci utilizatorul are nevoie fie de un alt scaun rulant, fie de o altă pernă ori scaunul rulant sau perna au nevoie de reparații, respectiv de modificări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 18 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază B.4: Evaluarea fizică Fiecare participant ar trebui să facă măsurători pentru ceilalți membrii ai grupului. Notați în tabel inclusiv numele persoanei care efectuează măsurătorile. 1. Numele utilizatorului de scaun rulant: _______________________________________ Măsurător 1: Măsurător 2: Măsurători corp Valori (mm) Valori (mm) A Lățime șold B Adâncime șezut S D C Lungime gambă S D D Partea inferioară a cutiei toracice E Partea inferioară a omoplaților 2. Numele utilizatorului de scaun rulant: _______________________________________ Măsurător 1: Măsurător 2: Măsurători corp Valori (mm) Valori (mm) A Lățime șold B Adâncime șezut S D C Lungime gambă S D D Partea inferioară a cutiei toracice E Partea inferioară a omoplaților Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 19 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Numele utilizatorului de scaun rulant: _______________________________________ Măsurător 1: Măsurător 2: Măsurători corp Valori (mm) Valori (mm) A Lățime șold B Adâncime șezut S D C Lungime gambă S D D Partea inferioară a cutiei toracice E Partea inferioară a omoplaților B.5: Prescrierea (selecția) – prezentare scaune rulante Completați fișa de caracteristici a scaunului rulant indicat de formator. Pentru a completa formularul, veți avea nevoie să: – priviți cu atenție scaunul rulant; – citiți toate informațiile scrise referitoare la scaunul rulant (dacă sunt disponibile); – faceți măsurători (dacă nu sunt disponibile în informația scrisă), ceea ce ar putea face necesară ajustarea scaunului la valorile minime și maxime ale acelor caracteristici ce permit modificări. Denumire scaun rulant: Producător/furnizor: Mărimi disponibile: Greutate totală: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 20 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Descriere: Cadru: Pliabil Fix sau rigid Lungime cadru Spătar: Pliabil/pânză Rigid Tensiune ajustabilă Șezut: Pliabil/pânză Rigid Tensiune ajustabilă Pernă: Fără pernă Spumă netedă Spumă modelată Suporturi picioare: Pliabile lateral Fixe Altele: Roți frontale: Diametru: Lățime: Roți spate: Pneumatice Diametru: Inele de antrenare Pline Lățime: Ax ajustabil Tub interior plin Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi brațe: Fixe Detașabile Altele: Mânere: Mânere Componente suplimentare/ opțiuni: Centură gambe Bară anti- răsturnare Măsuță Altele: Măsurători, opțiuni ajustare și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, menționați-le pe toate) Este ajustabil? Gama de ajustări (gama de ajustări ce pot fi efectuate la acest scaun rulant) Da Nu Lățime șezut: Adâncime șezut: Înălțime șezut: Înălțime spătar: Unghi spătar: Înălțime suport picioare: Unghi suport picioare: Înălțime mânere: Lungime cadru: Lungime bază roți: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 21 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Completați formularul de caracteristici pentru toate tipurile de scaun rulant disponibile local. Denumire scaun rulant: Producător/furnizor: Mărimi disponibile: Mărimi disponibile: Descriere: Cadru: Pliabil Fix sau rigid Lungime cadru Spătar: Pliabil/pânză Rigid Tensiune ajustabilă Șezut: Pliabil/pânză Rigid Tensiune ajustabilă Pernă: Fără pernă Spumă netedă Spumă modelată Suporturi picioare: Pliabile lateral Fixe Altele: Roți frontale: Diametru: Lățime: Roți spate: Pneumatice Diametru: Inele de antrenare Pline Lățime: Ax ajustabil Tub interior plin Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi brațe: Fixe Detașabile Altele: Mânere: Mânere Componente suplimentare/ opțiuni: Centură gambe Bară anti-răsturnare Măsuță Altele: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 22 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Măsurători, opțiuni ajustare și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, menționați-le pe toate) Este ajustabil? Gama de ajustări (gama de ajustări ce pot fi efectuate la acest scaun rulant) Da Nu Lățime șezut: Adâncime șezut: Înălțime șezut: Înălțime spătar: Unghi spătar: Înălțime suport picioare: Unghi suport picioare: Înălțime mânere: Lungime cadru: Lungime bază roți: Completați formularul de caracteristici pentru toate tipurile de scaun rulant disponibile local. Denumire scaun rulant: Producător/furnizor: Mărimi disponibile: Greutate totală: Descriere: Cadru: Pliabil Fix sau rigid Lungime cadru Spătar: Pliabil/pânză Rigid Tensiune ajustabilă Șezut: Pliabil/pânză Rigid Tensiune ajustabilă Pernă: Fără pernă Spumă netedă Spumă modelată Suporturi picioare: Pliabile lateral Fixe Altele: Roți frontale: Diametru: Lățime: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 23 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Roți spate: Pneumatice Diametru: Inele de antrenare Pline Lățime: Ax ajustabil Tub interior plin Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi brațe: Fixe Detașabile Altele: Mânere: Mânere Componente suplimentare/ opțiuni: Centură gambe Bară anti- răsturnare Tavă Altele: Măsurători, opțiuni ajustare și gama de ajustări: Valori (dacă scaunul rulant este disponibil în mai multe mărimi, menționați- le pe toate) Este ajustabil? Gama de ajustări (gama de ajustări ce pot fi efectuate la acest scaun rulant) Da Nu Lățime șezut: Adâncime șezut: Înălțime șezut: Înălțime spătar: Unghi spătar: Înălțime suport picioare: Unghi suport picioare: Înălțime mânere: Lungime cadru: Lungime bază roți: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 24 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază B.5: Prescrierea (selecția) – alegerea mărimii corespunzătoare a scaunului rulant Pentru fiecare din exemplele de mai jos: o decideți care este mărimea ideală a scaunului rulant și o alegeți dintre scaunele rulante disponibile mărimea care corespunde cel mai bine cerințelor utilizatorului. (Porniți de la ideea că perna pe care ar folosi-o utilizatorul de scaun rulant în ambele cazuri are înălțimea de 50 mm.) 1 Măsurători corp Valori (mm) Transformați valorile măsurătorilor corp în mărimea recomandată pentru scaunul rulant Valori scaun rulant A Lățime șold 380 mm Lățime șold = lățime șezut B Adâncime șezut S 400 mm B mai puțin de 30–50 mm = adâncimea șezutului (dacă lungimea diferă, folosiți valoarea cea mai mică) D 400 mm C Lungime gambă S 420 mm = de la partea superioară a pernei șezutului la înălțimea suportului de picioare sau = de la partea superioară a pernei șezutului la podea, în cazul propulsiei cu picioarele D 420 mm D Partea inferioară a cutiei toracice - = de la partea superioară a pernei șezutului la limita superioară a spătarului (măsurați D sau E – în funcție de cerințele specifice utilizatorului) E Partea inferioară a omoplaților 380 mm Mărimea ideală a scaunului rulant pentru acest utilizator de scaun rulant: Lățime șezut: Adâncime șezut: Înălțime spătar: Dintre scaunele rulante disponibile, care sunt modelul și mărimea cele mai potrivite pentru utilizator? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 25 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 2 Măsurători corp Valori (mm) Transformați valorile măsurătorilor corp în mărimea recomandată pentru scaunul rulant Valori scaun rulant A Lățime șold 420 mm Lățime șold = lățime șezut B Adâncime șezut S 460 mm B mai puțin de 30–50 mm = lățimea șezutului (dacă lungimea diferă, folosiți valoarea cea mai mică) D 460 mm C Lungime gambă S 360 mm = de la partea superioară a pernei pentru șezut la înălțimea suportului de picioare sau = de la partea superioară a pernei pentru șezut la podea, pentru propulsia cu picioarele D 360 mm D Partea inferioară a cutiei toracice 260 mm = de la partea superioară a pernei pentru șezut la partea superioară a spătarului (măsurați D sau E – în funcție de cerințele specifice ale utilizatorului) E Partea inferioară a omoplaților - Mărimea ideală a scaunului rulant pentru acest utilizator: Lățime șezut Adâncime șezut: Înălțime spătar: Dintre scaunele rulante disponibile, care sunt modelul și mărimea cele mai potrivite pentru utilizator? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 26 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază B.7: Pregătirea produsului (scaunului rulant) Listă verificare: este scaunul rulant gata de a fi folosit în condiții de siguranță? Numele furnizorului de servicii de scaune rulante: Numele utilizatorului de scaun rulant: Tip scaun rulant: Număr serie scaun rulant: Scaunul rulant în ansamblu Nu există margini ascuțite q Nu există părți defecte sau zgâriate q Scaunul rulant are o traiectorie dreaptă în timpul rulării q Roțile frontale Se învârt fără a întâmpina vreo rezistență q Se învârt fără a atinge furca roții q Șuruburile sunt strânse q Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență q Roțile spate Se învârt fără a întâmpina vreo rezistență q Șuruburile axului sunt strânse q Anvelopele sunt umflate în mod corect (la presiunea aplicată cu degetul mare, anvelopele se deformează mai puțin de 5 mm) q Inelele de antrenare sunt sigure q Frânele Funcționează corespunzător q Suporturile de picioare Suporturile de picioare sunt montate corespunzător q Cadrul În cazul unui scaun rulant pliabil-scaunul rulant se pliază și se depliază cu ușurință q În cazul unui scaun rulant cu spătar pliabil-spătarul se pliază și se depliază cu ușurință q Perna Perna este introdusă corect în husă q Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 27 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Perna este poziționată corect pe scaunul rulant q Materialul textil al pernei este întins pe suprafața acesteia, însă nu mai mult decât este necesar q Dacă șezutul scaunului rulant este unul rigid: perna acoperă în întregime șezutul scaunului rulant q Numele persoanei care a efectuat verificarea scaunului rulant: Semnătura: Data: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 28 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază B.8: Confecționarea pernei Dimensiunile zonei de reducere a presiunii Calculați dimensiunile corecte ale zonei de reducere a presiunii, pentru fiecare din utilizatorii din tabelul de mai jos: Lățime Adâncime Înălțime o Utilizator de scaun rulant adult – lățime șezut 360 mm o Utilizator de scaun rulant adult – lățime șezut 460 mm o Utilizator de scaun rulant copil – lățime șezut 280 mm Confecționarea pernei o Lucrați în perechi. o Pentru a confecționa o pernă, respectați instrucțiunile de mai jos. În cazul în care aveți întrebări, apelați la formatori. 1. Marcați liniile pentru decupare o Folosiți o bucată de spumă rigidă de 400 mm x 400 mm x 50 mm. o Centrul zonei pentru reducerea presiunii trebuie să se afle pe linia mediană (de mijloc) a pernei. o Pentru o pernă cu aceste dimensiuni, dimensiunea zonei de reducere a presiunii ar trebui să fie de 200 mm x 200 mm x 35 mm. o Trasați liniile pentru decupare cu un marker de culoare închisă, pe toate cele șase laturi ale bazei pernei. dimensiuni în mm 1/2 lățime șezut 1/2 lățime șezut Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 29 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 2. Decupați zona de reducere a presiunii: folosiți o lama ascuțită (pentru fierăstrău) sau un cuțit lung. Efectuați mișcări ample și lente, tăind atunci când trageți de lamă, pentru a avea un control mai mare asupra acțiunii. o Tăiați întâi prin partea posterioară a pernei, pe suprafața ce corespunde zonei de reducere a presiunii. o Decupați partea corespunzătoare zonei de reducere a presiunii. o Relipiți cele două părți laterale ale zonei de reducere a presiunii. 3. Tăiați marginea interioară a suprafeței corespunzătoare zonei de reducere a presiunii. 4. Pentru a confecționa o pernă pentru șezut pliabil: faceți o tăietură în unghi (oblică) pe ambele laturi ale părții inferioare (bazei). o Trasați liniile ca în imagine și decupați. o Acest tip de tăietură face ca baza pernei să se potrivească mai bine unui scaun rulant cu șezut pliabil. 5. Poziționați stratul de spumă superior pe partea de sus a pernei o Baza pernei și stratul superior se introduc în husa pernei împreună. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 30 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază o Nu este obligatorie lipirea celor două straturi. o Dacă stratul superior se murdărește sau se uzează, acesta poate fi spălat, uscat sau înlocuit. o Există posibilitatea adăugării unui strat suplimentar în interiorul husei (între stratul de bază și stratul superior) pentru a crește adâncimea zonei de sub pelvis. B.11: Instruirea utilizatorului de scaun rulant o Citiți exemplele prezentate mai jos. o Identificați cel puțin trei abilități din lista de verificare pentru instruire, abilități pe care utilizatorul este important să le dobândească atunci când primește noul scaun rulant. o Exersați instruirea utilizatorului de scaun rulant în ceea ce privește o abilitate (având, pe rând, rolul de personal furnizor de servicii de scaune rulante, de instructor și de membru de familie). Amintiți-vă să folosiți metodele de predare despre care ați discutat în timpul sesiunii. Moses Care sunt abilitățile care i-ar fi utile lui Moses? Moses are vârsta de 23 de ani. În urmă cu doi ani a căzut din spatele unui camion și a devenit paraplegic. A petrecut un an la spital și s-a întors în satul său cu un scaun rulant vechi, primit donație. Scaunul rulant s-a stricat foarte repede și el nu l-a mai putut utiliza. Moses a avut și o escară, care acum e vindecată. Moses tocmai a primit de la furnizorul de servicii de scaune rulante un scaun nou, cu o pernă pentru reducerea presiunii. Acesta este fabricat pentru a putea fi folosit pe teren accidentat. Moses este nerăbdător să se întoarcă acasă cu noul său scaun rulant și speră să devină mai independent. Sian Care sunt abilitățile care i-ar fi utile lui Sian? Sian are 40 de ani și are o amputație bilaterală, deasupra genunchilor. Este utilizator de scaun rulant de 20 de ani și în această perioadă a avut cinci scaune rulante. În opinia sa, acestea s-au defectat repede. Sian este o persoană foarte activă și lucrează într-un magazin din localitate. El merge de acasă la magazin în fiecare zi, pe un drum accidentat, frecvent acoperit de noroi. El a demonstrat personalului furnizor de servicii de scaune rulante cum știe să stea în echilibru pe două roți. Lui Sian tocmai i s-a recomandat un scaun rulant nou. El speră ca acesta să dureze mai mult de șase luni, cât a rezistat ultimul pe care l-a avut. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 31 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Zoe Care sunt abilitățile care i-ar fi utile lui Zoe? Zoe are vârsta de 16 ani. În copilărie, ea a avut poliomielită și din această cauză nu mai poate merge. Zoe este foarte timidă și nu a mers la școală până acum. Mama ei a învățat-o acasă să scrie și să citească. Ea tocmai a primit un scaun rulant și le-a demonstrat celor care oferă servicii utilizatorilor că poate efectua cu ușurință transferul în și din acesta. Zoe este interesată să urmeze cursurile unei școli profesionale din localitate, dar nu crede că se poate deplasa la școală și înapoi. Există și câteva trepte la intrarea în clădirea școlii. O îngrijorează aspectele legate de accesul la toaletă în timpul cât se află la școală. B.12: Întreținerea și reparațiile Întreținere: Identificați care sunt acțiunile ce se pot efectua pentru a asigura întreținerea la domiciliu a scaunului rulant și a pernei 1. _________________________________________________________________ _________________________________________________________________ 2. _________________________________________________________________ _________________________________________________________________ 3. _________________________________________________________________ _________________________________________________________________ 4. _________________________________________________________________ _________________________________________________________________ 5. _________________________________________________________________ _________________________________________________________________ 6. _________________________________________________________________ _________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 32 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Reparații: o Analizați fiecare scaun rulant disponibil pentru cursul de formare. o Identificați care sunt reparațiile necesare (dacă este cazul) și sugerați modalități prin care acestea pot fi efectuate acolo unde vă aflați. Scaunul rulant A Care sunt reparațiile necesare? Cum pot fi acestea efectuate acolo unde vă aflați? Scaunul rulant B Care sunt reparațiile necesare? Cum pot fi acestea efectuate acolo unde vă aflați? Scaunul rulant C Care sunt reparațiile necesare? Cum pot fi acestea efectuate acolo unde vă aflați? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 33 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT B.13: Monitorizarea o Citiți exemplele prezentate mai jos. o Discutați care sunt activitățile necesare. o Completați un formular de monitorizare pentru fiecare utilizator, incluzând activitățile recomandate în fiecare caz. Hala Hala locuiește cu fiica ei adultă și cu familia acesteia. În urmă cu șase luni, ea a primit un scaun rulant de la un furnizor de servicii de scaune rulante. Acum un an a suferit un accident vascular-cerebral și nu mai poate merge. Când a primit scaunul rulant, a învățat să facă transferul stând în picioare, cu ajutorul fiicei sale. Ea spune că își dorea un scaun rulant pentru a putea ajuta la treburile casei și pentru a putea merge la biserică. La vizita de monitorizare, Hala ne-a spus că nu părăsise casa de câteva luni. Drumul spre casa ei este destul de accidentat și la intrarea în casă există o treaptă. Cu toate acestea, Hala folosește scaunul rulant acasă și își ajută fiica, având grijă de nepoți. Stă în poziția așezat în scaunul rulant, iar acesta este în stare bună. Reușește să efectueze transferul singură, fără asistență din partea fiicei. Daarun Daarun are un traumatism vertebro-medular. Lucrează într-un atelier de reparații pentru aparate radio aflat în piața din localitate. În urmă cu doi ani, el a primit un scaun rulant și o pernă de reducere a presiunii. La vizita de monitorizare, Daarun a spus că folosește zilnic scaunul rulant, pentru a ajunge la locul de muncă și acasă. Daarun nu are nicio escară. Daarun a avut două anvelope dezumflate pe care le-a reparat chiar el. La verificarea scaunului rulant, reprezentantul furnizorului de servicii de scaune rulante a observat că spițele sunt slăbite și că lipsesc două șuruburi din baza șezutului. Spuma flexibilă din pernă s-a aplatizat foarte mult. El stă bine în scaunul rulant și spune că este foarte mulțumit de acesta. Talha Talha are 10 ani și are o formă ușoară de paralizie cerebrală. El merge la școala din localitate. În urmă cu un an, i s-a prescris un scaun rulant cu patru roți, dotat cu o pernă pentru suport postural. La vizita de monitorizare, Talha a menționat că își folosește scaunul rulant în fiecare zi, pentru a merge la școală. Tatăl său este cel care împinge scaunul rulant, deoarece el nu are forța necesară să facă acest lucru. Scaunul rulant este în stare bună. Tatăl său spune că a reparat o dată anvelopa. Cei din echipa furnizorului de servicii de scaune rulante au observant faptul că Talha a crescut, iar picioarele sale nu sunt susținute corespunzător de șezutul scaunului, pentru că suportul de picioare este situat mult prea sus. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 34 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Formular de monitorizare a utilizării scaunului rulant Acest formular se folosește pentru înregistrarea informațiilor obținute pe parcursul vizitei de monitorizare 1. Informații despre utilizatorul de scaun rulant Nume utilizator: Număr: Data probării scaunului rulant: Data monitorizării: Numele persoanei care realizează monitorizarea: _______________________________ Monitorizarea a avut loc la: Domiciliul utilizatorului o Centrul servicii de scaune rulante o Altele: ___________________ 2. Interviu Acțiunea recomandată Folosiți scaunul rulant atât de des pe cât vă doriți? Da o Nu o Dacă nu – de ce nu? Întâmpinați probleme în utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea? Aveți întrebări cu privire la utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea? Este necesară o instruire suplimentară? Utilizatorul de scaun rulant are escare? Da o Nu o Descrieţi (zona și stadiul) Cât de mulțumit/ă sunteți de scaunul rulant? (unde 1 înseamnă deloc mulțumit/ă, iar 5 înseamnă foarte mulțumit/ă)? Notați: Observații: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 35 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în condiții de siguranță? Da o Nu o Perna este în stare bună și poate fi utilizată în siguranță? Da o Nu o Dacă nu, care sunt motivele? 4. Verificare ajustări Scaunul rulant este adecvat pentru utilizator? Da o Nu o Dacă nu – care sunt motivele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = pericol) (dacă există pericolul apariției escarelor) Stânga: Dreapta: Utilizatorul stă confortabil în poziția așezat în următoarele situații: când stă nemișcat în scaunul rulant, când este mobil și pe tot parcursul zilei? Da o Nu o Dacă nu – care sunt motivele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 36 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Formular de monitorizare a utilizării scaunului rulant Acest formular se folosește pentru înregistrarea informațiilor obținute pe parcursul vizitei de monitorizare 1. Informații despre utilizatorul de scaun rulant Nume utilizator: Număr: Data probării scaunului rulant: Data monitorizării: Numele persoanei care realizează monitorizarea: _______________________________ Monitorizarea a avut loc la: Domiciliul utilizatorului o Centrul servicii de scaune rulante o Altele: ___________________ 2. Interviu Acțiunea recomandată Folosiți scaunul rulant atât de des pe cât vă doriți? Da o Nu o Dacă nu – de ce nu? Întâmpinați probleme în utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea? Aveți întrebări cu privire la utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea? Este necesară o instruire suplimentară? Utilizatorul de scaun rulant are escare? Da o Nu o Descrieţi (zona și stadiul) Cât de mulțumit/ă sunteți de scaunul rulant? (unde 1 înseamnă deloc mulțumit/ă, iar 5 înseamnă foarte mulțumit/ă)? Notați: Observații: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 37 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în condiții de siguranță? Da o Nu o Perna este în stare bună și poate fi utilizată în siguranță ? Da o Nu o Dacă nu, care sunt motivele? 4. Verificare ajustări Scaunul rulant este adecvat pentru utilizator? Da o Nu o Dacă nu – care sunt motivele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = pericol) (dacă există pericolul apariției escarelor) Stânga: Dreapta: Utilizatorul stă confortabil în poziția așezat în următoarele situații: când stă nemișcat în scaunul rulant, când este mobil și pe tot parcursul zilei? Da o Nu o Dacă nu – care sunt motivele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 38 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Formular monitorizare scaun rulant Acest formular se folosește pentru înregistrarea informațiilor obținute pe parcursul vizitei de monitorizare 1. Informații despre utilizatorul de scaun rulant Nume utilizator: Număr: Data probării: Data monitorizării: Numele persoanei care realizează monitorizarea: ________________________________ Monitorizarea a avut loc la: Domiciliul utilizatorului o Centrul servicii de scaune rulante o Altele: ___________________________ 2. Interviu Acțiunea recomandată Folosiți scaunul rulant atât de des pe cât vă doriți? Da o Nu o Dacă nu – de ce nu? Întâmpinați probleme în utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea? Aveți întrebări cu privire la utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea? Este necesară o instruire suplimentară? Utilizatorul de scaun rulant are escare? Da o Nu o Descrieţi (zona și stadiul) Cât de mulțumit/ă sunteți de scaunul rulant? (unde 1 înseamnă deloc mulțumit/ă, iar 5 înseamnă foarte mulțumit/ă)? Notați: Observații: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 39 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în condiții de siguranță? Da o Nu o Perna este în stare bună și poate fi utilizată în siguranță ? Da o Nu o Dacă nu, care sunt motivele? 4. Verificare ajustări Scaunul rulant este adecvat pentru utilizator? Da o Nu o Dacă nu – care sunt motivele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = pericol) (dacă există pericolul apariției escarelor) Stânga: Dreapta: Utilizatorul stă confortabil în poziția așezat în următoarele situații: când stă nemișcat în scaunul rulant, când este mobil și pe tot parcursul zilei? Da o Nu o Dacă nu – care sunt motivele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Caiet de exerciții practice Pagina 40 Caiet de exerciții pra ctice SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază B.14: Recapitulare Pregătiți o prezentare de 10 minute pentru întregul grup. Prezentarea ar trebui să includă următoarele: 1. Informații obținute în timpul evaluării: o obiectivele utilizatorului de scaun rulant (de ce își dorește un scaun rulant); o cerințele de ordin fizic ale utilizatorului de scaun rulant; o cerințele impuse de stilul de viață ale utilizatorului de scaun rulant; o dacă utilizatorul are deja un scaun rulant – dacă acest scaun rulant răspunde nevoilor sale; o prezența, riscul apariției escarelor sau escare anterioare; o metoda de propulsie; o postura în lipsa suportului; o rezultatele observării poziției bazinului și a șoldurilor. 2. Scaunul rulant și perna recomandate: o tipul de scaun rulant o tipul de pernă o orice dispozitiv de suport postural recomandat. 3. Ajustări: o orice probleme care au fost identificate în această etapă și care trebuie soluționate – în acest caz, cum au fost ele soluționate. 4. Instruirea utilizatorului: o care sunt aspectele pe care utilizatorul de scaun rulant și grupul au agreat să le abordeze pe parcursul instruirii? 5. Răspunsul utilizatorului de scaun rulant: o după primirea scaunului rulant, care a fost răspunsul utilizatorului? 6. Întreținerea și reparațiile: o după primirea scaunului rulant – care sunt operațiunile de întreținere necesare și care este frecvența lor? o ce trebuie făcut atunci când un scaun rulant sau o pernă au nevoie de reparații? 7. Plan de monitorizare: o ce acțiuni s-au făcut în vederea efectuării monitorizării? Materialul nu poate fi reprodus integral sau parțial fără menționarea sursei și fără acordul scris al Fundației Motivation România. Fundația Motivation România Str. Podișor, Nr. 1, Sat Buda, Comuna Cornetu, jud. Ilfov Tel. 021 448 02 42 | Fax: 021 448 11 07 E-mail: info@motivation.ro motivation.ro | clinicamotivation.ro | facebook.com/FundatiaMotivationRomania PUNEM ÎN MIȘCARE ROȚILE SCHIMBĂRII!

SERVICII PENTRU UTILIZATORII DE SCAUN RUL ANT MANUALUL PARTICIPA NTULUI PACHET DE INSTRUIRE - NIVEL DE BAZĂ

SERVICII PENTRU UTILIZATORII DE SCAUN RULANT MANUALUL PARTICIPANTULU I PACHET DE INSTRUIRE - NIVEL DE BAZĂ Publicat de Organizația Mondială a Sănătății în 2012, cu titlul Wheelchair Service Training Package: Basic Level. Reference manual for participants ©World Health Organization 2012 Directorul General al Organizației Mondiale a Sănătății a acordat dreptul de a traduce și de a publica ediția în limba română Fundației Motivation România, care este singura responsabilă pentru ediția în limba română. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - Nivel de bază. Manualul participantului 1. Scaune rulante – servicii. 2. Scaune rulante – furnizare și distribuire. 3. Scaune rulante – caracteristici. 4. Persoane cu dizabilități – recuperare. 5 Țări în curs de dezvoltare. 6. Organizația Mondială a Sănătății Editori: Chapal Khasnabis și Kylie Mines Autori: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler și Rebecca Jackson Stoeckle Revizuit de: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif și Isabelle Urseau Ilustrații: Melissa Puust Foto: Chapal Khasnabis și Jesse Moss Video: Chapal Khasnabis, Amanda McBaine și Jesse Moss Formatori: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju și Elsie Taloafiri Realizat cu sprijinul financiar al Agenției Statelor Unite pentru Dezvoltare Internațională și al Agenției Australiene pentru Dezvoltare Internațională. Organizații partenere: ASSERT East Timor, Association for the Physically Disabled of Kenya (APDK), Community Based Rehabilitation Unit of Solomon Islands Ministry of Health and Medical Services, Education Development Center (EDC), Handicap International, International Committee of the Red Cross (ICRC), International Society for Prosthetics and Orthotics (ISPO), Kilimanjaro Association of the Spinally Injured (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation România și Tanzania Training Centre for Orthopaedic Technologists (TATCOT) ©Fundația Motivation România, 2013 Această publicație a fost produsă cu sprijinul generos al poporului american, prin Agenția Statelor Unite pentru Dezvoltare Internațională (USAID). Conținutul este responsabilitatea Fundației Motivation România și nu reflectă în mod necesar punctul de vedere al USAID sau al Guvernului Statelor Unite. Terminologie În cadrul acestui document, următorii termeni sunt folosiți conform definițiilor din rândurile de mai jos. Scaun rulant corespunzător Este scaunul rulant care corespunde condițiilor de mediu ale utilizatorului; este potrivit și furnizează suport postural adecvat; este sigur și durabil; este disponibil în țara utilizatorului; poate fi obținut și întreținut, iar serviciile sunt sustenabile în țara respectivă, la cel mai economic și accesibil preț. Scaun rulant cu antrenare manuală Este scaunul rulant antrenat de către utilizator sau prin împingere de către o altă persoană. Scaun rulant Este un dispozitiv cu roți, care oferă mobilitate și suport postural, utilizat de persoane care întâmpină dificultăți de mers sau de deplasare. Furnizarea de scaune rulante Este termenul generic pentru proiectarea, producția, furnizarea de scaune rulante și servicii de scaune rulante. Servicii de scaune rulante Sunt acea parte a procesului de furnizare a scaunelor rulante care se preocupă de dotarea utilizatorului cu un scaun rulant corespunzător. Personal furnizor de servicii de scaune rulante Este personalul care are abilități pentru furnizarea de scaune rulante corespunzătoare. Utilizator de scaun rulant Este persoana care are dificultăți de mers sau de deplasare și utilizează un scaun rulant pentru mobilitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 4 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Terminologie ............................................................................................................ 3 Prefață ..................................................................................................................... 5 Despre Serviciile pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază ......................................................................... 6 Introducere .............................................................................................................. 6 Grupul țintă .............................................................................................................. 7 Scopul...................................................................................................................... 7 Conținutul ................................................................................................................ 8 Cunoștințe și abilități necesare ................................................................................ 9 Structura .................................................................................................................. 9 Procesul de dezvoltare a cursului............................................................................ 9 A. Noțiunile fundamentale ....................................................................................... 11 A.1: Utilizatorii de scaun rulant .......................................................................... 12 A.2: Serviciile de scaune rulante ....................................................................... 15 A.3: Mobilitatea în scaun rulant ........................................................................ 16 A.4: Poziția așezat ............................................................................................ 19 A.5: Escarele ..................................................................................................... 22 A.6: Scaunul rulant corespunzător .................................................................... 28 Părțile scaunului rulant ...................................................................................... 28 A.7: Pernele ....................................................................................................... 37 Care este rolul pernelor? ................................................................................... 37 Diferitele tipuri de perne .................................................................................... 37 Pernele pentru reducerea presiunii ................................................................... 38 A.8 Transferurile ................................................................................................ 43 B. Etapele furnizării serviciilor de scaune rulante .................................................... 48 Etapa 1: Trimiterea și programarea ................................................................... 49 Etapa 2: Evaluarea ............................................................................................ 52 Etapa 3: Prescrierea (selecția) .......................................................................... 64 Etapa 4: Finanțarea și plasarea comenzii ......................................................... 67 Etapa 5: Pregătirea produsului (scaunului rulant) ............................................. 69 Etapa 6: Probarea produsului (a scaunului rulant) ............................................ 77 Etapa 7: Instruirea utilizatorului de scaun rulant ................................................ 94 Etapa 8: Întreținere, reparații și monitorizare ..................................................... 97 Formular de monitorizare a utilizării scaunului rulant ........................................ 103 CUPRINS Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 5 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Prefață Scaunul rulant este unul dintre echipamentele asistive cele mai frecvent utilizate pentru îmbunătăţirea mobilităţii personale, aceasta fiind o precondiţie a realizării drepturilor omului şi demnităţii individuale, permiţând persoanelor cu dizabilităţi să devină membri activi ai comunităţii în care trăiesc. Pentru multe persoane, un scaun rulant corespunzător, proiectat şi ajustat pentru a răspunde nevoilor individuale, reprezintă primul pas spre incluziune şi participare socială. Regulile Standard ale Organizaţiei Naţiunilor Unite privind Egalizarea Şanselor pentru Persoanele cu Dizabilități, Convenţia ONU privind Drepturile Persoanelor cu Dizabilităţi şi Rezoluţia Adunării Mondiale a Sănătăţii WHA58.23, care abordează problema dizabilității inclusiv în termeni de prevenție, management și reabilitare, toate subliniază importanţa scaunelor rulante şi a altor echipamente asistive. Pentru a asigura accesul persoanelor cu dizabilități la un scaun rulant corespunzător, în special în zonele cu resurse limitate ale lumii, Organizația Mondiala a Sănătății (OMS) a elaborat Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, în parteneriat cu Agenția Statelor Unite pentru Dezvoltare Internațională (USAID) și Societatea Internațională pentru Ortezare și Protezare (ISPO). Pentru o instruire adecvată a resurselor umane și pentru un sistem de furnizare a scaunelor rulante fundamentat pe principiile ghidului, OMS a dezvoltat modulul Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Robert Horváth Manager Biroul pentru Democrație, Conflict și Asistență Umanitară Agenția Statelor Unite pentru Dezvoltare Internațională Alana Officer Coordonator Dizabilitate și Reabilitare Departamentul pentru Prevenirea Violenței, Leziunilor și Dizabilității Organizația Mondială a Sănătății Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 6 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Despre Serviciile pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază Introducere Ulterior publicării în 2008 a Ghidului privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate1, Organizația Mondială a Sănătății a elaborat un material denumit „Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază”. Scaunul rulant este unul dintre cele mai frecvent utilizate echipamente asistive pentru îmbunătățirea mobilității personale. Pentru persoanele care întâmpină dificultăți de deplasare, un scaun rulant care corespunde nevoilor lor fizice, stilului de viață și mediului în care trăiesc este un instrument esențial, ajutându-i să se bucure de o ameliorare semnificativă a stării de sănătate, precum și de bunăstare socială și economică. Mobilitatea oferă utilizatorilor de scaun rulant oportunitatea de a studia, de a lucra, de a lua parte la activități culturale și de a accesa servicii, cum ar fi cele de sănătate. Importanța mobilității este reflectată și în Convenția Organizației Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (CONUDPD) care pledează în favoarea unor „măsuri eficiente pentru asigurarea mobilității persoanelor cu dizabilități în cel mai înalt grad de independență posibil”. Pentru a asigura o mobilitate personală eficace, utilizatorul are nevoie de un scaun rulant care i se potrivește și care este în concordanță cu cerințe sale specifice. Acest lucru presupune o abordare care să răspundă nevoilor individuale ale utilizatorilor. O metodă eficientă pentru a răspunde acestor nevoi individuale ale utilizatorilor este furnizarea de scaune rulante prin intermediul serviciilor de scaune rulante. Cu toate acestea, statisticile arată că mai puțin de 5% dintre cei care au într-adevăr nevoie de acestea beneficiază de acces la un scaun rulant adecvat. În plus, există oportunitatea redusă de instruire a personalului implicat în servicii de scaune rulante, în vederea dobândirii de abilități pentru o prescriere corectă a scaunului rulant. „Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază” are ca scop sprijinirea instruirii de bază a personalului cu atribuții clinice și tehnice în cadrul serviciilor de scaune rulante (vezi Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, Figura 4.2). Pachetul de instruire susține transmiterea cunoștințelor teoretice și practice necesare pentru a începe lucrul cu utilizatorii de scaun rulant care pot menține poziția așezat fără suport postural suplimentar. Acesta include: modalitatea de evaluare a nevoilor individuale și de asistare în selecția și pregătirea scaunului rulant din rândul celor disponibile, componenta de instruire a utilizatorilor și însoțitorilor în ceea ce privește folosirea și întreținerea scaunului rulant, precum și monitorizarea. 1 Organizația Mondială a Sănătății. Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate. Geneva, (http://www.who.int/disabilites/publications/technology/wheelchairguidelines/en/index.html, accesat la data de 15 decembrie 2011). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 7 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Durata instruirii poate fi de 35-40 de ore, deși aceasta poate fi redusă sau extinsă, în funcție de nevoile specifice și de resursele disponibile în fiecare caz. Se recomandă exercițiul practic cu un îndrumător, pentru dezvoltarea competențelor și pentru creșterea capacității de a lucra independent. OMS speră ca aceste Servicii pentru utilizatorii de scaun rulant să fie livrate ca un curs de instruire de sine stătător, de scurtă durată, pentru personalul care lucrează deja în domeniu și, în egală măsură, să fie integrate în curricula programelor de instruire pentru personalul de reabilitare. Grupul țintă Acest pachet de instruire este pentru tot personalul și toți voluntarii care au ca atribuții la locul de muncă furnizarea de servicii de scaune rulante. Aici poate fi inclus personalul din domeniul sănătății, reabilitării sau personalul tehnic, personalul medical din comunități, precum și cel de reabilitare bazată pe comunitate, personalul de terapie ocupațională, fizioterapeuții, tehnicienii de protetică și ortetică, artizanii locali, meșteșugarii locali și utilizatorii de scaun rulant. Scopul Modulul de bază al pachetului de instruire a fost elaborat pentru a sprijini instruirea personalului sau a voluntarilor în furnizarea unui scaun rulant cu antrenare manuală corespunzător și a unei perne adecvate acelor fete, băieți, femei și bărbați care au deficiențe de mobilitate, dar pot sta în poziția așezat fără sprijin postural suplimentar. Principalul scop al instruirii este dezvoltarea abilităților și cunoștințelor personalului implicat în livrarea serviciilor de scaune rulante. Livrarea cursului va ajuta la: o creșterea numărului de utilizatori care vor primi un scaun rulant care răspunde nevoilor lor; o creșterea numărului de utilizatori de scaun rulant care primesc instruire în ceea ce privește folosirea și întreținerea scaunului rulant și menținerea stării de sănătate în scaunul rulant; o creșterea numărului de persoane care parcurg nivelul de bază al instruirii cu privire la furnizarea serviciilor de scaune rulante; o îmbunătățirea competențelor personalului furnizor de servicii de scaune rulante; o creșterea calității în furnizarea serviciilor de scaune rulante; o integrarea într-o mai mare măsură a furnizării serviciilor de scaune rulante în cadrul serviciilor de reabilitare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 8 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Conținutul Pachetul de instruire cuprinde: o o trecere în revistă a celor opt etape în furnizarea serviciilor de scaune rulante descrise în Ghidul OMS privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate (Tabelul 1); o lucrul cu utilizatorii de scaun rulant pentru evaluarea mobilității lor și identificarea celor mai bune soluții de mobilitate; o furnizarea unui scaun rulant corespunzător, cu o pernă adecvată; o rezolvarea problemelor prin modificări simple aduse scaunului rulant, pentru a ne asigura că acesta i se potrivește cât mai bine utilizatorului; o reparații și întreținere scaune rulante; o instruirea utilizatorilor pentru o cât mai bună folosire a scaunului rulant; o fabricarea unei perne din spumă modelată / burete. Includerea elementelor referitoare la modificări simple aduse scaunului rulant este relevantă în mod special în cazurile în care există limitări în gama de tipuri și dimensiuni de scaune rulante cu antrenare manuală disponibile. Deseori, trebuie făcute ajustări pentru ca scaunul rulant să se potrivească utilizatorului. Furnizarea triciclurilor nu este tratată în detaliu în cadrul acestui pachet de instruire, deși este recunoscută valoarea unui triciclu în cazul utilizatorilor care trebuie să parcurgă distanțe lungi. Tabelul 1. Etape cheie în furnizarea serviciilor de scaune rulante: Etapa 1 Trimiterea și programarea Etapa 2 Evaluarea Etapa 3 Prescrierea (selecția) Etapa 4 Finanțarea și plasarea comenzii Etapa 5 Pregătirea produsului (a scaunului rulant) Etapa 6 Probarea produsului (a scaunului rulant) Etapa 7 Instruirea utilizatorului Etapa 8 Întreținere, reparații și monitorizare Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 9 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cunoștințe și abilități necesare Nu este necesară experiența anterioară în furnizarea serviciilor de scaune rulante. Cu toate acestea, programul de instruire a fost creat pornind de la presupunerea că participanții au următoarele cunoștințe și abilități: o capacitatea de citi și de a scrie în limba în care este oferit programul de instruire; o cunoștințe de bază cu privire la condițiile de sănătate tipice sau o la deficiențele fizice care pot afecta persoanele ce beneficiază de pe urma scaunelor rulante, inclusiv paralizie cerebrală, amputație membru inferior, poliomielită, traumatism vertebro-medular și accident vascular-cerebral. În cazul în care participanții nu dețin deja informații referitoare la condițiile de sănătate sau deficiențele fizice, instructorii ar trebuie să le includă sub forma unei sesiuni suplimentare dedicate cunoștințelor de bază. Structura Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază este creat cu scopul de a fi predat de către formatori care au abilități în furnizarea de servicii de scaune rulante și pot demonstra cu ușurință competențele transmise în cadrul acestui program de instruire. Există mai multe resurse de predare, care includ: o Manualul formatorului și materialele anexe; o Manualul participantului (numit în continuare astfel); o Caietul de exerciții practice; o Formulare pentru servicii de scaune rulante; o Liste de verificare pentru servicii de scaune rulante; o Materiale suport vizuale, inclusiv prezentări PowerPoint, materiale video și postere. Procesul de dezvoltare a cursului După lansarea Ghidului privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, OMS a format un grup de lucru în vederea dezvoltării pachetului de instruire pentru servicii de scaune rulante. Prima întâlnire a grupului de lucru a fost convocată de către OMS în octombrie 2008, cu scopul de a determina temele și conținutul pachetului de instruire. După etapa în care materialul a circulat și a primit, de la mai mult de 20 de experți în domeniu, un feedback în ceea ce privește propunerea de conținut a pachetului de instruire, un grup-nucleu de specialiști a pregătit fiecare astfel de pachet pentru a fi folosit pe teren, în calitate de proiect pilot. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 10 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază În 2010, pachetul conținând nivelul de bază a fost implementat ca proiect pilot în India, Insulele Solomon și Kenya. Fiecare proiect a fost monitorizat de membri ai grupului de lucru OMS pentru pachetul de instruire destinat livrării serviciilor de scaune rulante. Răspunsurile primite de la instructori, participanții instruiți și de la acei utilizatori de scaun rulant care au luat parte la sesiunile practice au fost încorporate în variantele finale. Pe lângă aceste proiecte pilot, pachetul de instruire la nivel de bază a fost analizat și de către experți în domeniu, de la care s-au primit sugestii valoroase. Toți autorii implicați în elaborarea acestui pachet de instruire au completat o Declarație de Interes. Niciunul dintre autori nu a semnalat că ar exista vreun conflict de interese în ceea ce privește acest subiect. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 11 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A. Noțiunile fundamentale Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 12 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază A.1: Utilizatorii de scaun rulant Utilizatorii de scaun rulant sunt persoane care dețin deja un scaun rulant sau care pot beneficia de pe urma utilizării unui scaun rulant, deoarece capacitatea lor de a merge este limitată. Utilizatorii de scaun rulant includ: o copii, adulți și vârstnici; bărbați, femei, fete și băieți; o persoane cu diverse deficiențe de mobilitate, având stiluri de viață și roluri diferite, precum și experiențe de viață diferite; o persoane care trăiesc și lucrează în medii diferite, inclusiv în mediu rural, urban sau într-unul aflat la limita dintre acestea. Nevoile fiecărui utilizator de scaun rulant sunt diferite. Totuși, toți au nevoie de un scaun rulant corespunzător. Care sunt beneficiile unui scaun rulant? o Mobilitate: Scaunele rulante ajută utilizatorii să se deplaseze având cel mai înalt grad de independență posibil și să facă ceea ce își doresc să facă. o Sănătate: Un scaun rulant poate îmbunătăți starea de sănătate a utilizatorului în multe feluri. Un scaun rulant potrivit, care are o pernă, poate reduce incidența apariției unor probleme frecvente, cum ar fi escarele sau postura incorectă. Un scaun rulant care funcționează corect, care i se potrivește utilizatorului și care poate fi propulsat cu ușurință are capacitatea de a crește nivelul de activitate fizică al celui care îl folosește, îmbunătățindu-i astfel starea de sănătate. o Independență: Utilizatorii de scaun rulant pot fi mai independenți și pot avea un control mai mare asupra vieții lor. o Stimă de sine și încredere: Atunci când au un scaun rulant care li se potrivește și pe care îl pot folosi așa cum trebuie utilizatorii de scaun rulant pot dobâdi mai multă încredere în ei înșiși, având mai multă stimă de sine. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 13 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT o Acces la viața comunității: Cu ajutorul unui scaun rulant, utilizatorii pot fi mai implicați în viața comunității. De exemplu, acest echipament facilitează mersul la școală, vizitarea prietenilor, participarea la activități religioase sau alte tipuri de activități. Ce este „un scaun rulant corespunzător”?  Un „scaun rulant corespunzător” este un scaun rulant care: – răspunde nevoilor utilizatorului; – se potrivește condițiilor de mediu ale utilizatorului; – este alegerea cea mai potrivită pentru utilizator; – asigură suport postural (ajută beneficiarul să stea în poziția așezat); – poate fi întreținut și reparat local. Convenția Organizației Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități Convenția Organizației Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (CONUDPD) a intrat în vigoare la data de 3 mai 2008. Există drepturi ale omului care se aplică tuturor persoanelor. CONUDPD are ca scop recunoașterea universală a faptului că aceste drepturi se aplică și persoanelor cu dizabilități. Convenția include 50 de articole diferite. Unul dintre articole, cel cu numărul 20, se referă la „mobilitatea personală”. Mobilitatea personală reprezintă abilitatea unei persoane de a se deplasa în maniera în care dorește, atunci când își dorește. Articolul 20 prevede că: „Statele Părți vor adopta măsuri eficiente pentru a asigura mobilitatea personală a persoanelor cu dizabilități în cel mai înalt grad posibil de independență”. Scaunele rulante și serviciile de scaune rulante sunt foarte importante în asistarea majorității celor cu deficiențe de mobilitate în vederea dobândirii mobilității personale. Personalul furnizor de servicii de scaune rulante poate ajuta la implementarea prevederilor articolului 20 al CONUDPD prin: o furnizarea unui scaun rulant corespunzător pentru utilizatorii care apelează la serviciile lor; o asistarea utilizatorilor în învățarea de către aceștia a tehnicilor de transfer în și din scaun rulant; o oferirea de sprijin utilizatorilor în învățarea tehnicilor de manevrare a scaunului rulant; o încurajarea membrilor de familie în vederea susținerii de către aceștia a utilizatorilor de scaun rulant, pe parcursul procesului de dobândire a unui grad de independență cât mai ridicat. Există alte drepturi ale omului de care persoanele cu deficiențe de mobilitate se pot bucura mai ușor atunci când au un scaun rulant corespunzător. Acestea sunt: o dreptul la viață independentă și la incluziune în comunitate (articolul 19); Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 14 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază o dreptul la educație (articolul 24); o dreptul de a se bucura de cel mai înalt standard de sănătate disponibil (articolul 25); o dreptul de a lucra și de a fi angajate (articolul 27); o dreptul de a participa la viața politică și publică (articolul 29); o dreptul de a participa la viața culturală, dreptul la recreere, la implicarea în activități de petrecere a timpului liber și sportive (articolul 30). CONUDPD (Articolul 20 – Mobilitate personală): Statele Părți vor lua măsuri eficiente pentru asigurarea în cel mai înalt grad posibil de independență a mobilității personale a persoanelor cu dizabilități, inclusiv prin: a) Facilitarea mobilității personale a persoanelor cu dizabilități în maniera și în momentul alese de acestea, la un cost accesibil; b) Facilitarea accesului persoanelor cu dizabilități la echipamente asistive pentru mobilitate de calitate, la dispozitive, tehnologii asistive și modalități de asistență directă, precum și la intermedieri, inclusiv prin furnizarea lor la prețuri accesibile; c) Furnizarea de instruire pentru dobândirea de abilități de mobilitate atât persoanelor cu dizabilități, cât și personalului specializat, care lucrează cu persoane cu dizabilități d) Încurajarea producătorilor de echipamente de mobilitate și de tehnologii asistive să ia în considerare toate aspectele referitoare la mobilitatea persoanelor cu dizabilități. Ceea ce înseamnă că2: Țările ar trebui să asigure mobilitatea persoanelor cu dizabilități în cel mai înalt grad posibil de independență. Este necesar ca aceastea: • să asiste persoanele în ceea ce privește mobilitatea lor. • să asiste persoanele în obținerea unui scaun rulant de calitate, la un preț accesibil. • să ofere instruire cu privire la mobilitate. • să determine producătorii/ companiile să ia în considerare diversele nevoi ale persoanelor cu dizabilități. 2 Acord internațional privind drepturile persoanelor cu dizabilități (versiune prescurtată a CONUDPD), pregătită de către Departamentul pentru Muncă și Pensii al Marii Britanii de către serviciul „easy read” @ Inspired Services. IS164/07. Newmarket, Inspired Services, 2007 (http://odi.dwp.gov.uk/docs/wor/uncon/un-agree.pdf, accesat la data de 15 decembrie 2011). A.2: Serviciile de scaune rulante Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 15 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.2: Serviciile de scaune rulante Furnizorii de scaune rulante colaborează cu utilizatorul pentru a stabili care dintre echipamentele disponibile este cel mai potrivit pentru respectivul utilizator. Ghidul furnizării scaunelor rulante al OMS evidențiază opt etape pe care personalul care oferă servicii de scaune rulante trebuie să le parcurgă în furnizarea unui scaun rulant. Acești pași sunt prezentați mai jos. Fiecare dintre aceste etape este detaliată în Secțiunea B a acestui manual. Etapa Descriere 1. Trimiterea și programarea Metodele prin care utilizatorilor de scaun rulant li se vor recomanda aceste servicii vor fi diverse. Utilizatorii pot veni din proprie inițiativă sau pot fi trimiși prin intermediul unor rețele formate din angajați sau voluntari ai instituțiilor guvernamentale sau organizațiilor nonguvernamentale din domeniul sănătății și reabilitării, active la nivel de comunitate, local sau regional. Unele servicii de scaune rulante trebuie să identifice în mod activ potențialii utilizatori, în cazul în care aceștia nu beneficiază de servicii sociale sau de sănătate, nu merg la școală, nu lucrează sau nu participă la activități din comunitate. 2. Evaluarea Fiecare utilizator are nevoie de o evaluare individuală, care să ia în considerare aspecte precum dimensiunile utilizatorului, stilul de viață, activitatea profesională, mediul în care trăiește utilizatorul și condiția sa fizică. 3. Prescrierea (selecția) Pe baza informațiilor obținute la evaluare, prescrierea scaunului rulant se face împreună cu utilizatorul, cu membrii de familie sau cu însoțitorii acestuia. Prescrierea (selecția) detaliază tipul și dimensiunea scaunului rulant selectat, caracteristicile speciale și adaptările. Totodată, descrie instruirea de care utilizatorul are nevoie pentru a putea folosi și pentru a întreține scaunul rulant în mod corespunzător. 4. Finanțarea și plasarea comenzii Se identifică sursa de finanțare, iar scaunul rulant este comandat pentru a fi furnizat din stocul deținut sau de la un furnizor. 5. Pregătirea produsului (a scaunului rulant) Personalul instruit pregătește scaunul rulant pentru proba inițială. În funcție de produsul disponibil și de tipul de servicii oferite, acest lucru poate însemna asamblarea, eventual chiar modificarea produsului furnizat de producător sau confecționarea produsului în atelierul furnizorului de servicii de scaune rulante. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 16 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază 6. Probarea Utilizatorul probează scaunul rulant. Se fac ajustările finale, în așa fel încât scaunul rulant să fie corect asamblat și pregătit. Dacă sunt necesare modificări sau elemente pentru suport postural, este posibil să fie nevoie de ajustări suplimentare. 7. Instruirea utilizatorului Utilizatorul și însoțitorii sunt instruiți în ceea ce privește utilizarea și întreținerea scaunului rulant, eficient și în condiții de siguranță. 8. Întreținerea, reparațiile și monitorizarea Serviciile de scaune rulante oferă întreținere și reparații pentru problemele tehnice care nu pot fi rezolvate de către utilizator. Este recomandat ca la nivel de comunitate să aibă loc cât mai multe activități de monitorizare. Întâlnirile de monitorizare sunt o oportunitate de a verifica dacă scaunul rulant este potrivit și de a oferi instruire și asistență suplimentare. Temporizarea depinde de nevoile utilizatorului și de celelalte servicii disponibile. Dacă se constată faptul că scaunul rulant nu mai este corespunzător, devine necesară furnizarea unui nou astfel de echipament, reluând procesul de la prima etapă. Sursa: Organizația Mondială a Sănătății. Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, Figura 3.2. Geneva, 2008, pag. 76. A.3: Mobilitatea în scaun rulant Mulți utilizatori de scaun rulant trăiesc și lucrează în locuri în care le este dificil să se deplaseze, de exemplu, în zone unde terenul este accidentat, nisipos ori noroios sau unde există trepte, borduri și spații mici, înguste. Instruirea pentru însușirea abilităților de mobilitate în scaun rulant ajută utilizatorii să depășească unele din aceste obstacole, fie în mod independent, fie asistați. Mai jos sunt descrise diferite abilități de mobilitate în scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 17 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Abilități de manevrare a scaunului rulant: Pr op ul si a o O propulsie corectă necesită mai puțin efort. o Propulsia corectă se face pe arcul de cerc de la poziția ora 10 la poziția ora 2. o Pentru realizarea propulsiei, folosiți mișcări lungi, line. În to ar ce re a o Țineți unul din inelele de antrenare de partea anterioară, iar pe celălalt de partea posterioară. o Simultan, trageți mâna din față către spate și împingeți înainte mâna din spate. U rc ar ea p an te i o Înclinați corpul spre înainte – acest lucru va împiedica răsturnarea scaunului rulant. o Atunci când exersați, asigurați-vă că însoțitorul stă în spatele scaunului rulant. o Pentru a opri, poziționați scaunul rulant pe lateral. C ob or âr ea p an te i o Înclinați corpul pe spate. o Lăsați inelele de antrenare să alunece ușor prin palmă. o Utilizatorii de scaun rulant cu experiență, care pot sta în echilibru pe două roți (adică să mențină scaunul rulant în echilibru doar pe roțile din spate) pot coborî o pantă pe roțile din spate. Aceasta este o metodă foarte eficientă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 18 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază U rc ar ea tr ep te lo r, cu în so țit or o Poziționați scaunul rulant cu spatele la trepte. o Înclinați scaunul rulant pe roțile din spate, sprijinite de prima treaptă. o Însoțitorul trage de scaunul rulant înspre înapoi și în sus – scaunul rulant urcă. o Utilizatorul poate ajuta trăgând înspre înapoi inelele de antrenare. Un al doilea însoțitor îi poate asista susținând din față scaunul rulant, de cadrul acestuia (nu de suportul de picioare). C ob or âr ea tr ep te or , c u în so țit or o Poziționați scaunul rulant cu fața la trepte. o Înclinați scaunul rulant pe roțile din spate. o Însoțitorul lasă scaunul rulant să coboare, încet, câte o treaptă. o Utilizatorul poate ajuta controlând scaunul rulant cu ajutorul inelelor de antrenare. o Un al doilea însoțitor poate ajuta, susținând din față scaunul rulant, de cadrul acestuia (nu de suportul de picioare). M en țin er ea în e ch ili br u pe d ou ă ro ți o Învățarea manevrei de ridicare în echilibru pe două roți este foarte folositoare pentru utilizatorul de scaun rulant. o Utilizatorul de scaun rulant poate ridica roțile frontale pentru a depăși borduri joase, pietre și alte obstacole. o Împingeți scaunul rulant înspre înapoi până când mâinile ajung în dreptul poziției ora 10. Apoi împingeți în față cu rapiditate. o Roțile frontale ar trebui să se ridice. o Cu antrenament, este posibilă ridicarea roților frontale în vederea depășirii unor mici obstacole. o Asigurați-vă întotdeauna că există un însoțitor în spatele scaunului rulant atunci când utilizatorul începe să exerseze această manevră. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 19 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum să desfășurăm în siguranță instruirea pentru dobândirea abilităților de manevrare a scaunului rulant o La efectuarea transferului în și din scaun rulant, nu stați pe suportul de picioare. o Nu țineți degetele pe spițele roților și pe frâne. o La învățarea manevrei de urcare a pantei sau a ridicării în echilibru pe două roți, asigurați-vă că există ÎNTOTDEAUNA un însoțitor în spatele utilizatorului. o Oferiți asistență unui utilizator la urcarea sau coborârea treptelor doar în cazul în care sunteți convins că puteți controla scaunul rulant în condiții de siguranță. Dacă vă simțiți nesigur, solicitați ajutor. A.4: Poziția așezat Cei mai mulți utilizatori de scaun rulant petrec multe ore în poziția așezat. Acest lucru înseamnă că pentru ei scaunul rulant nu este doar un echipament de mobilitate. În egală măsură, acesta le oferă sprijin pentru poziția așezat. Poziția așezat/poziția neutră de ședere Ce este postura? Postura este modul în care sunt așezate părțile corpului unei persoane. Ori de câte ori este posibil, un scaun rulant potrivit ar trebui să ofere utilizatorului suportul necesar pentru ca acesta să poată adopta poziția așezat. Uneori, „poziția așezat” este descrisă ca poziție neutră de ședere. De ce este importantă poziția așezat? Poziția așezat îi este benefică utilizatorului de scaun rulant din mai multe puncte de vedere. Poziția așezat are impact pozitiv asupra următoarelor aspecte: o sănătate: poziția așezat ajută la digestia alimentelor și la respirație; o stabilitate: poziția așezat oferă mai multă stabilitate; o distribuția greutății: în poziția așezat, greutatea corpului este distribuită în mod egal – se reduce astfel pericolul apariției escarelor; o confort: atunci când greutatea corpului este distribuită în mod egal, crește nivelul de confort al utilizatorului; o prevenirea problemelor de postură: poziția așezat ajută la reducerea incidenței deformărilor de coloană vertebrală; o stimă de sine și încredere: poziția așezat poate ajuta utilizatorul de scaun rulant să aibă mai multă încredere în sine. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 20 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Chiar dacă poziția așezat are multe beneficii, în absența suportului postural este dificilă adoptarea acestei poziții de-a lungul întregii zile. Aceasta este cauza pentru care persoanele fără dizabilități recurg la diverse posturi pe perioada zilei. Unui utilizator care stă pe toată durata zilei în scaun rulant, acesta trebuie să-i ofere suficient suport pentru a-l ajuta să stea confortabil în poziția așezat. Cum determinăm dacă o persoană stă în poziția așezat Priviți din lateral și verificați dacă:  Pelvisul e drept;  Trunchiul este drept, spatele urmează cele trei curburi naturale;  Șoldurile sunt îndoite la un unghi de aproape 90 de grade;  Genunchii și gleznele sunt îndoite la un unghi de aproape 90 de grade;  Călcâiele sunt pe aceeași linie cu genunchii sau ușor mai în față sau mai în spate;  Tălpile sunt așezate pe podea sau pe suportul de picioare. Priviți din față și verificați dacă:  Pelvisul este la același nivel;  Umerii sunt la același nivel, relaxați, iar brațele au libertate de mișcare;  Picioarele sunt ușor depărtate (în abducție);  Capul stă drept și în echilibru în raport cu corpul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 21 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum afectează pelvisul modul în care stăm? Pelvisul constituie baza poziției așezat. Pentru a fi puternică și stabilă, orice clădire are nevoie de o fundație solidă. În același mod, pentru a fi stabil în poziția așezat, pelvisul trebuie să fie puternic și stabil. Atunci când utilizatorul de scaun rulant este în poziția așezat, pelvisul trebuie să fie: o la același nivel (văzut din față) și o drept sau ușor înclinat înainte (văzut din lateral). Pelvisul – vedere frontală Pelvisul - vedere laterală Orice schimbare la nivelul pelvisului va determina o modificare a poziției celorlalte părți ale corpului. Dacă pelvisul nu este drept, este dificilă realizarea poziției așezat. Pelvisul se mișcă în diverse moduri. Tabelul de mai jos ilustrează patru mișcări diferite ale pelvisului și felul în care este influențat trunchiul în cazul fiecărei mișcări. Mișcarea Ilustrație Schimbările la nivelul corpului Înclinat anterior: (înclinare pelviană anterioară) Pelvisul – vedere laterală o Trunchiul se îndreaptă, umerii sunt trași înapoi. o Crește curbura coloanei în zona de deasupra pelvisului. Înclinat posterior: (înclinare pelviană posterioară) Pelvisul – vedere laterală o Trunchiul se curbează, cu umerii orientați înainte. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 22 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Înclinat lateral: (înclinare pelviană laterală) Pelvisul – vedere posterioară o Trunchiul se îndoaie în lateral. Rotație Pelvisul – vedere de sus o Restul corpului se rotește și el. A.5: Escarele Escara este o necroză tisulară localizată frecvent la nivelul zonelor de presiune (sacru, ischioane, coate, calcaneu etc.) având drept factor determinant presiunea exagerată și prelungită a țesuturilor moi între planul osos și planul de sprijin. Care sunt cauzele apariției escarelor? Cele trei cauze principale ale apariției escarelor sunt. Presiunea: Escarele pot fi cauzate de presiunea exercitată pe piele atunci când corpul stă în aceeași poziție, așezat sau culcat, o perioadă prea lungă, fără schimbarea poziției. Utilizatorii de scaun rulant sunt o categorie expusă în mod deosebit la apariția escarelor, fiindcă pot petrece zilnic un timp îndelungat stând în scaunul rulant. Dacă presiunea nu este redusă, escara se poate dezvolta rapid. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 23 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Fricțiunea: Fricțiunea este frecarea continuă exercitată asupra pielii. De exemplu, frecarea brațului de o roată/un suport de brațe în timpul manevrării scaunului rulant poate cauza apariția unei escare. Alunecarea: Alunecarea are loc atunci când pielea rămâne imobilă și este întinsă sau ciupită de mișcarea mușchilor sau a oaselor. De exemplu, atunci când utilizatorul stă „prăbușit” în scaunul rulant, pielea poate fi afectată de alunecarea care se produce la nivelul oaselor bazinului, determinată de mișcarea înainte și înapoi a pelvisului sau de către prinderea pielii între oasele spatelui și spătar. Factori de risc ce pot determina apariția escarelor Pe lângă cele trei cauze principale ale producerii escarelor, există și alte elemente care pot crește probabilitatea apariției acestora. Aceștia se numesc factori de risc ce pot determina apariția escarelor. Următorii factori de risc pot duce la apariția escarelor: o Lipsa sensibilității (sensibilitate scăzută): în cazul oricărei persoane la care este absentă sensibilitatea sau la care sensibilitatea în zona feselor (așa cum se întâmplă în cazul celor mai mulți paraplegici sau tetraplegici), a bazinului sau picioarelor este scăzută, există pericolul apariției escarelor. o Imobilitatea: atunci când o persoană nu se poate mișca, este incapabilă să reducă presiunea. o Umezeala cauzată de transpirație, apă sau incontinență: umezeala face pielea moale și mai susceptibilă la afecțiuni. Dacă există probleme de management vezical și intestinal, urina și materiile fecale pot provoca leziuni la nivelul pielii. o Postura incorectă: imposibilitatea menținerii poziției așezat poate cauza creșterea presiunii la nivelul unei anumite zone. o Escarele anterioare sau escarele existente. o Nutriția necorespunzătoare și hidratarea insuficientă: un regim alimentar adecvat, care să includă și un consum suficient de apă, asigură corpului necesarul de fluide și nutrienți pentru o piele sănătoasă și pentru vindecarea rănilor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 24 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază o Înaintarea în vârstă: persoanele vârstnice au frecvent o piele mai subțire, sensibilă, care poate fi afectată cu ușurință. o Greutatea (subponderabilitatea sau supraponderabilitatea): persoanele supraponderale pot avea o circulație defectuoasă la nivelul pielii, aceasta putând fi afectată cu ușurință și vindecându-se greu. La utilizatorii de scaun rulant subponderali există riscul apariției escarelor din cauză că oasele lor nu sunt suficient protejate. Pielea din zonele osoase poate fi afectată într-un timp scurt. Zonele cele mai expuse apariției escarelor sunt: Vedere laterală Vedere posterioară Cele patru faze de evoluție ale unei escare3 Acțiuni necesare 1 Prezența pe piele a unei urme roșii sau de culoare închisă. Roșeața sau schimbarea de culoare nu se estompează în interval de 30 de minute de la înlăturarea presiunii. o Îndepărtați imediat presiunea care acționează asupra respectivei zone. o Evitați exercitarea presiunii asupra zonei afectate atâta timp cât pielea nu este pe deplin vindecată. Acest lucru poate însemna repaus la pat. o Identificați sursa și rezolvați acest aspect. o Instruiți utilizatorul cu privire la apariția escarelor și la profilaxia acestora. 2 O rană superificială. Stratul superior al pielii începe să se descuameze sau să formeze o veziculă. o Urmați pașii menționați la stadiul 1. o Recomandați persoanei să apeleze la personal medical experimentat, în vederea tratării escarei. o Escarele deschise trebuie curățate, pansate și atent monitorizate pentru a ne asigura că ele se vindecă și că nu prezintă risc de infecție. o Rănile în stadiul 4 pot necesita intervenție chirugicală. 3 O rană adâncă, întregul strat al pielii este distrus. 4 O rană foarte adâncă, care se extinde prin mușchi, posibil chiar până la os. 3 Spinal Injury Network. Fazele de evoluție a escarei (http://www.spinal-injury.net/pressure-sore-stages-sci.htm, accesat la data de 13 decembrie 2011). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 25 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum pot fi evitate escarele? Folosirea unei perne pentru reducerea presiunii: O pernă pentru reducerea presiunii va ajuta la diminuarea acesteia. Orice persoană la care există riscul apariției escarelor trebuie să primească o pernă pentru reducerea presiunii. Poziția așezat: Poziția așezat ajută la distribuirea egală a greutății. Acest lucru duce la reducerea presiunii sub părțile osoase și a incidenței apariției escarelor cauzate de aceasta. Poziția așezat contribuie și la evitarea escarelor cauzate de alunecare. Personalul furnizor de servicii de scaune rulante poate ajuta utilizatorii să stea în poziția așezat, asigurându-se că scaunul rulant este unul potrivit și explicându-le de ce este importantă adoptarea acesteia. Folosirea tehnicilor de reducere a presiunii: Reducerea presiunii la intervale de timp regulate poate fi eficientă în prevenirea apariției escarelor. Vedeți mai jos informații despre cum se poate proceda pentru reducerea presiunii. Nutriția corespunzătoare și hidratarea adecvată: Un regim alimentar care include legume proaspete, fructe și carne ajută la profilaxia escarelor. Hidratarea adecvată contribuie la menținerea sănătății pielii și la prevenirea apariției escarelor. Dacă vă îngrijorează regimul alimentar al unui utilizator de scaun rulant, recomandați-i un serviciu specializat în domeniu, care să îi poată oferi asistență. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 26 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Evitarea fricțiunii: Asigurați-vă că scaunul rulant are dimensiunea potrivită și că nu există margini dure. Utilizatorii în cazul cărora sensibilitatea este absentă trebuie instruiți să verifice dacă există părți ale corpului asupra cărora scaunul rulant exercită fricțiune. Instruiți utilizatorii să fie atenți la efectuarea transferurilor. Evitarea umezelii: Utilizatorii de scaun rulant trebuie sfătuiți să își schimbe imediat îmbrăcămintea udă sau pătată și să nu folosească perne ude. O rutină la nivel de management vezical și intestinal poate reduce problemele legate de umezeală. Recomandați utilizatorilor cu probleme de incontinență să apeleze la un serviciu specializat, care îi poate ajuta. Verificarea zilnică a suprafeței pielii: Escarele se pot dezvolta cu rapiditate. Este important ca escara să fie identificată fără întârziere și să se acționeze în acest sens. Încurajați acei utilizatori de scaun rulant la care există riscul apariției escarelor să își verifice zilnic suprafața pielii. Ei pot face acest lucru singuri, cu ajutorul unei oglinzi sau pot apela la un membru de familie. Dacă se observă o zonă în care pielea este roșie sau mai închisă la culoare (faza 1 a evoluției escarelor), trebuie luate măsuri imediate pentru înlăturarea presiunii exercitate asupra acelui punct. Schimbarea regulată a poziției așezat sau culcat: Schimbarea regulată a poziției ajută la reducerea presiunii. De exemplu, schimbați poziția așezat în poziția culcat. Acest lucru este deosebit de important în cazul persoanelor care prezintă mai mulți factori de risc de apariție a escarelor sau care au o escară vindecată recent. În ceea ce privește persoanele care nu își pot schimba poziția, la acestea există riscul apariției escarelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 27 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Tehnici de reducere a presiunii În timpul folosirii scaunului rulant, utilizatorii au posibilitatea de a reduce presiunea existentă la nivelul oaselor bazinului. Modalitatea adoptată variază, în funcție de forța și echilibrul pe care le are utilizatorul. Personalul furnizor de servicii de scaune rulante trebuie să instruiască toți utilizatorii la care există riscul apariției escarelor cu privire la cel puțin o tehnică de reducere a presiunii. Aplecarea înainte: O metodă care se potrivește majorității utilizatorilor de scaun rulant. Independent: pentru persoanele care au un bun echilibru și forță. Cu asistență: pentru persoanele care nu au un bun echilibru și forță. Aplecarea în lateral: O metodă care se potrivește utilizatorilor cu forță și echilibru limitate. Unii utilizatori pot agăța brațul de mâner, pentru mai mult sprijin. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 28 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază A.6: Scaunul rulant corespunzător Părțile scaunului rulant Spătar Mâner Cadru suport picioare Roată frontală Suport picioare Suport șezut Centură gambe Șezut Frână Inel antrenare Roată spate Pernă Suport lateral Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 29 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Definiția termenului de „scaun rulant corespunzător” Vă rugăm consultați secțiunea A.1 Utilizatori de scaun rulant. Răspunzând nevoilor utilizatorilor de scaun rulant Un scaun rulant corespunzător este cel care facilitează desfășurarea activităților de către utilizatori. Aceștia trebuie să fie capabili să efectueze transferul în și din scaun rulant, să îl propulseze, să îl plieze pentru a putea fi transportat și depozitat și să își desfășoare activitățile zilnice. Un scaun rulant adecvat poate facilita toate aceste aspecte. Vedeți exemplele de mai jos. Transferurile Transferul în și din scaunul rulant Utilizatorii efectuează transferul în și din scaun rulant prin diverse modalități, în funcție de abilitățile lor fizice. Anumite trăsături ale scaunelor rulante facilitează transferurile. Cele trei caracteristici care ajută la realizarea transferurilor sunt: suportul lateral, suportul de picioare și frânele. Suporturile laterale detașabile sau cele care urmează linia roților din spate sunt potrivite pentru persoanele care efectuează transferul în și din scaunul rulant pe lateral. Utilizatorii care se ridică în picioare pentru a face transferul în și din scaunul rulant pot avea nevoie de suporturile laterale pentru a se ridica în picioare. Suporturile de picioare care pot fi pliate sunt de ajutor celor care realizează în picioare transferul în și din scaun rulant. Persoanele care reușesc să facă transferul cu sprijin pe podea pot prefera un scaun rulant cu suporturi de picioare detașabile. Frânele sunt importante pentru toți utilizatorii. Ele sunt esențiale pentru a menține scaunul rulant nemișcat în timpul transferului în și din acesta. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 30 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Propulsia scaunului rulant Utilizatorii efectuează propulsia scaunului rulant în diferite moduri. Mulți dintre aceștia împing echipamentul de mobilitate cu brațele. Unii utilizatori propulsează scaunul rulant cu picioarele sau folosind un braț și un picior. Există utilizatori care au nevoie de cineva care să împingă scaunul rulant, fie uneori, fie tot timpul. Propulsia scaunului rulant cu ajutorul mâinii se face mai ușor atunci când suporturile laterale și spătarul au înălțimea potrivită. Spătarul este prea înalt. Utilizatorul nu își poate mișca liber brațele și umerii pentru a efectua propulsia scaunului rulant. Suporturile laterale sunt prea înalte. Utilizatorul nu ajunge cu ușurință la roți pentru a efectua propulsia scaunului rulant. Atunci când spătarul este mai jos, utilizatorul are libertate de mișcare la nivelul umerilor, pentru a propulsa scaunul rulant. Pentru un utilizator care poate sta în poziția așezat și care are un echilibru bun, aceasta este înălțimea corespunzătoare a spătarului. Propulsia scaunului rulant este mai simplă dacă utilizatorul poate ajunge ușor la inelele de antrenare. Roata din spate ar trebui astfel poziționată încât atunci când utili- zatorul are mâna poziționată pe partea superioară a inelului de antrenare, cotul să fie îndoit la 90 de grade. Aceasta este o poziție favorabilă realizării propulsiei. Dacă roata este poziționată mai în spate, efectuarea propulsiei de către utilizator este mai obositoare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 31 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT La unele scaune rulante, poziția roții frontale este ajustabilă. Poziția roților din spate are impact asupra felului în care se poate realiza echilibrul pe două roți. Echilibrul pe două roți este folositor atunci când terenul este accidentat, la urcarea și coborârea bordurilor sau a pantelor. Atunci când roțile din spate sunt plasate mai în față, devine mai ușoară realizarea echilibrului pe două roți. Dacă acestea sunt plasate mai în spate, ele sunt mai stabile, dar scaunul rulant este mai greu de împins, iar echilibrul pe două roți se realizează cu mai multă dificultate. Propulsia cu piciorul se face mai ușor dacă utilizatorul are suficientă putere într-un picior, dacă poate sta cu pelvisul sprijinit de scaunul rulant și cu laba piciorului întinsă pe podea. Pentru utilizatorii care propulsează scaunul rulant cu piciorul, este foarte importantă înălțimea de la podea a șezutului scaunului (inclusiv perna). Suporturile de picioare care se pot plia lateral sunt și ele esențiale. Printre utilizatorii care propulsează scaunul rulant cu picioarele, există și persoane care preferă ca scaunul rulant să fie dotat cu o măsuță sau cu suporturi laterale, pentru a se putea înclina atunci când împing scaunul rulant. Un scaun rulant cu o greutate mai mare va mobiliza mai multă energie pentru propulsie, indiferent dacă aceasta se face cu brațele, picioarele sau de către un însoțitor. Totuși, dacă scaunul rulant este bine construit și echilibrat, greutatea nu constituie o problemă însemnată. Greutatea scaunului rulant este importantă mai ales în cazul copiilor. Dacă scaunul rulant este greu, utilizatorul copil poate avea dificultăți în a-l manevra. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 32 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Plierea scaunului rulant Pentru a transporta sau a depozita scaunul rulant, acesta trebuie pliat. Există două modalități principale de pliere a scaunelor rulante. Scaunele rulante cu cadru pliabil se strâng prin apropierea celor două părți laterale. În unele cazuri, roțile sunt și ele detașabile. Acest tip de scaun rulant poate fi util în cazurile în care accesul utilizatorilor presupune trecerea prin cadre de ușă înguste. Pentru transport, unele persoane preferă un scaun rulant cu cadru pliabil. De exemplu, acesta poate încăpea mai bine pe intervalul dintre șirurile de scaune ale unui autobuz. Dezavantajul acestui tip de cadru este că mecanismul de pliere se poate deteriora, făcând scaunul rulant instabil. În acest caz, scaunul rulant devine mai greu de împins. Unele scaune rulante cu cadru rigid pot fi și ele pliate. Însă, în loc de alăturarea celor două părți laterale, spătarul este cel care poate fi pliat, iar roțile din spate pot fi detașate. Un avantaj al scaunelor rulante cu cadrul rigid este că ele sunt mai durabile, deoarece conțin mai puține părți mobile. Desfășurarea activităților Anumite caracteristici ale scaunului rulant au impact asupra modului în care utilizatorul de scaun rulant își desfășoară activitățile cotidiene. De exemplu, caracteristicile care ajută utilizatorul la propulsia scaunului rulant (descrise mai sus) vor determina ușurința cu care utilizatorul va putea participa la activități. Iată câteva exemple: Lungimea cadrului scaunului rulant: Lungimea totală a scaunului rulant poate afecta gradul de dificultate al utilizării sale în spații restrânse. În cazul unui utilizator care petrece multă vreme în interior, un scaun rulant cu o lungime mai mică poate fi cea mai bună alegere. Lungimea cadrului se măsoară de la punctul extrem al părții posterioare a scaunului până la punctul extrem al părții frontale. lungime cadru Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 33 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Suporturile de brațe: Suporturile de brațe înalte pot face dificilă apropierea scaunului rulant de o masă sau un birou. Rețineți: Un scaun rulant corespunzător răspunde nevoilor utilizatorului. Acest lucru înseamnă că utilizatorului de scaun rulant îi este mai ușor să își desfășoare activitățile. Scaunul rulant și mediul utilizatorului de scaun rulant Diferitele tipuri de scaune rulante se potrivesc unor medii diferite. Principalele caracteristici care determină modul în care scaunul rulant funcționează în diverse contexte sunt: o Distanța dintre roțile frontale și roțile din spate (baza roților); o Dimensiunea și lățimea roților. Distanța dintre roțile frontale și roțile din spate (baza roților). Distanța dintre roțile frontale și roțile din spate este importantă. Când această distanță este mai mare, avem ceea ce se numește o „bază roți lungă”. Când această distanță este mai redusă, avem o „bază roți scurtă”. Scaunele rulante care au baza roților lungă sunt mai stabile, iar probabilitatea ca ele să se răstoarne în față este mai mică. Acest tip de scaun rulant poate fi o alegere potrivită pentru persoanele care petrec mult timp în exterior și care au de trecut peste suprafețe accidentate și cu denivelări. Există scaune rulante cu baza roții lungă cu trei și cu patru roți. bază roți Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 34 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Scaunele rulante cu baza roții lungă și având trei roți sunt în general foarte stabile și potrivite utilizării în exterior, pe teren accidentat. Scaunele rulante cu baza roții lungă și având patru roți au roțile frontale situate sub suportul de picioare, nu în spatele acestora. Acest lucru conferă scaunului rulant o bază a roții mai mare. Scaunele rulante cu o bază a roții mai scurtă sunt adecvate pentru spațiile unde terenul este neted sau spațiul este restrâns - de exemplu, în interior. În cazul acestui tip de scaun rulant, probabilitatea ca scaunul rulant să se răstoarne în față la coborârea unei pante sau la întâlnirea de către roțile frontale a unui obstacol este mai mare. Acesta este un exemplu de scaun rulant ortopedic, cu o bază a roții scurtă. Acest scaun rulant nu ar putea fi împins cu ușurință pe un teren accidentat. Utilizatorii cu bune abilități de manevrare pot folosi în exterior un scaun rulant cu o bază a roții scurtă, pentru coborârea pantei și pentru deplasarea pe un teren accidentat, prin ridicarea scaunului rulant în echilibru pe două roți. Dimensiunea și lățimea roților Cu cât este mai mare roata, cu atât este mai ușoară împingerea ei pe teren accidentat. Roțile din spate late, precum și roțile frontale late și de dimensiuni mai mari ajută la evitarea blocării scaunului rulant în terenul aco- perit cu nisip sau noroi. Rețineți: Un scaun rulant corespunzător se potrivește condițiilor din mediul utilizatorului – adică locului în care utilizatorul își petrece cea mai mare parte a timpului. bază roțibază roți Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 35 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Dimensiunea potrivită și suportul postural Scaunele rulante sunt de mărimi diferite. Scaunul rulant trebuie să aibă dimensiunea potrivită pentru a fi adecvat utilizatorului și pentru a oferi suport postural. Din fericire, multe din scaunele rulante sunt disponibile într-o gamă largă de dimensiuni sau pot fi ajustate din acest punct de vedere. Este mai ușor să ne asigurăm că scaunele rulante se potrivesc utilizatorilor atunci când avem la dispoziție mai multe mărimi. Următoarele componente sau caracteristici vor determina modul în care un scaun rulant se va potrivi utilizatorului și în care el va contribui la adoptarea poziției așezat. Șezuturile Șezutul: Șezuturile scaunelor rulante pot fi rigide sau pliabile. Poza din partea stângă ne arată un șezut de scaun rulant de tip rigid. Acestea pot fi confecționate din plastic sau din lemn. În cazul acestui tip de șezut, folosirea pernei este obligatorie. Șezuturile pliabile sunt confecționate de obicei din pânză. Acestea sunt făcute din material textil atașat de părțile laterale ale cadrului. Uneori, șezuturile pliabile de calitate inferioară devin prea întinse sau se deformează sub greutatea utilizatorului și nu mai oferă suportul postural necesar. Persoana aflată în poza din partea stângă stă într-un scaun rulant al cărui șezut pliabil a devenit prea larg și care s-a deformat. El nu beneficiază de suport postural. În consecință, utilizatorului îi este dificil să stea în poziția așezat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 36 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Spătarul: Spătarul poate fi pliabil sau rigid. Toate spătarele rigide trebuie să fie prevăzute cu o căptușeală/pernă. Scaunele rulante au spătare de înălțimi diferite. Unele dintre ele au spătare cu înălțime ajustabilă. În cazul fiecărui utilizator, trebuie aleasă înălțimea adecvată. Suporturile laterale: Suporturile laterale pot oferi și ele sprijin. Unele suporturi laterale sunt reglabile pe înălțime. Cele care nu sunt, pot fi uneori modificate pentru a oferi mai mult suport, în cazul în care acest lucru este necesar. Pernele: Perna înseamnă confort, ajută la reducerea presiunii și oferă suport. De asemenea, împiedică alunecarea utilizatorului. Suportul de picioare: Suportul de picioare oferă sprijin utilizatorului. Este foarte important ca suportul să fie ajustat în mod corect. Din acest motiv, înălțimea acestuia este de obicei reglabilă. Unele suporturi de picioare pot fi ajustate și din punct de vedere al unghiului și al distanței față de scaunul rulant. Rețineți: Scaunul rulant corespunzător este cel care i se potrivește utilizatorului și care îi oferă suport postural. spătar suport lateral pernă suport picioare Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 37 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.7: Pernele Care este rolul pernelor? Perna este o componentă foarte importantă a fiecărui scaun rulant. Pernele oferă: o confort; o suport postural (ajută utilizatorul să stea mai bine în poziția așezat); o reducerea presiunii. Toți utilizatorii ar trebui să stea comod în scaunul rulant, iar o pernă bună îi ajută să adopte poziția așezat mai ușor și mai confortabil. Acesta este motivul pentru care fiecare utilizator trebuie să aibă o pernă. Nu este obligatoriu ca toți utilizatorii să aibă o pernă destinată reducerii presiunii. Diferitele tipuri de perne Pernele pot fi descrise în mai multe feluri, inclusiv luând în considerare următoarele aspecte: o materialul din care sunt confecționate (de exemplu: din spumă / burete sau fibre vegetale); o materialul cu care sunt umplute (de exemplu: aer, lichid sau gel); o principala lor utilizare (de exemplu: reducerea presiunii, confort, suport postural); o forma lor (de exemplu: netede sau modelate); o modul în care sunt confecționate (de exemplu, pernele de spumă / burete pot fi confecționate dintr-o bucată de material sau pot fi „în straturi” – având mai multe straturi de spumă / burete). Cele mai răspândite sunt pernele fabricate din spumă / burete. Acestea sunt, de obicei, și cele mai puțin costisitoare. Sunt ușor de confecționat în locurile unde spuma / burete constituie un material disponibil și ușor de modificat pentru a se potrivi fiecărui utilizator în parte. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 38 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Cine are nevoie de o pernă? Fiecare utilizator de scaun rulant trebuie să aibă o pernă. Utilizatorii la care există riscul apariției escarelor trebuie să folosească perne pentru reducerea presiunii. Pernele pentru reducerea presiunii Există diferite tipuri de perne pentru reducerea presiunii, inclusiv: o perne pentru reducerea presiunii, din spumă modelată / burete; o perne umplute cu aer/lichid/gel. Perne pentru reducerea presiunii confecționate din spumă Principalele caracteristici ale pernei confecționate din spumă / burete și destinate reducerii presiunii sunt următoarele: Baza rigidă stabilă: Baza unei perne pentru reducerea presiunii trebuie să fie rigidă. Astfel, ne asigurăm că perna oferă suport utilizatorului și că nu devine mobilă la mișcările utilizatorului. Stratul superior: Peste stratul de bază trebuie să existe un „strat de confort”. Acesta este un strat (sau mai multe straturi) confecționat din spumă / burete mai moale. Stratul superior ar trebui să fie suficient de moale pentru a permite oaselor bazinului să se afunde, dar nu atât de moale încât oasele bazinului să ajungă până la stratul de bază sau la șezutul scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 39 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Acest tip de perne contribuie la reducerea presiunii prin: o distribuirea greutății utilizatorului într-un mod cât mai egal posibil, pe toată suprafața șezutului scaunului rulant; o reducerea presiunii în zonele unde există riscul apariției escarelor, unde presiunea este puternică (oasele bazinului); o reducerea alunecării, sprijinind utilizatorul, astfel încât acesta să stea în poziția așezat. Forma pernei pentru reducerea presiunii Pernele pentru reducerea presiunii variază. Contururile unei astfel de perne includ: o o „adâncitură” sub oasele bazinului, pentru a reduce presiunea; o suport sub oasele șoldurilor (articulația coxo- femurală) pentru a ajuta la distribuirea greutății; o o parte înălțată în fața oaselor bazinului pentru a ține pelvisul mai drept și pentru a preveni alunecarea înainte; o adâncituri pentru coapse. Perne pentru reducerea presiunii, cu aer/lichid/gel o Pernele de flotație includ pernele umplute cu aer și cele care au în componență lichid sau gel. o Pernele cu gel trebuie să aibă o bază de spumă rigidă foarte similară cu cea a pernelor din spumă modelată. o Peste stratul de bază se află un strat de gel/lichid. o Stratul de gel ia în mod automat forma corpului utilizatorului de scaun rulant. Acest lucru contribuie la distribuirea în mod egal a greutății utilizatorului și reduce presiunea sub zonele osoase. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 40 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Ce fel de pernă trebuie utilizată? Există avantaje și dezavantaje atât în cazul pernelor din spumă modelată, cât și în cel al pernelor cu aer/lichid/gel. Avantaje Dezavantaje Pernă din spumă modelată / burete o Poate fi confecționată local (acolo unde există spumă / burete de bună calitate). o Poate fi modificată local, pentru a răspunde diverselor nevoi. o Nu este supusă „colapsului spontan” (un orificiu în perna cu aer/lichid/gel poate provoca scurgerea materialului din pernă și o împiedică să reducă presiunea, provocând acel „colaps spontan” al pernei). o Stratul superior al unei perne cu straturi poate fi înlocuit cu ușurință și cu costuri mici (spre deosebire de costul pe care îl presupune înlocuirea întregii perne). o Spuma / buretele se comprimă în timp (devin mai plate și mai tari). Din acest motiv, pernele de spumă / burete trebuie verificate la intervale regulate de timp și înlocuite cu o frecvență de 1-2 ani. o Uscarea lor poate dura (o problemă în cazul persoanelor care suferă de incontinență). o Spuma / buretele izolează și poate cauza o creștere în temperatură la nivelul țesutului. Perne cu aer/lichid/ gel o Presiunea este distribuită în mod egal pe suprafața șezutului scaunului rulant. o Stratul de gel se adaptează imediat corpului atunci când utilizatorul se mișcă sau își schimbă poziția. o Pernele cu aer/lichid/gel sunt deseori mai scumpe decât pernele din spumă / burete și mai greu de găsit la nivel local. o Unii utilizatori simt că pernele umplute cu aer/ lichid/gel îi fac să fie mai instabili. o Problema “colapsului spontan”. În situația în care utilizatorul nu are posibilitatea de a înlocui rapid perna, acest lucru poate constitui o problemă. Husele pernelor Perna pentru reducerea presiunii trebuie să aibă o husă care poate fi îndepărtată pentru a fi spălată și care este impermeabilă. Materialul folosit pentru husa pernei ar trebui să fie elastic sau suficient de lax, astfel încât să permită oaselor bazinului să se așeze în spuma / buretele din care este confecționată perna. Dacă materialul husei nu este elastic, atunci cel Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 41 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT mai indicat este un material textil subțire. Pliurile care se formează într-un material subțire au mai puțin impact asupra pielii utilizatorului, iar probabilitatea ca ele să determine apariția unei escare este mai mică. Dacă sub husa din material textil se folosește plastic subțire, acesta trebuie să fie și el suficient de larg pentru ca oasele bazinului să se poată așeza în stratul de spumă. Întotdeauna sfătuiți utilizatorii de scaun rulant ca atunci când perna sau husa devin umede, să le usuce și să le folosească din nou doar în momentul în care nu mai sunt deloc umede. În cazul utilizatorilor cu incontinență și la care există riscul producerii de escare, ar trebui utilizate două perne, în mod alternativ. Ce se poate face dacă nu există husă de pernă impermeabilă Oriunde este posibil, utilizatorii de scaun rulant cu incontinență au nevoie de o husă de pernă impermeabilă, care va ține lichidul departe de pielea utilizatorului. Dacă nu există husă impermeabilă: o identificați ce fel de asistență se poate oferi pentru reducerea incontinenței; o oferiți o a doua pernă – pentru a putea fi folosită cât timp cealaltă se usucă; o protejați perna pe interior, utilizând un sac de plastic foarte subțire. Dacă se utilizează un sac de plastic: o verificați dacă sacul nu provoacă „alunecarea” utilizatorului pe pernă; o asigurați-vă că nu există cute ale sacului de plastic, care ar putea provoca apariția unei escare; o utilizatorul de scaun rulant trebuie să se asigure că lichidul nu se „adună” deasupra plasticului, deoarece acest lucru crește riscul apariției escarelor; o în cazul în care husa s-a udat, înainte de folosire, utilizatorul de scaun rulant trebuie să se asigure că aceasta este uscată și că sacul de plastic este curățat sau înlocuit. Cum se testează funcționalitatea pernei pentru reducerea presiunii Ori de câte ori recomandați o pernă pentru reducerea presiunii, efectuați acest test manual simplu, pentru a verifica dacă perna reduce într-adevăr presiunea de sub oasele bazinului utilizatorului. Testul constă în poziționarea mâinilor sub oasele bazinului (ischioane) utilizatorului de scaun rulant. Întotdeauna explicați utilizatorului ce urmează să faceți și de ce testul este important. Întotdeauna faceți testul cu perna și scaunul rulant care i-au fost furnizate utilizatorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 42 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Testarea presiunii manual A Explicați utilizatorului de scaun rulant ce urmează să faceți și care este importanța testului. B Rugați utilizatorul să se ridice în scaun sau să se aplece în față, pentru a permite plasarea degetelor voastre sub oasele bazinului (ischioane), pe partea dreaptă sau pe cea stângă (cu palma în sus). Acest lucru se poate face cel mai bine din spatele scaunului rulant, introducând o mână sub tapițeria spătarului. C Rugați utilizatorul să se așeze pe degetele voastre. Utilizatorul trebuie să adopte poziția obișnuită, cu fața înainte și mâinile poziționate pe coapse. Acest lucru ne asigură că el va avea aceeași poziție de fiecare data când vă schimbați locul pentru a verifica un alt punct. Dacă degetele voastre nu sunt într-o poziție bună pentru a simți presiunea de sub oasele bazinului, rugați utilizatorul să se ridice din nou și repoziționați degetele. D Identificați dacă presiunea de sub oasele bazinului este de nivelul 1, 2 sau 3: Nivel 1 = sigur: Degetele se pot mișca în sus și în jos 5mm sau chiar mai mult. Nivel 2 = avertizare: Degetele nu se pot mișca, dar pot fi retrase cu ușurință. Nivel 3 = pericol: Degetele sunt strânse cu putere. Retragerea lor este dificilă. E Repetați operațiunea și pentru cealaltă parte a oaselor bazinului. Cum se reduce presiunea în cazul „avertizării” sau al „pericolului”? Atunci când se constată că presiunea de sub oasele bazinului este de nivel 2 (avertizare) sau de nivel 3 (pericol), se impune reducerea presiunii. O soluție simplă o constituie adăugarea unui strat suplimentar de spumă rigidă. Aceasta se numește „ridicare”. Stratul ar trebui să aibă aproximativ 20 de mm grosime și să aibă o zonă decupată sub oasele bazinului. Acest strat se plasează sub pernă și în interiorul husei. Uneori este nevoie de mai mult de un strat. Se recomandă ca personalul furnizor de servicii de scaune rulante să adauge un strat și să verifice presiunea. Dacă presiunea se situează tot la nivelul 2 sau 3, se adaugă încă un strat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 43 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT A.8 Transferurile Transferul în și din scaunul rulant Abilitatea de a se așeza în scaunul rulant și de a se ridica din acesta fără efort și în condiții de siguranță, cu sau fără asistență, va ajuta utilizatorul în viața de zi cu zi. Aceste două activități sunt cunoscute sub numele de „transfer”. De ce trebuie utilizatorii de scaun rulant să știe transferul în și din scaun rulant? Este posibil ca utilizatorii să fie nevoiți să se așeze în scaunul rulant și să se ridice din acesta de mai multe ori pe zi. De aceea, este nevoie de o metodă sigură, rapidă și care nu necesită un consum de energie prea mare. Utilizatorii au metode diferite de transfer, în funcție de abilitățile lor. Unii utilizatori de scaun rulant pot efectua transferul în și din scaunul rulant singuri, alții au nevoie de ajutor. Unii dintre ei se ridică în picioare pentru realizarea transferului, însă acest lucru nu este posibil în cazul altora. Trei tehnici de transfer în și din scaunul rulant Înainte de a-i recomanda utilizatorului de scaun rulant o anumită tehnică de transfer sau înainte de a o exersa, este necesar să stabilim dacă acesta poate efectua transferul singur sau dacă are nevoie de asistență. o Pentru efectuarea transferului independent în poziția așezat, verificați dacă utilizatorul își poate ridica greutatea susținându-se în brațe. Dacă nu poate face acest lucru, atunci utilizatorul are nevoie de ajutor pentru realizarea transferului. o Pentru efectuarea transferului independent în picioare, verificați dacă utilizatorul se poate ridica și își poate susține greutatea pe picioare. Dacă nu poate face acest lucru, atunci utilizatorul are nevoie de ajutor pentru realizarea transferului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 44 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Mai jos sunt prezentate câteva tehnici de realizare a transferului. Transfer independent în poziția așezat (din scaunul rulant pe pat) o Scaunul rulant se poziționează lângă pat, se acționează frânele. o Picioarele se coboară de pe suport, iar acesta se pliază lateral sau se detașează (acolo unde acest lucru este posibil). o Se îndepărtează suportul lateral de pe partea unde se află patul. o Utilizatorul se ridică împingându-se cu ajutorul brațelor și se mută înspre partea din față a scaunului rulant. o Având o mână așezată pe pat și cealaltă pe scaunul rulant, se ridică corpul în sus și se transferă pe pat. o Dacă utilizatorul are un echilibru precar, nu se poate ridica suficient sau nu se poate mișca destul în lateral, se poate folosi o placă de transfer. o La transferul pe pat, unii utilizatori preferă să își poziționeze picioarele pe pat înainte de a efectua transferul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 45 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Transfer asistat în poziția așezat, cu utilizarea unei plăci de transfer (din scaunul rulant pe pat) o Scaunul rulant se poziționează lângă pat, se acționează frânele. o Picioarele se coboară de pe suport, iar acesta se pliază lateral sau se detașează (acolo unde acest lucru este posibil). o Se îndepărtează suportul lateral de pe partea unde se află patul. o Se ajută utilizatorul să se miște spre partea din față a scaunului rulant. o Se pune placa de transfer sub bazin, peste scaunul rulant și pat. o Utilizatorul contribuie ridicând corpul de pe scaunul rulant și de pe pat și susținându-și cât mai mult posibil greutatea. o Însoțitorul stă în spatele utilizatorului și mută bazinul utilizatorului pe pat. Transfer asistat, în picioare (din pat în scaunul rulant) o Se poziționează scaunul rulant, se acționează frânele. o Picioarele se coboară de pe suport, iar acesta se pliază lateral sau se detașează (acolo unde acest lucru este posibil). o Se îndepărtează suportul lateral de pe partea unde se află patul. o Se ajută utilizatorul să se miște spre marginea patului și se pun picioarele pe podea. o Se susțin genunchii utilizatorului din lateral (genunchii nu se împing din față). o Se ridică corpul utilizatorului în față și în sus, cu sprijin sub omoplați. o Utilizatorul este întors spre scaunul rulant și lăsat să se așeze ușor în acesta. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 46 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Ce este o placă de transfer? O placă de transfer este o placă subțire, rezistentă, care ajută la crearea unei punți între scaunul rulant și suprafața pe care se efectuează transferul utilizatorului de scaun rulant. Plăcile de transfer sunt folositoare pentru utilizatorii de scaun rulant care învață să realizeze transferul în mod independent sau care au o forță redusă în brațe. Utilizatorul poate realiza transferul printr-o serie de ridicări reduse, în loc de o singură ridicare mai amplă. Placa de transfer poate reduce și gradul de asistență de care are nevoie utilizatorul. Plăcile de transfer pot fi făcute și local, din lemn sau placaj. Ele trebuie să fie subțiri, rezistente și foarte netede. Pe margini, grosimea trebuie să fie mai redusă. Dimensiunile recomandate sunt 300 mm x 600 mm. Grosimea plăcii depinde de rezistența materialului, dar dimensiunea tipică este între 20 și 25 de mm. Transferul independent, de pe podea în scaunul rulant o Acest tip de transfer presupune ca utilizatorul să aibă brațe puternice și un echilibru bun. o Utilizatorilor în cazul cărora există riscul apariției escarelor li se recomandă ca atunci când stau pe podea, să se așeze întotdeauna pe perna pentru reducerea presiunii. o Utilizatorul stă în fața scaunului rulant, cu genunchii ridicați la piept. o Privirea este în jos pe tot parcursul ridicării. o Se poziționează o mână pe podea, iar cealaltă pe partea din față a șezutului scaunului rulant. o Brațele și umerii se împing în jos, iar bazinul se ridică pe partea din față a șezutului scaunului rulant. o Utilizatorul se așază în scaunul rulant și se apleacă pentru a ridica perna. o Se balansează greutatea de pe o parte pe alta și se poziționează perna pe șezutul scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 47 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Transferul din scaunul rulant pe podea o Utilizatorul se așază pe partea din față a scaunului rulant. o Picioarele se ridică de pe suportul de picioare, se poziționează în față și ușor spre lateral (în direcția opusă celei în care se face transferul). o Perna se pune pe podea. o O mână se poziționează pe șezutul scaunului rulant, cealaltă se sprijină de podea. o Cu ajutorul umerilor și al brațelor, bazinul se așază pe perna plasată pe podea, printr-o mișcare controlată. Cum se realizează transferul în și din scaunul rulant în condiții de siguranță Pentru utilizatorul de scaun rulant: o La transferul în și din scaunul rulant, frânele trebuie să fie întotdeauna acționate. o Se verifică locul unde se efectuează transferul, pentru a ne asigura că nu există niciun obstacol. o Mișcarea trebuie să fie întotdeauna cea de ridicare. Nu târâți corpul – pielea ar putea fi rănită și acest lucru ar putea duce la apariția escarelor. Pentru persoanele care asistă utilizatorul: o Înainte de a oferi asistență utilizatorului, asigurați-vă că puteți să îi susțineți greutatea. o Explicați utilizatorului ce urmează să faceți. o Folosiți tehnici de ridicare sigure. o Femeile însărcinate sau persoanele care au afecțiuni ale spatelui trebuie să evite să ofere asistență utilizatorului la efectuarea transferului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 48 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază B. Etapele furnizării serviciilor de scaune rulante Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 49 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 1: Trimiterea și programarea Trimiterea Trimiterea înseamnă direcționarea unei persoane către un serviciu unde poate beneficia de îngrijire sau de asistență. Există mai multe metode prin care utilizatorii de scaun rulant pot ajunge la un furnizor de servicii de scaune rulante: o află despre aceste servicii și vin din proprie inițiativă; o sunt îndreptați către un astfel de serviciu de către spitalul din localitate, de centrul de sănătate publică, de serviciul de reabilitare bazată pe comunitate, de lideri din cadrul comunității rurale, din consiliul local sau din cadrul bisericii, de organizații ale persoanelor cu dizabilități sau de către alți utilizatori de scaun rulant. Furnizorii de servicii de scaune rulante pot ajuta la creșterea numărului de utilizatori de scaun rulant care apelează la acest tip de servicii, asigurându-se că toți cei care îi pot direcționa pe utilizatori către ei, cunosc că serviciul este disponibil. Punând la dispoziție un formular de trimitere, furnizorul de servicii de scaune rulante poate dobândi informații preliminare de bază despre utilizatorul de scaun rulant. Fiecare furnizor de servicii de scaune rulante trebuie să decidă dacă un astfel de formular de trimitere este un instrument util, tipul de informații pe care le va include și modul în care acesta va fi folosit (de exemplu, dacă va fi trimis prin poștă sau dacă îi va fi dat utilizatorului pentru a-l aduce chiar el). Pe pagina următoare veți găsi un model de formular de trimitere. Programarea Atunci când un utilizator de scaun rulant este trimis către un furnizor de servicii de scaune rulante, el trebuie programat pentru o evaluare, în cazul în care întâlnirea nu poate avea loc în aceeași zi. Programarea poate însemna că utilizatorul va vizita furnizorul de servicii/centrul sau că reprezentanții furnizorului de servicii vor vizita utilizatorul. Un sistem de programări îl ajută pe furnizorul de servicii de scaune rulante să își organizeze timpul într-un mod cât mai eficient. De asemenea, consecința este că utilizatorul nu trebuie să stea să aștepte să fie primit de personalul furnizor de servicii de scaune rulante. Modul în care se face o programare depinde de cât de ușoară este transmiterea mesajului către utilizatorul de scaun rulant. De exemplu, mesajele pot fi transmise prin poștă, prin telefon sau prin cel care a trimis utilizatorul către furnizorul de servicii de scaune rulante. Uneori, utilizatorii de scaun rulant vor veni fără o programare prealabilă. Dacă este posibil, se recomandă ca ei să fie primiți în aceeași zi, în special dacă au sosit de la distanță. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 50 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Bune practici în programare și trimitere o Începeți un dosar pentru fiecare utilizator de scaun rulant în momentul în care acesta este trimis către serviciul de scaune rulante. o Instruiți sursele care trimit utilizatori cu privire la acest serviciu și la modalitatea de a face trimiterile. o Furnizați acestor surse formularul de trimitere către serviciul de scaune rulante. o Acolo unde există mulți utilizatori de scaun rulant, furnizorul de servicii de scaune rulante trebuie să creeze un sistem pentru a decide cine sunt cei care au prioritate. Trebuie luate în considerare în special nevoile copiilor și ale persoanelor cu afecțiuni ce le pun în pericol viața, cum ar fi persoanele care au escare. Formular de trimitere către furnizorul de servicii de scaune rulante Vă rugăm completați formularul și expediați-l către: Numele și adresa furnizorului de servicii scaune rulante: Numele persoanei care face trimiterea: Organizația: Datele de contact ale persoanei care face trimiterea (unde puteți fi contactat cel mai ușor): Numele utilizatorului de scaun rulant: Data nașterii: Numele părintelui / însoțitorului: Adresa: Un formular de trimitere trebuie să aibă datele de contact clare ale serviciului, inclusiv numele acestuia, adresa poștală și numărul de telefon. În acest model de formular, furnizorul de servicii va contacta utilizatorul pentru a face o programare. Acest lucru nu este întotdeauna posibil. În acest caz, serviciul de scaune rulante poate accepta trimiteri fără programare prealabilă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 51 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum poate fi contactat utilizatorul de scaun rulant? __________________________________________________________________ Poștă o Telefon propriu o Telefon prieten/vecin o Dacă telefonic, vă rugăm precizați numărul de telefon: Dizabilitatea utilizatorului de scaun rulant, dacă există informația: Motivele pentru care se face trimiterea: o Nu deține un scaun rulant o Deține un scaun rulant defect o Deține un scaun rulant necorespunzător Vă rugăm precizați orice altă informație despre utilizatorul de scaun rulant pe care o considerați relevantă pentru furnizorul de servicii de scaune rulante: Utilizatorul de scaun rulant este de acord să fie trimis către furnizorul de servicii de scaune rulante? Da o Nu o Semnătura persoanei care face trimiterea: Data: Se recomandă ca persoana care face trimiterea să îi explice utilizatorului cu ce se ocupă serviciul de scaune rulante. Utilizatorul trebuie să fie de acord cu trimiterea. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 52 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Etapa 2: Evaluarea Cine are nevoie de un scaun rulant? Atunci când o persoană apelează la un furnizor de servicii de scaune rulante, acesta din urmă trebuie să se asigure că scaunul rulant este echipamentul de mobilitate de care este nevoie în cazul respectiv. De regulă, o persoană are nevoie de un scaun rulant atunci când: o nu se poate deplasa; o se poate deplasa, dar cu dificultate și numai pe distanțe scurte. De ce este nevoie de o evaluare? Evaluarea este o oportunitate pentru a aduna informații care contribuie la: o alegerea celui mai potrivit scaun rulant pentru fiecare utilizator, din cele disponibile; o alegerea celor mai adecvate componente ale scaunului rulant, din cele disponibile; o identificarea nevoii de instruire a utilizatorului și/sau a familiei acestuia, pentru o utilizare cât mai eficientă a scaunului rulant. Unde are loc evaluarea? Evaluarea ar trebui să se desfășoare într-un spațiu curat și liniștit. Acesta poate fi un spațiu aflat la sediul furnizorului de servicii de scaune rulante, la un centru de sănătate, un centru comunitar sau la domiciliul utilizatorului de scaun rulant. Este necesar să se verifice dacă persoana are escare - acest lucru se face într-un spațiu ferit. Respectați demnitatea și nevoia de intimitate a utilizatorului de scaun rulant, indiferent de vârstă, sex, religie sau statut socio–economic. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 53 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cele două componente ale evaluării: o interviul de evaluare; o evaluarea fizică. 1. Interviul de evaluare Cea mai bună metodă de a obține informații despre utilizatorul de scaun rulant este să puneți întrebări. Formularul de evaluare pentru scaun rulant ghidează personalul furnizor al acestor servicii cu scopul de a identifica cele mai relevante întrebări pentru realizarea evaluării. Există patru categorii distincte de informații. Acestea sunt: o informații despre utilizatorul de scaun rulant; o condiția fizică; o stilul de viață și mediul; o scaunul rulant existent. Informații despre utilizatorul de scaun rulant: Numele: ____________________ Numărul: ______________________ Vârsta: ____________________________ Bărbat o Femeie o Număr telefon: ________________ Adresa: _______________________ ________________________________________________________ Obiective: ________________________________________________ Aceste întrebări sunt importante pentru ca utilizatorul să poată fi contactat la o data ulterioară, pentru monitorizare. Totodată, ele oferă informații statistice despre utilizatorii care au fost văzuți de personalul furnizor de servicii de scaune rulante. La capitolul „obiective” notați motivul pentru care utilizatorul dorește un scaun rulant, precum și activitățile pe care dorește să le poată desfășura în scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 54 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Atunci când puneți întrebări, rețineți următoarele: o explicați de fiecare dată utilizatorului de scaun rulant de ce respectiva informație este importantă; o adresați-vă mereu utilizatorului (nu asistentului/unui membru de familie), excepție cazurile când este vorba despre un copil mic sau despre cineva care nu are abilitatea de a înțelege întrebările ori de a răspunde la ele; o folosiți metode de comunicare eficiente; o este posibil ca informația să nu vă parvină mereu în ordinea în care ea se regăsește în formular – familiarizați-vă cu formularul, în așa fel încât informația să fie înregistrată în mod corect. Condiția fizică: Aceste întrebări sunt importante, deoarece unele din aspectele ce țin de starea de sănătate pot avea impact asupra alegerii scaunului rulant. Găsiți mai jos câteva exemple. Condiția fizică Paralizie cerebrală o Poliomielită o Traumatism vertebro-medular o Accident vascular- cerebral o Constituție fragilă o Spasme sau mișcări involuntare o Amputație: o D deasupra genunchiului o D sub genunchi o S deasupra genunchiului o S sub genunchi Probleme de management urinar o Probleme de management intestinal o Dacă există probleme de management urinar sau de tranzit intestinal, acestea sunt gestionate? Da o Nu o Altele: ______________________________________________________________ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 55 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Diferite afecțiuni care influențează prescrierea (selecția) scaunului rulant: Ce trebuie să știți Rețineți întotdeauna Paralizie cerebrală Paralizia cerebrală afectează persoanele în moduri foarte diferite. În cazul unei persoane cu paralizie cerebrală, care poate sta în poziția așezat, este important să reținem faptul că acesteia îi poate fi dificil să păstreze poziția, din cauza oboselii. Astfel, desfășurarea activităților e îngreunată și mai solicitantă. Suportul adecvat este foarte important. Persoanele cu paralizie cerebrală pot avea nevoie de suport postural suplimentar atunci când stau în scaunul rulant. Pentru a rezolva acest aspect ușor și în mod eficient, este nevoie de instruire de nivel intermediar. Poliomielită În cazul unora din persoanele care au avut poliomielită, la nivelul unor părți ale corpului poate exista o stare de slăbiciune, de lipsă de forță. Poliomielita poate afecta membrele superioare și inferioare sau trunchiul, dar cel mai frecvent afectează membrele inferioare. Mușchii și oasele devin mai subțiri, membrele afectate nu cresc la fel de repede, rămânând mai scurte. Atunci când este afectat trunchiul, acesta poate părea mai scurt. Cu toate că la persoanele care au avut poliomielită este prezentă sensibilitatea, este important să aibă o pernă, pentru confort. O pernă mai înaltă poate oferi o poziție mai confortabilă în vederea realizării propulsiei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 56 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Ce trebuie să știți Rețineți întotdeauna Traumatism vertebro- medular Persoanele cu traumatism vertebro-medular sunt deosebit de predispuse la apariția escarelor. Acest lucru este o consecință a faptului că la majoritatea persoanelor cu traumatism vertebro-medular, sub nivelul leziunii, sensibilitatea este absentă. Prescrieți întotdeauna o pernă pentru reducerea presiunii. Accident vascular cerebral Persoanelor care au suferit un accident vascular-cerebral le este de regulă afectată o parte a corpului. Din această cauză, atunci când stau în scaunul rulant, ele pot avea tendința de a se lăsa mai mult pe o parte. Este posibil ca pe partea corpului afectată de accident sensibilitatea să le fie diminuată. Aceste persoane pot avea abilitatea de a efectua transferul în picioare. Este important să existe un sprijin adecvat. Verificați dacă este prezentă sensibilitatea – ar putea fi necesară o pernă pentru reducerea presiunii. O persoană care a avut un accident vascular cerebral poate prefera un scaun rulant cu suporturi de picioare pliabile, pentru a putea efectua transferul în picioare. Amputație membru inferior În cazul persoanelor cu dublă amputație lipsește greutatea picioarelor, care poate să contracareze răsturnarea pe spate a scaunului rulant. Atunci când o persoană cu amputație încearcă pentru prima dată un scaun rulant trebuie să fiți întotdeauna atenți. Verificați echilibrul scaunului rulant. Este posibil să fie necesară mutarea roții din spate mai în afară, pentru a oferi mai multă stabilitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 57 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Ce trebuie să știți Rețineți întotdeauna Constituție fragilă Persoanele în vârstă pot avea nevoie de un scaun rulant din diverse motive. De obicei, acest lucru se întâmplă deoarece le este dificil să se deplaseze. Scaunul rulant îi va ajuta să continue să facă parte din viața familiei și a comunității. Persoanele în vârstă pot avea capacitatea de a realiza transferul în picioare și vor prefera un scaun rulant cu suporturi de picioare pliabile pe verticală sau pe orizontală. Persoanele în vârstă trebuie să primească întotdeauna un scaun rulant care să fie confortabil și care să le ofere sprijin. Astfel, vor avea poziția corectă și vor fi evitate problemele cauzate de postura defectuoasă. Scaunele rulante cu suporturi de picioare pliabile pe verticală sau orizontală pot constitui cea mai bună opțiune. Spasme sau mișcări involuntare Unele persoane au probleme cauzate de mișcări spontane, dezordonate, pe care nu le pot controla (spasme). Din cauza acestor spasme, există posibilitatea ca greutatea persoanei să se deplaseze înspre spate, creând presiune pe spătar, fapt care poate duce la răsturnarea scaunului rulant. Acest tip de mișcări uneori determină picioarele „să sară” de pe suportul de picioare. Acest lucru se poate dovedi periculos în timpul realizării propulsiei. Alegeți un scaun rulant cu roțile din spate poziționate de așa manieră încât să ofere siguranță, sau unul care este foarte stabil. Centurile pot ajuta la controlul poziției labei piciorului. Notă: ori de câte ori se folosesc centuri, este important ca acestea să fie din material de tip Velcro, în așa fel încât acestea să poată fi desfăcute în cazul în care utilizatorul cade din scaunul rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 58 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Ce trebuie să știți Rețineți întotdeauna Probleme de management intestinal și vezical Unele persoane nu dețin controlul asupra vezicii sau al sfincterelor. Frecvent, această situație poate fi rezolvată cu dispozitivele potrivite (catetere, de exemplu), cu medicație și cu un program de instruire pentru management vezical și intestinal. Utilizatorii care au probleme de management vezical sau intestinal nu trebuie să stea pe perne umede sau pătate, fiindcă acest lucru poate dăuna rapid pielii. În plus, bacteriile prezente în materiile fecale pot duce, într- un interval de timp scurt, la escare infectate. Identificați acele persoane din zona în care vă desfășurați activitatea (de exemplu medici specialiști sau asistente), care pot oferi sfaturi și instruire pentru evitarea acestui tip de complicații. Furnizați o pernă cu o husă impermeabilă. Instruiți utilizatorul cu privire la spălarea și uscarea pernei. O pernă suplimentară poate ajuta utilizatorul să își continue activitățile cotidiene în timp ce perna se usucă. Stilul de viață și mediul: Aceste întrebări oferă informații cu privire la spațiul unde locuiește utilizatorul și la activitățile pe care trebuie să le desfășoare în scaun rulant. Stilul de viață și mediul Descrieți mediul în care va fi utilizat scaunul rulant: __________________________________________________________________________ Distanța parcursă zilnic: Mai puțin de 1 km o 1–5 km o Mai mult de 5 km o Numărul de ore pe zi de utilizare a scaunului rulant: Mai puțin de 1 oră o 1-3 ore o 3-5 ore o 5-8 ore o mai mult de 8 ore pe zi o Atunci când nu folosește scaunul rulant, unde și cum stă utilizatorul (poziția și tipul de suprafață)? __________________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 59 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Transfer: Independent o Asistat o În picioare o Așezat o Ridicat o Altele o Tip toaletă (dacă se face transferul la toaletă): La nivelul podelei o Tipică o Adaptată o Utilizatorul de scaun rulant folosește în mod frecvent mijloace de transport în comun/proprii? Da o Nu o Dacă da, precizați tipul: Mașină o Taxi o Autobuz o Altele________________ Scaunul rulant existent: Aceste întrebări sunt de ajutor pentru a stabili dacă scaunul rulant existent răspunde nevoilor utilizatorului, iar în cazul în care nu, la aflarea motivelor. Scaunul rulant existent (dacă persoana are deja un scaun rulant) Scaunul rulant răspunde nevoilor utilizatorului? Da o Nu o Scaunul rulant corespunde cerințelor mediului utilizatorului? Da o Nu o Este scaunul rulant adecvat și oferă suport postural corespunzător? Da o Nu o Este scaunul rulant sigur și durabil? (Luați în considerare existența pernei) Da o Nu o Perna asigură o reducere a presiunii adecvată (previne riscul apariției escarelor)? Da o Nu o Comentarii: ________________________________________________________________ Dacă răspunsul este ”da” la toate întrebările, atunci este posibil ca utilizatorul să nu aibă nevoie de alt scaun rulant. Dacă răspunsul la oricare din aceste întrebări este ”nu”, atunci utilizatorul are nevoie fie de un alt scaun rulant, fie de o altă pernă ori scaunul rulant sau perna au nevoie de reparații, respectiv de modificări. 2. Evaluarea fizică Există trei categorii distincte de informații. Acestea sunt: o prezența escarelor, risc de formare al acestora sau istoric escare; o metoda de propulsie; o efectuarea măsurătorilor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 60 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Prezența escarelor, riscul de formare al acestora sau istoric escare /// = lipsă sensibilitate O = escară anterioară  = escară prezentă Sensibilitate normală? Da o Nu o Escară anterioară? Da o Nu o Escară existentă? Da o Nu o Dacă da, este o escară deschisă (faza 1 – 4)? Da o Nu o Durata și cauza: _______________________________ ___________________________________________ Stânga Față Spate Dreapta Există riscul* formării de escare? *Se consideră că există pericolul apariției escarelor la persoanele la care sensibilitatea este absentă sau care prezintă 3 sau mai mulți factori de risc. Factori de risc: imobilitatea, umezeala, poziția incorectă, escare anterioare/existente, regim alimentar neadecvat, înaintarea în vârstă, greutatea. Da o Nu o Notați pe diagrama corpului: o zone unde sensibilitatea este absentă - acest simbol: //// o zone unde utilizatorul a avut o escară - acest simbol: O o zone unde utilizatorul are o escară la momentul evaluării - acest simbol:  Dacă utilizatorul spune că are o escară, întotdeauna solicitați să o vedeți. Asigurați-vă că acest lucru are loc într-un spațiu retras. Pericolul apariției escarelor există în lipsa sensibilității, precum și la utilizatorii la care se întâlnesc alți factori de risc: Factorii de risc includ: o lipsa sensibilității (sensibilitate scăzută); o imobilitatea; o umezeala cauzată de transpirație, apă sau incontinență; o postura incorectă; o escare anterioare sau existente; o nutriție necorespunzătoare și hidratare insuficientă; o înaintarea în vârstă; o greutatea (subponderal sau supraponderal). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 61 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Rețineți: orice utilizator la care există riscul apariției escarelor are nevoie de o pernă pentru reducerea presiunii și de instruire în ceea ce privește prevenirea escarelor. Metoda de propulsie Metoda de propulsie Cum va realiza utilizatorul propulsia scaunului rulant? Cu ambele brațe o Cu brațul stâng o Cu brațul drept o Cu ambele picioare o Cu piciorul drept o Cu piciorul stâng o Cu ajutorul unui însoțitor o Observații _______________________________________________________________ Este important să aflăm care este metoda de propulsie pe care o va folosi utilizatorul, fiindcă acest lucru poate avea impact asupra selecției scaunului rulant și a adaptărilor acestuia (vă rugăm să consultați partea A.6: Scaunul rulant corespunzător, secțiunea „Propulsia scaunului rulant”). Efectuarea măsurătorilor Sunt necesare patru măsurători ale utilizatorului de scaun rulant pentru a alege dimensiunea cea mai potrivită a scaunului rulant. Toate măsurătorile se regăsesc în dimensiunile scaunului rulant. Măsurători corp Valori (mm) Transformare măsurători corp în dimensiune ideală scaun rulant Valori scaun rulant A Lățime sold Lățime șold = lățime șezut scaun rulant B Adâncime șezut S B mai mic decât 30 – 60 mm = adâncime șezut scaun rulant (dacă lungimea este diferită, folosiți valoarea mai mică) D C Lungime gambă S = de la partea superioară a pernei șezutului* până la înălțimea suportului pentru picioare sau de la partea superioară a pernei șezutului* până la podea, în cazul propulsiei realizate cu piciorul D D Partea inferioară a cutiei toracice = de la partea superioară a pernei șezutului* până la limita superioară a spătarului (măsurați D sau E – în funcție de necesitatea utilizatorului) E Limita inferioară a omoplaților * verificați înălțimea pernei pe care o va folosi utilizatorul de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 62 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Instrumente pentru măsurare o Folosiți o ruletă metalică (ca în poza din dreapta). o Folosiți un clipboard/cărți pentru ca măsurătorile să fie exacte (vedeți capitolul despre realizarea măsurătorilor). o Șublerul de mari dimensiuni se poate dovedi un instrument suplimentar foarte util. Acesta poate fi confecționat local, din lemn. o Pentru a sprijini picioarele utilizatorilor de scaun rulant la înălțimea adecvată, se pot folosi plăci pentru picioare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 63 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum se efectuează măsurătorile? Rugați utilizatorul de scaun rulant să stea cât mai drept posibil. Laba piciorului utilizatorului trebuie să stea pe podea sau pe plăcile pentru picioare, astfel încât să se formeze un unghi de 90 de grade la nivelul articulației gleznei. În cazul tuturor măsurătorilor, asigurați-vă că ruleta este dreaptă și că utilizatorul este în poziția așezat, cu bazinul în poziție neutră. Ținând un clipboard/carte de fiecare parte a bazinului utilizatorului de scaun rulant, puteți obține măsurători exacte. Asigurați-vă că vedeți ruleta din unghiul potrivit. A o Înainte de a efectua măsurătorile, asigurați-vă că nu există obiecte în buzunarele utilizatorului. o Măsurați șoldurile sau cea mai lată parte a coapselor. o Ținând două clipboard-uri/cărți de fiecare parte a utilizatorului de scaun rulant, puteți obține valori exacte ale măsurătorilor. B o Poziționați un clipboard/carte la spatele utilizatorului de scaun rulant pentru a obține valori exacte. o Măsurați de la partea din spate a pelvisului până la partea din spate a genunchiului, în linie dreaptă. o Măsurați întotdeauna ambele picioare. Dacă există o diferență între cele două valori, verificați dacă utilizatorul stă în poziția corespunzătoare, cu bazinul în poziția neutră. În cazul în care diferența persistă, prescrieți scaunul rulant luând în considerare partea unde valorile sunt mai mici. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 64 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază C o Măsurați de la partea din spatele genunchilor până la baza călcâiului. o Asigurați-vă că gleznele utilizatorului sunt flexate la 90 de grade (dacă acest lucru este posibil). o Măsurați întotdeauna ambele picioare o Utilizatorul trebuie să poarte încălțămintea pe care o folosește în mod frecvent (dacă este cazul). D o Măsurați de la suprafața de ședere până la partea inferioară a cutiei toracice. o Pentru a localiza partea inferioară a cutiei toracice, poziționați mâinile pe ambele părți ale pelvisului. Apăsați ușor și mișcați-le în sus. Partea inferioară a cutiei toracice este chiar deasupra taliei. E o Măsurați de la suprafața de ședere până la partea inferioară a omoplatului, pe o linie verticală. o Pentru a găsi partea inferioară a omoplatului, rugați utilizatorul să ridice umerii. Pentru mai multe informații despre dimensiunea corectă a scaunului rulant, consultați secțiunea 6: Probarea produsului (a scaunului rulant). Etapa 3: Prescrierea (selecția) Ce este prescrierea (selecția)? Prescrierea (selecția) înseamnă alegerea variantei optime, corelând tipul de scaune rulante disponibile și nevoile utilizatorului. Prescrierea (selecția) trebuie să îl implice întotdeauna pe utilizatorul de scaun rulant, împreună cu un membru de familie sau cu însoțitorul, dacă acest lucru este potrivit. Prescrierea (selecția) include: • alegerea scaunului rulant corespunzător, a pernei, precum și a părților componente potrivite; • alegerea dimensiunii potrivite a scaunului rulant și a pernei; • stabilirea, împreună cu utilizatorul, a nevoii de instruire a acestuia, în ceea ce privește folosirea și îngrijirea scaunului rulant și a pernei. Scaune rulante și perne disponibile local Este foarte importantă alegerea unui scaun rulant cu dimensiunea adecvată. Scaunul rulant de mărime corespunzătoare este mai confortabil, ajută la menținerea poziției așezat și face mai ușoară manevrarea de către utilizator. Pentru mai multe informații despre dimensiunile potrivite ale scaunului rulant, consultați secțiunea 6: Probarea produsului (a scanului rulant). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 65 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT o Cadrul – de exemplu, observăm dacă este vorba de o bază a roții lungă sau scurtă și lungimea cadrului, fie că este vorba despre un scaun pliabil sau cu cadru rigid. o Caracteristici – inclusiv tipul de șezut, spătarul, suportul de picioare, suportul de brațe, roțile frontale, roțile din spate. o Dimensiunea scaunului rulant: este determinată de obicei de lățimea șezutului scaunului rulant și uneori și de adâncimea acestuia. Totodată, este util să știm înălțimea de la podea la șezutul scaunului rulant. o Opțiuni de ajustare: observăm care sunt componentele ajustabile și care sunt opțiunile de ajustare. De regulă, ajustările sunt posibile pentru două sau mai multe poziții diferite. De exemplu, cele mai multe scaune rulante au suporturi de picioare care pot fi ajustate pe înălțimi situate la intervale regulate. Posibilitățile de ajustăre cuprind opțiunile situate între valoarea minimă și maximă. o Perna: ce tip de pernă (dacă e cazul) se furnizează împreună cu scaunul rulant sau este disponibilă separat? Unii furnizori de scaune rulante oferă: a. broșuri sau o descriere a produsului; b. specificațiile produsului (scaunului rulant). Frecvent, acestea includ informații de tipul: măsurători ale scaunului rulant, greutatea, caracteristici și, uneori, componentele opționale. Verificați întotdeauna dacă există informații disponibile despre scaunul rulant pe care îl prescrieți. Citiți aceste informații pentru a vă familiariza cu produsul. Dacă furnizorii nu oferă aceste informații, solicitați-le. Înregistrarea prescrierii (selecției) Prescrierea (selecția) trebuie notată în scris. Mai jos aveți un exemplu de formular de prescriere (selecție) scaun rulant. Adaptați acest formular serviciului de scaune rulante local, menționând tipurile de scaun rulant și de perne pe care le furnizați, precum și mărimile acestora. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 66 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Formular prescriere (selecție) scaune rulante 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: _____________________________________ Numărul: ______________________________ Data evaluării: _______________________________________ Data probării: ______________________________ Numele persoanei care a făcut evaluarea: ________________________________________________________________________ 2. Tipul și mărimea scaunului rulant selectat: Pentru a alege tipul de scaun rulant: o Discutați cu utilizatorul de scaun rulant; o Gândiți-vă la cele mai importante nevoi ale utilizatorului de scaun rulant; o Verificați: cadrul scaunului rulant, roțile frontale și din spate, suporturile de picioare, suporturile de brațe, înălțimea spătarului (sau ajustabilitatea), poziția roților din spate, sprijinul și nivelul de confort. Tip scaun rulant Mărime o o o o o 3. Tipul de pernă selectată: Tip pernă Mărime e.g. Pernă pentru reducerea presiunii, din spumă / burete o e.g. Pernă plată, din spumă / burete o o Treceți tipurile de scaun rulant disponibile Treceți mărimile pentru diferitele tipuri de scaune rulante disponibile. Treceți tipurile de perne disponibile și mărimile acestora. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 67 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 4. De acord cu prescrierea efectuată Semnătură utilizator de scaun rulant: Semnătură evaluator: Semnătură manager: Etapa 4: Finanțarea și plasarea comenzii Finanțarea După ce scaunul rulant a fost prescris, costul produsului recomandat poate fi estimat cu acuratețe. Este esențial să știm care va fi sursa de finanțare a scanului rulant – poate fi plătit direct de către utilizatorul de scaun rulant sau poate fi vorba despre o subvenție din partea statului, a unei organizații neguvernamentale sau a unui donator. De asemenea ar putea fi decontat de către o companie de asigurări. În regiunile în curs de dezvoltare, mulți dintre cei care au nevoie de un scaun rulant nu își permit să îl achiziționeze. Cu toate acestea, oricine are nevoie de un scaun rulant, are dreptul să aibă un astfel de echipament de mobilitate, indiferent dacă deține sau nu mijloacele financiare pentru a-l plăti. De aceea, trebuie să existe fonduri disponibile pentru acei utilizatori care au nevoie de asistență financiară. În cazul celor mai mulți furnizori de servicii de scaune rulante, este esențial ca sursele de finanțare să fie identificate înainte de a comanda scaunul rulant. Deseori, această responsabilitate revine personalului administrativ sau managerilor de program, nefiind în atribuțiile personalului clinic sau tehnic. Plasarea comenzii După alegerea celui mai bun scaun rulant pentru utilizator și pregătirea formularului de prescriere (selecție) acesta trebuie comandat, în cazul în care el există pe stoc. Dacă furnizorul de servicii de scaune rulante are echipamentul de mobilitate pe stoc, plasarea comenzii poate însemna completarea unui formular de comandă care trebuie autorizat de către manager. În acest caz, scaunul rulant poate fi pregătit de către personalul responsabil care are această răspundere. Dacă furnizorul de servicii nu are scaune rulante pe stoc, atunci echipamentele de mobilitate trebuie comandate de la un furnizor extern. Sistemul pentru comandarea scaunelor rulante variază de la un serviciu de scaune rulante la altul. Notați mai jos aspectele pe care trebuie să le rețineți pentru a comanda scaunul rulant la furnizorul de servicii de scaune rulante local. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 68 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Cum să comand scaunul rulant la furnizorul de servicii de scaune rulante local: Bune practici în procesul de plasare a comenzilor o Asigurarea unui stoc disponibil de scaune rulante poate reduce timpul de așteptare al utilizatorilor de scaun rulant. o Comanda trebuie plasată cât mai curând posibil, pentru a evita întârzierile. o Întotdeauna indicați utilizatorului care este intervalul de timp necesar pentru ca scaunul rulant să fie disponibil. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 69 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 5: Pregătirea produsului (scaunului rulant) Ce este pregătirea produsului (scaunului rulant)? Pregătirea produsului (scaunului rulant) include: o pregătirea scaunului rulant pentru a fi în conformitate cu prescrierea (selecția) făcută; o verificarea scaunului rulant pentru a ne asigura că este gata de a fi utilizat în condiții de siguranță și că toate componentele funcționează corespunzător. Pregătirea scaunului rulant Pentru pregătirea scaunului rulant, urmați acești pași: 1. Verificați dacă măsurătorile pentru lățimea și adâncimea șezutului sunt corecte din punct de vedere al prescrierii (selecției). 2. Verificați că lățimea și lungimea pernei se potrivesc scaunului rulant. 3. Ajustați (acolo unde este posibil): • înălțimea și unghiul spătarului; • înălțimea suportului de brațe; • poziția roților din spate; • poziția frânelor; • înălțimea suportului de picioare; • înălțimea mânerelor; • orice alte ajustări necesare. 4. Faceți o verificare pentru a vă asigura că scaunul rulant poate fi folosit în siguranță. Bune practici în pregătirea produsului o Aplicați fiecărui scaun rulant pregătit o etichetă cu numele utilizatorului căruia îi este destinat. o Orice modificare adusă scaunului rulant trebuie făcută de către o persoană care are cunoștințele și abilitățile necesare. Modificările pot afecta rezistența și funcționarea unui scaun rulant. o Înainte ca utilizatorul să încerce scaunul rulant, verificați întotdeauna că acesta este sigur și gata pentru a fi folosit și că toate componentele funcționează (vedeți mai jos). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 70 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Listă de verificare preliminară utilizării scaunului rulant Utilizați lista de verificare de mai jos pentru a vă asigura că scaunul rulant poate fi utilizat în condiții de siguranță și că toate părțile componente funcționează. Faceți acest lucru întotdeauna înainte ca utilizatorul să încerce scaunul rulant. Listă de verificare: este scaunul rulant gata de a fi utilizat în condiții de siguranță? Scaunul rulant în ansamblu Modalități de verificare Nu există margini ascuțite.  Verificați scaunul rulant în ansamblu, vizual și cu mâinile.Nu există părți defecte sau zgâriate.  Traiectoria scaunului rulant este dreaptă.  Împingeți scaunul rulant în față, pentru a vă asigura că roțile frontale se mențin pe traiectoria corectă. Roțile frontale Se învârt fără a întâmpina vreo rezistență.  Înclinați scaunul rulant pe roțile din spate. Învârtiți roțile frontale.Se învârt fără a atinge furca roții.  Șuruburile sunt strânse.  Verificați dacă sunt imobile la atingere. Nu le strângeți prea mult. Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență.  Înclinați scaunul rulant pe roțile din spate. Învârtiți furcile roților frontale. Roțile din spate Se învârt fără a întâmpina vreo rezistență.  Înclinați scaunul rulant lateral, pe una din roțile din spate. Învârtiți cealaltă roată. Verificați și cealaltă parte. Șuruburile axului sunt strânse.  Verificați. Trebuie să fie imobile la atingere. Nu le strângeți prea mult. Anvelopele (dacă sunt pneumatice) sunt umflate corect.  Cu degetul mare, apăsați pe anvelope. Suprafața roții trebuie să cedeze puțin, dar nu mai mult de 5 mm. Inelele de antrenare nu prezintă niciun pericol.  Verificați. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 71 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Frânele Funcționează corespunzător.  Acționați frânele. Verificați dacă roata rămâne imobilă. Suporturile de picioare Suportul pentru picioare este montat corespunzător.  Verificați. Cadrul Scaunul rulant pliabil se închide și se deschide cu ușurință.  Pliați scaunul rulant pentru a verifica dacă mecanismele de pliere funcționează corect.În cazul unui scaun rulant cu spătar pliabil-spătarul se pliază și revine în poziția inițială cu ușurință.  Perna Perna este introdusă corect în husă.  În general, husa pernei se închide în partea din spate a pernei, dedesubt. Perna este poziționată corect pe scaunul rulant.  Dacă perna este cu contur, zona de reducere a presiunii de sub oasele bazinului trebuie să fie în spatele șezutului. Materialul textil al pernei este întins pe suprafața acesteia, însă nu mai mult decât este necesar.  Husa pernei nu trebuie să fie foarte întinsă peste partea cu contur a pernei. Perna acoperă în întregime șezutul scaunului rulant.  Verificați că nicio parte a șezutului scaunului rulant nu este vizibilă de sub pernă. Acest lucru este foarte important în cazul șezuturilor rigide. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 72 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Confecționarea pernei În cazul în care este disponibil materialul necesar (spumă / burete), personalul furnizor de servicii de scaune rulante poate recurge la confecționarea unei perne, utilizând doar câteva unelte. Personalul furnizor de servicii de scaune rulante trebuie să știe ce fel de spumă / burete se folosește în acest caz, precum și câteva măsurători importante. Discutați cu formatorul despre tipurile de spumă / burete disponibile în zona voastră, pentru a stabili care sunt cele adecvate pentru confecționarea unei perne pentru reducerea presiunii. Instrucțiunile de mai jos arată pașii confecționării unei perne standard pentru reducerea presiunii, din spumă / burete, cu două zone conturate esențiale. Acestea formează o adâncitură sub oasele bazinului și o porțiune mai ridicată în fața lor. Trăsăturile și dimensiunile pernei Principalele trăsături ale unei perne modelate standard, fabricate din spumă / burete, sunt următoarele: Un strat de bază, din spumă rigidă/ burete rigid Zonă de reducere a presiunii la nivelul oaselor bazinului o Eliberează presiunea de sub oasele bazinului și coccis. o Ajută pelvisul să stea drept în partea din spate a pernei. o Bază șezut pliabil. o Pernele care se folosesc în cazul scaunelor rulante cu șezut pliabil au o tăietură oblică de fiecare parte a stratului de bază. o Acest lucru permite pernei să ia forma șezutului pliabil a scaunului rulant. Partea superioară a pernei rămâne netedă. Un strat superior, confecționat din spumă moale / burete moale, pentru confort Strat superior, pentru confort: o Oferă confort, acoperind stratul de bază rigid. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 73 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Cum se confecționează stratul de bază al unei perne de reducere a presiunii? Următoarele instrucțiuni se referă la confecționarea unei perne cu următoarele dimensiuni: 400 mm lățime x 400 mm adâncime x 50 mm înălțime. Zona de reducere a presiunii la nivelul oaselor bazinului are 200 mm lățime x 200 mm adâncime x 35 mm înălțime. Aceasta pernă se potrivește unui utilizator care are nevoie de o lățime a șezutului scaunului rulant de 400 de mm. Adaptați dimensiunile pentru ca acestea să corespundă fiecărui utilizator de scaun rulant, urmărind indicațiile de mai jos: 1.Trasați pe spuma rigidă / burete liniile pentru decupare. o Începeți cu o bucată de spumă rigidă / burete rigid cu următoarele dimensiuni de 400 mm x 400 mm x 50 mm. o Centrul zonei de reducere a presiunii la nivelul oaselor bazinului trebuie să se situeze pe linia mediană a pernei. o Pentru o pernă cu aceste dimensiuni, zona de reducere a presiunii la nivelul oaselor bazinului trebuie să aibă dimensiunile de 200 mm x 200 mm x 35 mm. o Cu un marker închis la culoare, trasați liniile pentru decupare pe toate cele șase laturi ale stratului de bază. dimensiuni în mm 1/2 lățime șezut 1/2 lățime șezut Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 74 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Dimensiunile zonei de reducere a presiunii la nivelul oaselor bazinului Adaptați dimensiunile pernei și ale zonei de reducere a presiunii la nivelul oaselor bazinului pentru ca acestea să corespundă fiecărui utilizator de scaun rulant, după cum urmează: o lățimea zonei de reducere a presiunii = ½ din lățimea șezutului utilizatorului de scaun rulant sau 200 mm (alegeți valoarea mai mică) [a]; o adâncimea zonei de reducere a presiunii (din față înspre spate) = ½ din lățimea șezutului utilizatorului de scaun rulant sau 200 mm (alegeți valoarea mai mică) [b]; o înălțimea zonei de reducere a presiunii= 35 mm pentru adulți și 20–25 mm pentru copii [c]. 1. Decupați partea corespunzătoare zonei de reducere a presiunii la nivelul oaselor bazinului: Folosiți o lama de fierăstrău ascuțită sau un cuțit lung. Faceți mișcări ample, tăind în timpul mișcării de împingere a lamei, pentru un control mai bun. o Tăiați întâi prin partea posterioară a pernei, pe suprafața ce corespunde zonei de reducere a presiunii. o Decupați partea corespunzătoare zonei de reducere a presiunii la nivelul oaselor bazinului. o Fixați cu lipici cele două părți laterale ale zonei de reducere a presiunii la nivelul oaselor bazinului. Așteptați până când adezivul este aproape uscat și suprafața este lipicioasă la atingere. Aplicați presiune pe spumă / burete. c a b Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 75 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Tăiați oblic colțurile de pe partea interioară a zonei de reducere a presiunii la nivelul oaselor bazinului. 4. În cazul pernelor pentru scaunele rulante cu șezut pliabil: tăiați oblic pe ambele părți inferioare ale bazei. o Marcați așa cum se vede în desen și tăiați. o Această tăietură face ca baza pernei să se potrivească formei șezutului pliabil al scaunului rulant. 5. Așezați stratul de spumă / burete superior deasupra pernei o Atât baza pernei, cât și stratul superior al acesteia se introduc în husa pernei. o Nu este nevoie ca cele două straturi să fie lipite unul de cealaltă. o Dacă stratul superior se murdărește sau se uzează, acesta poate fi spălat și uscat sau chiar înlocuit. o În interiorul husei poate fi adăugat un element suplimentar, pentru a crește adâncimea zonei de reducere e presiunii la nivelul oaselor bazinului. Întrebări frecvente despre pernele pentru reducerea presiunii confecționate din spumă / burete: Cum decid ce material textil să folosesc pentru husa pernei? o Dacă este posibil, alegeți un material textil care să fie elastic. Se recomandă material impermeabil, dacă acesta este disponibil. Dacă materialul este rezistent la apă, asigurați-vă că nu este prea gros, în caz contrar, cutele pot lăsa urme pe pielea utilizatorului de scaun rulant, ceea ce poate provoca apariția escarelor. o Alegerea se va face în funcție de materialul textil disponibil. Uneori, variantele sunt limitate. o Dacă există mai multe opțiuni și nu sunteți sigur de alegere, rugați utilizatorii de scaun rulant să încerce diferite variante. o Personalul furnizor de servicii de scaune rulante va dobândi mai multă experiență pe măsură ce sunt încercate mai multe tipuri de materiale textile. Această pernă se potrivește oricărui utilizator? o Nu – această pernă nu i se va potrivi oricărui utilizator. o Cu toate acestea, avantajul acestei perne este că poate fi adaptată cu ușurință. 15 mm 15 mm Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 76 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Această pernă se poate încălzi sau poate provoca transpirație? o Pernele confecționate din spumă se pot încălzi și pot provoca transpirație. o Cu toate acestea, perna are multe alte avantaje, astfel că acest aspect este un compromis acceptabil. Toți utilizatorii de scaun rulant au nevoie de o pernă pentru reducerea presiunii? o Nu – nu toți utilizatorii de scaun rulant au nevoie de o pernă pentru reducerea presiunii. o Luați în considerare factorii de risc despre care ați învățat în cadrul acestui curs, pentru a decide dacă există sau nu pericolul apariției escarelor la respectivul utilizator de scaun rulant. o Chiar dacă nu este nevoie de o pernă pentru reducerea presiunii, perna poate îmbunătăți confortul și postura, chiar și în cazul utilizatorilor la care nu există riscul apariției escarelor. Ce se întâmplă atunci când perna este folosită invers, cu partea anterioară în spate sau cu partea superioară în jos? o Perna nu va funcționa corect și poate chiar să crească riscul apariției escarelor. o Întotdeauna asigurați-vă că utilizatorii de scaun rulant și membrii familiei acestora (acolo unde este cazul) înțeleg cum trebuie folosită perna și o întrețin în mod corect. o Dacă este necesar, marcați perna cu „față”, „spate”, „sus” și „jos”. Este această pernă adecvată pentru copii? o Da, această pernă li se potrivește și copiilor. Totuși, zona de reducere a presiunii la nivelul oaselor bazinului trebuie să fie mai mică. Vedeți mai sus cum trebuie stabilite dimensiunile unei perne pentru copii. o Mulți copii utilizatori de scaun rulant au nevoie de suport postural suplimentar. Există posibilitatea ca această pernă să nu ofere suficient sprijin postural. Probarea pernei Verificați întotdeauna dacă oasele bazinului sunt așezate pe zona de reducere a presiunii și nu pe marginea sau pe partea înaltă a pernei. Atunci când faceți proba unei perne pentru reducerea presiunii, asigurați-vă întotdeauna că: o presiunea sub oasele bazinului este „sigură” (vezi mai sus „Cum se testează funcționalitatea pernei pentru reducerea presiunii); o oasele bazinului sunt în interiorul zonei de reducere a presiunii, nu pe marginea sau pe stratul superior al acesteia. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 77 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 6: Probarea produsului (a scaunului rulant) Ce implică probarea produsului (a scaunului rulant)? În timpul probării, utilizatorul de scaun rulant și personalul furnizor de servicii verifică împreună următoarele aspecte: o scaunul rulant are mărimea potrivită și au fost efectuate toate modificările și ajustările, pentru a asigura un echipament de mobilitate corespunzător; o scaunul rulant și perna mențin utilizatorul în poziția așezat; o dacă a fost prescrisă o pernă pentru reducerea presiunii, aceasta este funcțională. Bune practici în etapa de probare o Ori de câte ori acest lucru este posibil, se recomandă ca persoana care a efectuat evaluarea să fie responsabilă și pentru probarea scaunului rulant. o Întotdeauna faceți verificarea atât cu scaunul rulant pe loc, cât și în timp ce se realizează propulsia de către utilizator sau când este împins de către însoțitor. o Efectuați operațiunile acestei etape în următoarea ordine: o verificați mărimea și adaptările; o verificați postura; o verificați presiunea; o verificați starea scaunului rulant în timp ce acesta este utilizat. o Folosiți lista de verificare primită, pentru a vă aminti de fiecare etapă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 78 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Verificați mărimea și adaptările Lățimea șezutului Dimensiunea corectă: Trebuie să se potrivească îndeaproape. Cum se verifică o Treceți degetele prin spațiul dintre exteriorul coapselor utilizatorului și părțile laterale ale scaunului rulant. Degetele ar trebui să poată trece fără efort și fără a se bloca. Asigurați-vă că părțile laterale ale scaunului rulant nu exercită presiune asupra coapselor utilizatorului. Acest lucru este deosebit de important în cazul utilizatorilor care nu simt presiunea la nivelul coapselor (sensibilitate diminuată). O presiune puternică pe coapse, cauzată de părțile laterale ale scaunului rulant, poate provoca apariția escarelor. Adâncimea șezutului Dimensiunea corectă: Distanță de două degete (30 mm) între partea posterioară a genunchilor și pernă. Cum se verifică o Verificați dacă utilizatorul de scaun rulant este în poziția așezat. o Treceți mâna prin spațiul dintre pernă și partea posterioară a genunchilor. Distanța ar trebui să fie suficient de mare pentru două degete (30 mm). Distanța poate fi mai mare în cazul utilizatorilor care au picioare lungi. Se acceptă o distanță de până la 60 de mm. o Glisați mâna în jos, în spatele gambelor și asigurați-vă că acestea nu ating șezutul scaunului sau perna. o Verificați întotdeauna ambele părți. Dimensiunea potrivită oferă suport la nivelul coapselor. Acest lucru reduce presiunea la nivelul oaselor bazinului și împiedică apariția escarelor. Dacă lungimea șezutului este prea mare, utilizatorul de scaun rulant nu va putea sta în poziția așezat. Dacă există o diferență între cele două părți, prescrierea se face conform valorilor rezultate la piciorul mai scurt. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 79 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Înălțimea suportului de picioare Dimensiunea corectă: Coapsele se sprijină în totalitate pe pernă, fără a se ridica. Picioarele sunt sprijinite în totalitate pe suportul de picioare, fără a se ridica. Cum se verifică o Treceți mâna prin spațiul dintre coapsă și pernă. Presiunea trebuie să fie egală și să nu se formeze spații între acestea. o Verificați poziția fiecărui picior pe suportul de picioare. Talpa piciorului trebuie să fie așezată pe suport, fără a se ridica în vreun punct. Dacă există spațiu sub coapsă, acest lucru poate însemna că suportul de picioare este poziționat prea sus. Dacă există spațiu sub talpa piciorului, acest lucru poate însemna că suportul de picioare este poziționat prea jos. Înălțimea spătarului Dimensiunea potrivită: Dimensiunea corespunzătoare trebuie să ofere utilizatorului de scaun rulant sprijinul de care acesta are nevoie, permițând persoanelor active să aibă libertate de mișcare la nivelul umerilor, pentru realizarea propulsiei scaunului rulant. Cum se verifică o Întrebați utilizatorul de scaun rulant dacă spătarul este confortabil. o Observați dacă trunchiul este în echilibru deasupra șoldurilor. o Utilizatorul de scaun rulant poate efectua propulsia scaunului rulant fără a fi împiedicat de spătar? Înălțimea spătarului depinde de cerințele utilizatorului. Utilizatorii care acționează ei înșiși scaunul rulant, au nevoie de un spătar care să le permită să își miște umerii liber. Utilizatorii care au dificultăți în a sta în poziția așezat au nevoie de un spătar mai înalt, care să ofere un sprijin crescut la nivelul coloanei. Pe formularul de evaluare, există două valori ale înălțimii spătarului (vezi Pasul 2: Evaluarea din secțiunea „Efectuarea măsurătorilor”). Efectuați ambele măsurători, deoarece uneori nu este clar de la evaluare care este înălțimea confortabilă utilizatorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 80 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Un spătar care oferă suport până la partea inferioară a cutiei toracice are înălțimea potrivită dacă utilizatorul de scaun rulant: o are o bună condiție fizică și este activ; o poate sta cu ușurință în poziția așezat și are un bun echilibru; o efectuează singur propulsia scaunului rulant și are nevoie de multă libertate de mișcare. Înălțimea spătarului D (partea inferioară a cutiei toracice) Un spătar care oferă suport până la partea inferioară a omoplaților are înălțimea potrivită dacă utilizatorul de scaun rulant: o obosește repede, de exemplu este o persoană în vârstă sau are o boală degenerativă; o are dificultăți în a sta în poziția așezat. Acest tip de spătar permite totuși un anumit grad de libertate de mișcare la nivelul umerilor, pentru ca utilizatorul să efectueze propulsia scaunului rulant cu ajutorul brațelor. Înălțimea spătarului E (partea inferioară a omoplaților) Poziția roților din spate – pentru realizarea propulsiei cu brațele Poziția corectă: Atunci când mâinile sunt poziționate pe inelele de antrenare, coatele utilizatorului trebuie să formeze un unghi drept. Cum se verifică o Cereți utilizatorului de scaun rulant să apuce inelele de antrenare în partea superioară a roților. Cotul trebuie să fie îndoit într-un unghi de 90 de grade. o Verificați împreună cu utilizatorul dacă roțile din spate sunt poziționate corect, pentru echilibru (înainte pentru activ, în spate pentru mai multă siguranță). Dacă utilizatorul de scaun rulant are nevoie ca roțile din spate să fie poziționate astfel încât să existe mai multă siguranță (înspre înapoi), acest lucru poate însemna că brațele trebuie să ajungă mai în spate, ceea ce este ideal pentru realizarea propulsiei. Explicați utilizatorului de scaun rulant necesitatea acestui compromis. Dacă se fac orice fel de ajustări ale poziției roților din spate, frânele trebuie și ele ajustate și reverificate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 81 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Înălțimea șezutului – pentru realizarea propulsiei cu picioarelor Dimensiunea corectă: o Atunci când utilizatorul este în poziția așezat, iar partea posterioară a bazinului se sprijină confortabil de spătar, talpa piciorului ar trebui să stea pe podea, fără a se ridica. Cum se verifică Cereți utilizatorului de scaun rulant să stea cu partea posterioară a bazinului sprijinită de spătar și cu piciorul cu care realizează propulsia sprijinit pe podea. Verificați dacă piciorul stă pe podea, fără a se ridica. Dacă înălțimea șezutului scaunului nu este corespunzătoare, personalul furnizor de servicii de scaune rulante poate încerca: o să reducă înălțimea pernei; o să atașeze un șezut rigid, poziționat mai jos decât șezutul original (apelați la sfatul sau sprijinul unei persoane care are cunoștințele tehnice necesare). În cazul unui utilizator care realizează propulsia scaunului rulant cu ajutorul unui picior, având celălalt picior poziționat pe suportul de picioare – verificați presiunea la nivelul oaselor bazinului pe partea piciorului poziționat pe suport (vezi partea A.7: Perne, secțiunea „Cum se testează funcționalitatea pernei pentru reducerea presiunii”. Verificarea posturii Observați din lateral și din față modul în care utilizatorul stă în scaunul rulant. Utilizatorul este în poziția așezat? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 82 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Unii utilizatori preferă să își țină picioarele poziționate sub ei. Anumite modele de scaune rulante permit acest lucru. Dacă această poziție îi este comodă utilizatorului și el reușește să își mențină echilibrul, atunci acest lucru este acceptat. Verificarea presiunii În cazul fiecărui utilizator de scaun rulant la care există pericolul apariției escarelor – verificați dacă presiunea de sub oasele bazinului se menține în limitele acceptate. Verificarea cu scaunul rulant aflat în mișcare Partea finală a etapei de probare a produsului (a scaunului rulant) este verificarea scaunului rulant atunci când acesta se află în mișcare. Dacă utilizatorul nu poate antrena singur echipamentul de mobilitate, rugați un membru de familie/însoțitor să împingă scaunul rulant. Aspecte de observat: o Din punct de vedere al spătarului, există la nivelul umerilor libertatea de mișcare necesară pentru antrenarea scaunului rulant? o Tălpile sunt poziționate pe suportul de picioare? o Poziția roților din spate este corectă pentru respectivul utilizator? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 83 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) 1. Este scaunul rulant pregătit? Scaunul rulant a fost verificat pentru a stabili dacă poate fi utilizat în condiții de siguranță și dacă toate părțile sunt funcționale?  2. Verificați mărimea și ajustările Lățimea șezutului Trebuie să se potrivească îndeaproape.  Adâncimea șezutului Distanță de două degete între partea posterioară a genunchiului și șezutul scaunului/pernă.  Înălțimea suportului de picioare: Coapsa este sprijinită în totalitate pe pernă, fără a se ridica. Fiecare picior se sprijină pe suportul de picioare, fără a se ridica.  Înălțimea spătarului: Utilizatorul are suportul necesar și libertate de mișcare la nivelul umerilor pentru a realiza propulsia scaunului rulant (în cazul în care propulsia se face de către acesta).  Poziția roților din spate (pentru realizarea propulsiei cu brațele): Atunci când brațul utilizatorului este întins, acesta trebuie să fie pe aceeași linie cu axul posterior. Atunci când mâinile sunt poziționate pe inelul de antrenare, cotul utilizatorului trebuie să formeze un unghi drept.  Frânele: Frânele sunt funcționale?  Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 84 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Înălțimea șezutului (pentru propulsia cu ajutorul piciorului): Atunci când utilizatorul stă în poziția așezat, spatele trebuie să fie sprijnit în mod confortabil de către spătar, iar talpa piciorului trebuie să fie poziționată pe podea.  3. Verificați postura Utilizatorul are poziția așezat și stă confortabil în scaunul rulant?  Verificați postura din lateral.  Verificați postura din față/din spate.  4. Verificați presiunea Verificați presiunea sub oasele bazinului în cazul tuturor utilizatorilor de scaun rulant la care există riscul apariției escarelor. A Explicați utilizatorului în ce constă testul. B Rugați utilizatorul de scaun rulant să se încline în față și să își ridice puțin corpul. Plasați degetele sub oasele bazinului utilizatorului de scaun rulant. C Rugați utilizatorul să se așeze pe degetele voastre. Asigurați-vă că utilizatorul stă în poziția așezat, cu mâinile pe coapse. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 85 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT D Identificați nivelul de presiune: Nivel 1 = sigur: Vârfurile degetelor se pot mișca în sus și în jos 5 mm sau chiar mai mult. Nivel 2 = avertizare: Vârfurile degetelor nu se pot mișca, dar pot fi retrase cu ușurință. Nivel 3 = pericol: Vârfurile degetelor sunt strânse cu putere. Este dificilă retragerea lor. E Repetați și pentru cealaltă parte a oaselor bazinului. 5. Verificarea cu scaunul rulant aflat în mișcare Din punct de vedere al spătarului, există la nivelul umerilor libertatea de mișcare necesară pentru antrenarea scaunului rulant?  Spătarul oferă suficient sprijin utilizatorului?  Picioarele utilizatorului sunt poziționate pe suportul de picioare?  Poziția roților din spate corespunde nevoilor respectivului utilizator?  6. Acțiuni recomandate? Sunt necesare acțiuni suplimentare? Notați-le în dosarul utilizatorului de scaun rulant.  Rețineți: După probare, urmează instruirea utilizatorului de scaun rulant. Rezolvarea problemelor Se poate întâmpla ca personalul furnizor de servicii de scaune rulante să aibă dificultăți în a face scaunul rulant disponibil să se potrivească cerințelor utilizatorului. Problema poate fi cauzată de fapul că: o oferta de tipuri și de mărimi de scaune rulante disponibile este limitată; o utilizatorul are nevoie de sprijin suplimentar pentru a sta confortabil în poziția așezat. Mai jos puteți găsi câteva soluții simple la cele mai frecvente probleme. Modificările și îmbunătățirea suportului postural sunt abordate în detaliu în modulul de instruire pentru nivelul intermediar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 86 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Toate aceste soluții presupun că utilizatorului i s-a selecționat deja scaunul rulant cu mărimea cea mai apropiată de cea recomandată, din cele disponibile. Verificați întotdeauna acest lucru, înainte de a recurge la modificarea unui scaun rulant. Problemă: Adâncimea șezutului scaunului rulant este prea mică Dacă adâncimea șezutului (din față înspre spate) este mai scurtă cu 100 de mm decât cea a șezutului utilizatorului de scaun rulant (în cazul unui adult), acest lucru constituie o problemă. Șezutul nu va oferi suficient sprijin pentru ca utilizatorul să poată sta confortabil. Totodată, scade și efectul de reducere a presiunii. Este necesară mărirea adâncimii șezutului. Soluție - Aici sunt descrise trei soluții diferite: Soluție Observații 1. Măriți adâncimea șezutului scaunui rulant prin extinderea cadrului șezutului și înlocuirea materialului textil (tapițeriei). o Dacă scaunul rulant are un cadru pliabil, verificați dacă șezutul este de sine stătător. Acest lucru înseamnă că el nu este integrat în ansamblul cadrului scaunului rulant. o În acest caz, se poate adăuga o extensie și se aplică un material textil care să aibă lungimea corespunzătoare. 2. Măriți adâncimea scaunului rulant prin înlocuirea materialului textil (tapițeriei). o Dacă scaunul rulant are un cadru rigid, acoperit cu material textil, verificați dacă șezutul scaunului rulant este depășit în lungime de cadrul său o În acest caz, materialul textil poate fi înlocuit cu unul nou, de lungimea corespunzătoare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 87 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT 3. Măriți adâncimea scaunului rulant adăugând o placă rigidă și o pernă. o Un șezut solid poate fi confecționat din lemn, plastic sau orice alt material rigid care nu se îndoaie sau nu se rupe. o Șezutul poate fi fixat deasupra părții corespunzătoare a cadrului. o Adăugați o pernă care are lățimea și adâncimea egale cu cele ale noului șezut. o Asigurați-vă că noul șezut este suficient de puternic pentru a suporta greutatea utilizatorului. Verificați șezutul, acesta nu trebuie să se îndoaie sau să se rupă în porțiunea ce depășește suprafața de ședere existentă. o Asigurați-vă întotdeauna că toate șezuturile rigide sunt prevăzute cu o pernă, pentru fiecare utilizator de scaun rulant. o În timpul probării scaunului rulant, verificați dacă spătarul și suportul de picioare sunt la înălțimea corectă. Șezutul solid și perna vor ridica utilizatorul în scaunul rulant. Problemă: Adâncimea șezutului scaunului rulant este prea mare Dacă valoare cea mai mică a adâncimii șezutului în cazul scaunelor rulante disponibile este prea mare, utilizatorului îi va fi imposibil să stea în poziția așezat. Adâncimea șezutului va trebui redusă. Soluție - Mai jos găsiți o soluție pentru această problemă. Soluție Observații 1. Micșorați adâncimea șezutului. o Pe șezutul existent, marcați care este adâncimea necesară. o Dacă șezutul este acoperit cu material textil (tapițerie): îndepărtați materialul, scurtați-l (folosind o mașină de cusut industrială) și înlocuiți. o Dacă șezutul scaunului rulant este rigid: îndepărtați șezutul, scurtați și înlocuiți. o Scurtați perna pentru ca aceasta să se potrivească noii dimensiuni a șezutului scaunului rulant. o Atunci când tăiați un șezut rigid – asigurați-vă întotdeauna ca toate marginile sunt netezite și că nu există așchii. o Atunci când tăiați o pernă – tăiați întotdeauna din partea frontală, pentru ca zona de reducere a presiunii, aflată în partea din spate a pernei, să nu fie modificată. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 88 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Problemă: Suportul de picioare este prea jos Dacă suportul de picioare se află prea jos, utilizatorul de scaun rulant nu își va putea poziționa în mod confortabil picioarele pe acesta. Acest lucru poate determina alunecarea în față în scaunul rulant sau senzația de instabilitate. În acest caz, nu există suficient sprijin pentru adoptarea poziției așezat. Poziția suportului de picioare trebuie modificată. Soluții - Mai jos sunt prezentate două soluții pentru această problemă. Soluție Observații 1. Măriți înălțimea suportului de picioare prin scurtarea cadrului pe care este montat acesta. o Pe cele mai multe scaune rulante cu patru roți, cadrul suportului de picioare poate fi scurtat. o Verificați întotdeauna dacă mecanismul de ajustare este în continuare funcțional. 2. Înălțați suportul de picioare prin adăugarea unor elemente suplimentare. o Folosiți lemn sau un alt material solid pentru a ajusta înălțimea suportului de picioare. o Verificați ca această ajustare să nu împiedice plierea suporturilor de picioare (acolo unde ele pot fi pliate), la efectuarea transferurilor în și din scaunul rulant. Suport de picioare ridicat prin adăugarea de elemente suplimentare (în această imagine, una dinte părți a fost ajustată, pentru a compensa scurtarea unuia dintre membrele inferioare). Problemă: Suportul de picioare este prea sus Dacă suportul de picioare este poziționat prea sus, coapsele utilizatorului nu vor avea o poziție confortabilă pe șezutul scaunului rulant. Suportul de picioare situat prea sus poate crește presiunea pe oasele bazinului. În acest caz, suportul de picioare va trebui poziționat mai jos. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 89 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Soluție - Mai jos sunt prezentate două potențiale soluții. Soluție Observații 1. Coborâți suportul de picioare prin lungirea tubului de extensie interior. o Verificați dacă tubul de extensie interior poate fi înlocuit cu unul mai lung. o Dacă da, înlocuiți-l cu unul similar, având același diametru și aceeași rezistență. o Asigurați-vă că suportul de picioare nu este poziționat atât de jos încât să atingă solul. În cazul în care se întâmplă acest lucru, apelați la soluția numărul 2. Dacă aceasta nu este adecvată, atunci scaunul rulant nu este corespunzător pentru respectivul utilizator. 2. Măriți înălțimea pernei. o Măriți înălțimea pernei sau ridicați perna prin adăugarea unui element solid sub aceasta. o Nu folosiți spumă moale pentru a crește înălțimea pernei. Aceasta se va comprima și, de asemenea, va da senzație de instabilitate. o În timpul probării scaunului rulant, verificați dacă spătarul este la înălțimea corectă. Perna mai înaltă va ridica utilizatorul în scaunul rulant. o Verificați dacă există probleme funcționale în cazul ridicării pernei. De exemplu – există posibilitatea ca utilizatorul să nu mai poată sta cu picioarele sub masă sau birou. Problemă: Picioarele au tendința de a se poziționa înspre interior sau exterior Uneori, picioarele utilizatorului pot avea tendința de a sta înspre interior sau înspre exterior. Acest lucru poate fi cauzat de modul în care utilizatorul este obișnuit să stea sau de alți factori fizici (de exemplu, de forță musculară redusă). Ajustări simple în ceea ce privește șezutul scaunului rulant sau perna pot ajuta la reducerea problemei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 90 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Soluție - În cele ce urmează sunt descrise trei posibile soluții. Soluție 1. Verificați cu atenție înălțimea suportului de picioare. Asigurați-vă că înălțimea suportului de picioare sprijină în mod corect utilizatorul de scaun rulant (presiunea la nivelul labei piciorului și sub coapse trebuie să fie distribuită în mod egal). 2. Verificați dacă șezutul este întins în mod corespunzător. o Dacă scaunul rulant are șezutul acoperit cu material textil – asigurați-vă că acesta este foarte bine întins. o Dacă șezutul se lasă în jos, acest lucru poate determina ca picioarele utilizatorului să alunece înspre interior. 3. Adăugați elemente suplimentare la perna existentă, pentru a menține coapsele în poziție neutră (așa cum este prezentat în materialul video și în imagine), furnizați utilizatorului o pernă modelată sau modificați perna, dacă acest lucru este necesar. o Unele perne modelate, destinate reducerii tensiunii, au o porțiune mai ridicată între coapse, ceea ce va ajuta la menținerea unei poziții în care picioarele stau ușor depărtate într-un mod confortabil. Această porțiune poate fi mărită pentru a oferi sprijin suplimentar, dacă este necesar. o Unele perne modelate pentru reducerea presiunii au adâncituri în care pot fi poziționate picioarele. Marginile acestor adâncituri pot fi înălțate, pentru a împiedica alunecarea picioarelor înspre exterior. Element adăugat la mijlocul părții frontale a pernei pentru a menține ușor îndepărtate picioarele utilizatorului de scaun rulant. Elemente adăugate în partea frontală a pernei pentru a împiedica picioarele utilizatorului să alunece în exterior. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 91 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Problemă: Picioarele alunecă de pe suportul de picioare Uneori, picioarele utilizatorului alunecă de pe suportul de picioare. Acest lucru poate fi determinat de factori fizici (de exemplu, lipsa forței musculare sau spasmele musculare). Soluție - Găsiți prezentate mai jos trei soluții. Soluție Observații 1. Verificați cu atenție înălțimea suportului de picioare. o Asigurați-vă că înălțimea suportului de picioare oferă utilizatorului un sprijin adecvat (presiunea la nivelul labei piciorului și sub coapse trebuie să fie distribuită în mod egal). 2. Ajustați unghiul suportului de picioare (acolo unde este posibil). o Verificați dacă unghiul suportului de picioare poate fi ajustat. o Dacă da – încercați să măriți unghiul suportului de picioare. Acest lucru poate ajuta la menținerea în poziția corectă a labei piciorului. o Verificați că presiunea de sub laba piciorului este egală. 3. Adăugați o centură. o Atașați o centură pe cadrul de susținere al suporturilor de picioare, la nivelul gleznelor. o Dacă laba piciorului are tendința să alunece în spate, centura se fixează în spatele picioarelor. o Dacă laba piciorului are tendința să alunece în față, centura se fixează în fața picioarelor. o Asigurați-vă că centura poate fi îndepărtată cu ușurință, în așa fel încât utilizatorul să poată efectua fără efort transferul în și din scaunul rulant. o Verificați dacă utilizatorul de scaun rulant poate ajunge fără ajutor la centură și dacă poate să o fixeze și să o îndepărteze cu ușurință. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 92 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază O centură pentru gambe poate contribui la menținerea în poziția corectă a picioarelor utilizatorului. Centurile poziționate în spatele labei piciorului oferă suport suplimentar, împiedicând picioarele utilizatorului să alunece de pe partea posterioară a suportului de picioare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 93 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Problemă: Scaunul rulant este prea lat Uneori, chiar și cea mai mică mărime disponibilă a scaunului rulant poate fi prea mare pentru utilizator. Dacă șezutul scaunului este prea lat, utilizatorului îi va fi greu să stea în poziția așezat și există posibilitatea să alunece într-o parte. Niște simple inserții de spumă / burete pot să ofere utilizatorului sprijinul necesar pentru a sta în poziția așezat. Soluție - Mai jos găsiți o propunere pentru rezolvarea acestei probleme. Soluție Observații 1. Adăugați inserții de spumă / burete de ambele părți ale pelvisului. o Măsurați spațiul dintre utilizator (poziționat pe mijlocul scaunului rulant, cu spatele sprijnit de spătar) și fiecare apăratoare laterală. o Tăiați și adăugați inserții de spumă / burete de ambele părți, pentru a umple spațiul dintre utilizator și partea laterală a scaunului rulant. o Verificați dacă se potrivește. o Aplicați o husă și atașați inserțiile de spumă. Dacă suporturile de brațe sunt rigide, aceste inserții pot fi atașate de suport. Ele pot fi aplicate și pe partea superioară a pernei. o Inserțiile nu trebuie să depășească nivelul până la care ajunge trunchiul utilizatorului. o Asigurați-vă că perna are aceeași lățime ca și șezutul scaunului rulant. o Dacă scaunul rulant este foarte lat, utilizatorul poate avea dificultăți în a ajunge la inelele de antrenare. Mișcarea forțată pentru a ajunge la inelele de antrenare poate provoca rănirea umărului. Înainte de a prescrie (selecta) scaunul rulant, asigurați-vă că acesta poate fi folosit în condiții de siguranță de către utilizator. Inserțiile de spumă / burete reduc lățimea părții interioare a scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 94 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Etapa 7: Instruirea utilizatorului de scaun rulant Informațiile și instruirea ajută utilizatorul să beneficieze cu adevărat de avantajele aduse de scaunul rulant. Fără această etapă, este posibil ca echipamentul de mobilitate să nu fie utilizat la întregul său potențial. Care sunt abilitățile care pot ajuta utilizatorul de scaun rulant? Cele mai importante șase aspecte care trebuie transmise în timpul instruirii sunt: o modalitatea de manevrare a scaunului rulant; o transferul în și din scaunul rulant; o mobilitatea scaunului rulant – în conformitate cu nevoile utilizatorului; o prevenirea apariției escarelor și ce trebuie făcut în cazul în care acestea se formează; o întreținerea la domiciliu a scaunului rulant și a pernei; o ce trebuie făcut în cazul apariției unor probleme. Lista de verificare de pe pagina următoare conține abilitățile specifice pe care utilizatorul de scaun rulant ar putea avea nevoie să le învețe. Este posibil ca unii utilizatori să dețină deja aceste abilități; în același timp, nu toate abilitățile sunt necesare tuturor utilizatorilor de scaun rulant. Personalul furnizor de servicii de scaune rulante poate folosi această listă de verificare pentru a selecta aspectele care trebuie incluse în instruirea utilizatorului. Acestea se stabilesc prin evaluare și prin discuțiile cu utilizatorul. Este posibil ca unii furnizori de servicii să folosească această listă de verificare ca formular, atașându-l dosarului fiecărui utilizator. În acest caz, lista de verificare poate fi utilă și pentru a înregistra temele care au fost incluse în instruirea utilizatorului de scaun rulant. Verificați întotdeauna împreună cu utilizatorul de scaun rulant dacă acesta dorește ca însoțitorii să fie instruiți și ei cu privire la respectivele abilități. O mare parte dintre utilizatori sunt asistați de către familie sau însoțitori, astfel este benefic pentru toți cei implicați ca aceștia să învețe modalități de utilizare și de întreținere a scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 95 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Ce înseamnă o instruire eficientă o Aflați care sunt aspectele pe care utilizatorul le cunoaște deja. o Explicați, demonstrați și dați utilizatorului oportunitatea de a exersa ceea ce a învățat. o Folosiți un limbaj care poate fi înțeles de către toată lumea. o Folosiți ca instructori alți utilizatori de scaun rulant. o Bune abilități de comunicare. o Încurajarea utilizatorului de scaun rulant. Listă de verificare instruire utilizator de scaun rulant Abilități de învățat Abilități învățate Manevrarea scaunului rulant Plierea scaunului rulant   Ridicarea scaunului rulant   Folosirea roților cu deblocare rapidă   Folosirea frânelor   Folosirea pernei, inclusiv poziționarea corectă în scaunul rulant   Transferuri Transfer independent   Transfer asistat   Altele   Mobilitate scaun rulant Propulsia corectă   Urcarea și coborârea unei pante   Urcarea și coborârea unei trepte   Deplasare pe teren accidentat   Menținerea în echilibru pe două roți   Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 96 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Prevenirea apariției escarelor Verificarea existenței escarelor   Tehnici pentru eliberarea presiunii   Alimentație și hidratare corespunzătoare   Ce trebuie făcut în cazul apariției unei escare   Întreținerea la domiciliu a scaunului rulant Curățarea scaunului rulant; spălarea și uscarea pernei și a husei   Lubrifierea părților mobile   Umflarea anvelopelor, dacă acestea sunt pneumatice   Strângerea șuruburilor și a piulițelor   Strângerea spițelor   Verificarea părții textile (tapițeriei)   Verificarea existenței petelor de rugină   Verificarea pernei   Ce trebuie făcut în cazul în care există o problemă Scaunul rulant are nevoie de reparații   Scaunul rulant nu se potrivește sau nu este confortabil   Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 97 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Etapa 8: Întreținere, reparații și monitorizare Îngrijirea regulată a scaunului rulant și a pernei duce la evitarea costurilor de reparații, crește durata de viață a acestuia și previne rănirea utilizatorului sau deteriorările pe termen lung ale stării de sănătate. Un scaun rulant bine întreținut este mai confortabil, este mai ușor de folosit, iar manevrarea sa necesită un consum de energie mai mic din partea utilizatorului. O pernă bine întreținută va oferi suport și va ajuta în continuare la reducerea presiunii. Personalul furnizor de servicii de scaune rulante are responsabilitatea de a informa utilizatorul de scaun rulant cu privire la modalitățile de întreținere la domiciliu ale scaunului rulant și ale pernei. Prevenirea reparațiilor: întreținerea la domiciliu Există șase lucruri pe care utilizatorii de scaun rulant le pot face acasă pentru a întreține scaunul rulant și perna. Explicați utilizatorului care sunt modalitațile de întreținere la domiciliu ale scaunului rulant și ale pernei și de ce trebuie să se recurgă la ele. Tabelul de pe pagina următoare explică pașii, importanța lor și modul în care trebuie să se procedeze. Resurse locale pentru reparații scaune rulante Identificați pe plan local cine ar putea să fie de ajutor în ceea ce privește reparațiile scaunelor rulante. Posibile variante: o atelier reparații biciclete; o atelier mecanic auto sau motociclete; o ateliere sudare, instalații (părți metalice), tâmplărie, dulgherie (părți de lemn); o utilizatorul de scaun rulant, un membru de familie al utilizatorului de scaun rulant, o rudă sau un vecin al acestuia; o croitor pentru repararea părților din material textil (tapițerie); o facilități pentru utilizatori scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 98 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Întreținerea la domiciliu a scaunului rulant De ce este important? Cum se procedează 1. Curățați scaunul rulant și perna Previne ruginirea părților metalice. Împiedică deteriorarea părților de lemn și a celor textile (tapițeria). Previne deteriorările produse de frecarea elementelor de murdărie de părțile mobile. Folosiți apă caldă cu puțin săpun. Clătiți și uscați. Tratați cu atenție părțile mobile și zonele unde materialul textil atinge cadrul. Îndepărtați husa pernei și spălați separat. Întotdeauna uscați perna la umbră – nu sub acțiunea directă a razelor de soare. 2. Lubrifiați părțile mobile Ajută la funcționarea corectă a părților mobile. Ajută la prevenirea apariției ruginii. Prima etapă o constituie spălarea și uscarea scaunului rulant. Folosiți un ulei pentru lubrifiere, de exemplu ulei de rulment. Aplicați pe toate părțile mobile. 3. Umflarea roților (pneumatice) Crește durata de utilizare a anvelopelor. Face propulsia scaunului rulant mai ușoară, scade necesarul de energie. Frânele vor funcționa în mod corect. Apăsați anvelopa cu degetul mare, pentru a verifica presiunea. Roata trebuie să se depresurizeze foarte ușor (circa 5 mm). Presiunea trebuie să fie egală în ambele roți. Umflați cu ajutorul unei pompe de bicicletă sau cu una similară. Reduceți presiunea eliberând aerul prin valvă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 99 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT De ce este important? Cum se procedează 4. Strângeți șuruburile și piulițele (dacă este cazul) Șuruburile necorespunzător strânse provoacă mișcări nedorite ale părților componente. Acest lucru poate cauza disconfort, uzarea părților componente sau pierderea acestora. Verificați scaunul rulant pentru a identifica șuruburile și piulițele necorespunzător strânse. Folosiți o cheie pentru a le strânge. Nu strângeți exagerat. 5. Strângeți spițele (dacă este cazul) Spițele strânse necorespunzător pot provoca îndoirea și deformarea roții. Strângeți toate spițele roții cu degetele, două câte două. Dacă o spiță cedează atunci când trageți ușor, este posibil ca aceasta să nu fie strânsă corespunzător. Strângeți cu o cheie pentru spițe. De asemenea, spițele ar putea fi prea strânse. Dacă acestea sunt prea rigide, ele sunt prea strânse și trebuie desfăcute. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 100 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază De ce este important? Cum se procedează 6. Verificați în mod regulat Verificați existența petelor de rugină și părțile textile Rugina reduce rezistența materialelor. Acest lucru poate duce la deterioarea anumitor părți și la rănirea utilizatorului. Partea textilă (tapițeria) trebuie să fie în stare bună, pentru a sprijini utilizatorul și pentru a oferi confort. Dacă aceasta se rupe brusc, utilizatorul de scaun rulant poate fi rănit. Verificați părțile metalice vopsite pentru a identifica zone ruginite/ corodate. Dacă există rugină, folosiți un șmirghel sau o perie metalică pentru a o îndepărta. Curățați cu un solvent și cu un material textil și revopsiți. Verificați dacă există rupturi, părți uzate, murdărie sau părți metalice ieșite în afară. Verificați dacă tensiunea la nivelul șezutului și al spătarului este corectă. Dacă materialul textil este rupt sau tensiunea șezutului pliabil este prea mică, trebuie efectuate reparații. Verificați perna Pernele trebuie să fie curate și uscate, pentru a proteja pielea. Pernele au o durată de utilizare mai mica decât cea a scaunului rulant. Verificarea la intervale regulate va ajuta utilizatorul să recunoască momentul în care perna trebuie înlocuită. Îndepărtați husa. Verificați dacă există zone uzate, murdărie sau găuri în husă și în spumă. Dacă perna este uzată, aceasta trebuie verificată de personalul furnizor de servicii de scaune rulante. Este posibil să fie necesară înlocuirea pernei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 101 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Reparații uzuale ale scaunului rulant și ale pernei Scaunele rulante și pernele necesită uneori reparații. Personalul furnizor de servicii de scaune rulante trebuie să poată efectua aceste reparații sau să sfătuiască utilizatorii de scaun rulant unde să apeleze pentru asistență. Unii utilizatori reușesc foarte bine să rezolve singuri problema reparațiilor, alții au nevoie de ajutor. Toți utilizatorii vor beneficia de pe urma informațiilor cu privire la locurile unde scaunul rulant și perna pot fi reparate. Ce este monitorizarea și cum se efectuează aceasta? Monitorizarea are loc după ce utilizatorul a primit scaunul rulant și l-a folosit o anumită perioadă de timp. Întâlnirile pentru efectuarea monitorizării constituie o oportunitate pentru: o a strânge informații de la utilizatorul de scaun; o a verifica dacă echipamentul de mobilitate este în stare bună de funcționare; o a vedea dacă scaunul rulant se potrivește. Vizita de monitorizare constituie un beneficiu pentru toți utilizatorii de scaun rulant. Cu toate acestea, monitorizarea este cea mai importantă în următoarele cazuri: o copii; o utilizatori de scaun rulant la care există pericolul apariției escarelor; o utilizatori de scaun rulant care au o afecțiune degenerativă; o utilizatori de scaun rulant care întâmpină dificultăți la instruire. Nu există o regulă cu privire la momentul în care trebuie efectuată monitorizarea, cu toate acestea, o vizită de monitorizare în decursul a șase săptămâni de la livrare este deseori utilă. Monitorizarea depinde de nevoile utilizatorului de scaun rulant. Totuși, în cazul copiilor, ideal este ca vizita de monitorizare să aibă loc o dată la șase luni, deoarece nevoile copiilor se schimbă mai des, pe măsură ce cresc. Monitorizarea poate fi făcută în decursul unei vizite la domiciliu, la un centru sau în orice alt loc pe care utilizatorul și personalul furnizor de servicii de scaune rulante le consideră convenabile. Acest lucru depinde de posibilitatea utilizatorului de a se deplasa la centru sau a furnizorului de servicii de scaune rulante de a se deplasa la domiciliul utilizatorului. Acțiuni de monitorizare uzuale  Verificați dacă scaunul rulant este în stare bună;  Oferiți sfaturi sau instruire suplimentară;  Dacă este nevoie – reajustați scaunul rulant; – efectuați reparații minore sau activități de întreținere; – efectuați reparații majore sau oferiți asistență utilizatorului în rezolvarea problemelor ce țin de reparația scaunului rulant. Formularul de pe pagina următoare poate fi folosit ca un ghid de monitorizare. Personalul Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 102 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază furnizor de servicii de scaune rulante trebuie să consemneze fiecare acțiune ce trebuie efectuată în urma vizitei de monitorizare. Modalități de gestionare a întâlnirilor de monitorizare o La momentul primirii scaunului rulant de către utilizator, stabiliți o programare pentru vizita de monitorizare. o Efectuați vizitele de monitorizare la domiciliul utilizatorului, acolo unde acest lucru este posibil. o Includeți vizitele de monitorizare în rutina vizitelor efectuate de către personalul implicat în reabilitatea bazată pe comunitate, căruia i s-a oferit instruire cu privire la vizitele de monitorizare. o În cazul în care transportul ridică dificultăți, iar utilizatorul de scaun rulant are acces la telefon, monitorizarea se poate face telefonic. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 103 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Formular de monitorizare a utilizării scaunului rulant Acest formular este pentru înregistrarea informațiilor obținute în decursul vizitei de monitorizare. 1. Informații utilizator scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data efectuării ajustărilor: Data efectuării monitorizării: Numele persoanei care realizează monitorizarea: Monitorizarea a avut loc la: Domiciliul utilizatorului o Centru de reparații scaune rulante o Altele: _________________________________ 2. Interviu Notați activitatea recomandată: Utilizați scaunul rulant atât de frecvent pe cât vă doriți? Da o Nu o Dacă nu – de ce nu? Întâmpinați vreo dificultate în utilizarea scaunului rulant? Da o Nu o Dacă da – care este aceasta? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da o Nu o Dacă da – care sunt acestea. Este nevoie de instruire suplimentară? Utilizatorul de scaun rulant prezintă escare? Da o Nu o Dacă da - descrieți (localizare și gravitate) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 104 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție pe care vi-l oferă scaunul rulant? (1 deloc satisfăcut, 5 foarte satisfăcut) Notă: Comentarii: 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună și poate fi utilizat în siguranță? Da o Nu o Perna este în stare bună și poate fi utilizată în siguranță? Da o Nu o Dacă răspunsul la oricare din întrebările de mai sus este „nu”, vă rugăm precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da o Nu o Dacă nu – care sunt problemele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul producerii de escare) Stânga: Dreapta: Utilizatorul are o poziție așezat confortabilă în scaunul rulant atunci când stă pe loc, când se deplasează și pe întreg parcursul zilei? Da o Nu o Dacă nu – care sunt problemele? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 105 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. 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Manualul participantului Pagina 106 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. 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Manualul participantului Pagina 107 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază. Manualul participantului Pagina 108 Manualul participantulu i SERVICII PENTRU UTILIZATO RII DE SCAUN RULANT Pachet de instruire - nivel de bază ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Materialul nu poate fi reprodus integral sau parțial fără menționarea sursei și fără acordul scris al Fundației Motivation România. 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Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 2. Servicii pentru utilizatorii de scaun rulant Pachet de instruire: Nivel de bază Manualul formatorului Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 3. Terminologie În cadrul acestui document, următorii termeni sunt folosiți conform definițiilor din rândurile de mai jos. Scaun rulant corespunzător Este scaunul rulant care răspunde condițiilor de mediu ale utilizatorului; furnizează suport postural adecvat; este sigur și durabil; este disponibil în țara utilizatorului; poate fi obținut și întreținut, iar serviciile sunt sustenabile în țara respectivă la cel mai economic și accesibil preț. Scaun rulant cu antrenare manuală Este scaunul rulant antrenat de către utilizator sau prin împingere de către o altă persoană. Scaun rulant Este un echipament de mobilitate și suport postural utilizat de persoane care întâmpină dificultăți de mers sau de deplasare. Furnizarea de scaune rulante Este termenul generic pentru design-ul, producția, furnizarea de scaune rulante și servicii de scaune rulante. Servicii de scaune rulante Sunt acea parte a procesului de furnizare a scaunelor rulante care se preocupă de dotarea utilizatorului cu un scaun rulant corespunzător. Personal furnizor de servicii de scaune rulante Este personalul care are abilități pentru furnizarea de scaune rulante corespunzătoare. Utilizator de scaun rulant Este persoana care are dificultăți de mers sau de deplasare pe care le soluționează prin folosirea unui scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 4. Cuprins Servicii pentru utilizatorii de scaun rulant .......................................................................................................... 1 Pachet de instruire: Nivel de bază ..................................................................................................................... 2 Manualul formatorului ........................................................................................................................................ 2 Terminologie ...................................................................................................................................................... 3 Cuprins............................................................................................................................................................... 4 Despre Servicii pentru utilizatorii de scaun rulant. Pachetul de instruire – nivel de bază ................................. 6 Introducere ......................................................................................................................................................... 6 Grup țintă ........................................................................................................................................................... 6 Scop ................................................................................................................................................................... 6 Conținut.............................................................................................................................................................. 7 Formatori ........................................................................................................................................................... 8 Cum să începem cursul ..................................................................................................................................... 8 1. Recomandări pentru formatori ....................................................................................................................... 9 1.1 Prezentarea generală a cursului .................................................................................................................. 9 1.2 Pachetul de instruire – desfășurător și durată ............................................................................................. 9 1.3 Planificarea sesiunilor ................................................................................................................................ 10 1.5 Observarea/monitorizarea progresului participanților ................................................................................ 11 1.6 Evaluarea programului de instruire după fiecare susținere a cursului ...................................................... 11 1.7 Bune practici în procesul de instruire ........................................................................................................ 11 2. Pregătirea livrării pachetului de instruire ..................................................................................................... 12 2.1 Cunoașterea rețelei de servicii de scaune rulante de unde provin participanții ........................................ 12 2.2 Clarificarea rolului participanților în procesul de livrare a serviciilor de scaune rulante ............................ 13 2.3 Revizuirea fiecărei sesiuni și adaptarea acesteia, dacă este cazul .......................................................... 13 2.4 Identificarea scaunelor rulante utilizate ..................................................................................................... 13 2.5 Invitarea utilizatorilor de scaun rulant la sesiunile practice ....................................................................... 13 2.6 Planificarea grupelor pentru sesiunile practice .......................................................................................... 15 2.7 Pregătirea spațiului pentru programul de instruire .................................................................................... 15 2.8 Pregătirea resurselor și materialelor pentru instruire ................................................................................ 17 3. Planificarea detaliată a sesiunilor ................................................................................................................ 22 Introducere ................................................................................................................................................... 23 A: Cunoștințe fundamentale ............................................................................................................................ 26 A.1: Utilizatorii de scaun rulant .................................................................................................................... 27 A.2: Serviciile pentru utilizatorii de scaune rulante ...................................................................................... 32 A.3: Mobilitatea în scaunul rulant ................................................................................................................ 37 A.4: Poziția așezat ....................................................................................................................................... 43 A.5: Escarele ............................................................................................................................................... 51 A.6: Scaunul rulant corespunzător .............................................................................................................. 59 A.7: Pernele ................................................................................................................................................. 76 A.8. Transferurile B: Etapele furnizării serviciilor de scaun rulante .............................................................................................. 92 B.1: Trimiterea și programarea .................................................................................................................... 93 B.2: Evaluarea ............................................................................................................................................. 97 B.3: Interviul de evaluare ........................................................................................................................... 101 B.4: Evaluarea fizică .................................................................................................................................. 111 B.5: Prescrierea (selecția) ......................................................................................................................... 121 B.6: Finanțarea și plasarea comenzii ........................................................................................................ 131 Sesiunea practică 1: Evaluarea și prescrierea (selecția) .......................................................................... 134 B.7: Pregătirea produsului (a scaunului rulant) ......................................................................................... 137 B.8: Confecționarea pernei ........................................................................................................................ 144 B.9: Probarea produsului (a scaunului rulant) ........................................................................................... 151 B.10: Soluționarea problemelor ................................................................................................................. 157 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 5. B.11: Instruirea utilizatorului de scaun rulant ............................................................................................ 164 B.12: Întreținerea și reparațiile ................................................................................................................... 169 Sesiunea practică 2: Probarea produsului (a scaunului rulant) și instruirea utilizatorului ......................... 174 B.13: Monitorizarea .................................................................................................................................... 178 Sesiunea practică 3: Monitorizarea ........................................................................................................... 182 Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului ........................................................................... 186 B.14: Sumarizare ....................................................................................................................................... 189 Anexe ................................................................................................................. Error! Bookmark not defined. Anexa 1: Orar sesiune de instruire pentru furnizare de servicii de scaune rulante - nivel de bază .......... Error! Bookmark not defined. Anexa 2: Formular de trimitere către furnizorul de servicii de scaune rulante .. Error! Bookmark not defined. Anexa 3: Formular de evaluare scaun rulant................................................. Error! Bookmark not defined. Anexa 4: Formular prescriere (selecție) scaun rulant .................................... Error! Bookmark not defined. Anexa 5: Formular de date tehnice ale scaunului rulant ............................... Error! Bookmark not defined. Anexa 6: Listă de verificare preliminară utilizării scaunului rulant ................. Error! Bookmark not defined. Anexa 7: Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) Error! Bookmark not defined. Anexa 8: Listă de verificare instruire utilizator de scaun rulant ..................... Error! Bookmark not defined. Anexa 9: Formular de monitorizare a utilizării scaunului rulant ..................... Error! Bookmark not defined. Anexa 10: Listă de verificare și observații pentru formatori ........................... Error! Bookmark not defined. Sesiunea practică 1: Evaluarea și prescrierea (selecția) Sesiunea practică 2: Probarea produsului (a scaunului rulant) Sesiunea practică 3: Monitorizarea Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant), instruirea utilizatorului de scaun rulant ............ Error! Bookmark not defined. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 6. Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază Introducere Pentru a asigura implementarea Ghidului de furnizare a scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, Organizația Mondială a Sănătății a dezvoltat acest pachet de instruire pentru furnizarea de servicii de scaune rulante, nivel de bază. Nevoia de personal care să furnizeze servicii de scaune rulante este universală. Scaunul rulant este unul dintre cele mai frecvent folosite dispozitive asistive pentru facilitarea mobilității personale. Totuși, există foarte puține oportunități pentru instruirea furnizorilor de servicii, pentru ca aceștia să poată asigura utilizatorilor de scaun rulant mobilitatea personală în cel mai înalt grad de independență posibil, pentru ca aceștia să fie membri productivi ai comunității și să aibă un nivel înalt al calității vieții. Acest pachet de instruire de bază este primul dintr-o serie dedicată formării în ceea ce privește furnizarea de servicii de scaune rulante. Pachetul de instruire nivel de bază cuprinde o serie de documente și prezentări pentru instruirea furnizorilor de servicii destinate utilizatorilor de scaun rulant. Cel mai important dintre acestea este Manualul formatorului. Din motive practice, acesta este disponibil doar în format electronic (nu există o versiune tipărită). Discul include Manualul formatorului și toate celelalte materiale de informare necesare susținerii unui program de instruire la nivel de bază, destinat furnizorilor de servicii de scaune rulante. Grup țintă Acest pachet de instruire este creat pentru personalul și voluntarii a căror activitate la locul de muncă presupune livrarea de servicii de scaune rulante. Aici putem include personalul din domeniul sănătății, al reabilitării și personalul tehnic, lucrătorii din domeniul sănătății publice și cei din sectorul reabilitării bazate pe comunitate, terapeuți ocupaționali, fizioterapeuți, persoane care își desfășoară în domeniul protezării și ortezării, meșteșugari locali, tehnicieni și utilizatori de scaun rulant. Nu este necesară experiență în ceea ce privește furnizarea de servicii de scaune rulante. Totuși, pachetul de instruire a fost creat pornind de la ideea că participanții au următoarele cunoștințe și abilități: o știu să scrie și să citească în limba în care are loc programul de instruire; o au cunoștințe de bază despre cele mai frecvente dizabilități fizice care îi afectează pe utilizatorii de scaune rulante, inclusiv paralizie cerebrală, amputații de membre inferioare, poliomielită, traumatism vertebro-medular și accident vascular cerebral. În cazurile în care participanții nu dețin deja informațiile referitoare la cele mai frecvente tipuri de dizabilități fizice, formatorii trebuie să includă acest tip de informații în sesiunea destinată cunoștințelor de bază. Scop Pachetul de instruire – nivel de bază este creat pentru instruirea personalului și voluntarilor care furnizează servicii utilizatorilor de scaun rulant și perne adecvate pentru copii și adulți cu dizabilități de mobilitate, dar care pot sta în poziția așezat fără suport postural suplimentar. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 7. Scopul principal al acestui program de instruire este dezvoltarea abilităților și cunoștințelor personalului implicat în livrarea serviciilor de scaune rulante. Acest pachet de servicii va ajuta la: o creșterea numărului de utilizatori care primesc un scaun rulant corespunzător cerințelor lor; o creșterea numărului de utilizatori care beneficiază de instruire cu privire la folosirea și întreținerea scaunului rulant și la modalități de menținere a stării de sănătate; o creșterea numărului de persoane instruite pentru livrarea de servicii de scaune rulante – nivel de bază; o îmbunătățirea competențelor personalului implicat în livrarea de servicii de scaune rulante; o creșterea calității în furnizarea serviciilor de scaune rulante; o creșterea nivelului de integrare a furnizării serviciilor de scaune rulante în cadrul serviciilor destinate reabilitării. Conținut Pachetul de instruire include: o cunoștințele de bază necesare livrării serviciilor de scaune rulante; o o prezentare a pașilor cheie în procesul de livrare a serviciilor de scaune rulante, cuprinși în Ghidul pentru furnizarea scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, elaborat de OMS (Tabel 1); o modalități de lucru cu utilizatorii de scaun rulant, pentru evaluarea nevoii de mobilitate, în vederea identificării soluției de mobilitate optime; o furnizarea unui scaun rulant corespunzător și a unei perne adecvate; o soluționarea problemelor, prin efectuarea de modificări simple ale scaunului rulant, pentru o cât mai bună potrivire cu cerințele utilizatorului; o reparații și întreținere scaune rulante; o instruirea utilizatorilor pentru valorificarea la maximum a beneficiilor oferite de scaunul rulant; o confecționarea unei perne din spumă modelată / burete. Includerea capitolului referitor la modificările scaunului rulant este relevant în contextul în care există limitări în ceea ce privește gama și măsurile scaunelor rulante cu antrenare manuală disponibile. În mod frecvent, sunt necesare modificări simple pentru ca scaunul rulant să se potrivească în totalitate. Furnizarea de tricicluri nu este abordată în amănunt în cadrul acestui pachet de instruire, cu toate că în cazul utilizatorilor de scaun rulant care trebuie să se deplaseze pe distanțe lungi, utilitatea triciclului este un fapt recunoscut. Tabel1. Principalele etape în furnizarea serviciilor de scaune rulante: Etapa 1 Trimiterea și programarea Etapa 2 Evaluarea Etapa 3 Presecrierea (selecția) Etapa 4 Finanțarea și plasarea comenzii Etapa 5 Pregătirea produsului (scaunului rulant) Etapa 6 Probarea produsului (a scaunului rulant) Etapa 7 Instruirea utilizatorului de scaun rulant Etapa 8 Întreținerea, reparațiile și monitorizarea Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 8. Formatori Abilități: Acest pachet de instruire este fundamentat pe ideea că sunt disponibili formatori care au abilități în livrarea serviciilor de scaune rulante la nivel de bază și care demonstrează că dețin competențele prevăzute în acest program de instruire. Experiența anterioară de formator constituie un avantaj. Utilizatori de scaun rulant: Se recomandă în mod deosebit includerea unui utilizator de scaun rulant în echipa care susține instruirea. Utilizatorii de scaun rulant pot face referire la propria lor experiență pentru a facilita transferul de cunoștințe și informații. De asemenea, în timpul cursului de formare, aceștia pot demonstra practic multe din tehnicile de manevrare ale scaunului rulant prevăzute în program. Instruirea susținută de un utilizator de scaun rulant va ajuta participanții să conștientizeze rolul central pe care aceștia îl au în procesul de selecție al scaunului rulant pe care îl vor folosi. Număr formatori: Se recomandă să existe doi formatori pentru fiecare grupă de 8–10 participanți. Acest raport este foarte important în cazul sesiunilor practice, pentru ca formatorii să poată oferi sprijin și recomandări și, totdată, să se asigure că acestea se desfășoară în condiții de siguranță pentru toți cei implicați. Un utilizator de scaun rulant experimentat, care cunoaște bine conținutul pachetului de instruire, poate constitui un punct forte în cadrul programului de instruire. Cum să începem Înainte de programul de instruire, trebuie să copiați discul (din partea interioară a mapei) pe hard-ul calculatorului. Spațiul necesar este de aproximativ 4Gb și pentru a utiliza discul aveți nevoie de un DVD player. Modalitatea cea mai simplă de a susține acest program de instruire este conform următoarelor sugestii: 1. Deschideți „Manualul formatorului” din fișierul cu manual. 1.1. Citiți secțiunea „Despre Servicii pentru utilizatorii de scaun rulant. Pachet de instruire – nivel de bază” și secțiunea „Recomandări pentru formatori”; 1.2. Imprimați și îndosariați un exemplar al Manualului formatorului pentru fiecare formator; 1.3. Imprimați un desfășurător și un formular de verificare pentru observații; 1.4. Imprimați formularele din pachet, formularele de evaluare ale programului de instruire și formularele referitoare la serviciile de scaune rulante, inclusiv listele de verificare pentru livrarea serviciilor de scaune rulante. 2. Faceți toate pregătirile, conform sugestiilor din secțiunea „Pregătirea furnizării pachetului de instruire” 3. Dați fiecărui participant un set complet de materiale de instruire, inclusiv: Manualul participantului (un exemplar pentru fiecare participant), Caietul de exerciții practice (un exemplar pentru fiecare participant) și un set de afișe (un set pentru fiecare participant). Dacă acestea nu există pe suport de hârtie, ele pot fi tipărite de pe disc. 4. Deschideți desfășurătorul și faceți clic pe hyperlink-urile de la fiecare sesiune, ceea ce vă va duce la materialele (PowerPoint și video) aferente fiecăreia. Cea mai buna metodă pentru furnizarea cursului este parcurgerea secțiunilor în ordinea indicată, cu respectarea strictă a duratei de timp alocată fiecărei sesiuni. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 9. 1. Recomandări pentru formatori 1.1 Prezentarea generală a cursului minute Întâmpinarea participanților, introducerea și prezentarea generală. Introducere 60 A: Cunoștințe de bază Sesiuni care oferă participanților cunoștințele de bază necesare parcurgerii procesului de instruire pentru livrarea serviciilor de scaune rulante. A.1 Utilizatorii de scaun rulant 45 A.2 Serviciile de scaune rulante 30 A.3 Mobilitatea în scaun rulant 90 A.4 Poziția așezat 60 A.5 Escarele 60 A.6 Scaunul rulant corespunzător 120 A.7 Pernele 75 A.8 Transferurile 120 B: Etapele furnizării serviciilor de scaune rulante Trimiterea și programarea B.1 Trimiterea și programarea 30 Evaluarea B.2 Evaluarea 30 B.3 Interviul de evaluare 90 B.4 Evaluarea fizică 90 Prescrierea (selecția) B.5 Prescrierea (selecția) 120 Finanțarea și plasarea comenzii B.6 Finanțarea și plasarea comenzii 15 Sesiunea practică 1 Evaluarea și prescrierea (selecția) 90 Pregătirea produsului (scaunului rulant) B.7 Pregătirea produsului (a scaunului rulant) 75 B.8 Confecționarea pernei 120 Probarea produsului (a scaunului rulant) B.9 Probarea produsului (a scaunului rulant) 60 B.10 Soluționarea problemelor 45 Instruirea utilizatorului de scaun rulant B.11 Instruirea utilizatorului de scaun rulant 60 Întreținerea, reparațiile și monitorizarea B.12 Întreținerea și reparațiile 120 Sesiunea practică 2 Probarea produsului (a scaunului rulant) și instruirea utilizatorului 120 Întreținerea, reparațiile și monitorizarea B.13 Monitorizarea 45 Sesiunea practică 3 Monitorizarea 90 Sesiunea practică 4 Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant), instruirea utilizatorului. 240 B.14 Sumarizare 105 1.2 Pachetul de instruire – desfășurător și durată Acest pachet de instruire poate fi livrat în zile consecutive sau în module, de-a lungul unei anumite perioade de timp. Durata minimă de timp necesară pentru parcurgerea completă a pachetului de Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 10. instruire - nivel de bază este de 35–40 de ore. O estimare a duratei de timp alocate fiecărei sesiuni este inclusă în plan. Notă – durata alocată fiecărei sesiuni variază în funcție de mai mulți factori: o experiența și abilitățile participanților; o numărul total de participanți; o numărul de tipuri de scaune rulante disponibile la nivel local; o dacă este nevoie de traducere în timpul sesiunii de instruire; o dacă sunt incluse materiale adiționale. În funcție de acești factori variază durata de timp necesară programului de instruire. Un model de desfășurător pentru cinci zile de curs poate fi găsit în Anexa 1. Acesta și un desfășurător necompletat sunt disponibile pe DVD. Formatorii sunt încurajați să adapteze și să modifice desfășurătorul, pentru ca acesta să se potrivească contextului local și ritmului cu care participanții asimilează cunoștințele. De exemplu: o sesiunile din pachetul de instruire pot fi incluse în programe de formare în domeniul sănătății sau reabilitării, deja existente; o în cazul în care personalul de reabilitare cunoaște deja unele aspecte cuprinse în pachetul de instruire, există posibilitatea ca sesiunile referitoare la acestea să nu fie necesare; o în cazul în care este nevoie de timp suplimentar pentru pregătirea scaunelor rulante (de exemplu, acestea trebuie asamblate în totalitate), poate fi necesară reducerea numărului de utilizatori de scaun rulant implicați în partea practică sau creșterea duratei de timp alocate acestei secțiuni. 1.3 Planificarea sesiunilor Pentru fiecare sesiune de instruire există o planificare, cu scopul de a ghida formatorii în ceea ce privește desfășurarea acestora. La începutul fiecărei planificări există următoarele informații. o Obiective: ce trebuie participantul să fie capabil să facă la sfârșitul sesiunii; o Resurse: care sunt resursele necesare pentru desfășurarea sesiunii; o Context: modul în care se recomandă ca sesiunea să fie adaptată pentru diverse contexte sau situații; o De pregătit: cum trebuie pregătită sesiunea; o Sumar: sumarul celor mai importante părți din cadrul sesiunii. Restul planificării este divizat pe teme. Pentru fiecare temă, planificarea oferă instrucțiuni cu privire la modul în care informația trebuie transmisă. Notă: o cuvintele în aldin reprezintă activități pentru formatori (de exemplu: întreabă, demonstrează, explică, prezintă material video); o informațiile din chenare oferă răspunsuri la întrebările adresate de către formatori – cu toate acestea, încurajați participanții să se gândească la propriile lor răspunsuri. La finalul fiecărei planificări există un sumar al punctelor cheie. În loc să citească aceste puncte cheie, formatorii ar putea pune participanților întrebări, de așa manieră încât aceștia să identifice singuri aspectele esențiale. Urmărind cu atenție planificarea, formatorii vor putea preda în condiții optime fiecare sesiune, respectând durata prevăzută. Planificările menționează toate aspectele cheie și abilitățile practice care trebuie trasmise. Formatorii sunt încurajați să se folosească și de propriile lor cunoștințe și abilități și să lucreze în stilul propriu. Cu toate acestea, este important să se urmărească temele și metodologia prevăzute în planificarea pachetului de instruire. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 11. 1.4 Prezentările PowerPoint Aproape toate sesiunile au prezentări în format PowerPoint. Formatorii trebuie să rețină faptul că în acestea sunt menționate doar punctele cheie. Formatorii trebuie să furnizeze informațiile menționate lângă fiecare pagină a prezentării, din Manualul formatorului, pentru a se asigura că sunt abordate toate punctele. Încercați să nu citiți ceea ce se află pe paginile de prezentare, ci să folosiți informațiile din Manualul formatorului. 1.5 Observarea/monitorizarea progresului participanților Formatorii trebuie să observe cu atenție evoluția fiecărui participant. Cea mai bună oportunitate pentru monitorizarea progresului o constituie sesiunile practice. Lista de verificare și observații pentru formatori pentru fiecare sesiune practică se găsește pe CD. Se recomandă ca formatorii să utilizeze această listă de verificare pentru: o a urmări evoluția fiecărei grupe de participanți, pe parcursul fiecărei sesiuni practice; o a înregistra exemplele de bună practică și aspectele care au nevoie să fie îmbunătățite – pentru a fi abordate în cadrul fiecărei sesiuni de răspunsuri. Lista de monitorizare utilizată de formator poate fi modificată și/sau dezvoltată de formatorii care doresc o înregistrare mai amănunțită cu privire la progresul fiecărui participant. 1.6 Evaluarea programului de instruire după fiecare susținere a cursului Se recomandă ca programul de instruire să fie evaluat la final, după încheierea sa. Formatorii pot să înregistreze reacții din partea participanților pe întreg parcursul programului de instruire. De asemenea, ei pot nota propriile lor idei cu privire la desfășurarea cursului. Aceste informații îi pot ajuta în evaluarea programului de instruire la finalul acestuia, inclusiv la identificarea punctelor slabe și punctelor tari. Acest lucru va contribui la îmbunătățirea atât a pachetului de instruire în sine, cât și a modalității de livrare a cursului. Formularele de evaluare a cursului de instruire sunt disponibile pe DVD. Formatorii pot să de adapteze, pentru ca acestea să corespundă cerințelor lor. 1.7 Bune practici în procesul de instruire Fiți pregătiți o înainte de a începe sesiunea de instruire, citiți fiecare planificare; o asigurați-vă că stăpâniți conținutul materialului; o pregătiți cu atenție resursele materiale necesare și încăperea unde se va desfășura cursul. Stabiliți un model de bună practică în livrarea de servicii de scaune rulante o arătați respect participanților și utilizatorilor de scaun rulant; o fiți atenți întotdeauna la măsurile de siguranță din sala unde se desfășoară cursurile; o fiți punctuali și respectați desfășurătorul cursului. Prezentați informația în mod clar o vorbiți clar și calm; o asigurați-vă că toți participanții aud ceea ce spuneți; o puneți întrebări pentru a vă asigura că mesajul a fost înțeles; o asigurați-vă că scrisul de pe panou poate fi citit de către toți participanții; o repetați aspectele esențiale, pentru a le sublinia. Gestionați bugetul de timp o fiți atenți la timpul alocat fiecărei sesiuni și încercați să respectați durata prevăzută; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 12. alocat o dacă este necesar să alocați timp suplimentar, luați acest lucru în considerare încă de la început; o asigurați-vă că parcurgeți toate sesiunile planificate pentru respectiva zi de curs. Demonstrațiile trebuie să fie clare și corecte o asigurați-vă că toată lumea poate să vadă demonstrația; o explicați ce urmează în cadrul demonstrației și descrieți acțiunile pe care le veți face; o faceți demonstrațiile într-un ritm mai lent și repetați dacă este necesar. „Construiți” abilitățile participanților o după fiecare demonstrație, oferiți participanților oportunitatea de a exersa; o rețineți că participanții au nevoie de timp pentru a înțelege informațiile noi. Încurajați succesul în cadrul activităților în grupe mici o observați modul în care se desfășoară activitățile de grup și oferiți ajutor, acolo unde este cazul; o asigurați-vă că ajungeți la fiecare grup, pentru a verifica progresul făcut de fiecare. Fiți conștienți de diferențele dintre diverse limbi o dacă participanții învață într-o altă limbă decât cea maternă, verificați dacă înțeleg informația și adoptați un ritm mai lent, în cazul în care acest lucru este necesar; o fiți conștienți de de diferențele de limbă care pot exista între utilizatorii de scaun rulant și însoțitorii lor; o folosiți interpreți, acolo unde este cazul. Încurajați participanții să fie activi și implicați pe întreaga durată a cursului de instruire o utilizați diversele modalități de predare și metodele prevăzute în planificare; o evitați să vorbiți prea mult – încurajați participanții să vorbească și să discute; o puneți întrebări pentru a încuraja participanții să se gândească la răspunsuri, evitând să le oferiți voi înșivă; o încurajați toți participanții să vorbească, nu lăsați ca discuția să fie dominată de unul dintre ei; o exprimați-vă aprecierea atunci când sarcinile sunt îndeplinite bine și oferiți feedback pozitiv; o informați participanții că pot pune întrebări în orice moment al cursului; o faceți corelații între aspectele predate și exemple reale, pe care participanții le pot recunoaște; o cursul de instruire trebuie să fie distractiv! Folosiți scurte activități/jocuri „de încălzire” o folosiți scurte activități de încălzire (5–10 minute) pentru ca participanții să se concentreze mai ușor. Recurgeți la activități care includ participanții cu dizabilități. O selecție de astfel de jocuri este inclusă în fișierul de instrumente de lucru al cursului de instruire. Luați în considerare cerințele persoanelor cu diverse abilități o gândiți-vă la nevoile oricărui participant cu deficiențe de vedere, auz sau de mobilitate. Unele activități sau abordări ale cursului vor trebui adaptate în consecință. 2. Pregătirea livrării pachetului de instruire 2.1 Cunoașterea rețelei de servicii de scaune rulante a participanților Formatorii trebuie să fie familiarizați cu sistemul de livrare a scaunelor rulante în locul de unde provin participanții. Acest lucru include informații cu privire la: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 13. o tipurile de scaune rulante care sunt disponibile local și furnizorii acestora; o serviciile de scaune rulante din zonă, inclusiv nivelul la care sunt ele furnizate; o sistemul de trimitere al beneficiarilor către serviciile de scaune rulante din respectiva zonă; o oamenii resursă din zona respectivă, inclusiv utilizatori de scaun rulant care pot asista la cursul de instruire; o alte servicii de reabilitare spre care pot fi îndreptați utilizatorii de către personalul de servicii de scaune rulante, atunci când este cazul. 2.2 Clarificarea rolului participanților în procesul de livrare a serviciilor de scaune rulante Aflați unde se situează furnizarea de servicii de scaune rulante în ansamblul atribuțiilor de serviciu ale participanților. De exemplu: participanții vor lucra doar la livrarea serviciilor de scaune rulante sau vor avea și alte sarcini de îndeplinit? Definiți rolul pe care participanții îl vor avea în procesul de livrare a serviciilor de scaune rulante. De exemplu, este posibil ca unii dintre ei să fie responsabili doar pentru aspectele clinice sau doar pentru cele tehnice prevăzute în cadrul cursului. Alții ar putea să îndeplinească ambele roluri. Caracteristicile acestui rol trebuie clarificate înainte de începerea cursului de instruire. Astfel, formatorii au posibilitatea de a aborda cursul în concordanță cu viitoarele responsabilități ale participanților. Înainte de curs, formatorii locali trebuie să îl adapteze, de așa manieră încât acesta să fie corelat cu rolul pe care participanții îl vor avea în procesul de livrare al serviciilor de scaune rulante. 2.3 Revizuirea fiecărei sesiuni și adaptarea acesteia, dacă este cazul Reluați fiecare planificare și desemnați formatorul principal pentru fiecare sesiune a cursului de instruire. Unele sesiuni ale cursului de instruire vor trebuie adaptate pentru ca ele să respecte contextul local. Sugestiile pentru corelarea sesiunilor cu diversele medii de predare se găsesc la începutul fiecărei planificări, la „Context”. 2.4 Identificarea scaunelor rulante utilizate Identificați tipurile de scaune rulante care vor fi utilizate în timpul cursului de instruire. Este recomandabil ca acestea să fie disponibile la locul de muncă al participanților. Dacă gama de scaune rulante este variată, alegeți cele mai bune exemple din fiecare tip și pe cele care sunt cel mai frecvent utilizate. Nu includeți scaune rulante cu caracteristici de nivel „intermediar”, cum ar fi dispozitive pentru suport postural ajustabile (de exemplu, ham umeri, suport pentru coloana vertebrală). Asigurați-vă că v-ați familiarizat în totalitate cu caracteristicile fiecărui scaun rulant. Completați un formular cu date tehnice (vezi DVD: Formulare servicii pentru utilizatorii de scaun rulant) pentru fiecare scaun rulant și colectați de la furnizor informații despre produs. 2.5 Invitarea utilizatorilor de scaun rulant la sesiunile practice Pentru ca participanții să poată exersa abilitățile dobândite în timpul cursului de instruire, sunt necesare activități practice desfășurate împreună cu utilizatori de scaun rulant. Înainte de Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 14. începerea cursului, formatorii trebuie să identifice utilizatorii de scaun rulant care au disponibilitatea de a participa. Mai jos este o listă de verificare, care să faciliteze identificarea utilizatorilor de scaun rulant. Listă de verificare pentru participarea utilizatorilor de scaun rulant (sesiunile practice): Acceptă de bunăvoie să participe la curs, pentru a facilita desfășurarea sesiunilor practice. Au o poziție corectă în scaunul rulant și nu necesită modificări sau suport postural suplimentar, deoarece acest aspect nu este cuprins în cursul de instruire. Sunt într-o formă fizică adecvată și au o stare de sănătate care le permite să participe fără dificultăți la programul de instruire. Nu au escare. Locuiesc suficient de aproape încât să poată participa la curs fără a se deplasa pe o distanță prea mare. Au timp la dispoziție pentru a participa la programul de instruire. Locuiesc suficient de aproape pentru ca organizația unde se desfășoară cursul să poată face și activitatea de monitorizare după încheierea programului de instruire. Numărul utilizatorilor de scaun rulant bărbați este egal cu cel al utilizatorilor de scaun rulant femei. Prezintă o tipologie mai largă de afecțiuni fizice. Reprezintă categorii de vârsta diferite. Pentru utilizatorii care participă la sesiunea de monitorizare – să fi folosit un scaun rulant pentru o perioadă de cel puțin trei luni. De câți utilizatori de scaun rulant este nevoie? Numărul utilizatorilor de scaun rulant recomandat pentru derularea sesiunilor practice depinde de numărul participanților la curs. Cu toate acestea, este nevoie de minimum 2-4 utilizatori, indiferent de mărimea grupului de participanți. De obicei, participanții vor lucra în grupe de două sau trei persoane, împreună cu câte un utilizator de scaun rulant. Este recomandabil să nu existe mai mult de trei utilizatori de scaun rulant, deoarece poate fi dificil pentru formatori să gestioneze, să monitorizeze și să observe mai multe grupe. Ce trebuie să știe utilizatorii de scaun rulant care participă la sesiunile practice ale cursului de instruire? Utilizatorii de scaun rulant trebuie să știe următoarele lucruri: o ce se va întâmpla în timpul sesiunilor la care vor participa; o care sunt sesiunile la care trebuie să participe și care este durata acestora; o că pot participa împreună cu un membru de familie sau un însoțitor; o dacă vor primi un scaun rulant pe parcursul participării la curs. Se recomandă formatorilor și organizațiilor unde se desfășoară programul de instruire să se asigure că toți participanții au transportul asigurat sau că li se decontează cheltuielile de transport și de participare la curs. Pe parcursul programului de instruire, participanților li se asigură masa. Formatorii și organizațiile care găzduiesc cursul de instruire pot decide să ofere diurnă participanților, pe perioada cursului. În fișierul de formulare de pe DVD sunt disponibile un model de scrisoare de invitație și un acord destinat utilizatorilor de scaun rulant. Acestea trebuie adaptate fiecărei situații specifice, traduse și trimise fiecărui utilizator de scaun rulant (voluntar), pentru a-l ajuta să ia o decizie, în cunoștință de cauză, cu privire la participarea la cursul de instruire. Monitorizare o formatorii sau organizațiile unde se derulează programul de instruire trebuie să planifice monitorizarea oricărui utilizator de scaun rulant care participă la curs, monitorizare care să aibă loc imediat după încheierea cursului, deoarece este posibil ca până la finalul cursului să nu poată fi rezolvate toate aspectele specifice fiecărui utilizator de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 15. o toți utilizatorii care primesc un scaun rulant pe parcursul programului de instruire trebuie monitorizați de către formator sau organizație la 6-8 săptămâni de la primirea echipamentului de mobilitate. 2.6 Planificarea grupelor pentru sesiunile practice Fiecare grupă trebuie să fie formată din cel mult trei participanți. Este mai bine să existe două grupe de câte două persoane, decât una de patru participanți. Astfel, toți participanții au oportunitatea de a aplica cunoștințele dobândite și de a-și dezvolta abilitățile. Formatorii trebuie să decidă componența grupelor. Decizia apartenenței la un grup de lucru nu va fi lăsată la latitudinea participanților. În funcție de abilitățile participanților și de context, formatorii pot utiliza următoarele criterii: o participanții care au mai multă încredere în abilitățile lor ar trebui să facă echipă cu cei care sunt mai puțin încrezători în capacitatea lor de a se descurca, primii putând să îi ajute pe aceștia din urmă. Observați cu atenție echipele, pentru a vă asigura că toată lumea ia parte la activități. o puneți în aceeași echipă persoanele care vor lucra împreună pe viitor, astfel ei au posibilitatea de a-și dezvolta abilitățile ca o echipă. Pentru Partea practică 1 și pentru Partea practică 2, mențineți aceeași structură a grupelor. Pentru părțile practice 3 și 4, componența echipelor poate fi schimbată, în funcție de modul în care membrii acestora lucrează împreună. Pentru fiecare sesiune practică, desemnați un „responsabil” de grup. Asigurați-vă că fiecare participant are ocazia să devină lider de grup. Această persoană va fi responsabilă pentru parcurgerea tuturor pașilor. De asemenea, responsabilul de grup va fi persoana de contact care va comunica cu utilizatorul de scaun rulant și cu familia sau însoțitorul acesteia, dacă acest lucru este necesar. 2.7 Pregătirea spațiului pentru programul de instruire Pentru a derula programul de instruire, este nevoie de o încăpere (sau un spațiu) mare. Spațiul trebuie să fie suficient de mare pentru ca participanții și utilizatorii de scaun rulant să poată desfășura sesiunile practice, fiind împărțiți pe echipe. Este nevoie și de un spațiu exterior pentru a putea exersa abilitățile de manevrare a scaunului rulant, de un spațiu rezervat pentru a lua masa, precum și de grupuri sanitare curate. Toate spațiile, inclusiv toaletele, trebuie să fie accesibile utilizatorilor de scaun rulant. Următoarea listă de verificare poate fi folosită pentru a evalua și a pregăti spațiul alocat derulării cursului de instruire: Listă de verificare pentru spațiul unde se desfășoară cursul de instruire: Spațiu pentru desfășurarea cursului Spațiu pentru desfășurarea cursului Scaune pentru fiecare participant – cu măsuță de scris Spațiu pentru a forma 2-3 echipe de lucru Spațiu pentru a prezenta și pentru a utiliza cel puțin trei scaune rulante Paravane pentru a oferi utilizatorilor de scaun rulant un spațiu delimitat, în timpul sesiunilor practice Mese mari sau bănci pentru sesiunile dedicate confecționării pernelor Lumină și ventilație corespunzătoare Spațiul trebuie să poată fi încuiat Spațiu pentru exerciții de manevrare a scaunului rulant Suprafețe netede, fără denivelări Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 16. O singură treaptă Un scurt șir de trepte Suprafață accidentată Suprafață în pantă Zona pentru pauza de masă Spațiu curat pentru a lua masa Mese și scaune Spațiu pentru spălat mâinile – prosoape curate și săpun Toalete Toalete curate cu apă, hârtie igienică, facilități pentru spălarea mâinilor, coșuri pentru deșeuri. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 17. 2.8 Pregătirea resurselor și materialelor pentru instruire Materiale imprimate Resursă Cantitate  Comentarii/Instrucțiuni Manuale, caiete de exerciții practice și afișe: Manualul formatorului 1 per formator Se comandă de la OMS sau se imprimă și se leagă. Manualul participantului 1 per participant Se comandă de la OMS sau se imprimă și se leagă. Caietul de exerciții practice 1 per participant Se comandă de la OMS sau se imprimă și se leagă. Set de afișe 1 per participant Se comandă de la OMS sau se imprimă și se leagă. Materiale suplimentare: Ghid de furnizare a scaunelor rulante cu antrenare manuală în regiuni cu resurse limitate, publicat de OMS Cel puțin 1 exemplar per formator Furnizați un exemplar electronic fiecărui participant, dacă acest lucru este posibil. Pentru varianta electronică sau versiuni în diverse limbi, vezi: http://www.who.int/disabilities/en/. Convenția Națiunilor Unite privind Drepturile Persoanelor cu Dizabilității (CNUDPD) 1 exemplar per participant Pentru versiuni în diverse limbi: http://www.un.org/disabilities/default.asp?id=150; http://uncrpdindia.org/about/text/. Formulare pentru programul de instruire: Formular pentru înregistrarea participanților 1 per curs de instruire Acest formular este necesar pentru a înregistra participanții la curs. Ecusoane 1 per participant și 1 per formator Desfășurător 1 per participant Modelele sunt disponibile pe DVD; adaptați pentru conformitate cu contextul local. Formular de acord foto 1 per participant și 1 per utilizator de scaun rulant (voluntar) Adaptați acest formular pentru formator/organizația unde are loc cursul de instruire, traduceți-l în limba în care va fi desfășurat cursul, asigurați-vă că toate persoanele care vor fi fotografiate semnează acest formular. Scrisoare de invitație și acord de participare pentru utilizatorii de scaun rulant 1 per utilizator de scaun rulant Adaptați modelul de scrisoare din pachet, pentru a invita la sesiunile practice fiecare utilizator de scaun rulant. Lista de utilizatori de scaun rulant pentru sesiunile practice 1 per formator Folosiți acest formular pentru a planifica participarea utilizatorilor de scaun rulant la sesiunile practice și pentru a avea o evidență a participării. Certificate pentru participanți 1 per participant Pregătiți certificatele pentru participanți și adaptați modelul furnizat. Formulare de evaluare ale cursului de instruire Formular de evaluare al programului de 1 per participant Modele de formulare de evaluare a cursului de instruire; acestea pot fi adaptate de către Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 18. instruire - pentru participanți formatori, în funcție de necesități. Formular de evaluare a sesiunii de instruire - pentru formator 1 per sesiune Formular de evaluare al programului de instruire – pentru formatori 1 per formator Lista de verificare și observații pentru formator - pentru sesiunile practice Partea practică 1 1 per formator Imprimați. Partea practică 2 Partea practică 3 Partea practică 4 Formulare pentru furnizarea serviciilor de scaune rulante: Formular de trimitere către furnizorul de servicii de scaune rulante 1 per participant Adaptați pentru a fi în concordanță cu contextul local sau folosiți formularul de trimitere disponibil pe plan local, dacă acesta există. Formular de evaluare a utilizatorului de scaun rulant 1 per utilizator de scaun rulant Adaptați la contextul local – de exemplu, adăugați numele furnizorului de servicii de scaune rulante sau informații suplimentare solicitate de furnizorii locali. Formular de prescriere (selecție) a scaunului rulant 1 per utilizator de scaun rulant Finalizați în funcție de mărimile de scaune rulante disponibile și de opțiuni. Formular de date tehnice scaun rulant 1 per scaun rulant Completați unul pentru fiecare tip de scaun rulant disponibil, înainte de începerea programului de instruire. Formular de monitorizare a utilizării scaunului rulant 1 per utilizator de scaun rulant Adaptați la contextul local – de exemplu, adăugați numele furnizorului de servicii de scaune rulante sau informații suplimentare solicitate de furnizorii locali. Liste de verificare: Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) 1 per participant Listele de verificare sunt disponibile la resurse imprimate, la „formulare pentru livrarea serviciilor de scaune rulante”. Listă de verificare instruire utilizator de scaun rulant Listă verificare preliminară utilizării scaunului rulant Afișe: Etapele furnizării serviciilor de scaune rulante 1 Abilitățile de manevrare a scaunului rulant 1 Escarele 1 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 19. Întreținereaa la domiciliu a scaunului rulant 1 Formular opțional (acest formular nu este inclus în pachet, folosiți dacă este disponibil la furnizorul local de servicii de scaune rulante): Formular comandă pentru scaun rulant 1 per participant Formatorul va folosi formularul de comandă, dacă acesta este disponibil local. Materiale Item Cantitate Marker pentru tablă de scris 3–4 Bucăți spumă / burete 4–5 Mostre pentru demonstrații (aproximativ 100 x 110 x 50 mm). Centură pentru glezne sau pentru gambe 2–3 seturi Dacă sunt disponibile. Echipament Item Cantitate Tablă de scris de dimensiuni mari 1 Videoproiector 1 Computer 1 Boxe audio portabile 1 set Pentru redare materiale audio aflate pe DVD. Camera foto digitală 1 Dacă este disponibilă – pentru diversele sesiuni. Pat pentru evaluare 1 per utilizator de scaun rulant, pentru sesiunile practice O bancă/pat pentru evaluare sau un suport. Înălțimea ar trebui să fie egală cu înălțimea medie a șezutului scaunului rulant. Evitați suprafețele tari, dacă este posibil – dacă folosiți bănci, așezați un strat subțire de spumă/burete sau o saltea utilizată în exercițiile de yoga. Set plăci pentru picioare 1 set Bucăți confecționate din lemn, pentru a oferi utilizatorilor de scaun rulant suport la nivelul picioarelor, atunci când se află pe Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 20. patul de evaluare. Acestea trebuie să fie de înălțimi diferite. Placă transfer 1 la 3 participanți Dacă e disponibilă. Ruletă 1 per participant ½ schelet anatomie, cu coloană vertebrală, pelvis și femur 1 Dacă e disponibil. Scaune rulante și perne pentru exerciții practice Cel puțin câte un scaun rulant și câte o pernă din fiecare tip disponibil local; ideal un scaun rulant și o pernă pentru fiecare 2 participanți. Asigurați-vă că toate scaunele rulante sunt în stare bună de funcționare și că au o pernă, asigurați-vă că există cel puțin o mostră de pernă pentru reducerea presiunii adecvată. Scaune rulante și perne pentru utilizatorii de scaun rulant voluntari 1 pentru fiecare utilizator de scaun rulant care participă la sesiunile practice Trebuie să existe suficiente scaune rulante și perne pentru ca utilizatorilor să li se prescrie echipamentul de mobilitate și perna corespunzătoare. Trusă de scule pentru întreținerea la domiciliu a scaunului rulant 1 la 3 participanți Include: cheie pentru piulițe ajustabilă, chei Allen, șurubelniță, pompă anvelope, ulei pentru lubrifiere, găleată, săpun, material textile, șmirghel. Hârtie pentru notițe 1 per participant Confecționarea pernelor – materiale și instrumente Item Cantitate Mostră de pernă pentru reducerea presiunii din spumă modelată / burete și husă 1 Dacă nu sunt disponibile, formatorii trebuie să le pregătească înainte de începerea programului de instruire. Mostră de strat de ridicare a pernei 1 Trusă pentru confecționarea pernelor 1 trusă la 2 participanți Include: o 1 x lamă de fierăstrău ascuțită sau un cuțit lung; o 1 x marker negru; o lipici pentru spumă/burete sau adeziv de contact Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 21. și bucăți de carton pentru a aplica lipiciul. Materiale perne 1 set la 2 participanți Include câte un element din următoarele: o spumă rigidă/burete rigid (e.g. spumă solidă) – 50 x 400 x 400 mm; o spumă moale/burete moale – 50 x 400 x 400 mm. Mostre de materiale disponibile care pot fi folosite pentru a fabrica husa de pernă 1 fiecare Pentru informații despre materialele adecvate, vezi sesiunile despre confecționarea pernelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 22. 3. Planificarea detaliată a sesiunilor Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 23. Introducere O B IE C TI V E La sfârșitul acestei sesiuni, participanții:  vor cunoaște obiectivele programului de instruire;  vor cunoaște numele formatorilor și al participanților;  vor avea o imagine globală asupra programului de instruire și al desfășurătorului acestuia;  vor cunoaște toate regulile importante de care trebuie să se țină cont în timpul programului de instruire. M A TE R IA LE Pentru sesiune:  prezentare PPT: Introducere;  Manualul participantului, pentru fiecare participant;  Caietul de exerciții practice, pentru fiecare participant;  DVD: Introducere  un exemplar din desfășurător, pentru fiecare participant;  ecusoane pentru toți formatorii și toți participanții. C O N TE X T Adaptați conținutul aceastei sesiuni pentru a fi în concordanță cu contextul local unde se desfășoară programul de instruire. De exemplu:  includeți o ceremonie de deschidere ce reflectă respectivul context cultural;  modificați sau adaptați secțiunea „prezentarea formatorilor și participanților” în așa fel încât acesta să se potrivească celor prezenți la curs;  modificați, adaptați și/sau completați lista de „reguli” și cea cu „așteptările participanților” după cum este necesar – exemplele pot fi găsite în descrierea programului de instruire;  modificați prezentarea ce conține descrierea cursului de instruire, dacă s-au făcut schimbări (de exemplu: obiective adăugate sau scoase). D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, vizionați materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Ceremonia de deschidere (dacă există). 2. Prezentarea formatorilor și a participanților. 3. Prezentarea generală a programului de instruire. 4. Desfășurătorul programului de instruire, Manualul participantului, Caietul de exerciții practice. 5. “Reguli” pentru desfășurarea cursului și așteptările participanților. 15 15 10 10 10 Total durată sesiune 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 24. 1. Ceremonia de deschidere (durata estimată 15 minute) 2. Prezentarea formatorilor și a participanților (15 minute) Formatori: Prezentați-vă. Oferiți o scurtă descriere a experienței pe care o aveți în furnizarea de scaune rulante. Cereți participanților ca la rândul lor să se prezinte, menționând numele, organizația pe care o reprezintă și ce speră să învețe de la programul de instruire. Oferiți ecusoane, dacă acestea nu au fost împărțite în timpul înregistrării participanților. 3. Prezentarea generală a programului de instruire (10 minute) Explicați: Scopul programului de instruire este ca fiecare participant să învețe cum să furnizeze un scaun rulant corespunzător și o pernă adecvată copiilor și adulților care pot menține poziția așezat.  Pachetul de instruire include: – Evaluarea utilizatorului de scaun rulant; – Selecția, pregătirea și probarea produsului (scaunului rulant); – Instruirea utilizatorului de scaun rulant; – Întreținerea și reparațiile; – Monitorizarea; – Cum se confecționează o pernă pentru reducerea presiunii din spumă/burete. Material video: Introducere – Acest DVD prezintă pe scurt programul de instruire pentru scaune rulante, scopul acestuia, obiectivele și așteptările. Prezentați materialul video. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 25. 4. Desfășurătorul programului de instruire, Manualul participantului și Caietul de exercitii practice (10 minute) Oferiți fiecărui participant un exemplar cu desfășurătorul programului de instruire. Explicați următoarele aspecte: o Programul de instruire va începe cu partea teoretică/sesiuni desfășurate în sala de curs. o Participanții vor exersa apoi câteva din abilitățile pe care le-au dobândit în timpul sesiunilor teoretice, împreună cu utilizatorii de scaun rulant care s-au oferit să îi asiste. Oferiți fiecărui participant un exemplar din Manualul participantului. Cereți acestora să își scrie numele în manual. Explicați că pot trece în manual informațiile suplimentare pe care doresc să le noteze. Oferiți fiecărui participant un exemplar din Caietul de exerciții practice. Cereți acestora să își scrie numele în caiet. Explicați că pot folosi acest caiet pentru exercițiile practice desfășurate pe parcursul programului de instruire și că acesta trebuie adus la fiecare sesiune a cursului. 5. Reguli de desfășurare și așteptări (10 minute) Explicați următoarele aspecte, după cum este necesar: o unde sunt localizate toaletele; o persoana de contact în ceea ce privește cazările; o persoana de contact pentru decontarea transportului (nu intrați în detalii); o cum se procedează în caz de urgențe. Explicați care sunt așteptările pe care le aveți de la participanți, în cadrul programului de instruire, după cum este necesar: o fiecare sesiune va începe la ora stabilită – participanții trebuie să se asigure că sosesc la timp la începutul fiecărei zi de pregătire și că se întorc la timp din pauzele de pe durata sesiunilor; o se recomandă ca participanții să pună întrebări oricând există neclarități; o tratați în mod egal toți utilizatorii de scaun rulant și respectați-le demnitatea; o închideți telefoanele mobile pe parcursul sesiunilor; o distrați-vă! Explicați: Pe durata programului de instruire, participanții vor folosi și vor manevra scaune rulante. La utilizarea scaunelor rulante, trebuie să vă amintiți următoarele măsuri de siguranță. o nu stați pe suportul de picioare la efectuarea transferului în și din scaunul rulant; o țineți degetele departe de spițele roților și de frâne; o la urcarea sau coborârea pantelor, este indicat să existe un însoțitor în spatele scaunului rulant, pentru cazul în care acesta s-ar putea răsturna pe spate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 26. A: Cunoștințe fundamentale Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 27. A.1: Utilizatorii de scaun rulant O B IE C TI V E La finalul acestei sesiuni, participanții vor putea:  să enumere cel puțin șapte beneficii ale unui scaun rulant corespunzător;  să explice cum personalul furnizor de servicii de scaune rulante poate sprijini dreptul la mobilitate personală al utilizatorului de scaun rulant;  să enumere cel puțin cinci modalități prin care utilizatorii de scaun rulant pot fi implicați în mod activ în furnizarea de scaune rulante. M A TE R IA LE Pentru sesiune:  prezentare PPT A.1 Utilizatorii de scaun rulant;  Manualul Participantului;  DVD: Beneficiile unui scaun rulant corespunzător;  exemplare din Convenția Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (CNUDPD), dacă acestea sunt disponibile; Materile suplimentare (pentru formatori): o Ghidul pentru frunizarea scaunelor rulante cu antrenare manuală în regiunile cu resurse limitate, publicat de OMS (pagina 23). C O N TE X T Adaptați conținutul acestei sesiuni pentru a fi în concordanță cu contextul cunoscut de participanți. De exemplu:  Participanții ar putea fi deja familiarizați cu CNUDPD– în acest caz, puteți să întrebați care sunt aspectele pe care le cunosc în legătură cu aceasta;  verificați dacă CNUDPD a fost semnată/ratificată în țară de unde provin participanții. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, vizionați materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Care sunt beneficiile unui scaun rulant? 3. Ce este un „scaun rulant corespunzător”? 4. Convenția Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități. 5. Utilizatorii de echipament de mobilitate sunt parteneri egali în livrarea serviciilor de scaune rulante. 6. Recapitulare puncte cheie. 2 10 5 5 20 3 Total durată sesiune 45 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 28. 1. Introducere (2 minute) Explicați: În cadrul acestei sesiuni, prezentați avantajele pe care le are utilizatorul de scaun rulant atunci când folosește un echipament de mobilitate corespunzător. Gândiți-vă la modalitățile prin care participanții pot implica în mod activ utilizatorii de scaun rulant în procesul furnizării echipamentului de mobilitate și la motivele pentru care acest lucru este important. De asemenea, prezentați pe scurt Convenția Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (UNCDPD), în special Articolul 1, Articolul 3 și Articolul 20. 2. Care sunt beneficiile unui scaun rulant? (10 minute) Citiți definiția scaunului rulant corespunzător. Explicați: o Această definiție este luată din Ghidul privind furnizarea scaunelor rulante cu antrenare manuală în regiunile cu resurse limitate, publicat de OMS. Pe parcursul programului de instruire vom face deseori referire la acest ghid. o În cazul fiecărui utilizator, „scaunul rulant corespunzător” va însemna un echipament de mobilitate de acest tip, care să răspundă cerințelor fizice individuale și condițiilor de mediu (locul unde locuiește și lucrează). Material video: Beneficiile scaunului rulant corespunzător – Acest material scurt va înfățișa mai mulți utilizatori de scaun rulant diferiți, implicați în diverse activități. Urmăriți cu atenție, deoarece vom vorbi despre beneficiile pe care scaunul rulant le aduce în fiecare din cazurile prezentate. Prezentați materialul video. Verificați dacă există întrebări. Întrebare: Care sunt beneficiile unui scaun rulant în cazul utilizatorilor prezentați în materialul video? Răspunsuri: o mobilitate; o stare bună de sănătate; o sprijin pentru poziția așezat; o confort; o stimă de sine și încredere; o demnitate; o posibilitatea de a de deplasa la școală; o posibilitatea de implicare în activități sportive; o posibilitatea de a avea un loc de muncă; o integrare în familie și în comunitate; o nivel crescut de independență. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 29. Explicați: o Așa cum se poate vedea și din listă, există multe avantaje care decurg din utilizarea unui scaun rulant. o Este foarte important să reținem faptul că furnizarea de scaune rulante nu se rezumă doar la echipamentul de mobilitate, care este doar un produs. o Furnizarea de scaune rulante înseamnă să oferim utilizatorilor de scaun rulant capacitatea de a se deplasa, posibilitatea de a-și menține starea de sănătate și oportunitatea de a participa pe deplin la viața comunității. o Fiecare utilizator de scaun rulant prezentat în materialul video este diferit. Cu toate acestea, ceea ce au în comun este că fiecare utilizează un scaun rulant „corespunzător”. 3. Ce este un scaun rulant corespunzător? (5 minute)  Un „scaun rulant corespunzător” este un echipament de mobilitate care: – răspunde cerințelor utilizatorului; – răspunde condițiilor de mediu ale utilizatorului; – i se potrivește utilizatorului; – asigură suport postural (ajută utilizatorul să stea în poziția așezat); – poate fi întreținut și reparat la nivel local. 4. Convenția Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (5 minute) Explicați: o Știm cu toții că multe persoane care au nevoie de un scaun rulant nu au încă un echipament de mobilitate adecvat. Totuși, avem la îndemână un instrument important, cu care putem să susținem drepturile acestor persoane. o În 2006 s-a semnat Convenția Națiunilor Unite privind Drepturile Persoanelor cu Dizabilități (CNUPDP). În 2008, aceasta a devenit lege internațională. (În cazul în care CNUDPD a fost semnată în țara/țările unde are loc programul de instruire, subliniați acest lucru.) Întrebare: Ați auzit de această convenție? Rețineți care sunt persoanele care au auzit de acest document. Explicați: Există drepturi ale omului care se aplică tuturor. Scopul CNUDPD este asigurarea recunoașterii faptului că aceste drepturi se aplică și în cazul persoanelor cu dizabilități. Explicați: o Convenția cuprinde 50 de articole diferite. o Articolul 20 se referă la mobilitatea personală. o Mobilitatea personală înseamnă: o capacitatea persoanei de a se mișca în maniera și la momentul alese de către aceasta. Întrebare: Cum pot participanții, prin rolul lor în cadrul serviciilor de scaune rulante, să sprijine dreptul la mobilitate al utilizatorului de scaun rulant? Încurajați participanții să răspundă și notați pe tabla de scris. Cele mai relevante răspunsuri: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 30. o implicând utilizatorii de scaun rulant în deciziile cu privire la echipamentul de mobilitate; o înțelegând care sunt nevoile utilizatorului de scaun rulant și răspunzând acestor nevoi; o contribuind la furnizarea unui scaun rulant corespunzător; o ajutând utilizatorii de scaun rulant să învețe efectuarea transferului în și din scaunul rulant; o ajutând utilizatorii de scaun rulant să învețe cum să efectueze propulsia scaunului rulant; o încurajând membrii familiei să sprijine utilizatorul de scaun rulant în efortul său de a fi mai independent; o susținând încercările pentru a o mai mare disponibilitate în țară a unor echipamente de mobilitate îmbunătățite; o promovând un mediu lipsit de bariere. Întrebare: Vă puteți gândi la alte drepturi ale omului de care o persoană cu dizabilităși de mobilitate se poate bucura cu mai multă ușurință atunci când are un scaun rulant corespunzător? Încurajați participanții să răspundă și notați pe tabla de scris. (dacă este nevoie, dați exemple de diverse drepturi). Răspunsuri (nu este nevoie să fie menționate articolele din Convenție): o dreptul de a trăi independent și de a fi inclus în comunitate (articolul 19); o dreptul la educație (articolul 24); o dreptul de a se bucura de cel mai înalt standard de sănătate posibil (articolul 25); o dreptul de a lucra și de a avea un loc de muncă (articolul 27); o dreptul de a participa la viața politică și publică (articolul 29); o dreptul de a participa la viața culturală, la recreere, activități de petrecere a timpului liber și sportive (articolul 30). 5. Utilizatorii sunt parteneri egali în furnizarea serviciilor de scaune rulante (20 de minute) Explicați: Utilizatorii vor știi deseori ce înseamnă pentru ei un „scaun rulant corespunzător”. Dacă au folosit deja un scaun rulant, vor știi ce funcționează în cazul lor și ce ar dori să schimbe. Persoanele care nu au mai folosit un scaun rulant vor avea nevoie de mai multe informații. Personalul furnizor de servicii de scaune rulante trebuie să lucreze cu utilizatorul în condițiile unui parteneriat. Activitate în grupe de dimensiuni reduse Grupe: Grupe de câte 2-3 participanți. Instrucțiuni: Cereți fiecărei grupe să petreacă cinci minute creând un joc de rol cu durata de două minute, în care utilizatorul de scaun rulant cere un astfel de echipament de mobilitate. Unul dintre participanți va fi utilizatorul, unul va reprezenta personalul furnizor de servicii de scaune rulante, iar celălalt participant va avea rolul unui membru de familie. Cereți ca jumătate din numărul de grupe să aibă câte un reprezentant care să joace rolul personalului furnizor de servicii de scaune rulante care NU RESPECTĂ dreptul utilizatorului de a avea un scaun rulant corespunzător și NU ÎL TRATEAZĂ pe acesta ca pe un participant activ în livrarea serviciilor de scaune rulante. Cereți celor din restul de grupe să aibă câte un reprezentant care să joace rolul personalului furnizor de servicii de scaune rulante care RESPECTĂ dreptul utilizatorului de a avea un scaun rulant corespunzător și ÎL TRATEAZĂ pe acesta ca pe un participant activ în livrarea serviciilor de scaune rulante. Monitorizare: Monitorizați/observați activitatea grupelor și oferiți sprijin, acolo unde este cazul. Durată: 5 minute pentru pregătire; 10 minute pentru jocul de rol și 5 minute pentru Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 31. feedback. Feedback: Cereți cel puțin unei grupe unde s-a jucat rolul de personal furnizor de servicii de scaune rulante care NU RESPECTĂ drepturile utilizatorului de scaun rulant și unei grupe unde s-a jucat rolul personalului care le RESPECTĂ să prezinte jocul de rol. Discuții ulterioare: o discutați diferențele în modalitatea prin care personalul furnizor de servicii de scaun rulant comunică cu utilizatorul de scaun rulant și cu familia acestuia; o întrebați persoanele care au avut rolul de utilizator de scaunul rulant, în fiecare grupă, despre modul în care s-a simțit; o dacă sunt prezenți utilizatori de scaun rulant, întrebați-i dacă au avut experiențe pozitive sau negative similare celor prezentate prin jocurile de rol. Întrebare: Pornind de la jocul de rol, care sunt câteva din modalitățile prin care personalul furnizor de servicii de scaune rulante pot implica în mod activ utilizatorii în procesul de furnizare al scaunului rulant? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o comunicarea directă cu utilizatorul de scaun rulant; o solicitarea opiniei utilizatorului de scaun rulant; o oricând este posibil, oferirea posibilității ca utilizatorul să facă alegerea și respectarea aceastei alegeri; o oferirea tuturor informațiilor necesare, în așa fel încât utilizatorul să poată face o alegere; o strângerea informații de la utilizatorii, cu privire la viața lor, la lucrurile pe care vor să le facă în scaun rulant și la mediul în care locuiesc și unde lucrează. 6. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 32. A.2: Serviciile pentru utilizatorii de scaun rulant O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să explice ce este un scaun rulant;  să identifice rolul pe care îl au în cadrul unui serviciu de scaune rulante – nivel de bază;  să definească „servicii la nivel de bază” în furnizarea de servicii de scaune rulante. M A TE R IA LE Pentru sesiune:  prezentare PPT: A.2: Servicii scaune rulante;  Manualul participantului;  afiș: Pașii în serviciile de scaune rulante. Materiale suplimentare (pentru formatori):  Ghidul pentru furnizarea scaunelor rulante cu antrenare manuală în regiunile cu resurse limitate, publicat de OMS (paginile 71-72, 76-77). C O N TE X T Adaptați conținutul acestei sesiuni pentru ca informațiile să fie în concordanță cu contextul cunoscut de participanți. Luați în considerare următoarele:  Rolul fiecărui participant la locul de muncă - în ceea ce privește furnizarea de servicii de scaune rulante. De exemplu, fiecare participant va fi responsabil pentru fiecare dintre cele opt etape în furnizarea serviciilor de scaune rulante? Folosiți această sesiune pentru a clarifica cu participanții care va fi rolul fiecăruia. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT și citiți planificarea sesiunii.  Pregătiți informațiile despre rolul fiecărui participant în cadrul fiecărei etape în livrarea serviciilor de scaune rulante. P R E ZE N TA R E 1. Introducere. 2. Servicii de scaune rulante. 3. Rolurile personalului furnizor de servicii de scaune rulante. 4. Ce înseamnă „serviciu la nivel de bază”? 5. Recapitulare puncte cheie. 2 10 10 5 3 Total durată sesiune 30 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 33. 1. Introducere (2 minute) Explicați: În cadrul aceste sesiuni: o explicați ce este un serviciu pentru utilizatorii de scaune rulante și diferența dintre serviciile la nivel de „bază” și la nivel „intermediar”; o vorbiți despre pașii cheie în livrarea serviciilor de scaune rulante; o discutați rolul pe care fiecare participant îl va avea în furnizarea unui scaun rulant în cadrul unui serviciu de scaune rulante - nivel de bază. 2. Serviciile pentru utilizatorii de scaun rulant (10 minute) Explicați: Furnizorul de servicii de scaune rulante lucrează cu utilizatorii pentru ca fiecare dintre aceștia să primească scaunul rulant adecvat (din cele disponibile). Întrebare: Ce ar trebui să facă personalul de servicii de scaune rulante pentru a ajuta la furnizarea scaunului rulant optim în cazul fiecărui utilizator? Încurajați participanții să răspundă și notați pe tabla de scris. Cele mai relevante răspunsuri: o să afle care sunt cerințele utilizatorului în ceea ce privește scaunul rulant (evaluare); o să ajute la alegerea celui mai bun scaun rulant pentru utilizator (prescriere); o să furnizeze un scaun rulant (plasare comandă, eventual asamblare, ajustare și probarea produsuluif). Întrebare: Ce ar trebui să facă personalul furnizor de servicii de scaune rulante pentru a ajuta utilizatorul să beneficieze de toate avantajele pe care i le poate oferi scaunul său rulant? Încurajați participanții să răspundă și notați pe tabla de scris. Cele mai relevante răspunsuri: o să instruiască utilizatorii de scaun rulant cu privire la folosirea echipamentului de mobilitate și la întreținerea acestuia (instruirea utilizatorului de scaun rulant); o să ajute utilizatorii de scaun rulant să facă reparații (întreținere la domiciliu, reparații și monitorizare); o să ofere sprijin și monitorizare pentru a se asigura că echipamentul de mobilitate răspunde în continuare nevoilor utilizatorului; o să îndrume utilizatorii de scaun rulant către alte servicii care le pot oferi asistență. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 34. 3. Rolul personalului furnizor de servicii de scaune rulante (10 minute) Prezentați afișul cu „Pașii în furnizarea de servicii de scaune rulante”. Explicați: Rolul personalului furnizor de servicii de scaune rulante – nivel de bază este să ofere utilizatorilor care pot sta în poziția așezat (fără suport postural suplimentar) cel mai bun scaun rulant disponibil. Pentru a face acest lucru, personalul va lucra cu fiecare utilizator de scaun rulant și cu familia acestuia, urmând etapele cheie ale procesului de livrare a serviciilor de scaune rulante. Explicați fiecare etapă, după cum urmează. Trimiterea și programarea: o Trimiterea este modalitatea prin care utilizatorii ajung în legătură cu serviciul de scaune rulante. o Modul prin care se face trimiterea utilizatorilor de scaun rulant variază. o Utilizatorii vor apela la aceste servicii fie din proprie inițiativă, fie prin rețele de lucrători sau voluntari din organizații guvernamentale/nonguvernamentale din domeniul sănătății și reabilitării, lucrând la nivel de județ sau regional. o Fiecare serviciu de scaune rulante trebuie să aibă un sistem pentru gestionarea programărilor. Evaluare: o Fiecare utilizator de scaun rulant are nevoie de o evaluare individuală. o Acest lucru include strângerea de informații cu privire la stilul de viață al utilizatorului, activitatea de la locul de muncă, spațiul unde locuiește, condiția fizică, precum și efectuarea măsurătorilor. Prescrierea (selecția): o Pornind de la informația obținută la evaluare se ajunge, împreună cu utilizatorul, un membru al familiei acestuia sau cu un însoțitor, la prescrierea (selecția) unui scaun rulant. o Prescrierea (selecția) include detalii despre tipul de scaun rulant ales, mărime, caracteristici speciale sau modificări. o Prescrierea (selecția) poate include și înregistrarea nevoii de instruire a utilizatorului în ceea ce privește folosirea și întreținerea în bune condițiide a scaunului rulant. Finanțarea și plasarea comenzii: o Se identifică sursa de finanțare și se comandă un scaun rulant din stocul pe care îl are respectivul furnizor de servicii sau de la producător. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 35. Pregătirea produsului (scaunului rulant): o Personalul furnizor de servicii de scaune rulante pregătește echipamentul de mobilitate. o În funcție de scaunul rulant ales și de facilitățile disponibile, pregătirea poate include: o asamblarea scaunului rulant; o fabricarea în întregime a scaunului rulant; o modificări minore aduse scaunului rulant. Probarea produsului (a scaunului rulant): o Utilizatorul încearcă scaunul rulant. o Scopul ajustărilor finale este să ne asigurăm că scaunul rulant este corect asamblat și pregătit. o Dacă sunt necesare modificări sau componente pentru suport postural, produsul (scaunul rulant) va trebui încercat din nou. Instruirea utilizatorului: o Personalul serviciului de scaune rulante trebuie să verifice care sunt informațiile pe care utilizatorul de scaun rulant și însoțitorul le au deja cu privire la folosirea și întreținerea echipamentului de mobilitate și identifică aspectele unde este nevoie de instruire. o Personalul serviciului de scaune rulante oferă instruirea necesară. Unele din temele esențiale sunt: o tehnici de manevrare a scaunului rulant; o tehnici de transfer în și din scaunul rulant; o mobilitatea în scaunul rulant; o întreținerea scaunului rulant; o prevenirea apariției escarelor; o cum se acționează în cazul în care există o problemă. o Unele servicii de scaune rulante oferă și consultanță în ceea ce privește modificări ale mediului în care locuiește utilizatorul, a școlii sau a locului de muncă, pentru facilitarea accesului. Acest aspect nu este cuprins în programul de instruire. Întreținerea, reparațiile și monitorizarea: o Oferă servicii de întreținere și reparații pentru probleme tehnice ce nu pot fi rezolvate în comunitate. o Întâlnirile de monitorizare sunt o componentă importantă în procesul de furnizare a serviciilor de scaune rulante. o În timpul monitorizării, personalul furnizor de servicii de scaune rulante verifică dacă echipamentul de mobilitate este potrivit și dacă oferă în continuare instruire și sprijin. o Dacă se constată că scaunul rulant nu mai este corespunzător, va fi furnizat un alt scaun rulant, reluându-se procesul de la etapa 1. Explicați: Pe parcursul programului de instruire, participanții vor învăța cum să parcurgă fiecare din aceste etape. Totuși, în cazul unor furnizori de servicii, persoane diferite pot fi responsabile pentru etape diferite. De exemplu, stabilirea programărilor poate fi în sarcina unui administrator, iar instruirea va fi făcută de un instructor utilizator de scaun rulant. Întrebare: Aveți întrebări cu privire la rolul de furnizor de servicii de scaune rulante? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 36. 4. Ce înseamnă servicii de scaune rulante la „nivel de bază”? (5 minute) Explicați: o Utilizatorii de scaun rulant au cerințe fizice diferite. Este nevoie de mai multe cunoștințe și abilități pentru a furniza un scaun rulant unei persoane cu probleme de postură sau menținere a echilibrului decât în cazul unui utilizator de scaun rulant care poate sta în poziția așezat și care are un bun echilibru. o Un serviciu de scaune rulante – nivel de bază poate oferi soluții pentru cerințele fizice ale utilizatorilor care pot menține poziția așezat. În acest program de instruire – nivel de bază, participanții învață cum să furnizeze un scaun rulant unui utilizator care poate menține poziția așezat. o În programele de instruire la nivel avansat, participanții învață cum să furnizeze scaune rulante persoanelor care nu pot menține poziția așezat și care au probleme posturale. o Este foarte important ca înainte de a furniza scaune rulante persoanelor cu probleme posturale, personalul furnizor de servicii de scaune rulante să beneficieze de instruire suplimentară. Acest lucru e necesar pentru a înțelege mai multe despre postură, despre cauzele problemor posturale și despre modalitatea de a oferi suport, în condiții de siguranță, unui utilizator de scaun rulant cu astfel de dificultăți. Explicați: Clara trăiește în Timorul de Est. Ea lucrează în magazinul pe care îl deține familia ei și care este în fața casei lor. Clara a avut poliomielită și are nevoie de un scaun rulant pentru a se mișca în interiorul casei, pentru a lucra la magazin și pentru a se deplasa prin sat. Ea poate menține poziția așezat fără sprijin și folosește un scaun cu antrenare manuală, care a fost ajustat și modificat în așa fel încât să i se potrivească. Clara este un exemplu de persoană căreia i se poate furniza un scaun rulant printr-un furnizor de servicii de scaune rulante – nivel de bază. Explicați: Ishade are vârsta de opt ani și locuiește în Sri Lanka. Are paralizie cerebrală. Acest lucru înseamnă că Ishade are dificultăți în a-și controla membrele superioare, inferioare, capul și gâtul. Nu poate menține poziția așezat fără sprijin. Ishade este un exemplu de persoană care are nevoie de suport postural suplimentar în scaunul rulant. Acest aspect nu este abordat în cadrul acestui curs de instruire - nivel de bază. Lui Ishade trebuie să i se furnizeze un scaun rulant printr-un furnizor de servicii de scaune rulante – nivel intermediar sau avansat. 5. Rezumat puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 37. A.3: Mobilitatea în scaunul rulant O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să se folosească, în condiții de siguranță, de abilitățile de manevrare a scaunului rulant, incluzând aici propulsia, întoarcerea, urcarea și coborârea unei pante, urcarea și coborârea treptelor cu însoțitor, menținerea echilibrului pe două roți. M A TE R IA LE Pentru sesiune:  prezentare PPT A.3: Mobilitatea în scaunul rulant;  Manualul participantului;  DVD: Manevrarea scaunului rulant;  DVD: Abilități de manevrare a scaunului rulant;  Afiș: Abilități de manevrare a scaunului rulant;  câte un scaun rulant pentru fiecare pereche de participanți. C O N TE X T Adaptați conținutul acestei sesiuni pentru ca informațiile să fie în concordanță cu contextul cunoscut de participanți.  Formatorii ar trebui să predea tehnica menținerii echilibrului pe două roți în cadrul acestei sesiuni doar în cazul în care consideră că au capacitatea de a demonstra această manevră și de a superviza participanții în timpul exersării abilității. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, vizionați materialul video și citiți planificarea sesiunii.  Alegeți un spațiu potrivit pentru exersarea abilităților de manevrare a scaunului rulant – o suprafață netedă, câteva porțiuni de teren aflat în pantă, una sau două trepte, o porțiune de teren accidentat.  Invitați un utilizator cu bune abilități de manevrare a scanului rulant să asiste la predarea acestor abilități.  Exersați voi înșivă abilitățile de manevrare, folosind materialul video ca punct de referință, pentru a vă asigura că aveți capacitatea de a demonstra respectivele tehnici.  Asigurați-vă că scaunele rulante sunt în bună stare de funcționare și că anvelopele sunt umflate corespunzător. P R E ZE N TA R E 1. Introducere. 2. De ce sunt importante abilitățile de manevrare a scaunului rulant? 3. Abilități de manevrare a scaunului rulant – siguranță. 4. Abilități de manevrare a scaunului rulant – demonstrație și exerciții practice. 5. Rezumat puncte cheie 2 15 5 65 3 Total durată sesiune 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 38. 1. Introducere (2 minute) Explicați: Pe parcursul acestei sesiuni, participanții vor învăța abilități de manevrare a scaunului rulant - nivel de bază, care îi vor ajuta să instruiască utilizatorii, în așa fel încât aceștia să atingă un nivel cât mai înalt de mobilitate. 2. Care este importanța abilităților de manevrare a scaunului rulant? (15 minute) Explicați: Un număr mare de utilizatori de scaun rulant trăiesc și lucrează în locuri unde accesul lor este îngreunat. Întrebare: Care sunt câteva din trăsăturile mediului local care fac dificilă utilizarea scaunului rulant? Încurajați participanții să răspundă și notați răspunsurile pe tablă. Cele mai relevante răspunsuri: o teren noroios; o teren nisipos; o pante abrupte; o spații reduse (de exemplu, în interiorul clădirilor); o teren accidentat sau denivelat; o pavaje sparte sau denivelate; o mașini sau alte obstacole aflate pe trotuare. Explicați: Instruirea în ceea ce privește abilitățile de manevrare a scaunului rulant poate ajuta utilizatorii să depășească unele din aceste obstacole/dificultăți, fie independent, fie cerând asistență. Material video: Abilități de manevrare a scaunului rulant. În acest material video, o tânără pe nume Sai vorbește despre faptul că faptul că a învățat să manevreze scaunul rulant, a produs o schimbare în viața ei. Prezentați materialul video. Verificați dacă sunt întrebări. Întrebați: Care au fost abilitățile de mobilitate în scaun rulant învățate de Sai? Cele mai relevante răspunsuri: o transferul în și din scaunul rulant; o depășirea unei borduri/denivelări – pentru a intra și a ieși din casă; o urcarea și coborârea unei pante; o propulsia. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 39. Întrebare: Ce schimbare aduc în viața lui Sai aceste abilități? Cele mai relevante răspunsuri: o este mai independentă; o are mai multă încredere în sine; o poate să iasă din casă, să meargă la școală, să își facă prieteni și să se joace. 3. Abilități de mobilitate în scaunul rulant – siguranță (5 minute) Prezentați afișul cu Abilitățile de mobilitate în scaunul rulant. Explicați: Siguranța este foarte importantă atunci când învățăm despre abilitățile de mobilitate în scaun rulant sau când predăm aceste abilități. Întrebare pentru participanți – care sunt principalele măsuri de siguranță în cazul lucrului cu scaune rulante abordate în cadrul cursului? Cele mai relevante răspunsuri: o nu stați pe suportul de picioare în timpul efectuării transferului în și din scaunul rulant; o nu poziționați degetele de spițele roții și pe frâne; o când exersați urcarea și coborârea pe un teren aflat în pantă, asigurați-vă ÎNTOTDEAUNA că există un însoțitor în spatele scaunului rulant, în cazul în care acesta se răstoarnă pe spate. Explicați: o În această sesiune, veți exersa diverse abilități de manevrare, inclusiv urcarea și coborârea unui teren aflat în pantă și ridicarea scaunului rulant în echilibru pe două roți (menținerea în echilibru a scaunului rulant doar pe roțile din spate). Explicați: o Asigurați-vă întotdeauna că există un însoțitor în spatele scaunului rulant în care se află persoana care își însușește aceste abilități. o Însoțitorul trebuie să stea aproape de partea posterioară a scaunului rulant. o Asistentul trebuie să fie pregătit să stabilizeze scaunul rulant în cazul în care acesta se înclină pe spate. Asistentul nu trebuie să țină scaunul rulant cu ajutorul mânerelor. o Nu asistați un utilizator de scaun rulant la urcarea și coborârea unui teren în pantă decât dacă sunteți foarte sigur/ă că aveți capacitatea de a controla echipamentul de mobilitate în condiții de siguranță. Dacă nu sunteți convins/ă de acest lucru, solicitați asistență. 4. Abilități de mobilitate în scaunul rulant – demonstrație și exerciții practice (65 de minute) Material video: Abilități de mobilitate în scaunul rulant. Cereți participanților să vizioneze cu atenție materialul video care prezintă demonstrații ale diverselor abilități de mobilitate. Este necesar ca ei să urmărească aceste abilități, deoarece ulterior le vor exersa și ei, la rândul lor. Prezentați materialul video. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 40. Verificați dacă sunt întrebări. Explicați o Participanții vor exersa abilitățile de mobilitate în scaun rulant prezentate în materialul video, cu excepția menținerii echilibrului pe două roți. o Menținerea echilibrului pe două roți este o abilitate mai complexă, care necesită exercițiu. Un utilizator de scaun rulant care poate să își mențină echilibrul pe roțile din spate poate folosi această abilitate pentru deplasarea pe teren accidentat, pentru coborârea pantelor, bordurilor și a treptelor . Nu încercați acest lucru dacă nu este prezent un formator experimentat. o Însușirea abilităților de mobilitate pe care le vom exersa astăzi este foarte utilă pentru orice persoană care lucrează cu utilizatori de scaun rulant. Dacă voi înșivă le stăpâniți deja, vă va fi mai ușor să îi ajutați pe aceștia să își însușească respectivele abilități. Activitate Grupe: Formați grupe alcătuite din câte doi participanți. Este recomandat ca membrii echipei să aibă înălțime, greutate și forță similare. Fiecare grupă primește câte un scaun rulant. Instrucțiuni: Cereți participanților să consulte secțiunea referitoare la mobilitatea în scaun rulant din Manualul participantului. Explicați că trebuie să lucreze în perechi, pentru a exersa: 1. propulsia și întoarcerea; 2. urcarea și coborârea unei pante; 3. urcarea și coborârea treptelor cu însoțitor; 4. ridicarea în echilibru pe două roți. Reamintiți-le participanților: o să exerseze tehnicile prezentate în materialul video și descrise în Manualul participantului; o asigurați-vă ÎNTOTDEAUNA că există o persoană în spatele fiecărui participant atunci când se exersează urcarea și coborârea unei pante sau echilibrul pe două roți; o atunci când se exersează pe urcarea sau coborârea treptelor, asigurați-vă că doar cei care pot să ridice greutăți fac această manevră. Supervizați/observați cu atenție, pentru a vă asigura că exercițiul se desfășoară în condiții de siguranță. Monitorizare: Treceți pe la fiecare grupă și supervizați activitatea pentru a vă asigura că tehnicile sunt exersate corect și în condiții de siguranță. În momentul în care observați nerespectarea procedurilor de siguranță, opriți activitatea grupelor pentru a le reaminti care sunt acestea. Demonstrați care este maniera corectă de manevrare a scaunului rulant, după cum este necesar. (vezi tehnicile de mai jos). Durată: Durata exercițiului va fi de 50 de minute, iar cea a discuțiilor ulterioare de 15 minute. Feedback: Refaceți grupele de participanți. Corectați toate erorile comune în tehnica de manevrare a scaunului rulant, observate de către formatori în timpul monitorizării exercițiului (demonstrați modalitatea corectă). Întrebare: Ce au învățat participanții din exersarea abilităților de mobilitate? Explicați: În timpul programului de instruire, participanții sunt încurajați să exerseze cu scaunele rulante disponibile înainte de începerea sesiunilor sau în timpul pauzelor de prânz. Trebuie întotdeauna să se asigure că au un însoțitor în spatele scaunului rulant atunci când exerseaza tehnica urcării și coborârii pantei sau pe cea a ridicării în echilibru pe două roți, până când ajung să aibă foarte multă încredere modul în care stăpânesc aceste tehnici. Notă pentru formatori – reluați aceste puncte în timpul exercițiilor practice. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 41. P ro pu ls ia o O propulsie corectă necesită mai puțin efort. Propulsia corectă se face pe arcul de cerc de la poziția ora 10 la poziția ora 2. o Pentru realizarea propulsiei, folosiți mișcări lungi, line. În to ar ce re a o Țineți unul din inelele de antrenare de partea anterioară, iar pe celălalt de partea posterioară. o Simultan, trageți mâna din față către spate și împingeți înainte mâna din spate. U rc ar ea p an te i o Înclinați corpul spre înainte – acest lucru va împiedica răsturnarea scaunului rulant. o Atunci când exersați, asigurați-vă că însoțitorul stă în spatele scaunului rulant. o Pentru a opri sau pentru a vă odihni – poziționați scaunul rulant pe lateral. C ob or âr ea p nt ei o Înclinați corpul pe spate. o Lăsați inelele de antrenare să alunece ușor prin palmă. o Utilizatorii de scaun rulant cu experiență, care pot sta în echilibru pe două roți” (adică să mențină scaunul rulant în echilibru doar pe roțile din spate) pot coborî o pantă pe roțile din spate. Aceasta este o metodă foarte eficientă. U rc ar ea tr ep te lo r, cu în so țit or o Poziționați scaunul rulant cu spatele la trepte. o Înclinați scaunul rulant pe roțile din spate, sprijinite de prima treaptă. o Însoțitorul trage de scaunul rulant înspre înapoi și în sus – scaunul rulant urcă. o Utilizatorul poate ajuta trăgând înspre înapoi inelele de inelele de antrenare. Un al doilea însoțitor poate ajuta ținând din față scaunul rulant, de cadrul acestuia (nu de suportul de picioare). C ob or âr ea tr ep te lo r, cu în so țit or o Poziționați scaunul rulant cu fața la trepte. o Înclinați scaunul rulant pe roțile din spate. o Însoțitorul lasă scaunul rulant să coboare, încet, câte o treaptă pe rând. o Utilizatorul poate ajuta controlând scaunul rulant cu ajutorul inelelor de antrenare. o Un al doilea însoțitor poate ajuta, susținând scaunul rulant de cadrul acestuia (nu de suportul de picioare). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 42. M en țin er ea e ch ili br ul ui p e do uă ro ți o Învățarea manevrei de ridicare în echilibru pe două roți este foarte folositoare pentru utilizatorul de scaun rulant. o Utilizatorul de scaun rulant poate ridica roțile frontale pentru a depăși borduri joase, pietre și alte obstacole. o Împingeți scaunul rulant înspre înapoi până când mâinile ajung în dreptul poziției ora 10. Apoi împingeți în față cu rapiditate. o Roțile din față ar trebui să se ridice. o Cu antrenament, este posibilă ridicarea roților frontale atunci când este nevoie să se depășească mici obstacole. o Asigurați-vă întotdeauna că există un însoțitor în spatele scaunului rulant atunci când utilizatorul începe să exerseze această manevră. 5. Rezumat puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 43. A.4: Poziția așezat O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere cel puțin zece caracteristici ale „poziției așezat” (poziția neutră de ședere);  să enumere cel puțin șase beneficii ale poziției așezat;  să demonstreze patru modalități prin care bazinul se poate mișca;  să explice modul în care mișcarea bazinului poate schimba postura;  să recunoască diverse posturi de ședere și cum se deosebesc acestea de poziția așezat. M A TE R IA LE Pentru sesiune:  prezentare PPT: A.4 Poziția așezat;  Manualul participantului;  Caietul de exerciții practice;  ½ schelet de anatomie cu bazin, coloană vertebrală și femur (dacă este disponibil). C O N TE X T Adaptați conținutul acestei sesiuni pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții și pentru ca acestea să răspundă nevoilor lor de instruire.  Această sesiune presupune cunoștințe de bază despre bazin. Dacă participanții nu cunosc încă structura osoasă a bazinului, acest aspect trebuie abordat în cadrul acestei sesiuni sau înainte de începerea programului de instruire. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Poziția așezat / Poziția neutră de ședere. 3. Cum afectează bazinul modul în care stăm. 4. Diverse posturi. 5. Rezumat puncte cheie. 2 20 10 25 3 Total durată sesiune 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 44. 1. Introducere (2 minute) Explicați: Cei mai mulți utilizatori de scaun rulant petrec multe ore în poziția așezat. Scaunul rulant nu este doar un dispozitiv de mobilitate. El contribuie și la menținerea poziției neutre de ședere confortabile. Pe parcursul acestei sesiuni ne vom concentra pe aspecte legate de poziția așezat. Vom vorbi despre caracteristicile poziției așezat. Vom avea în vedere avantajele ce decurg din menținerea acestei poziții. Participanții vor exersa identificarea diferențelor dintre poziția așezat și alte posturi. Vom discuta și despre problemele care apar atunci când nu se menține poziția așezat. 2. Poziția așezat/poziția neutră de ședere (20 de minute) Întrebare: Poate cineva să explice termenul „postură”? Încurajați participanții să răspundă. Explicați: Exista diverse „posture de ședere”. Evidențiați poziția în care sunt așezați participanții la curs. Explicați: o Atunci când furnizați un scaun rulant, este important să încurajați utilizatorii să stea în poziția așezat. o “poziția așezat” este uneori denumită “poziția neutră de ședere”. Rugați o persoană din grup să se așeze într-un scaun în fața restului participanților la curs. Cereți-i să stea în „poziția așezat”. (Asigurați-vă că voluntarul stă în poziția corectă, poziția neutră de ședere). Cereți grupului să descrie postura voluntarului. Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o bazinul drept și la același nivel; o umerii la același nivel, brațele au libertate de mișcare; o trunchiul este drept; o spatele prezintă cele trei curburi naturale; o capul stă drept și în echilibru în raport cu corpul; o șoldurile sunt îndoite la 90 de grade; o picioarele aflate ușor în abducție; o genunchii și gleznele flexate la un unghi de aproape 90 de grade; o călcâiele sunt pe aceeași linie cu genunchii sau ușor mai în față sau mai în spate; o întreaga suprafață a tălpilor atinge podeaua. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 45. Cum determinăm dacă o persoană menține poziția așezat Priviți din profil și verificați dacă:  Bazinul e drept;  Trunchiul este drept, spatele prezintă cele trei curbe naturale;  Șoldurile sunt îndoite la un unghi de aproape 90 de grade;  Genunchii și gleznele sunt îndoite la un unghi de aproape 90 de grade;  Călcâiele sunt pe aceeași linie cu genunchii sau ușor mai în față sau mai în spate;  Tălpile așezate pe podea sau pe suportul de picioare. Priviți din față și verificați:  Bazinul la același nivel;  Umerii la același nivel, brațele au libertate de mișcare;  Picioarele aflate ușor în abducție;  Capul stă drept și în echilibru în raport cu corpul. Explicați: o Poziția așezat nu este aceeași pentru toate persoanele. o Următoarele slide-uri vor arăta care sunt elementele cheie cărora trebuie să li se acorde atenție – totuși, acestea nu sunt decât niște linii directoare. o Aspectul cel mai important în ceea ce privește poziția așezat este ca persoana să fie relaxată, confortabilă și să aibă echilibru. Parcurgeți prezentarea pentru a evidenția punctele cheie. Explicați: o Șoldurile, genunchii și gleznele pot fi mai depărtate sau flectate – acest lucru nu constituie o greșeală. o Persoana trebuie să aibă echilibru și să se simtă confortabil. Parcurgeți prezentarea pentru a evidenția punctele cheie. Cereți tuturor participanților să adopte poziția neutră de ședere. Întrebare: Ar putea participanții să stea în această poziție pe parcursul întregii zile, fără suport (de exemplu spătar)? Cei mai mulți vor răspunde NU. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 46. Explicați: o Fără un suport adecvat în scaun, ar fi foarte dificilă menținerea acestei poziții de-a lungul întregii zile. Acesta este motivul pentru care persoanele își schimbă frecvent poziția în care sunt așezate. o Pentru a menține poziția așezat, un utilizator de scaun rulant care stă în scaunul rulant pe parcursul întregii zile, va avea nevoie de suport adecvat la nivelul echipamentului de mobilitate - pernă, spătar și suport de picioare. Întrebare: Care sunt beneficiile poziției așezat? Încurajați participanții să răspundă și notați pe tablă. Cele mai relevante răspunsuri: o sănătate; o stabilitate; o distribuția greutății; o confort; o mai multă activitate; o prevenirea problemelor posturale; o respect de sine și încredere. Întrebare: Cum poate personalul furnizor de servicii de scaune rulante să ajute utilizatorul în vederea menținerii poziției așezat? Încurajați participanții să răspundă și notați pe tablă. Cele mai relevante răspunsuri: o asigurându-se că scaunul rulant este unul potrivit utilizatorului; o explicând utilizatorilor de ce este important să adopte poziția așezat, dacă pot face acest lucru; o arătând utilizatorilor cum adoptă poziția așezat. Explicați: Nu toți utilizatorii de scaun rulant pot sta în poziția așezat. Acest aspect va fi abordat în decursul acestei sesiuni. 3. Cum influențează poziția bazinului modul în care stăm (10 minute) Explicați: Bazinul constituie baza poziției așezat. Pentru a fi puternică și stabilă, orice clădire are nevoie de o fundație solidă. În același mod, pentru a fi stabil în poziția așezat, bazinu trebuie să fie puternic și stabil. Explicați: Bazinul se mișcă în diferite moduri în raport cu trunchiul și cu articulațiile șoldului. Aceste mișcări sunt : o înclinat anterior (înclinare pelviană anterioară). Explicați: Imaginea arată o vedere din profil a bazinului. o înclinat posterior (înclinare pelviană posterioară). Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 47. Explicați: Imaginea arată o vedere posterioară a bazinului. o înclinare laterală (înclinare pelviană laterală). Explicați: Imaginea arată o vedere de sus a bazinului. o rotație. Cereți fiecărei persoane să își poziționeze mâinile pe partea superioară a bazinului (deasupra crestei iliace). Poziționați mâinile pe creasta iliacă și demonstrați fiecare mișcare a bazinului. Cereți participanților să procedeze la fel. Mișcarea Ilustrație Schimbări la nivelul corpului Înclinat anterior: (înclinare pelviană anterioară). Bazinul - vedere laterală o Trunchiul se îndreaptă, umerii sunt trași înapoi. o crește curbura coloanei în zona de deasupra bazinului. Înclinat posterior: (înclinare pelviană posterioară). Bazinul – vedere laterală o Trunchiul se curbează, cu umerii orientați înainte. Înclinat lateral: (înclinare pelviană laterală). Bazinul – vedere posterioară o Trunchiul se îndoaie în lateral. Rotație. Bazinul – vedere de sus o Restul corpului se rotește și el. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 48. După fiecare mișcare, cereți participanților să descrie ce sesizează la nivelul corpului. Întrebare: Cum v-ați simțit menținând corpul în aceste posturi? Dacă participanții nu sunt siguri, cereți-le să repete mișcările și să mențină postura, pentru a observa aceste aspecte. Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o inconfortabil; o dificultăți de mișcare; o distribuție inegală a greutății; o dificultăți în a folosi brațele pentru a desfășura diverse activități; o dificultăți de respirație; o oboseală; o presiune pe organe; o dificultăți în menținerea echilibrului. Explicați: În poziția așezat, bazinul este și el drept (sau ușor înclinat anterior) și la același nivel. Dacă bazinul nu este drept, poziția neutră de ședere nu este posibilă. 4. Diverse posturi de ședere (25 de minute) Activitate Grupe: Alcătuiți echipe de câte 2-3 participanți. Instrucțiuni: Cereți fiecărui grup: o să observe cu atenție fiecare exemplu de postură din fișele de lucru aflate în caietul de exerciții practice; o să noteze modul în care fiecare postură diferă de poziția așezat; o să se gândească la caracteristicile poziției așezat, privită din față și din lateral. Monitorizare: Supervizați activitatea grupelor și oferiți asistență, dacă e necesar. Durata: Durata exercițiului va fi de 10 minute. Feedback: Arătați pe rând imaginile care înfățișează câte o postură. Cereți fiecărei grupe (pe rând) să descrie diferențele dintre postura din imagine și poziția așezat. Cereți participanților să adauge orice aspect care nu este deja notat pe fișele lor de lucru. Informații pentru formatori – Cele mai relevante răspunsuri: o bazinul nu este la același nivel (partea dreaptă este mai sus); o umerii nu se află la același nivel (partea stângă este mai sus); o trunchiul este curbat pe o parte; o piciorul drept este orientat înspre interior; o glezna dreaptă este orientată înspre interior; o glezna stângă este orientată înspre interior. Informații pentru formatori – Cele mai relevante răspunsuri: o bazinul este înclinat posterior; o trunchiul colapsat (curbat anterior, pe lateral și rotit); o umerii nu se află la același nivel; o capul este înclinat spre spate și bărbia este orientată în față – nu se află în echilibru în raport cu bazinul; o genunchii nu sunt îndoiți în poziție neutră; o gleznele nu sunt îndoite în poziție neutră; o un braț poziționat între picioare, iar celălalt poziționat în spatele mânerelor – utilizatorul nu stă stabil în scaunul rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 49. Informații pentru formatori – Cele mai relevante răspunsuri: o bazinul nu este în echilibru (înclinare pelviană posterioară); o trunchiul este curbat înspre înainte; o umerii sunt rotunjiți și orientați înspre înainte; o capul nu se află în echilibru în raport cu bazinul; o bărbia este orientată înspre înainte. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 50. Explicați: o Cele trei exemple arătate participanților arată posturi care sunt diferite de „poziția așezat”. Acestea pot fi „rigide”, ceea ce înseamnă că ele nu mai pot fi corectate. În alte cazuri, postura poate fi flexibilă, deci persoana poate sta în poziția neutră de ședere, în cazul în care există sprijin postural. o Atunci când o persoană nu stă în poziția așezat (nici cu suport) și este „fixată” într-o altă postură, acest lucru poate fi uneori soluționat aducând modificări scaunului rulant. Acest program de instruire nu acoperă însă aceste aspecte. Întrebare: Care sunt problemele care pot să apară în absența poziției așezat? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o apariția escarelor; o în timp, corpul utilizatorului poate să rămână fixat într-o poziție diferită, existând posibilitatea ca acesta să nu mai poată sta în poziția așezat; o dificultăți în mișcarea capului și a gâtului, cu impact asupra câmpului vizual, dificultăți în a desfășura activități; o dificultăți la nivel de respirație, poate afecta procesul de digestie; o nivel crescut de oboseală; o îngreunează deglutiția; o poate cauza disconfort și durere; o îngreunează menținerea echilibrului; o îngreunează folosirea brațelor și mâinilor; o spasticitate sau rigiditate musculară; o stimă de sine scăzută. Enumerați problemele cauzate de absența poziției așezat, așa cum se vede în prezentare. 5. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 51. A.5: Escarele O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere cele patru faze ale escarei;  să evalueze dacă persoana cu escară trebuie să fie consultată de un specialist;  să enumere serviciile disponibile la nivel local, unde utilizatorii de scaun rulant pot primi tratament pentru escare;  să enumere cele trei cauze majore ale apariției escarelor;  să identifice principalele zone predispuse la apariția escarelor;  să enumere factorii de risc care pot duce la apariția escarelor;  să enumere modalitățile prin care utilizatorii de scaun rulant pot evita apariția escarelor;  să demonstreze două tehnici de reducere a presiunii. M A TE R IA LE Pentru sesiune:  prezentare PPT: A.5 Escarele;  Manualul participantului;  DVD: Testimonial escare;  Afiș: Escarele;  un scaun rulant (dotat cu o pernă) pentru fiecare grupă alcătuită din câte doi participanți (unul pentru fiecare pereche). C O N TE X T Adaptați conținutul acestei sesiuni pentru ca informația să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare:  invitarea unui utilizator de scaun rulant care a avut o escară, pentru ca acesta să își împărtășească participanților experiența avută. D E P R E G Ă TI T  Pregătiți materialele, revedeți prezentarea PPT și citiți planificarea sesiunii.  Pregătiți o listă a serviciilor disponibile la nivel local, unde utilizatorii de scaun rulant pot primi tratament pentru escare. Dacă participanții vin din zone îndepărtate, îi puteți ruga să aducă aceste informații la curs.  Invitați un utilizator de scaun rulant care a avut o escară, pentru ca acesta să poată împărtăși această experiență.  Introduceți lista resurselor în slide-ul 6 al prezentării PPT a acestei sesiuni. P R E ZE N TA R E 1. Introducere. 2. Escare. 3. Când și unde trebuie solicitat ajutor. 4. Care sunt cauzel„e apariției escarelor? 5. Factori de risc în apariția escarelor 6. Cum poate fi prevenită apariția escarelor? 7. Testimonial escare. 8. Tehnici de reducere a presiunii. 9. Rezumat puncte cheie. 2 5 5 10 10 10 5 10 3 Total durată sesiune 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 52. 1. Introducere (2 minute) Explicați: Pe parcursul acestei sesiuni, vom învăța despre escare. Nu toți utilizatorii de scaun rulant sunt predispuși la apariția escarelor. Totuși, în cazul persoanelor la care apar escare, consecințele pot fi foarte grave. 2. Escarele (5 minute) Prezentați afișul Escarele. Întrebare: Ați avut ocazia să vedeți o escară? Discutați pe scurt. Explicați: o Cu cât escara este mai extinsă, cu atât problemele determinate de acestea sunt mai mari. o Escarele pot însemna perioade lungi de repaus la pat. o Dacă escara se infectează, infecția se poate răspândi în sânge, la inimă sau în oase. Acest lucru poate determina boli grave, chiar fatale. o Explicați: Există patru stadii în dezvoltarea escarelor. Explicați: o Etapa 1 se manifestă printr-o pată întunecată pe piele. Roșeața sau schimbarea culorii nu se estompează în interval de 30 de minute de la îndepărtarea presiunii. o Etapa 2 este reprezentată de o rană superficială, iar stratul superior al pielii începe să se descuameze sau să formeze o veziculă. o Etapa 3 înseamnă o rană adâncă, întregul strat de piele este distrus. o Etapa 4 este echivalentul unei răni foarte adânci, care se extinde prin mușchi, ajungând chiar până la os. Întrebare: Care sunt zonele cele mai predispuse la apariția escarelor? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o oasele bazinului; o coccisul; o baza coloanei vertebrale (zona sacrală); o oasele șoldurilor; o omoplați; o coloana vertebrală. 3. Când și unde se poate solicita ajutor (5 minute) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 53. Întrebare: Ce fel de sfat trebuie să primească un utilizator de scaun rulant care are o escară în faza 1? Încurajați participanții să răspundă. Subliniați (sau oferiți) răspunsul corect. Cele mai relevante răspunsuri: o În cazul unei persoană cu o escară aflată în faza 1: o se îndepărtează imediat presiunea exercitată asupra respectivei zone; o se îndepărtează presiunea de pe zona afectată, până la vindecarea completă a pielii. o Acest lucru poate însemna repaus la pat (în funcție de localizarea escarei). o Identificați cauza și îndepărtați-o. o Instruiți utilizatorul de scaun rulant cu privire la modalitatea de apariție a escarelor și prevenirea acestora. Întrebare: Ce fel de sfat trebuie să primească un utilizator de scaun rulant care are o escară în faza 2, 3 sau 4? Încurajați participanții să răspundă. Subliniați (sau oferiți) răspunsul corect. Cele mai relevante răspunsuri: o Urmați pașii prevăzuți în cazul escarei în aflate în faza1. și Utilizatorul de scaun rulant trebuie să primească tratament de la un cadru medical cu experiență. Escarele deschise trebuie toaletate, pansate și monitorizate pentru a asigura vindecarea lor și prevenirea infecțiilor. Este posibil ca escarele aflate în faza 4 să necesite intervenție chirurgicală. Cereți participanților să copieze lista în tabelul din Caietul de exerciții practice (pagina 4). 4. Care sunt cauzele apariției escarelor? (10 minute) Explicați: Cele trei cauze principale ale apariției escarelor sunt. Citiți informațiile de pe slide. Explicați: Vom analiza mai în detaliu fiecare din aceste cauze. Explicați: o Escarele pot fi cauzate de presiunea exercitată pe piele la menținerea pe o perioadă prea lungă a poziției (așezat sau culcat), fără schimbarea acesteia. o Escarele sunt o cauză majoră de deces a persoanelor cu leziuni ale coloanei vertebrale. Cereți participanților să își poziționeze mâinile sub bazin și să fie atenți la presiunea exercitată de oasele bazinului. Întrebare: Ce s-ar Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 54. întâmpla dacă ați menține această poziție un timp îndelungat, fără a vă mișca? Răspuns: o În scurt timp, poziția devine inconfortabilă din cauza presiunii permanente exercitate asupra aceleiași părți a corpului. Explicați: o Fricțiunea este frecarea continuă exercitată asupra pielii. De exemplu, contactul brațului cu roata/suportul de brațe în timpul mișcării scaunului rulant poate provoca apariția unei escare. o Fricțiunea constituie o problemă mai ales în cazul utilizatorilor de scaun rulant care și-au pierdut sensibilitatea. o Loviturile pot avea loc la efectuarea transferurilor sau la manevrarea scaunului rulant. o Explicați: o Alunecarea are loc atunci când pielea rămâne imobilă și este întinsă sau ciupită atunci când se mișcă mușchii sau oasele. Cereți participanților să își poziționeze din nou pe mâinile sub bazin și să își miște bazinul înspre spate, observând senzația produsă la nivelul oaselor. De exemplu, atunci când utilizatorul stă „prăbușit” în scaunul rulant, pielea poate fi deteriorată de alunecarea care se produce la nivelul oaselor bazinului, determinată de mișcarea înainte și înapoi a bazinului sau de către prinderea pielii între oasele spatelui și spătar. 5. Factori de risc ce pot determina apariția escarelor (10 minute) Explicați: o Pe lângă cele trei cauze principale care duc la apariția escarelor, există niște factori care cresc potențialul producerii acestora. Aceștia se numesc factori de risc ce determină apariția escarelor. Întrebare: Puteți să numiți câțiva factori de risc ce determină apariția escarelor? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o lipsa sensibilității (sensibilitate scăzută); o imobilitatea; o umezeala cauzată de transpirație, apă sau incontinență; o nutriție necorespunzătoare și hidratare insuficientă; o înaintarea în vârstă; o greutatea (subponderabilitate sau supraponderabilitate); o postura incorectă; o escare anterioare sau actuale; o traumatisme, lovituri sau izbituri; o căldura/febra; o înțepături de insecte. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 55. Explicați: Cei mai importanți factori de risc pe care trebuie să îi reținem sunt: o lipsa sensibilității (sensibilitate scăzută); o imobilitatea; o nutriție necorespunzătoare și hidratare insuficientă; o postura incorectă; o escare anterioare sau actuale; o nutriție necorespunzătoare și hidratare insuficientă; o înaintarea în vârstă; o greutatea (subponderabilitate sau supraponderabilitate). Explicați: o Cel mai important factor de risc este lipsa sensibilității. Persoana care nu percepe senzațiile nu poate simți presiunea. Acest lucru înseamnă că probabilitatea ca persoana să își schimbe poziția, pentru a reduce presiunea exercitată, este scăzută. La persoanele care nu percep senzația sau la care senzația tactilă la nivelul feselor, șezutului sau picioarelor este scăzută există riscul apariției escarelor. o Cele mai multe persoane cu traumatism vertebro-medular nu pot percepe senzații în părțile corpului aflate sub nivelul leziunii. Acest lucru reprezintă un factor de risc ce poate determina apariția escarelor. În cazul persoanelor cu traumatism vertebro-medular există posibilitatea ca ele să nu aibă control la nivelul vezicii urinare sau al sfincterului. În lipsa unei modalități de a gestiona incontinența, riscul apariției escarelor este mai mare, din cauza umezelii rezultate. Explicați: o Personalul furnizor de servicii de scaune rulante trebuie să cunoască factorii de risc ce duc la apariția escarelor, pentru a putea identifica utilizatorii de scaun rulant la care acest risc este prezent. o Verificarea existenței factorilor de risc ce duc la apariția escarelor este parte a etapei de evaluare: o riscul apariției escarelor este prezent la persoanele la care este absentă sensibilitatea; o riscul apariției escarelor există în cazul persoanelor la care sunt prezenți trei sau mai mulți factori. Factorii de risc ce determină apariția escarelor sunt: o Absența sensibilității (sensibilitate scăzută): În cazul oricărei persoane la care este absentă sensibilitatea sau la care nivelul sensibilității este scăzut în zona feselor (ca în cazul celor mai multe persoane paraplegice sau tetraplegice), a bazinului sau picioarelor există pericolul apariției escarelor. o Imobilitatea: Atunci când o persoană nu se poate mișca, este incapabilă să reducă presiunea. o Umezeala cauzată de transpirație, apă sau incontinență: Umezeala face pielea moale și mai susceptibilă la afecțiuni. Dacă există probleme de management vezical și intestinal, urina și materialele fecale pot provoca leziuni la nivelul pielii. o Postura incorectă: O altă poziție decât poziția neutră de ședere poate cauza creșterea presiunii într-una din zone. o Escare anterioare sau actuale. o Nutriție necorespunzătoare și hidratare insuficientă: Un regim alimentar adecvat, care să includă și un consum suficient de apă asigură corpului necesarul de fluide și nutrienți pentru o piele sănătoasă și pentru vindecarea rănilor. o Înaintarea în vârstă: Persoanele vârstnice au deseori o piele subțire, sensibilă, care poate fi afectată cu ușurință. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 56. o Greutatea (subponderabilitate sau supraponderabilitate): Persoanele supraponderale pot avea o circulație defectuoasă la nivelul pielii, aceasta putând fi ușor afectată și vindecându- se greu. La utilizatorii de scaun rulant subponderali există riscul apariției escarelor din cauză că oasele lor nu sunt suficient de protejate. Pielea din zonele osoase poate fi afectată rapid. Zonele cele mai expuse la presiune: Vedere laterală Vedere posterioară 6. Cum pot fi evitate escarele? (10 minute) Explicați: o Personalul furnizor de servicii medicale poate ajuta utilizatorii de scaun rulant în ceea ce privește prevenirea apariției escarelor. o Profilaxia escarelor duce la evitarea perioadelor lungi de spitalizare, elimină acele situații în care utilizatorii nu se pot folosi de scaunul rulant și poate preveni chiar decesul. o Diferitele metode prin care poate fi prevenită apariția escarelor includ: Explicați: Folosirea unei perne pentru reducerea presiunii  O pernă pentru reducerea presiunii va ajuta la diminunarea acesteia. Orice persoană la care există riscul apariției escarelor trebuie să primească o pernă pentru reducerea presiunii. Explicați: Poziția așezat  Poziția așezat ajută la distribuirea uniformă a greutății. Acest lucru duce la reducerea presiunii sub părțile osoase și a incidenței apariției escarelor cauzate de presiune.  Poziția așezat ajută și la evitarea escarelor cauzate de alunecare.  Asigurați-vă că scaunul rulant are dimensiunea potrivită. Astfel, utilizatorul va putea sta în poziția așezat.  Instruiți utilizatorii de scaun rulant cu privire la importanța poziției neutre de ședere. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 57. Explicați: Folosirea tehnicilor de reducere a presiunii  Reducerea presiunii la interval de timp regulate poate fi eficientă în prevenirea apariției escarelor.  Acest aspect va fi abordat în detaliu pe parcursul acestei sesiuni. Explicați: Nutriție corespunzătoare și hidratare suficientă  O dietă echilibrată, care include legume proaspete, fructe și carne poate ajuta la prevenirea apariției escarelor.  Consumul de lichide ajuta la păstrarea sănătății pielii și la evitarea apariției escarelor.  Dacă vă îngrijorează dieta unui utilizator de scaun rulant, luați în considerare posibilitatea de a-l trimite către un serviciu specializat, care îi poate oferi asistență. Explicați: Evitarea fricțiunii  Asigurați-vă că scaunul rulant are dimensiunea potrivită și că nu are margini dure.  Utilizatorii în cazul cărora sensibilitatea este absentă trebuie instruiți să verifice dacă există părți ale corpului asupra cărora scaunul rulant exercită fricțiune.  Instruiți utilizatorii să fie atenți la efectuarea transferurilor. Explicați: Evitarea umezelii  Utilizatorii de scaun rulant trebuie sfătuiți să își schimbe imediat îmbrăcămintea udă sau pătată și să nu folosească perne ude.  O rutină a managementului vezical și intestinal poate reduce problemele legate de umezeală.  Recomandați utilizatorilor cu probleme de incontinență să apeleze la un serviciu care îi poate ajuta. Explicați: Verificarea zilnică a pielii Escarele se pot dezvolta cu rapiditate. Este important ca escara să fie identificată fără întârziare și să se acționeze în acest sens. Încurajați utilizatorii de scaun rulant la care există riscul apariției de escare să își verifice zilnic suprafața pielii. Ei se pot verifica singuri, cu ajutorul unei oglinzi sau pot apela la un membru de familie.  Dacă observă o zonă în care pielea este roșie sau mai întunecată (faza 1 a evoluției escarelor), trebuie luate măsuri imediate pentru înlăturarea presiunii exercitate asupra acelui punct. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 58. Explain: o Changing position regularly helps to relieve pressure. o For example, change position from sitting to lying. o This is particularly important for someone who has a number of pressure sore risk factors, or has a recently healed pressure sore. o People who cannot change position by themselves are at risk. Expl cați: Schimbarea regulată a poziției așezat sau culcat  Schimbarea regulată a poziției ajută la reducerea presiunii. De exemplu, schimbați poziția așezat în poziția culcat.  Acest lucru este deosebit de important în cazul persoanelor la care sunt prezente mai mulți factori de risc de pariție a escarelor sau care au o escară vindecată recent.  În ceea ce privește persoanele care nu își pot schimba poziția, la acestea există riscul apariției escarelor. 7. Testimonial escare (5 minute) Materialul video ce conține testimonialul referitor la Escare. Prezentați materialul video. Verificați dacă există întrebări. 8. Tehnici de reducere a presiunii (10 minute) Explicați: o În timpul folosirii scaunului rulant, utilizatorii au posibilitatea de a reduce presiunea existentă la nivelul oaselor bazinului. o Modalitatea adoptată variază, în funcție de forța și echilibrul pe care le are utilizatorul. o În cadrul acestui program de instruire, vor fi prezentate două metode sigure pentru reducerea presiunii. Acestea sunt aplecarea înainte și aplecarea în lateral. o Personalul furnizor de servicii de scaune rulante trebuie să instruiască toți utilizatorii la care există riscul apariției escarelor cu privire la cel puțin o tehnică de reducere a presiunii. Activitate Grupe: Cereți participanților să formeze grupe de câte doi participanți. Instrucțiuni: Furnizați câte un scaun rulant fiecărei echipe de participanți. Cereți perechilor să se poziționeze în așa fel încât să vă poată urmări. Demonstrați fiecare metodă și explicați cum diversele modalități sunt utile pentru utilizatori de scaun rulant diferiți. Cereți participanților să exerseze fiecare metodă imediat după ce aceasta a fost demonstrată. Monitorizare: Supervizați cu atenție și corectați tehnicile, dacă acest lucru este necesar. Durată: Durata exercițiului este de 10 minute. Observații pentru formatori: Unii utilizatori de scaun rulant reduc presiunea sprijinind-se pe brațe și ridicându-și corpul. Pentru ca circulația să se restabilească în mod corespunzător, utilizatorul trebuie să mențină această poziție timp de două minute. Acest lucru necesită multă forță și solicită în mod deosebit umerii. În plus, utilizatorii trebuie să fie capabili să își controleze cu atenție corpul (greutatea) atunci când se așază înapoi în scaunul rulant. Dacă se așază cu prea multă forță, pot Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 59. să producă leziuni la nivelul pielii. Din această cauză, această metodă nu este cuprinsă în acest program de instruire. Aplecarea înainte: O metodă care se potrivește majorității utilizatorilor de scaun rulant. Recomandați tuturor utilizatorilor de scaun rulant să folosească frecvent această metodă, pe tot parcursul zilei. Independent: Pentru persoanele care au un bun echilibru și forță. Cu asistență: Pentru persoanele care nu au un bun echilibru și forță. Aplecarea în lateral: O metodă care se potrivește utilizatorilor cu forță și echilibru limitate. Unii utilizatori își pot agăța brațul de mâner pentru mai mult sprijin. 9. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. A.6: Scaunul rulant corespunzător O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să descrie cel puțin patru caracteristici ale unui scaun rulant „corespunzător”;  să identifice părțile componente ale scaunului rulant care au impact asupra poziției utilizatorului;  să explice cum diferitele părți ale scaunului rulant răspund cerințelor specifice ale utilizatorilor;  să identifice scaunele rulante care sunt mai potrivite pentru utilizarea în exterior/ pe teren accidentat;  să recomande cele mai adecvate scaune rulante pentru fiecare utilizator, în funcție de cerințele acestuia. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 60. M A TE R IA LE Pentru sesiune:  prezentare PPT: A.6: Scaunul rulant corespunzător;  Manualul participantului;  Caietul de exerciții practice;  DVD: Ce înseamnă pentru mine un scaun rulant corespunzător;  DVD: Scaunul rulant și utilizatorul de scaun rulant;  DVD: Scaunul rulant și mediul utilizatorului de scaun rulant;  cel puțin câte o mostră din fiecare din scaunele rulante disponibile la nivel local. C O N TE X T Adaptați conținutul acestei sesiuni pentru ca informațiile să fie în concordanță cu contextul în care vor lucre participanții.  Dacă în locul unde își desfășoară activitatea participanții sunt disponibile doar una sau două tipuri de scaune rulante, folosiți mai multe scaune rulante de același tip, pentru ca fiecare grupă să poată lucra cu câte un echipament de mobilitate. Puteți folosi afișe care să prezinte o gamă mai mare de scaune rulante.  Dacă este necesar, adaptați studiile de caz pentru ca ele să se fie adecvate contextului local. D E P R E G Ă TI T  Pregătiți materialele, revedeți prezentările PPT, vizionați materialul video și citiți planificarea sesiunii.  Căutați un spațiu exterior care are și o parte de teren accidentat (de exemplul, pietriș, nisip, obstacole), care să fie suficient de mare pentru ca participanții să poată urmări modul în care fiecare dintre ei parcurge terenul accidentat. În cazul în care este cald, se recomandă un spațiu aflat la umbră.  Verificați ca toate scaunele rulante să fie funcționale și ca fiecare echipament de mobilitate să fie dotat cu o pernă.  Faceți ajustări la unul din scaunele rulante, pentru ca el să fie corespunzător pentru unul din participanți.  Pregătiți scaunele rulante, în ordine, în încăperea unde se desfășoară cursul de instruire. P R E ZE N TA R E 1. Introducere. 2. Definiția scaunului rulant „corespunzător”. 3. Răspunzând nevoilor utilizatorului de scaun rulant. 4. Răspunzând cerințelor mediului utilizatorului de scaun rulant. 5. Dimensiunea potrivită și suport postural. 6. Scaune rulante corespunzătoare nevoilor utilizatorilor. 7. Rezumat puncte cheie. 2 10 30 30 15 30 3 Total durată sesiune 120 1. Introducere (2 minute) Explicați: Pe parcursul acestei sesiuni, vom vorbi despre diferite tipuri de scaune rulante și despre caracteristicile acestora. Vom înțelege mai bine ce înseamnă un „scaun rulant corespunzător”. Scaunul rulant corespunzător: – răspunde nevoilor utilizatorului; – răspunde cerințelor mediului utilizatorului; – se potrivește utilizatorului; – asigură suport postural (ajută utilizatorul să stea în poziția așezat); – poate fi întreținut și reparat pe plan local. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 61. 2. Definiția „scaunului rulant corespunzător” (10 minute) Material video: Ce înseamnă pentru mine un scaun rulant corespunzător. În acest material video scurt, Faustina, care este un utilizator cu experiență, ne explică ce înseamnă pentru ea un scaun rulant corespunzător. Prezentați materialul video. Verificați dacă există întrebări. 3. Răspunzând nevoilor utilizatorului de scaun rulant (30 de minute) Întrebare: Care sunt activitățile pe care utilizatorii de scaun rulant trebuie să le desfășoare în timpul petrecut în scaun rulant? Încurajați participanții să răspundă Cele mai relevante răspunsuri: o transferul în și din scaunul rulant (transfer); o propulsia scaunului rulant; o plierea scaunului rulant pentru depozitare sau transport; o desfășurarea activităților cotidiene (de exemplu: activități la locul de muncă, activități casnice, petrecerea timpului cu prietenii, folosirea grupului sanitar, igienă, îmbrăcat, trecerea dintr-o încăpere în alta, poziționarea picioarelor sub mese și birouri). Explicați: Un scaun rulant corespunzător este cel care facilitează desfășurarea activităților. Vom analiza caracteristicile scaunelor rulante care au impact asupra modului în care utilizatorii își pot desfășura activitățile. 3.1 Transferurile Transferul în și din scaunul rulant Explicați: Utilizatorii efectuează transferul în și din scaun rulant prin diverse modalități. Cele trei părți ale scaunului rulant care au impact asupra modului în care utilizatorii efectuează transferul sunt: Explicați: (faceți clic pentru a evidenția săgeata de pe fiecare componentă) o suporturile laterale; o suportul pentru picioare; o frânele. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 62. Explicați: Suporturile laterale detașabile sau cele care urmează linia roților din spate sunt potrivite pentru persoanele care efectuează transferul în și din scaunul rulant pe lateral. o Explicați: o Utilizatorii care se ridică în picioare pentru a face transferul în și din scaunul rulant pot avea nevoie de suporturile laterale pentru a se ridica în picioare. o Suporturile de picioare care pot fi pliate sunt de ajutor celor care realizează în picioare transferul în și din scaun rulant. o Persoanele care reușesc să facă transferul cu sprijin pe podea pot prefera un scaun rulant cu suporturi de picioare detașabile. Explicați:  Frânele sunt importante pentru toți utilizatorii. Ele sunt esențiale pentru a menține scaunul rulant nemișcat în timpul transferului în și din acesta.  3.2 Propulsia scaunului rulant Explicați: Părțile scaunului rulant care influențează modul în care utilizatorul efectuează propulsia sunt: Explicați: (faceți clic pentru a evidenția săgeata de pe fiecare componentă o suporturile laterale; o spătarul; o inelele de antrenare; o mânerele; o greutatea totală a scaunului rulant poate influența ușurința cu care utilizatorul realizează propulsia. Explicați: o Pentru a ajunge la inelele de antrenare și pentru a realiza propulsia cu ușurință, utilizatorul trebuie să își poate întinde fără dificultate brațele peste suporturile laterale. o Utilizatorul de scaun rulant din imaginea alăturată nu poate ajunge cu ușurință la inelele de antrenare din cauză că suporturile laterale sunt prea înalte. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 63. Explicați: o Înălțimea spătarului poate avea impact asupra ușurinței cu care utilizatorul realizează propulsia scaunului rulant. o Dacă spătarul este prea înalt, atunci utilizatorului îi va fi dificil să miște brațele și umerii pentru a efectua propulsia. o Utilizatorului de scaun rulant din imaginea alăturată îi va fi greu să realizeze propulsia, din cauză că spătarul este prea înalt. Explicați: o Atunci când spătarul are o înălțime redusă, utilizatorul are libertate de mișcare la nivelul umerilor, pentru a împinge scaunul rulant. o Pentru un utilizator care poate sta în poziția așezat și care are un echilibru bun, aceasta este înălțimea corespunzătoare a spătarului. Explicați: o În cazul utilizatorilor de scaun rulant care realizează propulsia cu brațele, modul în care aceștia ajung la roți (inele de antrenare) influențează ușurința cu care ei le pot împinge. o În imaginea alăturată, avem un utilizator de scaun rulant care tocmai realizează mișcarea de propulsie. Observați cu câtă ușurință reușește să ajungă la roți (inele de antrenare). Explicați: o Ca o recomandare generală, roata din spate trebuie să fie astfel poziționată încât atunci când utilizatorul are mâna pe partea superioară a inelui de antrenare, cotul să fie îndoit la 90 de grade. o Dacă roțile sunt poziționate mai în spate, utilizatorul ajunge mai greu la inelele de antrenare. În acest caz, este mai obositor pentru utilizator să realizeze propulsia. Explicați: o La unele scaune rulante, poziția roții frontale este ajustabilă. o Poziția roților din spate are impact asupra ușurinței cu care se poate realiza echilibrul pe două roți. o Echilibrul pe două roți este folositor atunci când terenul este accidentat, la urcarea și coborârea bordurilor sau a pantelor. o Atunci când roțile din spate sunt plasate mai în față, devine mai ușoară realizarea echilibrului pe două roți. o Dacă acestea sunt plasate mai în spate, ridicarea în echilibru pe două roți se face mai greu. În acest caz există mai multă stabilitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 64. Explicați: o Unii utilizatori de scaun rulant efectuează propulsia cu picioarele. o Pentru o propulsie cu piciorul eficientă, utilizatorul trebuie să fie capabil să stea cu bazinul bine sprijinit de spătarul scaunului și cu laba piciorului întinsă pe podea o Pentru acești utilizatori, înălțimea șezutului scaunului de rulant în raport cu podeaua (luând în calcul și perna) este foarte importantă. o Suporturile de picioare care pot fi pliate în lateral sunt foarte importante. o Unii utilizatori care folosesc propulsia cu picioarele preferă o măsuță sau suporturi laterale, pentru a se putea înclina în față atunci când împing scaunul rulant. Explicați: o Un scaun rulant cu o greutate mai mare necesită mai multă energie pentru realizarea propulsiei. Dacă scaunul rulant este bine proiectat și echilibrat, efectul greutății poate fi diminuat. o Greutatea scaunului rulant este un element important în special în cazul copiilor. Dacă scaunul rulant este greu, utilizatorul copil poate avea dificultăți în a-l manevra. Explicați: o Unii utilizatori de scaun rulant nu pot realiza propulsia și au nevoie de asistență. o Alți utilizatori efectuează propulsia singuri în cele mai multe cazuri, având nevoie de ajutor doar ocazional, de exemplu, pentru urcarea sau coborârea treptelor sau când trebuie să traverseze un teren accidentat. o Mânerele solide ajută însoțitorii să asiste utilizatorul de scaun rulant. În cazul utilizatorilor de scaun rulant copii, mânerele situate mai sus vor fi utile adulților care îi asistă. 3.3 Plierea scaunului rulant Explicați: Din punct de vedere al depozitării sau transportului, este util un scaun rulant pliabil. Scaunele rulante se pliază în două moduri. Explicați: o Scaunele rulante cu cadru pliabil se pliază prin alăturarea celor două părți laterale. Uneori este posibilă și înlăturarea roților. o Scaunele rulante cu cadru pliabil sunt utile atunci când există căi de acces strâmte. o Atunci când este necesară transportarea scaunului rulant, unele persoane preferă scaunul rulant pliabil. o Dezavantajul cadrelor pliabile este că mecanismul de pliere se poate deteriora, făcând scaunul rulant instabil. Acesta devine mai greu de propulsat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 65. Explicați: o Unele scaune rulante cu cadru rigid pot fi și ele pliate. Spătarul se pliază în față, pe șezut, iar roțile din spate se pot detașa. o Atât scaunele rulante cu cadru rigid, cât și cele cu cadru pliabil au anumite avantaje și dezavantaje. Alegerea cea mai bună depinde de stilul de viață al utilizatorului, de modalitatea de transfer în și din scaunul rulant și de preferințele lor personale. Activitate Grupe: Formați grupe de câte 3 participanți. Instrucțiuni: Cereți fiecărei grupe să identifice modul în care se pliază scaunele rulante utilizate în cadrul exercițiilor. Monitorizare: Verificați dacă toți participanții știu cum să plieze și să deplieze scaunele rulante. Corectați metodele utilizate, acolo unde este cazul. Durata: Durata exercițiului este de 5 minute. 3.4 Desfășurarea activităților Explicați: Există mai multe caracteristici ale scaunului rulant care influențează modul în care utilizatorul poate desfășura activitățile. Câteva dintre aceste trăsături au fost deja menționate. De exemplu, ușurința cu care utilizatorul poate efectua propulsia scaunului rulant va avea un impact direct asupra modului în care acesta poate participa la diverse activități. Iată câteva exemple: Explicați: o Lungimea totală a unui scaun rulant influențează modul în care acesta va fi folosit în spații restrânse. o Lungimea se măsoară ca distanța dintre cele două puncte extreme, situate posterior și anterior. Întrebare: Care este scaunul rulant cu lungimea cea mai mare dintre cele aflate în încăpere? Explicați: o Suporturile de brațe înalte pot face dificilă poziționarea scaunului rulant foarte aproape de o masă sau un birou. Explicați: Trebuie să reținem faptul că cel mai important aspect în alegerea scaunului rulant corespunzător se referă la activitățile pe care utilizatorul trebuie să le desfășoare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 66. Prezentați materialul video: Scaunul rulant și cerințele utilizatorului. Cereți participanților să urmărească materialul video cu atenție și să identifice acele caracteristici ale scaunelor rulante care îi ajută pe utilizatori în desfășurarea activităților. Explicați că aceste aspecte vor fi discutate după vizionarea materialului. Vizionați materialul video. Explicați: În materialul video sunt prezentați mai mulți utilizatori cu diferite tipuri de scaune rulante imiplicate în mai multe tipuri de activități. Întrebare: Care erau aceste activități? Răspunsurile includ: o activități la locul de muncă (într-un birou, supermarket, atelier de tapițerie); o dans; o transferul în și din mașină; o plimbări (cu mama și cu câinele); o baschet. Întrebare: Care au fost acele caracteristici ale scaunului rulant care l-au ajutat pe Roger să își desfășoare activitatea în supermarket? Încurajați participanții să răspundă (Găsiți mai jos note pentru formatori). Întrebare: Poate cineva să dea un alt exemplu din materialul video, care să arate modul în care caracteristicile scaunului rulant răspund nevoilor utilizatorului? Încurajați participanții să răspundă – reamintiți-le participanților care au fost persoanele prezentate în materialul video și vizionați-l din nou, dacă este necesar. Întrebare: Poate cineva să mai dea un exemplu? Încurajați participanții să răspundă. Note pentru formatori: o Nu este necesar să se discute cazul fiecărui utilizator de scaun rulant; o Pentru fiecare utilizator de scaun rulant prezentat în materialul video sunt oferite informații care să îi ajute pe formatori să răspundă întrebărilor participanților; Utilizator de scaun rulant Activitatea desfășurată Caracteristicile scaunului rulant care facilitează activitățile Roger Lucrează într-un supermarket; așază marfa pe raft. o Baza roților este scurtă – acest lucru îl ajută să se apropie mai mult de rafturi și să manevreze scaunul rulant în spații restrânse. o Roțile din spate sunt poziționate adecvat pentru realizarea propulsiei, iar spătarul cu înălțimea redusă (Roger nu are nevoie de un spătar mai înalt) îl ajută pe Roger să realizeze propulsia scaunului rulant în mod eficient. o Nu există suporturi de braț – astfel, lui Roger îi este mai ușor să poziționeze obiecte pe genunchi și are mai multă mobilitate. Ruan Plimbare cu mama sa și cu câinele. o Mânerele – sunt la înălțimea potrivită pentru ca mama lui să poată împinge scaunul rulant. o Ruan are sprijin postural suplimentar (nu Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 67. abordați în detaliu), ceea ce îl ajută să stea mai confortabil și să fie mai în siguranță. James (numărul 14) și colegii de echipă Baschet în scaun rulant. James și colegii săi de echipă folosesc scaune rulante speciale, pentru sport. Caracteristicile acestora includ: o Baza roților din spate este înclinată în exterior. o Roțile din spate sunt mai subțiri (ceea ce duce la creșterea vitezei); o Roțile frontale sunt mici (se reduce greutatea și crește viteza); o Centuri gambe și coapse – oferă utilizatorului de scaun rulant stabilitate și siguranță; o Înălțimea mică a spătarului – permite o mare libertate de mișcare în timpul activității sportive; o Roțile din spate sunt poziționate în mod corespunzător pentru realizarea propulsiei. Mark Lucrează într-un atelier de tapițerie. Mark poate efectua propulsia scaunului cu un picior – acest lucru înseamnă că nu este necesar să folosească ambele brațe. Astfel, atunci când lucrează în atelier, el are unul din brațe libere pentru a putea mânui obiecte. o Scaunul rulant facilitează acest lucru prin faptul că suportul de picioare poate fi pliat în lateral. Dawid and Pinky Lucrează ca agenți de pază într-un supermarket. o Ambii au scaune rulante cu o bază a roții relativ scurtă, ceea ce le oferă posibilitatea de a se deplasa în interiorul magazinului. o Amândoi își manevrează independent scaunul rulant – cu toate acestea, Dawid folosește pentru propulsie roțile din spate, iar Pinky are un scaun rulant cu antrenare electrică. Faizel Lucrează într-un birou. o Roțile spate sunt poziționate în mod corespunzător pentru realizarea propulsiei. o Spătarul are o înălțime suficient de redusă pentru a permite libertate de mișcare la nivelul umerilor, dar este suficient de înalt pentru a oferi sprijinul adecvat. o Folosește mănuși – acest lucru îi permite să antreneze cu mai multă ușurință roțile din spate și inelele de antrenare. o Nu există suporturi de brațe – astfel, lui Faizel îi este mai ușor să poziționeze scaunul rulant sub birou. Keith (scaun rulant cu trei roți) și Ralph (scaun rulant cu patru Lucrează într-un atelier asamblare scaune rulante. o Ralph și Keith: Nu există suporturi de brațe – facilitează lucrul cu uneltele și la bancul de lucru, este mai ușor transportarea obiectelor Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 68. roți) pe genunchi. o Scaunul rulant cu trei roți a lui Keith îi permite să ajungă aproape de obiectele pe care trebuie să le ridice, deoarece încape cu ușurință între echipamentul de lucru și celelalte obiecte. o Ralph are un scaun rulant cu o bază a roții scurtă, ceea ce îi permite să se apropie de suprafața de lucru. o Ralph și Keith: Roțile din spate sunt poziționate în mod corespunzător pentru realizarea propulsiei, iar spătarul cu înălțime redusă oferă libertare de mișcare. Ryan Transfer în și din mașină. o Scaunul rulant al lui Ryan se pliază, iar roțile din spate pot fi demontate (roți cu deblocare rapidă) – acest lucru îi permite să ridice scaunul rulant și să îl poziționeze în mașină. Fără această trăsătură, Ryan nu ar putea să realizeze independent transferul în și din mașină. Jenee Dansează. o Lungimea totală a scaunului rulant este redusă – permite un arc de cerc necesar întoarcerii foarte mic. o Lungimea totală a bazei roți este redusă - manevrabilitatea este îmbunătățită. o Spătarul cu înălțime redusă permite o mare libertate de mișcare. o Dispozitiv anti-răsturnare – previne răsturnarea pe spate a scaunului rulant (există probabilitatea ca scaunul rulant să se răstoarne din cauza lungimii reduse a bazei roții) 4. Răspunzând cerințelor mediului utilizatorului de scaun rulant (30 de minute) Explicați: Diferitele tipuri de scaun rulant de potrivesc unor medii diferite. Principalele caracteristici care determină modul în care scaunul rulant funcționează în contexte diferite sunt: o Distanța dintre roțile frontale și roțile din spate (baza roților); o Dimensiunea și lățimea roților. Iată câteva exemple: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 69. Explicați: o Distanța dintre roțile frontale și roțile din spate este importantă. o Când această distanță este mai mare, ea se numește „bază roți lungă”. o Când această distanță este mai redusă, ea se numește „bază roți scurtă. Explicați: o Scaunele rulante cu baza roților lungă sunt mai stabile, iar probabilitatea ca ele să se răstoarne în față este mai mică. o Acest tip de scaun rulant poate fi o alegere potrivită pentru persoanele care petrec mult timp în exterior și care au de trecut peste suprafețe accidentate și cu denivelări. o Scaunele rulante cu trei roți sunt un exemplu de scaun rulant cu baza roții lungă. De regulă sunt foarte stabile și potrivite pentru utilizare în exterior, pe teren accidentat. o Scaunele rulante cu trei roți nu sunt adecvate pentru toți utilizatorii. o De exemplu, un scaun rulant cu trei roți nu este potrivit pentru a persoană care dorește să se ridice în picioare pentru a face transferul în și din scaunul rulant, deoarece suportul de picioare este fix, iar tija frontală poate împiedica transferul. o Scaunele rulante cu patru roți, cu o bază a roții lungă pot fi folosite cu succes pe suprafețe cu denivelări. o În exemplul alăturat, roțile frontale sunt poziționate sub suportul de picioare și nu în spatele acestora. Acest lucru face ca scaunul rulant să aibă o bază a roții mai lungă și să fie mai stabil. Explicați: o Scaunele rulante cu o bază a roții mai scurtă sunt adecvate pentru spațiile unde terenul este drept și relativ fără denivelări. o În cazul acestui tip de scaune rulante, probabilitatea ca scaunul rulant să se răstoarne înspre înainte la întâlnirea unui obstacol în timpul coborârii unei pante este mai mare. Explicați: o Acesta este un exemplu de scaun rulant ortopedic, cu o bază a roții scurtă o Acest scaun rulant nu ar putea fi împins cu ușurință pe un teren accidentat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 70. Explicați: o Scaunele rulante cu o bază a roții scurtă sunt o alegere bună pentru utilizatorii care petrec mult timp în interior. Explicați: o Scaunele rulante cu patru roți, de tip „activ”, au frecvent baza roții redusă. o Utilizatorii cu bune abilități de mobilitate pot folosi pe un teren accidentat un scaun rulant cu baza roții scurtă – de exemplu, pentru ridicarea în echilibru pe roțile din spate la coborârea pantei și la deplasarea pe un teren accidentat. Explicați: o Cu cât este mai mare roata, cu atât este mai ușoară manevrarea ei pe teren accidentat și peste obstacole, cum ar fi pietrele sau bucățile de lemn. o Roțile din spate late, precum și roțile frontale ajută la evitarea blocării scaunului rulant pe suprafețele de teren acoperite cu nisip sau noroi. o Roțile din spate standard sunt de 24”. Cu toate acestea, în multe regiuni, roțile de 24” sunt greu de găsit. Din acest motiv, unii producători fabrică roți de 26”. o Scaunele rulante pentru utilizatorii copii pot avea roți de 20” sau de 22”. o Roțile din spate și cele frontale pot fi umplute cu aer (anvelope pneumatice) sau solide. o Anvelopele pneumatice trebuie să fie umflate pentru ca ele să funcționeze corect. o În anumite regiuni, penele de cauciuc pot apărea în mod frecvent. Utilizatorii trebuie să fie capabili să repare aceste pene ei înșiși sau să poată apela fără dificultăți la cineva care poate să facă acest lucru. o Anvelopele solide sunt o alternativă. Acestea nu trebuie umflate și nu se produc pene. Totuși, pe teren accidentat, anvelopele solide pot fi „dure” pentru utilizatorul de scaun rulant. o Nu toate anvelopele solide rezistă un timp îndelungat la utilizarea în exterior. Anvelopele solide de o calitate mai puțin bună se pot desprinde de pe marginile roților. o Există două tipuri de anvelope solide: o Anvelope de cauciuc solid – acestea sunt grele, destul de tari si pot fi foarte durabile dacă sunt de bună calitate. o Anvelopele de poliuretan (PU) – acestea sunt ușoare. Totuși, cu excepția faptului când sunt de foarte bună calitate, aceste anvelope se uzează repede când sunt folosite în exterior și devin neutilizabile. Material video: Răspunzând cerințelor mediului utilizatorului de scaun rulant. Cereți participanților să urmărească cu atenție materialul video, pentru a identifica acele caracteristici ale scaunelor rulante care îi ajută pe utilizatori să aibă mai multă mobilitate în diverse medii. Explicați că aceste aspecte vor fi discutate după vizionarea materialului. Vizionați materialul video. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 71. Explicați: În materialul video sunt prezentați mai mulți utilizatori de scaun rulant care se deplasează pe diverse tipuri de suprafețe, în interior sau în exterior, pe teren cu denivelări sau pe suprafețe acoperite de noroi. Întrebare: Doi utilizatori de scaun rulant, Venkamarantu și Sione, se deplasează pe teren un teren cu o suprafață relativ denivelată și acoperită de noroi. Care sunt acele caracteristici ale scaunelor rulante care le facilitează deplasarea? Răspunsuri: o Scaun rulant cu trei roți – oferă stabilitate pe un teren fără denivelări. o Roți frontale late – trec peste obstacole, iar posibilitatea ca ele să se blocheze în noroi/nisip este mai redusă. o Roțile din spate poziționate corespunzător pentru realizarea propulsiei – facilitează propulsia scaunului rulant. Întrebare: Jean, cea care gătește în bucătărie, și Jacques, instructorul de la sala de sport, se află în interior. Care sunt acele caracteristici ale scaunelor rulante care le facilitează mobilitatea în interior? Răspunsurile includ: o Baza roții redusă și lungimea totală redusă o Roți frontale mai mici/mai înguste – facilitează deplasarea pe suprafețe fără denivelări. Întrebare: Unul dintre utilizatorii de scaun rulant din materialul video (Lalithamma) se deplasa în exterior. Drumul nu avea denivelări, dar a trebuit să treacă peste un șanț. Care sunt acele caracteristici ale scaunului rulant care au facilitat acest lucru? Răspunsurile includ: o Scaun rulant cu patru roți, cu baza roții lungă – baza roții lungă oferă o bună stabilitate (ceea ce a ajutat-o pe Lalithamma să transporte apa). o Roțile frontale late. o Roțile din spate în poziție corespunzătoare pentru realizarea propulsiei – facilitează propulsia. Activitate în grupe mici Grupe: Toți participanții trebuie să se deplaseze la suprafața cu teren accidentat, acolo unde trebuie să existe trei tipuri diferite de scaune rulante. Instrucțiuni: Reamintiți-le participanților regulile de siguranță: să nu stea pe suportul de picioare, să nu introducă degetele în spițele roților sau la frâne în timpul coborârii pantei în scaunul rulant, să se asigure că au un însoțitor în spatele scaunului rulant, în cazul în care acesta se răstoarnă pe spate. Rugați doi dintre participanți să fie voluntari: o Cereți unuia dintre voluntari să aleagă un scaun rulant, cel pe care îl consideră cel mai ușor de propulsat pe o suprafață accidentată; o Cereți celuilalt voluntar să aleagă un scaun rulant, cel pe care îl consideră cel mai dificil de propulsat pe o suprafață accidentată; o Cereți fiecărui voluntar să parcurgă o distanță de 5 m și să se întoarcă; o Repetați cu alți doi voluntari, până când toți au avut ocazia să exerseze. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 72. Monitorizare: Asigurați-vă că această activitate se desfășoară în condiții de siguranță. Nu încurajați participanții să facă din această activitate o întrecere, deoarece acest lucru poate fi periculos. Time: Durata exercițiului este de 20 de minute. Feedback: Întrebare: Care din scaunele rulante s-a dovedit a fi cel mai ușor de propulsat pe suprafața accidentată? De ce? Încurajați participanții să se gândească la dimensiunea și lățimea scaunului rulant, la lungimea bazei roții, ușurința cu care se ajunge la roți pentru a le antrena, la înălțimea spătarului. Explicați: unora dintre participanți li s-ar fi părut mai ușoară această activitate dacă ar fi fost suficient de norocoși să aibă un scaun rulant care să li se potrivească. 5. Dimensiunea potrivită și suportul postural (15 minute) Explicați: o Fiecare utilizator de scaun rulant are măsuri diferite. Scaunul rulant trebuie să aibă dimensiunea potrivită pentru a i se potrivi fiecărui utilizator și pentru a-i oferi suport postural. Din fericire, multe tipuri de scaune rulante sunt disponibile într-o gamă largă de dimensiuni sau pot fi ajustate din punct de vedere al dimensiunii. Este mai ușor să ne asigurăm că scaunul rulant se potrivește utilizatorului atunci când avem la dispoziție scaune rulante cu mai multe mărimi. o Următoarele componente sau caracteristici vor determina modul în care se potrivesște scaunul rulant și în care acesta contribuie la menținerea poziției așezat a utilizatorului. Șezutul Arătați slide-urile: Totodată, evidențiați caracteristicile scaunelor rulante care se află în sala de curs. Explicați: o Șezuturile scaunelor rulante pot fi rigide sau pliabile. o Șezuturile rigide pot fi confecționate din plastic sau din lemn. Șezuturile rigide trebuie dotate întotdeauna cu o pernă. o Șezuturile pliabile (prezentate în imaginea alăturată) sunt fabricate, de obicei, din pânză. o „Mărimea” unui scaun rulant este de multe ori descrisă prin valoarea lățimii șezutului. Explicați: o Șezuturile pliabile sunt fabricate din pânză și, de regulă, sunt atașate de fiecare parte a cadrului șezutului scaunului rulant. o Șezuturile pliabile de o calitate inferioară se vor întinde și se vor deforma (se vor lăsa) mai repede. În acest caz, șezutul nu mai oferă sprijinul necesar. o În această imagine, utilizatorul de scaun rulant nu poate sta în poziția neutră de ședere pentru că scaunul rulant nu oferă sprijinul necesar. Acest lucru face dificilă menținerea poziției așezat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 73. Explicați: o Perna oferă confort și ajută la reducerea presiunii. o Pernele împiedică alunecarea utilizatorului într-o poziție incorectă. o Aspectele legate de perne vor fi discutate în detaliu în cadrul următoarei sesiuni. Explicați: o Spătarele pot fi solide sau pliabile. Toate spătarele solide trebuie să fie căptușite sau să fie prevăzute cu perne. Unele scaune rulante au spătar reglabil pe înălțime. Trebuie aleasă înălțimea spătarului care i se potrivește utilizatorului. Acest aspect va fi abordat mai târziu. o Unele scaune rulante au unghiuri de ajustare și la nivelul spătarului. Explicați: o Suporturile de picioare sprijină utilizatorul de scaun rulant. Este foarte important ca aceste suporturi să fie corect poziționate. Din acest motiv, înălțimea suportului de picioare este de regulă ajustabilă. o Unele suporturi de picioare pot fi ajustate și în ceea ce privește unghiul sau distanța dintre acestea și cadrul scaunului rulant. Explicați: o Suporturile de brațe pot oferi și ele sprijin. o Unele suporturi laterale sunt reglabile pe înălțime. o Cele care nu sunt, pot fi uneori modificate pentru a oferi mai mult suport, acolo unde este necesar. 6. Scaunul rulant corespunzător nevoilor utilizatorului (30 de minute) Activitate Grupe: Fiecare grupă este formată din doi sau trei participanți. Instrucțiuni: Cereți fiecărei grupe: o să citească descrierea fiecărui utilizatorul de scaun rulant prezentat în fișele de lucru din caietul de exerciții practice; o să discute care dintre scaunele rulante disponibile se potrivește nevoilor fiecărui utilizator și de ce; o să noteze răspunsurile. Monitorizare: Supervizați activitatea grupelor și oferiți sprijin, dacă acest lucru este necesar. Durata: Durata exercițiului este de 20 de minute, cu 10 minute pentru discuțiile ulterioare. Feedback: Pe rând, cereți fiecărui grup să vină în față și: o să comunice care este scaunul rulant adecvat (dintre cele disponibile) în cazul unuia dintre utilizatorii descriși; o să ofere cel puțin trei motive pentru care alegerea lor este cea mai potrivită; o să întrebe restul participanților dacă sunt de acord cu decizia grupei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 74. (Alocați 2–3 minute pentru fiecare feedback). La finalul sesiunii de feedback, reamintiți-le participanților că alegerea făcută este o recomandare care trebuie discutată cu utilizatorul de scaun rulant. Decizia finală trebuie să îi aparțină utilizatorului de scaun rulant. Cazul utilizatorului de scaun rulant Aspecte de reținut Bao locuiește într-o așezare rurală. Are o amputație bilaterală, deasupra genunchilor. Înainte de accident, avea o băcănie situată la șoseaua care trece prin sat. Acum poate ajunge la magazin doar dacă este ajutat, deoarece drumul de acasă și până la șosea este lung (aproape un km), accidentat și deseori plin de noroi. Acest lucru face ca lui Bao și familiei lui să le fie greu să se ocupe de băcănie. Cu multă vreme în urmă, Bao a primit donație un scaun rulant ortopedic. Scaunul este ruginit, iar tapițeria șezutului este ruptă. Roțile frontale sunt mici, iar anvelopele roților din spate sunt subțiri și uzate. Bao nu poate împinge scaunul rulant pe drumul ce leagă casa lui de sat, pentru că roțile se împotmolesc. El își dorește să ajungă singur la băcănie, pentru a nu mai fi nevoit să fie ajutat de soția lui sau de către altcineva. o Bao are nevoie de un scaun rulant pe care să îl poată propulsa independent, pe teren accidentat sau moale. o Este important ca utilizatorul să aibă acces la roți, pentru a efectua propulsia. o Un suport postural bun este un avantaj, deoarece, zilnic, el va petrece mult timp stând în scaunul rulant. o Acolo unde sunt disponibile tricicluri, formatorii pot sublinia faptul că un triciclu poate fi un mijloc de mobilitate foarte eficient în cazul utilizatorilor de scaun rulant care au forță și care trebuie să se deplaseze pe distanțe mai lungi. Cazul utilizatorului de scaun rulant Aspecte de reținut Amanthi are 24 de ani și locuiește împreună cu familia ei într-un mic oraș. La vârsta de 18 ani a avut un accident de mașină și a devenit paraplegică. De curând, Amanthi a avut o ulcerație, care a avut nevoie de șase luni pentru a se vindeca. Amanthi are un scaun rulant ortopedic, dar acesta nu îi oferă suportul de care are nevoie și ea obosește foarte mult. Scaunul rulant nu are pernă. Ea crede că acesta este motivul apariției escarei. Amanthi a fost chemată să participe la un curs de secretariat și își dorește să meargă. Cu toate acestea, este îngrijorată că având acest scaun rulant, ea nu va putea să stea în poziția așezat toată ziua. o Amanthi are nevoie de un scaun rulant care să îi permită să efectueze ușor transferul, care să îi ofere suport postural adecvat și care are o pernă pentru reducerea presiunii. o Este important ca scaunul rulant să încapă sub birou. o Dimensiunea roților frontale depinde de tipul de teren pe care se va deplasa utilizatorul. Phillip are vârsta de 62 de ani și trăiește într-o comunitate mică, pe o insulă. Cu șase luni în urmă, el a avut un accident vascular-cerebral. După o lună în spital, el s-a întors acasă fără un scaun rulant. De atunci, stă în pat sau într-un scaun, pe veranda casei lui. Phillip nu își poate mișca brațul stâng și nici piciorul stâng. Totuși, pe zi ce trece el este mai puternic și poate sta în picioare, cu ajutorul unui membru de familie. Își folosește mâna dreaptă și își dorește mult un scaun rulant, pentru a avea mai multă libertate de mișcare și pentru a depinde mai puțin de familie. El vrea să se poată deplasa în casa lui, care are dimensiuni reduse și este pe un singur nivel, precum și în comunitatea din care face parte. Terenul este foarte nisipos. Unul din nepoții săi are o mașină și i-a spus lui o Phillip are nevoie de un scaun rulant care să îi permită să efectueze transferul stând în picioare. Suporturile de picioare pliabile ar facilita acest lucru. o Roțile frontale mai mari, precum și roțile din spate groase ar face mai ușoară realizarea propulsiei scaunului rulant. o Este capabil să se deplaseze pe distanțe scurte, împingând scaunul rulant cu brațul și cu piciorul drept – așadar, înălțimea șezutului scaunului rulant (cu pernă) ar trebui să îi permită să Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 75. Phillip că îl va lua cu mașina atunci când va avea un scaun rulant. stea cu piciorul așezat pe podea. o Un scaun rulant care se pliază în cruce sau unul cu spătar pliabil și ale cărui roți pot fi demontate îl poate ajuta să se deplaseze în mașina nepotului său. Sabina are 56 de ani și trăiește într-o comunitate mică, pe o insulă. După nașterea celui de al patrulea copil, în urmă cu mulți ani, și-a pierdut aproape total capacitatea de a-și folosi picioarele. Poate sta în picioare puțin, dar nu poate merge. Nu a avut niciodată un scaun rulant. Sabina locuiește într-un mic sat aproape de mare- terenul din jurul casei sale și din sat este accidentat și nisipos. Sabina își petrece timpul gătind, cosând și ajutând la îngrijirea nepoților. În casa ei nu există spațiu pentru un scaun rulant, dar acesta poate fi ținut dedesubt, deoarece construcția este pe piloni. o Sabina are nevoie de un scaun rulant pe care să îl poată propulsa cu ușurință pe suprafețe accidentate sau acoperite de nisip. Este important ca scaunul rulant să aibă roți frontale de dimensiuni mari. O bază a roții lungă va oferi stabilitate scaunului rulant. o Pentru că poate sta în picioare, probabil că preferă suporturi de picioare care pot fi pliate înspre exterior, pentru a putea efectua astfel transferul în și din scaunul rulant. o Scaunul rulant trebuie să fie rezistent și solid, pentru a se potrivi cu stilul ei de viață, care presupune mult timp petrecut în exterior. 7. Sumarizare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 76. A.7: Pernele O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere beneficiile pernelor;  să enumere diferitele tipuri de perne disponibile pe plan local;  să explice ce este o pernă „pentru reducerea presiunii”;  să demonstreze modul în care se verifică dacă perna pentru reducerea presiunii este funcțională;  să explice faptul că prin adăugarea unei inserții de spumă/burete la perna pentru reducerea presiunii, presiunea exercitată va fi diminuată. M A TE R IA LE Pentru sesiune:  prezentări PPT: A.7 Pernele;  Manualul participantului;  Caietul de exerciții practice;  DVD: Demonstrație test pentru stabilirea presiunii;  câte o mostră din fiecare tip de pernă disponibilă local, câte o pernă pentru reducerea presiunii poziționată într-un scaun rulant la fiecare grupă de trei participanți, o pernă pentru reducerea presiunii cu „inserție” suplimentară. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul local în care vor lucra participanții. Luați în considerare următoarele aspecte:  tipurile de perne disponibile în regiunile unde lucrează participanții – această sesiune oferă informații despre perne de spumă/burete sau cu lichid/gel – dacă există și alte tipuri de perne disponibile în regiunile participanților, includeți-le și pe acestea;  dacă nu este disponibilă nicio pernă pentru reducerea presiunii, va fi dificilă predarea acestei sesiuni – de asemenea, în acest caz, după programul de instruire, participanților le va fi greu să recomande scaune rulante în mod adecvat – identificați metode prin care să găsiți perne pentru reducerea presiunii la prețuri accesibile înainte de programul de instruire. În acest sens, apelați la perne fabricate local sau contactați organizații din exterior, pentru a le cere sprijinul. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii.  Asigurați-vă că unele din scaunele rulante disponibile sunt prevăzute cu o pernă pentru reducerea presiunii.  Asigurați-vă că în sala de instruire există câte o mostră din fiecare tip de pernă disponibilă local și o mostră de strat de ridicare pentru pernă. P R E ZE N TA R E 1. Introducere. 2. Care este rolul pernelor? 3. Diferite tipuri de perne. 4. Pernele pentru reducerea presiunii. 5. Cum se verifică dacă perna pentru reducerea presiunii este funcțională. 6. Care sunt metodele de reducere a presiunii? 7. Sumarizare puncte cheie. 2 5 5 25 30 5 3 Total durată sesiune 75 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 77. 1. Introducere (2 minute) Explicați: În cadrul acestei sesiuni vom vorbi despre pernele pentru scaune rulante. Vom vedea de ce sunt importante, diferitele tipuri de perne și despre modalitatea prin care putem verifica dacă o pernă se potrivește în mod corect. 2. Care este rolul pernelor? (5 minute) Întrebare: Care sunt beneficiile utilizatării de perne pentru scaunul rulant? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o reducerea presiunii; o suportul postural; o confortul. Explicați: o În cazul fiecărui utilizator, perna este o componentă esențială a scaunului rulant. o Tipul de pernă corespunzător depinde de nevoile individuale ale fiecărui utilizator. o Persoanele la care este prezent pericolul apariției escarelor trebuie să utilizeze perne pentru reducerea presiunii. o Nu toți utilizatorii de scaun rulant au nevoie de o pernă pentru reducerea presiunii. o Cu toate acestea, este important ca toți utilizatorii să stea confortabil în scaunul rulant, iar perna le va oferi suport, în așa fel încât aceștia să poată menține poziția așezat. 3. Tipuri de perne (5 minute) Explicați: Există mai multe tipuri de perne pentru scaunul rulant. Întrebare: Care sunt tipurile de perne pe care participanții le-au mai întâlnit sau despre care au auzit? Încurajați participanții să răspundă și notați pe tablă. Potențiale răspunsuri: o perne din spumă modelată / burete; o perne din fibră de nucă de cocos; o perne cu aer; o perne cu lichid sau gel; o perne plate; o perne cu contur; o perne modelate; o perne în straturi. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 78. Explicați: Există mai multe tipuri de perne. Pernele pot fi descrise din mai multe puncte de vedere, inclusiv: o materialul din care sunt confecționate (de exemplu, din spumă/ burete sau fibre); o materialul cu care sunt umplute (de exemplu, aer, fluid sau gel); o principala lor utilizare (de exemplu, reducerea presiunii, confort, suport postural); o forma lor (de exemplu, netede sau cu contur); o modul în care sunt confecționate (de exemplu, pernele de spumă/burete pot fi „modelate” dintr-o bucată de spumă/burete sau „în straturi” – având mai multe straturi de spumă/burete. Prezentați pe rând pernele disponibile la nivel local. Descrieți fiecare pernă din punct de vedere al materialului, funcției principale și al formei, specificând dacă perna este modelată sau în straturi. Asigurați-vă că fiecare tip de pernă ajunge la toți participanții. 4. Pernele pentru reducerea presiunii (25 de minute) Explicați: În sesiunea referitoare la escare, am vorbit despre faptul că trebuie să ne asigurăm că orice utilizator de scaun rulant la care este prezent pericolul apariției escarelor are nevoie de o pernă pentru reducerea presiunii. Pe parcursul acestei sesiuni, vom vedea ce înseamnă o pernă reducerea presiunii. Întrebare: Care dintre pernele prezentate aici ar putea avea rolul de pernă pentru reducerea presiunii? Răspuns: o orice pernă din spumă modelată; o orice pernă umplută cu aer sau cu lichid. Pernele pentru reducerea presiunii ajută la reducerea acesteia prin: o distribuirea greutății utilizatorului cât mai egal posibil pe toată suprafața șezutului scaunului rulant; o reducerea presiunii în zonele de risc, cu presiune ridicată (oasele bazinului, oasele șoldurilor, coccis); o reducerea alunecării prin suportul oferit utilizatorului pentru ca acesta să stea în poziția așezat. Perne pentru reducerea presiunii confecționate din spumă/burete Explicați: În primul rând, vom discuta despre pernele confecționate din spumă/burete. Explicați: Bază rigidă stabilă: o Baza unei perne pentru reducerea presiunii trebuie să fie rigidă. o Astfel ne asigurăm că perna oferă suport utilizatorului și că nu devine mobilă la mișcările utilizatorului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 79. Explicați: Stratul superior o Acesta este un strat (sau mai multe straturi) confecționat din spumă/burete mai moale. o Stratul superior ar trebui să fie suficient de moale pentru a permite oaselor bazinului să se scufunde, dar nu atât de moale încât oasele bazinului să ajungă până la stratul de bază sau la șezutul scaunului rulant. Explicați: Multe perne pentru reducerea presiunii fabricate din spumă/burete au o anumită formă (contur) la nivelul șezutului. Acest contur: o sprijină utilizatorul; o ajută la distribuirea într-un mod egal a greutății utilizatorului pe suprafața șezutului; o ajută la reducerea presiunii sub oasele bazinului și coccis. Formele ce pot fi găsite la o pernă pentru reducerea presiunii pot include următoarele (faceți clic pentru a arăta săgețile din imagine): o o “adâncitură” sub oasele bazinului, pentru a reduce presiunea; o o parte înălțată în fața oaselor bazinului pentru a ține pelvisul mai drept și pentru a preveni alunecarea înainte; o suport sub oasele șoldurilor (articulația coxo-femurală) pentru a ajuta la distribuirea greutății; adâncituri pentru pentru coapse. o adâncituri pentru coapse. Perne pentru reducerea presiunii cu aer/lichid/gel Explicați: Vom discuta în cele ce urmează despre pernele cu aer/lichid/gel: Explicați: o Pernele cu flotație includ pernele umplute cu aer și cele care au în componență lichid sau gel. o Pernele cu gel trebuie să aibă o bază de spumă rigidă / burete rigid foarte similară cu cea a pernelor din spumă modelată / burete. o Peste stratul de bază se află un strat de gel/ lichid. o Stratul de gel ia în mod automat forma corpului utilizatorului de scaun rulant. Acest lucru contribuie la distribuirea în mod egal a greutății utilizatorului și reduce presiunea sub zonele osoase. Ce fel de pernă trebuie utilizată? Explicați: Există avantaje și dezavantaje, atât în cazul pernelor din spumă modelată/burete, cât și în cel al pernelor cu aer/lichid/gel. Desenați pe tablă tabelul de mai jos (fără a trece și răspunsurile). Întrebare: Care sunt avantajele și dezavantajele? Notați avantajele și dezavantajele menționate de către participanți. Asigurați-vă că sunt abordate toate aspectele din lista de mai jos. Avantaje Dezavantaje Perne din spumă conturată/burete o Poate fi confecționată local (acolo unde există spumă/burete de bună calitate). o Poate fi modificată local, pentru a răspunde diverselor nevoi. o Nu este supusă unui „colaps spontan” (un orificiu în perna cu o Spuma/buretele se comprimă în timp (devin mai plate și mai tari). Din acest motiv, pernele de spumă / burete trebuie verificate la intervale regulate de timp și înlocuite cu o frecvență de 1-2 ani. o Uscarea lor poate dura (o Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 80. aer/lichid/gel poate provoca scurgerea materialului din pernă și o împiedică să reducă presiunea, provocând acel „colaps spontan” al pernei). o Stratul superior al unei perne cu straturi poate fi înlocuit cu ușurință și cu costuri mici (comparativ cu costul înlocuirii întregii perne). problemă în cazul persoanelor care suferă de incontinență). o Spuma/buretele izolează și poate cauza o creștere în temperatură la nivelul țesutului. Pernele cu aer/lichid/gel o Presiunea este distribuită în mod egal pe suprafața șezutului scaunului rulant. o Stratul de gel se adaptează imediat corpului atunci când utilizatorul se mișcă sau își schimbă poziția. o o Pernele cu aer/lichid/gel sunt deseori mai scumpe și mai greu de găsit local decât pernele din spumă/burete. o Unii utilizatori simt că pernele umplute cu aer/lichid/gel îi fac să fie mai instabili. o Problema „colapsului spontan”. În orice situație în care utilizatorul nu are posibilitatea de a înlocui rapid perna, acest lucru poate constitui o problemă. Husele pernelor Explicați: Toate pernele trebuie să aibă o husă. Tipul de husă este important. Asigurați-vă că fiecare tip de husă disponibilă ajunge la toți participanții. Cereți participanților să se uite cu atenție la huse și să se gândească la întrebările din imagine. o Husa este rezistentă la apă sau impermeabilă? o Husa este rezistentă? (durată lungă de utilizare)? o Husa este elastică? o Husa este fabricată din material subțire sau gros? o Husa poate fi îndepărtată cu ușurință și înlocuită, pentru a putea fi spălată? Întrebare: o Care (dacă vreuna) din husele de pernă este rezistentă la apă sau impermeabilă? o Când este aceasta o caracteristică utilă? Răspuns: o în cazul utilizatorilor de scaun rulant care au incontinență; o în cazul utilizatorilor care trebuie să își depoziteze scaunul rulant în exterior sau care petrec mult timp în exterior. Explicați: o Umezeala este un factor de risc care crește riscul apariției escarelor. Este foarte important ca perna să fie menținută uscată. o Sfătuiți utilizatorii de scaun rulant să își usuce perna imediat ce aceasta devine umedă. Perna nu trebuie uscată sub directa acțiune a razelor soarelui, iar husa trebuie îndepărtată. o În cazul utilizatorilor de scaun rulant cu incontinență, luați în cosiderare posibilitatea de a le furniza două perne. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 81. Notă pentru formatori: Există posibilitatea ca participanții să dorească să afle care sunt opțiunile în cazul în care nu există perne cu huse rezistente la apă sau impermeabile, iar utilizatorul are incontinență. Aceste opțiuni sunt: o să identifice soluțiile care pot reduce incontinența utilizatorului de scaun rulant; o să furnizeze încă o pernă – astfel ca una din ele să fie folosită în timp ce cealaltă se usucă; o să protejeze perna pe interior cu un sac de plastic foarte subțire; Dacă folosiți un sac de plastic: o verificați dacă sacul de plastic nu îl determină pe utilizator „să alunece” de pe pernă; o utilizatorul trebuie să se asigure că lichidul nu se „adună” deasupra plasticului – acest lucru determină creșterea riscului de apariție a escarelor. o în cazul în care husa s-a udat, utilizatorul de scaun rulant trebuie să se asigure că aceasta este uscată și că sacul de plastic este curățat sau înlocuit. Întrebare: o Care (dacă vreuna) din husele de pernă pare să fie cea mai rezistentă la utilizare? Explicați: durabilitatea este o caracteristică importantă a oricărei perne. Întrebare: o Care (dacă vreuna) din husele de pernă este elastică? o Care sunt motivele pentru care această caracteristică se poate dovedi utilă? Răspuns: o o husă elastică se mulează mai bine pe conturul pernei – dacă husa nu este elastică, este nevoie de mai mult spațiu pentru ca aceasta să se muleze pe contur. Întrebare: o Care este cel mai subțire material textil? Care este cel mai gros material textil? o De ce este importantă grosimea materialului textil? Răspuns: o materialele textile groase pot avea o durată de utilizare mai mare, dar nu se mulează la fel de bine pe conturul pernei – pliurile care se formează în materialul textil gros pot determina apariția escarelor; o materialele textile subțiri se mulează mai ușor pe conturul pernei, iar riscul apariției escarelor este mai redus, dar durata lor de utilizare este mai redusă – acest lucru depinde de calitatea materialului textil. Întrebare: Care sunt husele care pot fi îndepărtate, cu scopul de a fi curățate? Explicați: Aceasta este o caracteristică importantă pentru utilizatorii care au incontinență, care petrec mult timp în exterior sau care își depozitează scaunul rulant în exterior. Explicați: În ceea ce privește utilizatorii de scaun rulant, pernele sunt disponibile în mai multe mărimi. Este important ca perna selectată pentru fiecare utilizator să se potrivească cu dimensiunile șezutului scaunului rulant, care trebuie să aibă mărimea corespunzătoare pentru fiecare utilizator. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 82. 5. Cum se verifică dacă perna pentru reducerea presiunii este funcțională (30 de minute) Explicați: Atunci când furnizăm unui utilizator de scaun o pernă pentru reducerea presiunii, este esențial să verificăm dacă perna reușește să reducă presiunea. Întrebare: Care este acea parte a corpului utilizatorului de scaun rulant la nivelul căreia există cel mai mare risc de apariție a escarelor, atunci când utilizatorul se află în poziția așezat? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o oasele bazinului; o coccisul – în special dacă utilizatorul de scaun rulant are o postură incorectă (poziție „prăbușit”). Prezentați materialul video: Demonstrație test presiune. Materialul video arată un test simplu prin care se poate verifica dacă perna pentru reducerea presiunii diminuează presiunea la nivelul oaselor bazinului. Cereți participanților să urmărească atent materialul, deoarece ulterior va trebui să exerseze. Prezentați materialul video. Verificați dacă există întrebări. Explicați nivelele de presiune: Nivelul 1: o Degetele se pot mișca în sus și în jos. Există comprimare la nivelul țesutului, dar oasele degetelor se pot mișca 5 mm sau chiar mai mult. Nivelul 2: o Degetele nu se pot mișca, dar pot fi retrase cu ușurință de sub oasele bazinului. Nivelul 3: o Degetele sunt strânse cu putere. Retragerea lor este dificilă. Explicați: Întotdeauna verificați, pe rând, ambele părți ale oaselor bazinului. Nivel Presiune Acțiune 1 Sigur Nu este necesar 2 Avertizare Da, în cazul în care există mai mulți factori de risc 3 Pericol Da Explicați: Pe parcursul acestei sesiuni vom vorbi despre acțiunile recomandate. Activitate Grupe: Formați grupe de câte 2-3 participanți. Încercați ca perechile să fie alcătuite din persoane de același sex. Fiecăre grupă trebuie să aibă câte un scaun rulant prevăzut cu pernă pentru reducerea presiunii. Instrucțiuni: Cereți fiecărei grupe: o să exerseze modalitatea de verificare a presiunii de fiecare parte a oaselor bazinului; o să înregistreze nivelul de presiune în cazul fiecărei persoane din grupa în care se află. Asigurați-vă că toți participanții au posibilitatea să fie pe rând persoana care efectuează testul și persoana care are rolul utilizatorului de scaun rulant. Monitorizare: o Monitorizați și observați cu atenție activitatea fiecărei echipe. o Corectați tehnica folosită, acolo unde este necesar. Durata: Durata exercițiului este de 15 minute, plus 5 minute pentru feedback. Feedback: Întrebare: Cum v-ați simțit în postura de utilizator de scaun rulant? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 83. Explicați: Este important să îi explicați clar utilizatorului ce faceți, care este importanța acestui test și să vă asigurați că utilizatorul este de acord cu acest test. Întrebare: Aveți întrebări cu privire la această tehnică? Note pentru formatori: Atunci când monitorizați activitatea grupelor de participanți, asigurați-vă că următorii pași sunt respectați. A o Folosirea unor termeni simpli atunci când utilizatorului de scaun rulant i se explică în ce va consta testul și de ce este acesta important. B o Utilizatorul este rugat să se ridice în scaunul rulant sau să se incline în față, pentru a permite poziționarea degetelor sub oasele bazinului de pe partea dreaptă sau stângă (cu palma în sus). o Acest lucru se poate face cel mai bine din spatele scaunului rulant, introducând o mână sub tapițerie. C o Utilizatorul de scaun rulant este rugat să se așeze pe degetele persoanei care efectuează testul. o Utilizatorul trebuie să stea în poziția așezat, cu fața înainte și să așeze mâinile pe coapse. Acest lucru ne asigură că el va avea aceeași poziție de fiecare dată când se schimbă locul pentru a verifica un alt punct. o Dacă degetele persoanei care efectuează testul nu sunt într-o poziție bună pentru a simți presiunea de la nivelul oaselor bazinului, utilizatorul este rugat să se ridice din nou, iar degetele sunt repoziționate. D o Este identificată presiunea sub oasele bazinului și se stabilește dacă este de nivelul 1, 2 sau 3: Nivel 1 = sigur: Degetele se pot mișca în sus și în jos 5 mm sau chiar mai mult. Nivel 2 = avertizare: Degetele nu se pot mișca, dar pot fi retrase cu ușurință. Nivel 3 = pericol: Degetele sunt strânse cu putere. Retragerea lor este dificilă. E Operațiunea se reia și pentru cealaltă parte a oaselor bazinului. 6. Ce se poate face pentru a reduce presiunea? (5 minute) Explicați: o Atunci când presiunea identificată sub oasele bazinului nu se încadrează la nivelul de siguranță, trebuie acționat în vederea reducerii acesteia. o O soluție simplă poate fi adăugarea unui strat suplimentar de spumă rigidă/burete rigid. Această operațiune se numește „ridicare”. o Acest element suplimentar ar trebui să aibă aproximativ 20 de mm grosime și să aibă o zonă decupată sub zona oaselor Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 84. bazinului. o Se plasează deasupra stratului de bază și sub stratul de spumă/ burete, care are rolul de a oferi confort. Explicați: Uneori este nevoie de mai mult de un strat. Personalul furnizor de servicii de scaune rulante ar trebui să adauge un strat și să verifice din nou nivelul presiunii. Dacă presiunea se situează tot la nivelul 2 sau 3, se adaugă încă un strat. Faceți să circule pe la toți participanții un astfel de strat pentru ridicare și o pernă căreia i s-a adăugat acest strat, în vederea reducerii presiunii. Explicați: În timpul sesiunilor practice din cadrul programului de instruire, vom exersa modul în care poate fi adăugat acest strat suplimentar, din spumă/burete. 7. Rezumat puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 85. A.8: Transferuri Transferul în și din scaunul rulant O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere acele aspecte cheie care au legătură cu transferul în și din scaunul rulant, în condiții de siguranță pentru utilizator;  să demonstreze diverse modalități de transfer în și din scaunul rulant;  să aleagă metoda optima de transfer pentru cazurile individuale. M A TE R IA LE Pentru sesiune:  prezentări PPT: A.8: Transferurile;  Manualul participantului;  Caietul de exerciții practice;  DVD: Demonstrație transfer;  scaune rulante – unul pentru fiecare grupă alcătuită din câte trei participanți;  pat evaluare pentru exersarea transferurilor– unul pentru fiecare grupă alcătuită din câte trei participanți;  placă de transfer (dacă este disponibilă). C O N TE X T Adaptați conținutul sesiunii în așa fel încât să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  scaunele rulante disponibile local, care pot să influențeze asupra tehnicilor de transfer predate – de exemplu, un transfer efectuat în picioare, cu un scaun rulant cu trei roți, în loc de un scaun rulant cu patru roți cu suport de picioare pliabil, va determina schimbări în metodă sau va necesita metode suplimentare;  care sunt metodele de transfer folosite cel mai frecvent în locurile unde își desfășoară activitatea participanții – formatorii pot alege să schimbe metodele predate sau să adauge altele;  în cazul în care se predau mai mult de trei tehnici de transfer, trebuie prevăzute 20-25 de minute pentru fiecare metodă nou introdusă în programă. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii.  Exersați fiecare tehnică de transfer în și din scaunul rulant, pentru a putea face demonstrația.  Dacă aveți posibilitatea, apelați la un utilizator care poate demonstra transferul în și din scaun rulant și care poate participa la exercițiile practice. P R E ZE N TA R E 1. Introducere. 2. De ce este necesar ca utilizatorii să învețe cum se poate efectua transferul în și din scaunul rulant? 3. Efectuarea în condiții de siguranță a transferului în și din scaunul rulant. 4. Trei tehnici de transfer în și din scaunul rulant și feedback individual. 5. Transferul independent de pe podea în scaunul rulant. 6. Alegerea tehnicii de transfer. 7. Sumarizare puncte cheie. 2 5 10 60 20 20 3 Total durată sesiune 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 86. 1. Introducere (2 minute) Explicați: o Abilitatea de a efectua transferul în și din scaunul rulant, fără dificultate și în condiții de siguranță, cu sau fără asistență, va ajuta utilizatorul în ceea ce privește activitățile sale cotidiene. o Mișcarea prin care utilizatorul se așază sau iese din scaunul rulant poate fi numită „transfer”. o Pe parcursul acestei sesiuni, participanții vor exersa patru metode diferite, prin care utilizatorii pot efectua transferul în și din scaunul rulant. 2. De ce este necesar ca utilizatorii să învețe cum se poate efectua transferul în și din scaunul rulant? (5 minute) Întrebare: Dați exemple de situații în care utilizatorii trebuie să efectueze transferul în și din scaunul rulant. Încurajați participanții să răspundă și notați pe tablă. Posibile răspunsuri: o transferul în și din pat; o mersul la toaletă; o transferul în și din scaun/pat/triciclu/podea etc.; o urcarea sau coborârea din mașină/autobuz/taxi/alt mijloc de transport etc. Explicați: o Este posibil ca utilizatorii de scaun rulant să aibă nevoie să efectueze transferul în și din scaunul rulant de mai multe ori în decursul unei zile. o Din acest motiv, utilizatorii au nevoie de o metodă sigură, rapidă și care să nu necesite un consum energetic prea mare. o Utilizatorii de scaun rulant folosesc metode diferite, în funcție de abilitățile lor. Unii utilizatori pot efectua independent transferul în și din scaunul rulant, alții au nevoie de asistență. Există utilizatori care se pot ridica în picioare pentru transfer, pentru alții, acest lucru nu este posibil. o Personalul furnizor de servicii de scaune rulante îi poate instrui cu privire la o metodă care să li se potrivească. 3. Transferul în și din scaunul rulant, în condiții de siguranță (10 minute) Explicați: Siguranța este foarte importantă în timpul efectuării transferului. Care sunt aspectele cu privire la siguranță, care trebuie luate în considerare atunci când se realizează transferul? Încurajați participanții să răspundă și notați pe tablă. Cele mai relevante răspunsuri: o acționarea frânelor; o verificarea suprafeței pe care se face transferul – ne asigurăm că nu există obstacole; o întotdeauna ridicăm corpul – nu îl lăsăm în cădere liberă și nu îl tragem – acest lucru poate provoca leziuni ale pielii și să determine apariția escarelor; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 87. o înainte de a asista un utilizator, trebuie să ne asigurăm că putem să îi susținem greutatea; o nu trebuie să ofere asistență persoanele însărcinate sau care au afecțiuni ale spatelui. Repetați cele trei aspecte principale legate de siguranță: o acționarea frânelor; o verificarea suprafaței pe care se face transferul; o ridicarea corpului – nu lăsat în cădere liberă și nu tras. 4. Trei tehnici de transfer în și din scaunul rulant și feedback individual (60 de minute) Explicați: o Vom observa și vom exersa trei tehnici diferite de transfer în și din scaunul rulant. o Una dintre metode este un transfer „independent”, iar celelalte două sunt transferuri „asistate”. Înainte de a recomanda o tehnică sau de a exersa transferul împreună cu utilizatorul de scaun rulant, trebuie să știți dacă acesta este capabil să efectueze singur transferul sau dacă are nevoie de asistență. Dacă nu sunteți siguri, întrebați utilizatorul sau testați. o Pentru a efectua transferul independent în poziția așezat, verificați dacă utilizatorul își poate susține greutatea, împingându-se cu brațele. Dacă nu poate face acest lucru, atunci utilizatorul are nevoie de asistență pentru efectuarea transferului. o Pentru a realiza independent transferul în picioare, verificați dacă utilizatorul poate sta în picioare și dacă își poate susține greutatea. Dacă nu poate face acest lucru, atunci utilizatorul are nevoie de asistență pentru efectuarea transferului. Explicați: În cazul oricărui transfer, participanții trebuie să rețină următoarele: o să verifice dacă utilizatorul poate efectua transferul independent sau dacă are nevoie de asistență; o să poziționeze scaunul rulant aproape de pat/suprafața pe care se realizează transferul; o să acționeze frânele; o dacă scaunul rulant are suporturi laterale care pot împiedica transferul, să verifice dacă acestea pot fi îndepărtate. o Pentru realizarea transferului în picioare, pliați suportul de picioare (dacă acest lucru este posibil). o Întotdeauna ridicați – nu trageți. În caz contrar, pielea poate fi afectată, ceea ce poate provoca apariția escarelor. o Atunci când se efectuează transferul asistat, încurajați utilizatorul de scaun rulant să contribuie cât mai mult posibil la realizarea transferului. o Atunci când asistați la realizarea transferului, nu țineți utilizatorul de haine sau de curea, deoarece acest lucru poate fi foarte incomod pentru acesta. Activitate Groupe: Formați grupe de câte trei participanți. Fiecare grupă are nevoie de un scaun rulant și de un pat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 88. Instrucțiuni: Explicați – participanții vor viziona materialul video cu cele trei tehnici diferite de transfer. După fiecare demonstrație, materialul video va fi oprit. În perechi, utilizatorii vor exersa tehnica prezentată. Dacă este nevoie, participanții pot consulta Manualul participantului. Prezentați materialul video. Verificați dacă există întrebări. Monitorizare: După fiecare demonstrație prezentată în materialul video, evidențiați punctele cheie prezentate mai jos. Monitorizați și corectați tehnica, acolo unde este necesar. Asigurați-vă că toți participanții au ocazia să exerseze atât efectuarea transferului, cât și oferirea de asistență pentru realizarea acestuia. Durata: Durata exercițiului este de 60 de minute. Feedback: Verificați dacă există întrebări. Clarificați problemele frecvente observate sau erorile pe care le-ați identificat la participanți, pe tot parcursul exercițiului. 1. Transfer independent în poziția așezat (din scaunul rulant pe pat) Evidențiați următoarele puncte cheie, după prezentarea demonstrației din materialul video și înainte de a exersa. o Scaunul rulant se poziționează lângă pat, se acționează frânele. o Picioarele se coboară de pe suport, iar acesta se pliază lateral sau se detașează (acolo unde acest lucru este posibil). o Se îndepărtează suportul lateral de pe partea unde se află patul. o Utilizatorul se ridică împingându-se cu ajutorul brațelor și se mută înspre partea din față a scaunului rulant. o Având o mână așezată pe pat și cealaltă pe scaunul rulant, se împinge corpul în sus și se poziționează pe pat. o Dacă utilizatorul are un echilibru precar, nu se poate ridica suficient sau nu se poate mișca destul în lateral, se poate folosi o placă de transfer. Explicați: o La transferul pe pat, unii utilizatori preferă să își poziționeze picioarele pe pat înainte de a efectua transferul. 2. Transfer asistat în poziția așezat, cu utilizarea unei plăci de transfer (din scaunul rulant pe pat) Evidențiați următoarele puncte cheie după prezentarea demonstrației din materialul video și înainte de a exersa. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 89. o Scaunul rulant se poziționează lângă pat, se acționează frânele. o Picioarele se coboară pe suport, iar acesta se pliază lateral sau se detașează (acolo unde acest lucru este posibil). o Se îndepărtează suportul lateral de pe partea unde se află patul. o Se ajută utilizatorul să se miște spre partea din față a scaunului rulant. o Se pune placa de transfer sub bazin, peste scaunul rulant și pat. o Utilizatorul contribuie ridicând corpul de pe scaunul rulant și de pe pat și susținându-și cât mai mult posibil greutatea. o Însoțitorul stă în spatele utilizatorului și mută bazinul utilizatorului pe pat. 3. Transfer asistat, în picioare (din pat în scaunul rulant) Evidențiați următoarele puncte cheie după prezentarea demonstrației din materialul video și înainte de a exersa. o Se poziționează scaunul rulant, se acționează frânele. o Picioarele se coboară de pe suport, iar acesta se pliază lateral sau se detașează (acolo unde acest lucru este posibil). o Se îndepărtează suportul lateral de pe partea unde se află patul. o Se ajută utilizatorul să se miște spre marginea patului și se pun picioarele pe podea. o Se susțin genunchii utilizatorului din lateral (genunchii nu se împing din față). o Se aduce corpul utilizatorului în față și în sus, sprijinind sub omoplați. o Utilizatorul este întors spre scaunul rulant și lăsat să se așeze ușor în acesta. 5. Transfer independent transfer de pe podea în scaunul rulant (20 de minute) Explicați: o Acest tip de transfer presupune ca utilizatorul să aibă brațe puternice și un echilibru bun. Utilizatorilor în cazul cărora există riscul apariției escarelor li se recomandă ca atunci când stau pe podea să se așeze întotdeauna pe perna pentru reducerea presiunii. Activitate Grupe: Formați grupe de câte doi participanți. Fiecare pereche va primi un scaun rulant. Instrucțiuni: Demonstrați efectuarea transferului, în cazul în care ați dobândit deja această abilitate (sau solicitați unui utilizator de scaun rulant care poate face acest lucru să demonstreze modul de realizare a acestei tehnici). Evidențiați aspectele cheie prezentate mai jos. Cereți participanților să exerseze în perechi. Monitor: Monitorizați și corectați dacă este necesar. Asigurați-vă că toți participanții au ocazia să exerseze. Durata: Durata exercițiului este de 10 minute. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 90. Feedback: Întrebare: Câți participanți au reușit să efectueze acest tip de transfer? Luați în considerare faptul că pentru această tehnică e nevoie de suficientă forță în partea superioară a corpului. În cazul utilizatorilor de scaun rulant activi, care au forță în brațe, este o abilitate care merită exersată. Transfer independent, de pe podea în scaunul rulant Explicați: La realizarea transferului de pe podea în scaunul rulant: o Utilizatorul stă în fața scaunului rulant, cu genunchii ridicați la piept. o privirea este îndreptată în jos pe tot parcursul ridicării. o se poziționează o mână pe podea, iar cealaltă pe partea din față a șezutului scaunului rulant. o brațele și umerii se împing în jos, iar bazinul se ridică pe partea din față a șezutului scaunului rulant. o utilizatorul se așază în scaunul rulant și se apleacă pentru a ridica perna. o se balansează greutatea de pe o parte pe alta pentru a poziționa perna pe șezutul scaunului rulant. Explicați: La realizarea transferului din scaunul rulant pe podea: o utilizatorul se așază pe partea din față a scaunului rulant. o picioarele se ridică de pe suportul de picioare, se poziționează în față și ușor spre lateral (în direcția opusă celei în care se face transferul). o perna se plasează pe podea. o se poziționează o mână pe șezutul scaunului rulant, iar cealaltă se sprijină pe podea. o cu ajutorul umerilor și al brațelor, bazinul se așază pe perna poziționată pe podea, printr-o mișcare controlată. 6. Alegerea metodei de transfer (20 de minute) Explicați: o Atunci când furnizorul de servicii de scaune rulante oferă unui utilizator un astfel de echipament de mobilitate, acesta trebuie să se asigure că utilizatorul este capabil să efectueze transferul în și din scaunul rulant, fără dificultate și în condiții de siguranță. o Mulți utilizatori și-au însușit deja o metodă de a efectua transferul. o Solicitați întotdeauna utilizatorilor să vă arate metoda prin care realizează transferul în și din scaunul rulant. o Dacă tehnica de transfer folosită este sigură și eficientă, nu e nevoie de acțiuni suplimentare. o În caz contrar, personalul furnizor de servicii scaune rulante va instrui utilizatorul de scaun rulant cum să efectueze transferul în și din scaunul rulant. o Primul pas este decizia cu privire la tehnica de transfer care i se potrviește cel mai bine utilizatorului de scaun rulant. Scopul următoarei activități este să ajute participanții să exerseze alegerea tehnicii de transfer potrivite fiecărui utilizator individual. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 91. Activitate Grupe: Formați echipe de câte trei participanți. Instrucțiuni: Cereți fiecărei echipe: o să citească cazurile prezentate în caietul de exerciții practice; o să decidă care este tehnica de transfer care se potrivește cel mai bine în fiecare caz. Monitorizare: Monitorizați activitatea echipelor și oferiți asistență dacă este necesar. Durata: Durata exercițiului este de 10 minute. Feedback: Cereți fiecărei echipe să numească tehnica de transfer recomandată în cazul fiecărui utilizator și să explice motivele alegerii acesteia. Cazul utilizatorului de scaun rulant Aspecte de reținut Faridah are vârsta de 60 de ani. Cei de la spitalul din localitate i-au recomandat să apeleze la furnizorul de servicii de scaun rulante. Recent, ea a avut un accident vascular- cerebral si are nevoie de un scaun rulant, deoarece nu se mai poate deplasa. Faridah poate sta în picioare puțin și își poate susține greutatea. Totuși, are mari dificultăți în a-și menține stabilitatea. Faridah locuiește cu fiica ei și cu familia acesteia. Fiica ei nu lucrează și de aceea are posibilitatea de a o ajuta acasă. Faridah are un scaun rulant cu patru roți și cu suport de picioare ce se pliază lateral. o Faridah ar trebui să aibă capacitatea de a realiza transferul stând în picioare. o Fiica ei este acasă și îi poate oferi asistență. Ea ar trebui să fie implicată în instruirea cu privire la tehnicile de transfer. Jose are 45 de ani și este utilizator de scaun rulant de 10 ani. El are o amputație bilaterală, de deasupra nivelului genunchilor, și lucrează într-un atelier de reparații radio, în piața din localitate. Jose a apelat la furnizroul de servicii de scaune rulante pentru că are nevoie de un scaun rulant nou, cel pe care îl are fiind uzat. o Jose ar trebui să aibă capacitatea de a realiza transferul independent. Tahir are vârsta de 14 ani și este utilizator de scaun rulant. Lui Tahir i s-a recomandat să apeleze la un furnizor de servicii de scaune rulante după ce a suferit un traumatism vertebro- medular, în urma unei căzături din copac. Tahir își poate folosi brațele, dar nu este încă foarte puternic. Nu își poate folosi deloc picioarele. o Tahir ar trebui să poată să realizeze transferul în poziția așezat cu însoțitor sau cu placa de transfer. Dacă exersează, poate dobândi abilitatea de a efectua transferul singur. 6. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 92. B: Etapele furnizării serviciilor de scaun rulante Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 93. B.1: Trimiterea și programarea O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să descrie modalitățile prin care utilizatorii de scaun rulant pot fi direcționați către un furnizor de servicii de scaune rulante;  să descrie sistemul de programări folosit de către furnizorul de servicii de scaune rulante local. M A TE R IA LE Pentru sesiune:  prezentare PPT: B.1 Trimiterea și programarea;  Manualul participantului;  Formular trimitere către furnizorul de servicii de scaune rulante (dacă este disponibil). C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  modul în care utilizatorii de scaun rulant sunt direcționați către furnizorii de servicii de scaune rulante în zona de unde își desfășoară activitatea participanții;  dacă furnizorii de servicii unde participanții își desfășoară activitatea au un sistem bine definit pentru realizarea trimiterilor și programărilor, folosiți-l pe acesta în cadrul sesiunii – apelați la formularele folosite de aceștia și oferiți-le participanților oportunitatea să exerseze completarea acestora. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii.  Pregătiți SAU cereți participanților să prezinte o listă a metodelor prin care utilizatorii sunt direcționați către furnizorul de servicii de scaune rulante. P R E ZE N TA R E 1. Introducere. 2. Trimitere. 3. Programare. 4. Recapitulare puncte cheie. 2 12 13 3 Total durată sesiune 30 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 94. 1. Introducere (2 minute) Explicați: Trimiterea și programarea constituie prima etapă în furnizarea serviciilor de scaune rulante. Pe parcursul acestei sesiuni, vom discuta despre diferitele modalități prin care utilizatorii de scaun rulant pot fi îndreptați către un furnizor de servicii de scune rulante, precum și despre sistemele de efectuare a programărilor. 2. Trimiterea (12 minute) Întrebare: Ce înseamnă „trimiterea”? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o trimiterea sau direcționarea unei persoane către serviciul care îi poate oferi îngrijirea sau asistența necesare. Arătați prezentarea ppt. Explicați: Există diferite moduri prin care utilizatorii de scaun rulant pot fi direcționați către furnizorii de servicii rulante. De exemplu, utilizatorii: o pot să afle ei înșiși despre aceste servcii; o pot fi direcționați către aceste servicii de către spitalul din localitate, centrul de sănătate publică, serviciul de reabilitare bazată pe comunitate, lideri sau reprezentanți ai comunității rurale/consiliului local/ai bisericii, organizații ale persoanelor cu dizabilități, alți utilizatori de scaun rulant. Întrebare: Ce alte organizații, servicii sau ce alte persoane pot direcționa utilizatorii către furnizorii de servicii de scaune rulante? Încurajați participanții să răspundă. Posibile răspunsuri: o medici; o lideri sau reprezentanți ai comunității rurale/consiliului local/ai bisericii; o centre de recuperare medicală; o organizații ale persoanelor cu dizabilități; o alți utilizatori de scaun rulant; o organizații nonguvernamentale. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 95. Explicați: Aceste organizații, servicii sau persoane pot fi numite „surse”. Furnizorii de servicii de scaune rulante pot crește numărul utilizatorilor de scaune rulante care apelează la ele, asigurându-se că toate aceste surse știu că serviciile sunt disponibile. Cereți participanților să citească modelul de formular de trimitere către furnizorul de servicii rulante care se găsește în Manualul participantului SAU Distribuiți participanților formularul de trimitere utilizat de furnizorul local, dacă există un astfel de formular. Explicați: o Oferind „surselor” un formular de trimitere, furnizorul de servicii de scaune rulante poate dobândi informații inițiale de bază despre utilizatorul de scaun rulant. o Fiecare furnizor de servicii de scaune rulante trebuie să decidă care este formularul care îi este cel mai util și modul în care acesta va fi folosit (de exemplu, dacă va fi trimis prin poștă sau dacă va fi adus de către utilizatorul de scaun rulant). 3. Programarea (13 minute) Explicați: o Atunci când un utilizator este direcționat către un furnizor de servicii de scaune rulante, acesta trebuie să fie programat pentru o evaluare. Această programare presupune că utilizatorul va merge la sediul furnizorului de servicii sau că personalul acestuia se va deplasa la utilizator. o Un sistem de programări va ajuta furnizorul de servicii de scaune rulante să își organizeze timpul. De asemenea, astfel se evită situațiile în care utilizatorul trebuie să aștepte la sediul furnizorului pentru a fi primit de către personalul acestuia. o Modul în care este făcută programarea depinde de cât de ușor se poate trasmite mesajul către utilizatorul de scaun rulant. Întrebare: Puteți enumera câteva modalități prin care furnizorul de servicii de scaune rulante poate transmite mesaje către utilizatori? Încurajați participanții să răspundă. Posibile răspunsuri: o telefon; o poștă; o transmiterea mesajului cu ajutorul unui asistent social; o radio; o trimiterea unui mesaj către „sursă”, pentru ca aceasta să contacteze utilizatorul de scaun rulant; o trimiterea unui mesaj cu ajutorul unui prieten/membru de familie. Explicați: Uneori, utilizatorii de scaun rulant vor veni fără o programare prealabilă. Dacă este posibil, se recomandă ca ei să fie primiți în aceeași zi, în special dacă au sosit de la distanță. Dacă furnizorul de servicii de scaune rulante unde își desfășoară activitatea participanții are un sistem specific de programare, explicați care sunt caracteristicile acestui sistem. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 96. 4. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 97. B.2: Evaluarea O B IE C IT V E La sfârșitul acestei sesiuni, participanții vor putea:  să explice care este scopul evaluării;  să enumere cele două părți componente ale evaluării;  să enumere tipurile de informație care se dobândesc pe parcursul realizării evaluării. M A TE R IA LE Pentru sesiune:  prezentare PPT: B.2 Evaluarea;  Manualul participantului; C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  modul în care se realizează evaluarea în cadrul serviciului de scaune rulante unde își desfășoară activitatea participanții. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Cine are nevoie de un scaun rulant? 3. De ce este necesară realizarea evaluării? 4. Locul unde se realizează evaluarea. 5. Cele două părți ale unei evaluări de bază. 6. Recapitulare puncte cheie. 2 5 10 5 5 3 Total durată sesiune 30 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 98. 1. Introducere (2 minute) Explicați: o Evaluarea este cea de a doua etapă a furnizării serviciilor de scaune rulante. o Pe parcursul acestei sesiuni, vom explica de ce este importantă evaluarea și vom discuta despre cele două părți ale evaluării. o Pe parcursul evaluării, rețineți că utilizatorul de scaun rulant trebuie să fie implicat activ în realizarea acestei etape – puneți întrebări și fiți atenți la răspunsurile și opiniile lor. 2. Cine care nevoie de scaun rulant? (5 minute) Explicați: Atunci când o persoană apelează la furnizorul de servicii pentru a primi un scaun rulant, este important să ne asigurăm că scaunul rulant este într-adevăr echipamentul de mobilitate de care aceasta are nevoie. Întrebare: Cum putem determina dacă o persoană are nevoie de scaun rulant? Încurajați participanții să răspundă și notați. Cele mai relevante răspunsuri: o persoana nu se poate deplasa; o persoana se poate deplasa – însă îi este dificil să facă acest lucru sau se poate deplasa doar pe distanțe scurte. Explicați: o Chiar dacă o persoană se poate deplasa pe distanțe scurte, ea ar putea avea nevoie de un scaun rulant pentru a parcurge distanțe mai lungi. o De obicei, utilizarea unui scaun rulant nu va împiedica o persoană să se folosească de capacitatea sa de a se deplasa. o Alegerea corectă este cea care îl ajută pe utilizator să ajungă la un nivel cât mai ridicat de mobilitate și să aibă o bună calitate a vieții. Este dreptul utilizatorului să facă această alegere. 3. De ce este necesară evaluarea? (10 minute) Întrebare: De ce este necesară evaluarea? Încurajați participanții să răspundă și notați. Cele mai relevante răspunsuri: o pentru a putea alege scaunul rulant care corespunde cel mai bine fiecărui utilizator, dintre cele disponibile; o pentru a putea alege cele mai potrivite componente din cele disponibile; o pentru a determina care este nevoia de instruire a utilizatorului și/sau a familiei, de așa manieră încât acesta să poată beneficia de avantajele scaunului rulant la întreaga capacitate a echipamentului de mobilitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 99. Întrebare: Care sunt acele informații pe care participanții consideră că trebuie să le obținem în timpul realizării evaluării? Încurajați participanții să răspundă și notați. Potențiale răspunsuri: o numele, vârsta, adresa; o domiciliul utilizatorului – tipul de teren, dimensiunea casei, trepte etc.; o locul unde utilizatorul frecventează școala sau merge la serviciu; o activitățile pe care le desfășoară utilizatorul sau pe care dorește să le desfășoare (stilul de viață) o distanța pe care utilizatorul trebuie să o parcurgă zilnic; o tehnica de transfer în și din scaunul rulant pe care o folosește; o persoanele cu care locuiește utilizatorul; o tipul de deficiență sau de dizabilitate a utilizatorului; o abilitățile sale fizice; o durata de timp pe care utilizatorul o petrece zilnic în scaunul rulant; o starea de sănătate – inclusiv riscul apariției escarelor; o dimensiunile fizice; o dacă utilizatorul are deja un scaun rulant și dacă acesta este unul corespunzător; o modul în care utilizatorul se deplasează pe distanțe lungi – de exemplu, dacă folosește mijloace de transport în comun? Explicați: o Toate aceste informații îi ajută atât pe utilizatorii de scaun rulant, cât și personalul furnizor de servicii de scaune rulante: o să aleagă scaunul rulant și perna corespunzătoare; o să aleagă cele mai adecvate părți componente/caracteristici și o să identifice nevoia de instruire sau de asistență a utilizatorului de scaun rulant. o De exemplu: o un utilizator care își petrece întreaga zi stând în scaunul rulant și care se deplasează pe distanțe lungi, va avea nevoie de un astfel de echipament de mobilitate confortabil, care să îi ofere un sprijin adecvat, rezistent și potrivit pentru utilizarea în exterior; o un utilizator care nu stăpânește o tehnică eficientă de transfer în și din scaunul rulant va avea nevoie de instruire cu privire la modalitățile de transfer. 4. Locul unde se realizează evaluarea (5 minute) Explicați: o Evaluarea trebuie efectuată întotdeauna într-un spațiu curat și liniștit. o Acesta poate fi un spațiu aflat la sediul furnizorului de servicii de scaune rulante, la un centru de sănătate ori un centru comunitar sau la domiciliul utilizatorului de scaun rulant. Întrebare: Care este spațiul desemnat pentru realizarea evaluării la sediul furnizorului de servicii de scaune rulante unde urmează să lucreze participanții? Rețineți răspunsurile. Dacă participanții nu știu, reamintiți-le că trebuie să se asigure că există un spațiu curat și liniștit, în care să se poată desfășura această activitate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 100. 5. Cele două părți ale unei evaluări de bază (5 minute) Explicați: Evaluarea constă în două părți: o Interviul de evaluare; o Evaluarea fizică. Informația se înregistrează într-un formular de evaluare. Pe parcursul sesiunilor următoare, participanții vor exersa modalitatea de realizare a unei evaluări. 6. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 101. B.3: Interviul de evaluare O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să demonstreze practic cum se realizează interviul de evaluare;  să înregistreze informațiile dobândite pe parcursul evaluării într-un formular de evaluare;  să explice felul în care întrebările din interviul de evaluare ajută la alegerea celui mai adecvat scaun rulant și la identificarea nevoii de instruire a utilizatorului. M A TE R IA LE Pentru sesiune:  prezentare PPT: B.3 Interviul de evaluare;  Manualul participantului;  Caietul de exerciții practice;  Câte un scaun rulant pentru fiecare grupă alcătuită din trei participanți. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții.  În cazul în care există un tip de dizabilitate care se întâlnește în mod frecvent în cadrul unui context local și nu este prevăzut în formularul de evaluare, includeți această dizabilitate în formular și în sesiunea de instruire.  In cazul în care cazurile prezentate nu se potrivesc contextului local, înlocuiți-le. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Informații despre utilizatorul de scaun rulant. 3. Condiția fizică. 4. Stilul de viață și mediul în care trăiește. 5. Scaunul rulant existent. 6. Exercițiu practic pentru interviul de evaluare. 7. Recapitulare puncte cheie. 2 10 15 15 5 40 3 Total durată sesiune 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 102. 1. Introducere (2 minute) Explicați: Pe parcursul acestei sesiuni, participanții: o vor învăța cum se realizează prima parte a evaluării – interviul; o vor analiza fiecare parte a interviului de evaluare și vor învăța în ce mod răspunsurile la întrebările din formular au impact asupra alegerii scaunului rulant. Fiecare participant va avea oportunitatea să exerseze rolul persoanei care adresează întrebările. 2. Informații despre utilizatorul de scaun rulant (10 minute) Explicați: Înainte de a discuta despre întrebările din interviul de evaluare, trebuie să ne amintim câteva aspecte despre modalitatea de a pune întrebări. o Înainte de a adresa întrebările, explicați întotdeauna utilizatorului de scaun rulant faptul că acestea vă vor ajuta să alegeți scaunul rulant corespunzător. o Adresați-vă mereu utilizatorului (nu asistentului/unui membru de familie), excepție cazurile când este vorba despre un copil mic sau despre o persoană care nu are abilitatea de a înțelege întrebările ori de a răspunde la ele; o Folosiți metode de comunicare eficiente; Întrebare: Puteți să dați câteva exemple de tehnici de comunicare eficiente? Încurajați participanții să răspundă și notați. Cele mai relevante răspunsuri: o vorbire clară; o folosirea unor termeni ușor de înțeles; o explicarea în avans a activității care urmează să se desfășoare; o după explicarea tuturor aspectelor, verificarea faptului că utilizatorul de scaun rulant a înțeles cele comunicate; o atenție la mesaj, pentru a avea siguranța că cele comunicate de către utilizatorul de scaun rulant au fost înțelese corect; o păstrarea contactului vizual (acolo unde acest lucru este acceptat de normele de comportament); o respectful pentru înlocuitor; o evitarea presupunerii că reprezentantul furnizorului de servicii de scaune rulante cunoaște cel mai bine aspectele legate de scaunul rulant; o demonstrarea de interes în comunicarea cu utilizatorul de scaun rulant. Înmânați fiecărui participant un formular de evaluare. Începeți prezentarea PPT B.3 Interviul de evaluare. Explicați: o În formularul de evaluare de înregistrează informații din patru categorii diferite. o Vom analiza fiecare categorie de informații și vom explica modul în care întrebările din interviul de evaluare vor influența alegerea scaunului rulant. o Nu este obligatoriu ca întrebările să fie puse în ordinea în care ele sunt în formular. Uneori, utilizatorii de scaun rulant oferă răspunsuri înainte de a li se adresa o anumită întrebare sau, la rândul nostru, putem constata că o altă ordine a acestora este Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 103. mai firească. Explicați: o „Informațiile despre utilizatorul de scaun rulant” ne oferă toate datele necesare contactării ulterioare a acestuia. o Totodată, ele oferă informații statistice despre utilizatorii care au fost evaluați de personalul furnizor de servicii de scaune rulante. 3. Condiția fizică (15 minute) Explicați: o La capitolul „Condiția fizică”, se va nota diagnosticul utilizatorului, dacă această informație este disponibilă. De asemenea, se notează orice problemă fizică ce va influența selecția scaunului rulant. o Unele dintre cele mai frecvent întâlnite diagnostice sunt incluse în formular și pot fi bifate. Acestea sunt: paralizie cerebrală, poliomielita, traumatismul vertebro-medular și accidentul vascular-cerebral. o Există și o categorie denumită „Altele”. Dacă bifați această variantă, notați respectivul diagnostic. Explicați: o Este util (deși nu obligatoriu) să cunoaștem diagnosticul utilizatorului de scaun rulant. o Anumite diagnostice au caracteristici care pot influența selecția scaunului rulant. o Vom discuta acum despre cele mai importante aspecte legate de diagnostic, acelea pe care trebuie să le avem în vedere atunci când facem prescrierea (selecția) scaunului rulant. o Aceste informații se regăsesc în Manualul participantului. o Explicați:  Paralizia cerebrală afectează persoanele în moduri foarte diferite.  În cazul unei persoane cu paralizie cerebrală, care poate sta în poziția așezat, este important să reținem faptul că acesteia îi poate fi dificil să păstreze poziția, din cauza oboselii. Astfel, desfășurarea activităților e îngreunată și devine mai solicitantă.  Este foarte important să existe un bun sprijin postural.  Persoanele cu paralizie cerebrală pot avea nevoie de suport postural suplimentar atunci când stau în scaunul rulant. Pentru a rezolva acest aspect ușor și în mod eficient, este nevoie de instruire nivel intermediar. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 104. Explicați: o În cazul unora din persoanele care au avut poliomielită, la nivelul unor părți ale corpului poate exista o stare de slăbiciune, de lipsă de forță. Poliomielita poate afecta membrele inferioare, membrele superioare sau trunchiul, dar cel mai frecvent afectează picioarele. o Mușchii și oasele devin mai subțiri, membrele afectate nu cresc la fel de repede, rămânând mai scurte. o Atunci când este afectat trunchiul, acesta poate părea mai scurt. o Cu toate că la persoanele care au avut poliomielită este prezentă sensibilitatea, este important ca ele să aibă o pernă, pentru confort. o O pernă mai înaltă poate oferi o poziție mai confortabilă în vederea realizării propulsiei. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Explicați: o Persoanele cu traumatism vertebro-medular sunt deosebit de predispuse la apariția escarelor. o Acest lucru este o consecință a faptului că la majoritatea persoanelor cu traumatism vertebro-medular, sub nivelul leziunii, sensibilitatea este absentă. o Prescrieți întotdeauna o pernă pentru reducerea presiunii. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Explicați: o Persoanelor care au suferit un accident vascular cerebral le este de regulă afectată o parte a corpului. Din această cauză, atunci când stau în scaunul rulant, ele pot avea tendința de a se lăsa mai mult pe o parte. o Este posibil ca sensibilitatea pe partea corpului afectată de accident să le fie diminuată. o Aceste persoane pot avea abilitatea de a efectua transferul în picioare. o Este foarte important să existe un bun sprijin postural. o Verificați dacă este prezentă sensibilitatea – s-ar putea ca să fie nevoie de o pernă pentru reducerea presiunii. o O persoană care a avut un accident vascular cerebral poate prefera un scaun rulant cu suporturi de picioare pliabile, pentru a putea efectua transferul în picioare. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Explicați: o Vom discuta acum despre alte diagnostice care pot influența selecția scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 105. Explicați: o În cazul persoanelor cu dublă amputație lipsește greutatea picioarelor, care să contracareze răsturnarea pe spate a scaunului rulant. o Fiți atenți întotdeauna atunci când o persoană cu amputație încearcă pentru prima dată un scaun rulant. o Verificați echilibrul scaunului rulant. Este posibil să fie necesară mutărea roții din spate spre o poziție posterioară mai avansată, pentru a oferi mai multă stabilitate. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Explicați: o Persoanele în vârstă pot avea nevoie de un scaun rulant din diverse motive. De obicei, acest lucru se întâmplă deoarece le este dificil să se deplaseze. Scaunul rulant îi va ajuta să continue să facă parte din viața familiei și a comunității. o Persoanele în vârstă pot avea capacitatea de a realiza transferul în picioare și vor prefera un scaun rulant cu suporturi de picioare pliabile pe verticală sau pe orizontală. o Persoanele în vârstă trebuie să utilizeze mereu scaune rulante care le oferă confort și sprijin. Astfel, ele vor sta în poziție corectă și vor fi evitate problemele cauzate de postura incorectă. o Cea mai bună alegere o constituie suporturile de picioare pliabile pe orizontală sau pe verticală. o Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Explicați: o Unele persoane au probleme cauzate de mișcări spontane, dezordonate, pe care nu le pot controla (spasme). o Din cauza acestor spasme, greutatea persoanei poate să se deplaseze înspre spate, fapt care poate duce la răsturnarea scaunului rulant. o Acest tip de mișcări poate determina picioarele „să sară” de pe suportul de picioare, ceea ce se poate dovedi periculos în timpul realizării propulsiei. Centurile pentru gambe pot ajuta la controlul poziției piciorului, la fel ca și cele pentru bazin. o Centurile trebuie să se închidă și să se desfacă cu material de tip Velcro, în așa fel încât acestea să poată fi desprinse în cazul în care utilizatorul cade din scaunul rulant. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. Explicați: o Unele persoane nu dețin controlul asupra vezicii sau al sfincterului. o Frecvent, această situație poate fi rezolvată cu dispozitivele potrivite (catetere, de exemplu), cu medicație și cu un program de instruire pentru management vezical și intestinal. o Utilizatorii care au probleme de management vezical sau intestinal nu trebuie să stea pe perne umede sau pătate, fiindcă acest lucru poate dăuna rapid pielii. În plus, bacteriile prezente în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 106. materiile fecale pot duce, într-un interval de timp scurt, la escare infectate. o Furnizați o pernă cu o husă impermeabilă. o O pernă suplimentară ajută utilizatorul să își continue activitățile cotidiene în timp ce perna se usucă. Parcurgeți prezentarea pentru a evidenția aspectele cheie ce trebuie reținute. . 4. Stilul de viață și mediul (15 minute) Explicați: o Întrebările referitoare la stilul de viață și la mediu aduc informații cu privire la spațiul în care locuiește utilizatorul de scaun rulant și la activitățile pe care trebuie să le desfășoare în scaun rulant. Citiți cu voce tare fiecare punct și adresați următoarea întrebare: Cum vor contribui răspunsurile la această întrebare la alegerea scaunului rulant corespunzător sau la evaluarea nevoii de instruire a utilizatorului? Ascultați răspunsurile și dați exemple, dacă acest lucru este necesar. Întrebare: Cele mai relevante răspunsuri Descrieți spațiul unde va fi folosit scaunul rulant de către utilizator. o Scaunul rulant trebuie să fie ușor de utilizat la domiciliu, la locul de muncă sau la școală. De exemplu: o dacă scaunul rulant va fi folosit la domiciliu, utilizatorul trebuie să aibă posibilitatea de a-l manevra cu ușurință în spațiul din casă , pentru a desfășura activitățile cotidiene; o pentru un utilizator care lucrează într-un birou, este necesar un scaun rulant care să încapă cu ușurință în spațiul de la locul de muncă; o un utilizator care merge la școală are nevoie de un scaun rulant care poate fi introdus în sala de curs și care poate fi poziționat lângă un pupitru sau de o măsuță atașată echipamentului de mobilitate; o un utilizator care trebuie să parcurgă o distanța mai mare, de exemplu, până la piață, de exemplu, are nevoie de un scaun rulant care să reziste folosirii pe teren accidentat. Distanța parcursă zilnic. o Putem să ne deplasăm pe jos pe distanțe scurte, dar să alegem să folosim o bicicletă pe distanțe mai lungi. Similar, un utilizator poate folosi scaunul rulant pentru distanțele scurte și triciclul pentru cele mai lungi. o Un triciclu presupune un efort mai mic din partea utilizatorului și ajută la parcurgerea distanței într-un timp mai scurt. Numărul de ore zilnic de utilizare a scaunului rulant. o Cu cât o persoană petrece mai mult timp în scaunul rulant, cu atât mai mare devine pericolul apariției escarelor. Luați în considerare gradul de suport de care are nevoie persoana, precum și modul în care perna reduce presiunea și oferă confortul necesar. o Oricărei persoane în scaun rulant „active”, scaunul rulant trebuie să îi ofere, pe tot parcursul zilei, posibilitatea ca manevrarea și celelalte activități să se desfășoare cât mai eficient posibil. Poziția roților este Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 107. importantă. De asemenea, este important să verificăm dacă spătarul oferă sprijin, fără a reduce libertatea de mișcare la nivelul umerilor. Tehnica de transfer folosită. o Suporturile de brațe și de picioare pot influența modul în care utilizatorul de scaun rulant efectuează transferul în și din scaunul rulant: o pentru realizarea transferului în picioare, sunt recomandate suporturile de picioare care se pliază și suporturile de brațe care pot fi ridicate; o pentru transferurile care nu se realizează în picioare, suporturile de brațe detașabile sau cele care urmăresc profilul roților ușurează transferul. Tipul de toaletă. Tipul de toaletă și accesul fizic la aceasta vor influența ușurința cu care utilizatorul va folosi scaunul rulant. Este posibil ca utilizatorul să aibă dificultăți din cauza tipului de toaletă. De exemplu, celor mai mulți utilizatori le este dificil să folosească toalete situate la nivelul podelei. Cerând informații despre tipul de toaletă și localizarea acesteia, personalul furnizor de servicii de scaune rulante poate oferi sfaturi cu privire la realizarea transferului la toaletă. De asemenea, poate oferi utilizatorului sfaturi cu privire la modalitățile de adaptare a toaletei. Frecvența utilizării mijloacelor de transport proprii/publice. Dacă utilizatorul are nevoie în mod frecvent de mijloace de transport, este necesar ca scaunul rulant să poată fi transportat fără dificultate. Caracteristicile scaunului rulant care facilitează acest lucru includ: o greutatea scaunului rulant – un scaun rulant mai ușor poate fi manevrat cu mai puțină dificultate; o roți detașabile și cadru/spătar pliabil. Dacă se folosesc mjloace de transport în comun, componentele detașabile constituie un avantaj, pentru că astfel scaunul rulant este mai ușor de transportat. Cu toate acestea, există și dezavantajul ca acestea să se desfacă, să se piardă sau să fie chiar furate. 5. Scaunul rulant existent (5 minute) Explicați: o Dacă utilizatorul deține deja un scaun rulant, este important să identificăm acele aspecte care îl fac necorespunzător în cazul respectivului utilizator. o Citiți toate întrebările din formularul de evaluare „Scaunul rulant existent”. Dacă răspunsul la oricare din întrebări este „nu”, personalul utilizator de scaune rulante trebuie să descrie problema la secțiunea „Comentarii”. În funcție de resursele disponibile, în timpul prescrierii putem să încercăm să identificăm o cale de a modifica sau de a repara scaunul rulant existent. Dacă răspunsul la toate întrebările este „da”, atunci este posibil ca utilizatorul să nu aibă nevoie de un alt scaun rulant. Acest lucru trebuie discutat cu utilizatorul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 108. 6. Interviul de evaluare – exercițiu practic (40 de minute) Activitate Grupe: Formați grupe de câte trei participanți. Instrucțiuni: Cereți fiecărei grupe să desfășoare un joc de rol pentru a exersa realizarea interviului de evaluare – trebuie să utilizeze cazurile prezentate în caietul de exerciții practice. Scoateți în evidență faptul că, acolo unde este posibil, doar persoana care va avea rolul utilizatorului de scaun rulant trebuie să citească respectivul caz. De fiecare dată, un alt membru al echipei ar trebui să aibă rolul utilizatorului de scaun rulant. Folosind informațiile specifice cazului individual ales, acesta răspunde întrebărilor ce îi sunt puse de către persoana care are rolul de a realiza interviul de evaluare. Cel care este în postura utilizatorului de scaun rulant nu va citi prezentarea cu voce tare. Ceilalți doi participanți lucrează împreună pentru a realiza interviul de evaluare și înregistrează informația în formularul de interviu de evaluare din caietul de exerciții practice. Monitorizare: Monitorizați activitatea grupelor și oferiți asistență acolo unde este necesar. Durata: Durata fiecărui interviu ar trebui să fie de 10 minute, iar sesiunea de întrebări și răspunsuri care implică toți participanții este tot de 10 minute. Feedback: Discutați pe scurt fiecare caz prezentat. Prezentați materialul ppt care corespunde fiecărui utilizator prezentat și adresați următoarele întrebări: o Care sunt cele mai utile informații despre Felicia/Anton/Chantou care contribuie la alegerea unui scaun rulant corespunzător pentru fiecare dintre ei? o Care sunt informațiile care vor ajuta personalul furnizor de servicii să identifice nevoia de instruire în cazul fiecărui utilizator de scaun rulant? o Scaunele rulante pe care le au în prezent Anton și Chantou răspund nevoilor lor individuale? De ce/de ce nu? Formatorii pot face referire la aspectele de ma jos. Caz utilizator de scaun rulant Aspecte de reținut Felicia este o femeie în vârstă, cu o formă severă de artrită, având dureri în brațe, mâini și picioare. Nu se poate deplasa mai mult de câțiva pași, din cauza durerilor și îi este dificil să aibă grijă de ea. Felicia a participat la evaluare împreună cu fiica ei. Locuiește într-un oraș mic, iar casa ei are trei trepte la intrare. Nu are alte probleme de sănătate, cu excepția artritei. Obișnuia să meargă la biserică în mod regulat, dar nu mai poate face asta. Casa în care locuiește are o toaletă tipică. Familia Feliciei nu deține un autoturism și folosește mijloacele de transport în comun. Pentru a veni la evaluare, ele au închiriat un taxi, ceea ce este o cheltuială importantă. La ora actuală, ea nu deține un scaun rulant. Informații care contribuie la alegerea scaunului rulant corespunzător: o Felicia experimentează un grad ridicat de durere. Este foarte posibil ca din cauza durerii să aibă nevoie de însoțitor pentru manevrarea scaunului rulant. o Felicia poate merge pe o distanță de câțiva pași. Există o mare probablitate ca ea să efectueze transferul în și din scaun rulant stând în picioare. Astfel, ea ar avea de beneficiat de pe urma unui scaun rulant ale cărui suporturi de picioare pot fi pliate. o Familia Feliciei nu deține o mașină, din acest motiv, ea va trebui să apeleze la mijloacele de transport în comun. În consecință, ar fi util ca scaunul rulant să fie unul pliabil. Informații pentru a identifica nevoia de instruire în cazul Feliciei: o Felicia beneficiază de ajutorul fiicei sale – atât Felicia, cât și fiica ei trebuie să învețe tehnici sigure de realizare a transferului în și din scaunul rulant, precum și urcarea și coborârea treptelor. Anton are poliomielită. Are 26 de ani Informații care contribuie la alegerea scaunului rulant Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 109. și locuiește într-un oraș mic. Studiază informatica și își dorește mult ca în viitor să aibă propria lui afacere. El a participat la evaluare împreună cu soția lui. În urmă cu multă vreme, Anton a primit donație un scaun rulant de tip ortopedic. Acesta este ruginit, iar tapițeria este ruptă. Roțile frontale sunt mici și subțiri. Anvelopele roților spate sunt foarte subțiri și uzate. Scaunul rulant este inconfortabil și dificil de împins. Anton folosește aceeași toaletă pe care o folosește și familia sa. Drumurile din oraș sunt accidentate, iar scaunul rulant se împotmolește de multe ori. Cu toate acestea, Anton vrea să se poată deplasa singur de acasă la centrul de pregătire vocațională. Distanța este de 1½ km. La ora actuală, el are nevoie de ajutor din partea fratelui său mai mic, dar acesta nu îl poate duce întotdeauna la timp. corespunzător: o Anton locuiește într-o zonă cu drumuri accidentate. El vrea să fie capabil să se deplaseze de la domiciliul său la școala unde frecventează cursurile – are nevoie de un scaun rulant pe care să îl poată propulsa singur, pe teren accidentat. o Anton petrece mult timp în scaun rulant – este important suportul postural corespunzător din cauza numărului de ore pe care el le va petrece zilnic în echipamentul de mobilitate. Informații pentru a identifica nevoia de instruie în cazul lui Anton: o Anton trebuie să aibă un grad ridicat de mobilitate pe un teren cu o suprafață care face manevrarea scaunului rulant dificilă – îi va fi de un real folos instruirea pentru dezvoltarea abilităților de manevrare a scaunului rulant. o Anton folosește mult scaunul rulant pe teren accidentat. Are nevoie să învețe aspecte despre întreținerea scaunului rulant, pentru ca acesta să funcționeze adecvat. Scaunul rulant pe care Anton îl deține în prezent: o Scaunul rulant pe care îl are Anton la ora actuală este deteriorat și nu corespunde nevoilor sale fizice, nici condițiilor din mediul în care trăiește el. Observație: Acolo unde sunt disponibile tricicluri, formatorii trebuie să menționeze că acestea pot constitui o soluție bună pentru acest utilizator de scaun rulant, pentru a-l ajuta la parcurgerea zilnică a distanței până la centrul de formare. Chantou este o fată de 13 ani, care și-a pierdut ambele picioare (de deasupra genunchilor) în timpul unui cutremur. Locuiește împreună cu familia ei într-un apartament dintr-un oraș aflat în apropiere. A venit la evaluare împreună cu mama și cu sora ei mai mare. Are un scaun rulant primit ca donație, care este unul de tip ortopedic, destinat adulților. Scaunul rulant este prea mare pentru Chantou. Trebuie să își întindă brațele peste suporturile de brațe pentru a ajunge la inelele de antrenare, ceea ce este dificil pentru ea. Spătarul este și el prea înalt și nu există o pernă. Chantou ar vrea să se întoarcă la școală, dar se simte fizic inconfortabil în scaunul său rulant. De asemenea, este jenată de faptul că nu se poate deplasa singură. Și-ar dori un scaun rulant pe care să îl poată manevra ea însăși și care să îi ofere mai mult suport. Ea ar merge cu autobuzul școlii, dacă ar putea să își ia scaunul Informații care contribuie la alegerea scaunului rulant corespunzător: o Chantou are o poziție foarte neconfortabilă în scaunul rulant pe care îl deține și în care trebuie să petreacă mult timp. Ea are nevoie de un scaun cu dimensiunile potrivite, astfel încât să beneficieze de suportul postural necesar. Acest suport postural o va ajuta să fie mai energică în timpul zilei, atunci când este la școală. o Chantou trebuie să se deplaseze cu autobuzul școlii – are nevoie de un scaun rulant pe care să îl poată lua cu ea. Scaunul rulant pe care Chantou îl deține la ora actuală: o Scaunul rulant pe care îl are în acest moment este prea mare și ea nu îl poate manevra în mod independent; în cazul lui Chantou este indicat un scaun rulant mai ușor, care să îi ofere sprijin postural corespunzător. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 110. rulant cu ea. 7. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 111. B.4: Evaluarea fizică O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să înregistreze informații cu privire la prezența, riscul apariției sau istoricul escarelor;  să explice care sunt pașii de parcurs în cazul în care utilizatorul are o escară sau dacă există pericolul apariției unei escare;  să identifice și să noteze modul în care utilizatorul va efectua propulsia scaunului rulant;  să demonstreze modalitatea corectă de efectuare a măsurătorilor pentru prescrierea unui scaun rulant (lățimea șezutului, adâncimea șezutului, lungimea gambei, lungimea spatelui);  să descrie modul în care valorile măsurătorilor determină mărimea scaunului rulant prescris. M A TE R IA LE Pentru sesiune:  prezentare PPT B.4: Evaluarea fizică;  Manualul participantului;  Caietul de exerciții practice;  DVD: Măsurători – demonstrație;  Scaune rulante cu suporturi de picioare detașabile (dacă sunt disponibile) – 1 scaun rulant pentru fiecare trei participanți;  Formulare de evaluare – 1 formular pentru fiecare utilizator de scaun rulant.  Rulete pentru a exersa efectuarea măsurătorilor – câte una pentru fiecare participant. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  locul unde participanții vor realiza evaluările – de exemplu, la domiciliul utilizatorului, la spitalele din localitate sau într-un spațiu dedicat furnizării serviciilor de scaune rulante. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii.  Aranjați scaunele rulante în încăperea în care va avea loc activitatea.  Asigurați-vă că cel puțin unul din scaunele rulante are suporturi de picioare care se pliază vertical sau lateral (pentru a exersa propulsia cu piciorul). P R E ZE N TA R E 1. Introducere. 2. Pregătire. 3. Prezența, riscul apariției sau istoricul escarelor. 4. Metoda de realizare a propulsiei. 5. Efectuarea măsurătorilor. 6. Cum se efectuează măsurătorile. 7. Recapitulare puncte cheie. 2 5 10 20 30 20 3 Total durată sesiune 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 112. 1. Introducere (2 minute) Explicați: Pe parcursul acestei sesiuni vom exersa partea practică a procesului de evaluare: o vom învăța modalitatea de a înregistra aspectele legate de prezența, riscul apariției sau istoricul escarelor; o vom discuta despre metodele de propulsie folosite și vom exersa metoda propulsiei cu piciorul; o vom învăța modalitatea de realizare a celor mai importante măsurători, pentru a alege dimensiunea corectă a scaunului rulant. 2. Pregătire (5 minute) Explicați: Pentru evaluarea fizică, rugați utilizatorul de scaun rulant să se transfere din scaunul rulant (dacă acesta este un scaun pentru poziția așezat) pe un pat destinat efectuării evaluării. Astfel vă va fi mai ușor să observați postura utilizatorului și să efectuați măsurătorile. De asemenea, puteți observa și modul în care utilizatorul realizează transferul. Mai jos sunt câteva aspecte de reținut. Explicați: o Așa cum se recomandă și în cazul interviului, evaluarea trebuie să aibă loc într-un spațiu curat și liniștit. o Este important să fie un spațiu care poate fi izolat de restul încăperii, pentru a putea verifica existența escarelor. o Întotdeauna explicați utilizatorului de scaun rulant ce urmează să faceți și de ce. o Atunci când utilizatorul efectuează transferul, fiți pregătiți să îl asistați – pentru cazul în care acesta nu poate realiza transferul independent în condiții de siguranță. o Când utilizatorul se află pe patul unde are loc evaluarea: o în cazul în care picioarele nu sunt poziționate confortabil pe podea, folosiți plăci pentru picioare; o rămâneți în apropiere, până când sunteți siguri că utilizatorul este în siguranță și stă confortabil în poziția așezat, fără sprijin. 3. Prezența, riscul apariției și istoricul escarelor (10 minute) Explicați: Am vorbit deja în detaliu despre importanța prevenirii apariției escarelor. Întrebare: Puteți enumera cei mai importanți factori de risc în apariția escarelor – elementele care cresc probabilitatea incidenței acestora? Încurajați participanții să răspundă. Încercați să obțineți prin răspunsuri toate variantele menționate mai jos. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 113. Cele mai relevante răspunsuri: o absența sensibilității (sensibilitate diminuată); o imobilitatea; o umezeala provenită de la transpirație, apă sau incontinență; o nutriție necorespunzătoare, consum insuficient de lichide; o înaintarea în vârstă; o postura incorectă; o escare anterioare sau prezente; o greutatea – subponderabilitatea sau supraponderabilitatea. Explicați: Formularul de evaluare va ajuta participanții să determine gradul de risc în apariția escarelor. Parcurgeți prezentarea și explicați următoarele: o în cazul persoanelor la care este absentă sensibilitatea, există riscul apariție escarelor; o persoana la care se regăsesc trei sau mai mulți factori de risc este în pericol de a avea escare. Cereți participanților să citească formularul de evaluare. Explicați: Participanții adresează utilizatorului de scaun rulant întrebările din formular. o Utilizatorul prezintă un grad normal de sensibilitate? o Utilizatorul a avut vreodată o escară? Dacă da – unde a fost aceasta localizată? În formularul de evaluare, marcați locul pe desenul înfățisând corpul uman. o La momentul evaluării, utilizatorul are escare? o dacă da – întrebați dacă puteți vedea escara, pentru a fi siguri de localizarea și de gravitatea acesteia; o procedați cu tact atunci când solicitați să vedeți escara; o asigurați-vă ca spațiul este izolat de restul încăperii cu ajutorul unui paravan; o notați dacă este o escară deschisă sau închisă și marcați localizarea pe formular; o întrebați utilizatorul de scaun rulant care crede că a fost cauza apariției escarei și despre perioada de timp care a trecut de la apariția acesteia. o Încercuiți toți factorii de risc existenți în cazul respectivului utilizator. o Bifați dacă a fost sau nu identificat riscul apariției escarelor la respectivul utilizator. Întrebare: Care sunt pașii care se impun în cazul escarelor deschise, ale escarelor aflate în faza 2 sau într-o fază chiar mai avansată? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o trimiterea utilizatorului de scaun rulant pentru a fi consultat de către personalul medical; o recomandarea cu privire la înlăturarea sursei care exercită presiune – acest lucru poate însemna întreruperea utilizării scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 114. Întrebare: Care sunt pașii care trebuie urmați dacă a fost identificat pericolul apariției escarelor? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o oferirea de perne pentru reducerea presiunii – verificați dacă perna este funcțională, prin testarea nivelului de presiune sub oasele bazinului; o instruirea și profilaxia – ajutați la însușirea de către utilizator a tehnicilor de reducere a presiunii și subliniați importanța schimbării regulate a poziției, precum și a verificării zilnice a suprafeței pielii. Notă pentru formatori: Această întrebare se referă la persoanele la care am identificat existența pericolului apariției escarelor. Dacă escară este deja prezentă, există un alt set de măsuri. 4. Metoda realizării propulsiei (20 de minute) Explicați: o Este important să aflăm metoda prin care utilizatorul va realiza propulsia scaunului rulant. o Utilizatorii de scaun rulant au diverse metode de realizare a propulsiei. o Există utilizatori care folosesc în acest scop membrele superioare, alții care folosesc membrele inferioare, iar unii au nevoie de însoțitor. Întrebare: Care sunt abilitățile fizice care vor influența modul în care utilizatorul efectuează propulsia scaunului rulant? Încurajați participanții să răspundă. Răspunsuri: o forța și controlul membrelor superioare; o forța și controlul memebrelor inferioare o abilitatea de a sta în poziția așezat; o stabilitatea și controlul în ansamblu – dacă utilizatorul nu are stabilitate sau are un echilibru precar, el se va echilibra cu ajutorul brațelor; în acest caz el, nu le va putea utiliza pentru efectuarea propulsiei scaunului rulant. o Forța și controlul membrelor superioare și inferioare sunt importante, în aceeași măsură în care contează și stabilitatea generală. Un scaun rulant cu dimensiunea potrivită oferă un suport postural adecvat și facilitează propulsia scaunului rulant. Întrebare: Care este poziția ideală a roților din spate atunci când utilizatorul realizează propulsia scaunului rulant cu ajutorul brațelor? Răspuns: o Atunci când mâna utilizatorului este poziționată pe partea superioară a inelului de antrenare, cotul trebuie să fie îndoit într- un unghi de 90 de grade. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 115. Explicați: o Pentru realizarea propulsiei cu picioarele, poziția utilizatorului în scaunul rulant trebuie să permită călcâielor să stea pe podea, cât mai confortabil posibil. Bazinul trebuie să fie sprijinit de spătar. o Este important ca scaunul rulant să aibă suporturi de picioare pliabile. Utilizatorul poate avea nevoie de aceste suporturi atunci când scaunul rulant este împins de către un însoțitor, pe distanțe mai mari. o Suporturile de brațe sunt și ele folositoare, deoarece utilizatorul de scaun rulant se poate sprijini de ele atunci când se apleacă, în momentul realizării propulsiei. o Dacă utilizatorul folosește metoda propulsiei cu picioarele, iar scaunul rulant nu corespunde aplicării acestei metode, utilizatorul va fi nevoit să își schimbe postura în vederea efectuării propulsiei. Acest lucru determină un grad mai mare de oboseală, iar pe termen lung poate cauza probleme de suport postural. Explicați: În timpul sesiunii practice pentru dezvoltarea abilităților de manevrare a scaunului rulant am exersat metoda propulsiei cu brațele. Acum veți avea cu toții ocazia să exersați propulsia scaunului rulant cu ajutorul picioarelor. Activitate Grupe: Formați grupe de câte trei participanți (în mod ideal, membrii fiecărei grupe au înălțimi diferite, pentru a avea în vedere impactul asupra modului în care utilizatorul reușește să atingă podeaua cu picioarele). Fiecare grupă va lucra cu câte un scaun rulant. Instrucțiuni: Solicitați participanților să exerseze pe rând metoda propulsiei cu picioarele. Este recomandabil ca aceștia să stea cu bazinul sprijinit de spătarul scaunului rulant. Dacă acest lucru nu este posibil, participanții trebuie să încerce să găsească metode pentru a poziționa picioarele pe podea, pentru a putea efectua propulsia. Acest lucru îi va ajuta să înțeleagă ce se întâmplă atunci când scaunul rulant nu este corespunzător pentru folosirea aceastei modalități de propulsie Cereți participanților să exerseze propulsia scaunului rulant cu ajutorul picioarelor, având trunchiul înclinat înspre înainte sau înspre înapoi, precum și propulsia cu călcâiul sau cu degetele de la picioare. Monitorizare: Monitorizați activitatea grupelor. Asigurați-vă că activitatea se desfășoară în condiții de siguranță. Durata: Durata activității este de 10 minute pentru exercițiul practic și 5 minute pentru feedback. Feedback: Întrebați grupele: o participanții cărora le-a fost dificil să atingă podeaua – ce au fost nevoiți să facă pentru a putea poziționa piciorul pe podea? (Răspuns: fie să îndoaie spatele, fie să stea într-o poziție mai avansată pe șezutului scaunului rulant); o propulsia se realizează mai ușor atunci când trunchiul este înclinat înspre înainte sau înspre înapoi? (Răspuns: atunci când trunchiul este înclinat înspre înainte – ideal, cu bazinul sprijinit de spătar); o care sunt elementele care ajută utilizatorul să încline trunchiul înspre înainte? (Răspuns: suporturile de brațe sau o măsuță care oferă un punct de sprijin); o propulsia se realizează mai ușor cu degetele de la picioare sau cu călcâiul? (Răspuns: cu călcâiul). Explicați: o Pe parcursul activității, utilizatorii vor înțelege cât de obositoare și dificilă poate fi propulsia cu piciorul, în cazul în care scaunul rulant nu este corespunzător acestui tip de propulsie. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 116. o Un scaun rulant corespunzător propulsiei cu piciorul presupune o înălțime adecvată a șezutului acestuia în raport cu suprafața de contact. Iată câteva metode: o alegerea unui scaun rulant care are distanța dintre șezut și podea adecvată fiecărui utilizator individual (trebuie luată în considerare înălțimea pernei); o reducerea grosimii pernei –reducerea înălțimii în ansamblu; o plasarea unui șezut de scaun rulant solid mai jos de poziția inițială a acestuia. o Dacă utilizatorul realizează propulsia cu picioarele, personalul furnizor de servicii de scaune rulante îi va explica modul în care trebuie să stea cu bazinul sprijinit de spătar, cum trebuie să încline trunchiul înspre înainte și cum să „înainteze” punând jos mai întâi călcâiul. o Întotdeauna instruiți utilizatorul să propulseze scaunul rulant înainte și nu înapoi. Întrebare: Dacă scaunul rulant al utilizatorului este (uneori sau permanent) manevrat de către un însoțitor, cum va afecta acest lucru alegerea scaunului rulant? Răspuns: o este important ca scaunul rulant să aibă mânere rezistente; o în cazul utilizatorilor copii – mânerele situate la o înălțime mai mare vor ajuta însoțitorul adult să împingă scaunul rulant. Explicați: Metoda prin care se realizează propulsia influențează instruirea utilizatorului de scaun rulant și (acolo unde este cazul) a familiei sau însoțitorilor acestuia. 5. Realizarea măsurătorilor (30 de minute) Explicați: o Pe parcursul evaluării, personalul furnizor de servicii de scaune rulante efectuează anumite măsurători. Ulterior, aceste măsurători vor fi comparate cu dimensiunile scaunelor rulante disponibile, pentru a determina care este alegerea optimă. o Măsurătorile sunt înregistrate în formularul de evaluare. o O descriere a modului în care se efectuează fiecare dintre aceste măsurători poate fi găsită în Manualul participantului. Material video: Demonstrație măsurători. Acest material video vă va arăta cum se realizează cinci măsurători esențiale ale utilizatorului de scaun rulant. Cereți participanților să fie atenți la conținutul prezentării, deoarece vor exersa aceste măsurători. Prezentați materialul video. Verificați dacă există întrebări. Activitate Grupe: Formați grupe de câte trei participanți. Instrucțiuni: Cereți fiecărei grupe: o să realizeze măsurători pentru fiecare membru al echipei și să înregistreze valorile; o să se asigure că fiecare membru efectuează măsurători pentru toți cei din echipa sa – astfel, măsurătorile vor putea fi comparate la sfârșitul exercițiului; o să înregistreze valorile în caietul de exerciții practice. Monitorizare: Monitorizați cu atenție fiecare grupă de participanți. Folosiți ghidul de mai jos pentru a vă asigura că participanții folosesc tehnicile corecte. Verificați măsurătorile pentru a evalua acuratețea cu care participanții le-au Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 117. efectuat în timpul exercițiului. Formatorul poate trece valorile obținute de el pe panoul de scris, pentru ca diferențele să poată fi observate. Durata: Durata exercițiului este de 15 minute (5 minute per participant) pentru partea practică și de 15 minute pentru feedback. Feedback: o Întrebare: Toate măsurătorile efectuate în cazul aceleiași persoane au fost identice? o Întrebare: De unde pot proveni diferențele? (Răspuns: diferențele intervin atunci când nu se folosește tehnica corectă – de exemplu, dacă utilizatorului nu i se solicită să stea în poziția așezat corectă, dacă ruleta nu este în poziția corectă, dacă nu se citesc corect valorile indicate de ruletă). o Întrebare: Care sunt problemele ce decurg din efectuarea eronată a măsurătorilor? (Răspuns: scaunul rulant nu i se va potrivi utilizatorului). Formatori – folosiți următorul ghid pentru a verifica dacă participanții folosesc tehnicile corecte. În cazul tuturor măsurătorilor, asigurați-vă că ruleta este ținută drept și că utilizatorul de scaun rulant stă în poziția așezat corectă. În cazul în care picioarele nu stau confortabil pe podea, ele trebuie poziționate sau sprijinite pe plăci pentru picioare, A Înainte de a efectua măsurătorile, verificați că nu există obiecte în buzunarele utilizatorului. Măsurați șoldurile sau partea cea mai lată a coapselor. Folosind câte un clipboard de fiecare parte a șoldurilor utilizatorului de scaun rulant, putem să obținem valori mai exacte. B Poziționați un clipboard sau o carte la spatele utilizatorului de scaun rulant pentru a vă asigura că obțineți valoarea corectă. Măsurați în linie dreaptă de la partea posterioară a pelvisului până în spatele genunchiului. Întotdeauna măsurați ambele picioare. Dacă există o diferență, verificați dacă utilizatorul stă în poziția așezat corectă, cu bazinul în poziție neutră. Dacă diferența persistă, prescrieți scaunul rulant luând în considerare valorile mai mici. C Măsurați de la partea din spatele genunchilor până la baza călcâiului. Asigurați-vă că gleznele utilizatorului formează un unghi de 90 de grade (dacă acest lucru este posibil). Măsurați întotdeauna ambele picioare. Utilizatorul trebuie să poarte încălțămintea pe care o folosește în mod frecvent (dacă este cazul). D Măsurați de la suprafața de ședere până la partea inferioară a cutiei toracice. Pentru a localiza partea inferioară a cutiei toracice, poziționați mâinile pe ambele părți ale bazinului. Apăsați ușor și mișcați-le în sus. Partea inferioară a cutiei toracice este chiar deasupra taliei. E Măsurați de la suprafața de ședere până la partea inferioară a omoplatului, pe linie verticală. Pentru a găsi partea inferioară a omoplatului, rugați utilizatorul să ridice umerii. 6. Cum se efectuează măsurătorile (20 de minute) Explicați: Am exersat modalitatea prin care se efectuează măsurătorile. În continuare, vom vedea cum se raportează acestea la dimensiunile scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 118. Cereți participanților să citească formularul de evaluare. Indicați a treia coloană din tabelul de măsurători. Explicați: Aici este explicat modul în care măsurătorile corp sunt raportate la dimensiunile scaunului rulant. Le vom analiza pe rând. Explicați: o Măsurătoarea A: Lățimea șoldurilor este egală cu lățimea șezutului scaunului rulant. o Lățimea șezutului scaunului rulant trebuie să fie cât mai apropiată de valoarea măsurată pentru lățimea șoldurilor utilizatorului, dar niciodată nu trebuie să fie mai mică. o Dacă la utilizatorul de scaun rulant este absentă sensibilitatea, este esențial să ne asigurăm că lateralele scaunului rulant nu exercită presiune asupra bazinului sau a coapselor. Explicați: o Măsurătoarea B: Adâncimea șezutului minus aproximativ 30 de mm este adâncimea ideală a șezutului scaunului rulant. o Dimensiunea potrivită oferă coapselor suportul necesar. În acest fel se reduce presiunea sub oasele bazinului și se evită formarea escarelor. o În cazul utilizatorilor cu o lungime a picioarelor mai mare, această diferență poate crește. Valoarea acceptată este de până la 60 de mm. o Dacă șezutul scaunului rulant este prea lung, utilizatorul nu va putea sta în poziția așezat corectă. De asemenea, s-ar putea produce fricțiune între partea posterioară a coapselor și marginea șezutului scaunului rulamt, provocând disconfort și/sau apariția escarelor. o Dacă există o diferență între partea dreaptă și cea stângă, folosiți valorile mai mici la prescrierea scaunului rulant. Explicați: o Măsurătoarea C echivalează fie cu: o distanța de la partea superioară a pernei șezutului scaunului rulant până la suportul de picioare sau o distanța de la partea superioară a pernei șezutului scaunului rulant până la podea (în cazul propulsiei cu ajutorul picioarelor). o Înălțimea potrivită a suportului de picioare este importantă, deoarece ea asigură sprijinul corect la nivelul coapselor și al piciorului. o Înălțimea suportului are nevoie aproape întotdeauna de ajustări care se fac în timpul etapei de probare a produsului (scaunului rulant), pentru că este dificil de estimat gradul de comprimare al pernei în momentul în care utilizatorul stă așezat pe aceasta. o Înălțimea corectă a șezutului scaunului rulant în cazul utilizatorilor care realizează propulsia cu ajutorul picioarelor înseamnă un sprijin adecvat la nivelul coapselor și faptul că piciorul stă confortabil pe podea, pentru o propulsie eficientă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 119. Explicați: o Măsurătoarea D sau E înseamnă distanța dintre partea superioară a pernei șezutului scaunului rulant și partea superioară a spătarului. o Dimensiunea potrivită a scaunului rulant oferă utilizatorului suportul de care acesta are nevoie și permite utilizatorului activ să dispună de suficientă libertate de mișcare la nivelul umerilor. Explicați: o Măsurătoarea D – dă valoarea care este echivalentul înălțimii spătarului situat la nivelul părții inferioare a cutiei toracice. o Această înălțime a spătarului este potrivită pentru: o utilizatorii activi, cu o bună condiție fizică; o utilizatorii care pot menține cu ușurință poziția așezat și echilibrul. o Măsurătoarea E – dă valoarea care este echivalentul înălțimii spătarului situat la nivelul părții inferioare a omoplaților. o Această înălțime a spătarului este potrivită pentru: o utilizatorii la care oboseala se instalează repede; o utilizatorii care mențin cu dificultate poziția așezat. Explicați: Se recomandă să efectuați întotdeauna ambele măsurători, deoarece uneori nu este clar chiar din etapa evaluării care dintre valorile referitoare la lungimea spătarului este cea mai potrivită. Explicați: Vom discuta acum despre modalitatea de completare a tabelului de măsurători. Arătați tabelul de măsurători cu măsurătorile completate pentru utilizatorul din exemplu. Întrebare: În cazul acestei persoane, care sunt dimensiunile: o lățimea șezutului scaunului rulant? (faceți clic pentru a indica răspunsul); o adâncimea șezutului scaunului rulant? (faceți clic pentru a indica răspunsul); o înălțimea suportului de picioare? (faceți clic pentru a indica răspunsul); o înălțimea spătarului până la partea inferioară a cutiei toracice (faceți clic pentru a indica răspunsul); o înălțimea spătarului până la partea inferioară a omoplaților (faceți clic pentru a indica răspunsul). Întrebare: Cum ați proceda în cazul unei diferențe între valoarea adâncimii șezutului măsurată pe partea dreaptă și cea măsurată pe partea stângă? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o atunci când există o diferență între valorile măsurate pe cele două părți, adâncimea adecvată a scaunului rulant se va stabili în funcție de valoarea mai mică. Explicați: Rețineți – aceste măsuri sunt doar un exemplu de caz ideal. Personalul furnizor de servicii de scaune rulante trebuie să cunoască dimensiunile tipurilor de scaune rulante disponibile, astfel încât să poată alege dimensiunsiunea care i se potrivește cel mai bine utilizatorului. Vom discuta mai multe despre acest aspect în cadrul următoarei sesiuni. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 120. 7. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 121. B.5: Prescrierea (selecția) O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere activitățile incluse în etapa de prescriere (selecție);  să descrie principalele caracteristici ale scaunelor rulante disponibile local;  să identifice cea mai bună corespondență între nevoile utilizatorului și tipurile de scaun rulant disponibile local;  selecteze dimensiunea corespunzătoare a scaunului rulant în cazul fiecărui utilizator;  să înregistreze datele necesare prescrierii în formularul de prescriere (selecție). R E S U R S E Pentru sesiune:  prezentare PPT: B.5 Prescrierea (selecția);  Manualul participantului;  Caietul de exerciții practice (vă rugăm aveți în vedere faptul că în Caietul de exerciții practice există două secțiuni ce corespund capitolului B5)  Cel puțin câte unul din fiecare tip de scaun rulant disponibil local, cu pernă, precum și broșura sau caracteristicile tehnice ale acestuia, dacă sunt disponibile;  Rulete și orice alt instrument necesar manevrării părților ajustabile (e.g. suportul de picioare). C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  adaptarea duratei de timp alocate sesiunii în funcție de tipurile de scaun rulant disponibile local;  pregătirea și includerea oricăror formulare de prescriere (selecție) a scaunului rulant sau a materialelor de prezentare a datelor tehnice – un formular de prescriere (selecție) este util în cazul oricărui scaun rulant la care există o gamă de opțiuni sau de ajustări. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii.  Completați câte un formular de date tehnice pentru fiecare scaun rulant disponibil, pentru a-l avea ca model.  Familiarizați-vă cu fiecare tip de scaun rulant disponibil: caracteristici, gamă de ajustări, opțiuni și modalități de ajustare.  Adaptați formularul de prescriere (selecție) pentru a include toate opțiunile și ajustările care se pot efectua la scaunele rulante disponibile local (excepție cazurile în care există un formular de prescriere - selecție dedicat unui produs anume).  Poziționați scaunele rulante în sala de curs, împreună cu orice fel de materiale furnizate de către producător (de exemplu, broșuri sau informații despre produs). P R E ZE N TA R E 1. Introducere. 2. Ce este „prescrierea/selecția”? 3. Scaune rulante și perne disponibile local. 4. Alegerea scaunului rulant corespunzător și a componentelor adecvate. 5. Alegerea dimensiunii potrivite a scaunului rulant. 6. Înregistrarea prescrierii (selecției). 7. Recapitulare puncte cheie. 2 5 60 15 25 10 3 Total durată sesiune 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 122. 1. Introducere (2 minute) Explicați: o Prescrierea (selecția) este cea de-a treia etapă din cele opt ale furnizării serviciilor de scaune rulante. o Pe parcursul acestei sesiuni, participanții vor învăța modalitatea de a prescrie (a selecționa) un scaun rulant pe baza informațiilor obținute în etapa de evaluare. 2. Ce este prescrierea (selecția)? (5 minute) Explicați: o Prescrierea (selecția) înseamnă găsirea celei mai bune corespondențe între scaunele rulante (cu perne) disponibile și cerințele utilizatorului de scaun rulant. o Prescrierea (selecția) trebuie să se facă mereu în colaborare cu utilizatorul, inclusiv cu membrii familiei acestuia sau cu însoțitorii, dacă acest lucru este acceptat. o Prescrierea (selecția) include: o alegerea dimensiunii potrivite a scaunului rulant și a pernei; o alegerea celui mai adecvat tip de scaun rulant și a pernei corespunzătoare, precum și a componentelor potrivite; o agrearea, împreună cu utilizatorul, a aspectelor referitoare la nevoia de instruire în ceea ce privește manevrarea și întreținerea scaunului rulant și a pernei. Explicați: Pentru acest lucru, personalul furnizor de servicii de scaune rulante trebuie: o să înțeleagă care sunt nevoile utilizatorului de scaun rulant – prin realizarea evaluării și ascultând cu atenție ceea ce spune utilizatorul de scaun rulant; o să cunoască tipurile de scaune rulante și de perne disponibile; o să discute opțiunile cu utilizatorul de scaun rulant. 3. Tipurile de scaun rulant și perne disponibile local (60 de minute) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 123. Explicați: Personalul furnizor de servicii de scaune rulante trebuie să cunoască foarte bine tipurile de scaun rulant și perne disponibile local. Acesta trebuie să dețină următoarele informații. o Cadrul: de exemplu, observăm dacă este vorba de o bază a roții roții lungă sau scurtă; fie că este vorba despre un scaun cu cadru rigid sau de unul cu cadru pliabil. o Caracteristici: – inclusiv tipul de șezut, de spătar, suportul de brațe, roțile frontale și roțile din spate. o Dimensiune scaun rulant: Aceasta este de obicei echivalentul lățimii șezutului scaunului rulant, uneori a adâncimii acestuia. Este util să cunoaștem și înălțimea de la podea la șezutul scaunului rulant. Opțiuni de ajustare: observăm care sunt componentele ajustabile și care sunt opțiunile de ajustare. De regulă, ajustările sunt posibile pentru două sau mai multe poziții diferite. De exemplu, cele mai multe scaune rulante au suporturi de picioare care pot fi ajustate pe înălțimi situate la intervale regulate. Posibilitățile de ajustăre cuprind opțiunile situate între valoarea minimă și maximă. o Pernă: ce tip de pernă (dacă este cazul) se furnizează împreună cu scaunul rulant sau este disponibilă separat? o Unii furnizori de scaune rulante oferă: a. broșuri sau prezentări ale produsului b. specificații tehnice (pentru scaunul rulant). o Aceste informații conțin frecvent informații referitoare la: dimensiunile scaunului rulant, greutatea, caracteristicile și uneori componentele opționale. o Verificați întotdeauna dacă există informații cu privire la scaunele rulante pe care le prescrieți (alegeți). Citiți aceste informații pentru a vă familiariza cu produsul. o Dacă furnizorii nu oferă aceste informații – solicitați-le. Explicați: În cadrul acestei sesiuni, participanții vor analiza cu atenție câteva dintre tipurile de scaun rulant disponibile local. Ei vor completa formularul de date tehnice din caietul de exerciții practice. Acest lucru va include efectuarea de măsurători. Aceasta este modalitatea de a măsura un scaun rulant. Explicați: o Măsurați lățimea șezutului scaunului dintre cele două părți exterioare ale cadrului șezutului. o Dacă suporturile de brațe sunt situate deasupra cadrului șezutului scaunului rulant, măsurați distanța dintre acestea. o Măsurați adâncimea șezutului scaunului rulant de la baza spătarului până la partea din față a șezutului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 124. o Măsurați înălțimea șezutului scaunului rulant de la partea din față a șezutului până la podea. o Măsurați înălțimea spătarului (fără pernă) de la mijlocul părții din spate a șezutului scaunului rulant până la partea superioară a spătarului. o Măsurați înălțimea suportului de picioare măsurând distanța dintre partea din spate a suportului și șezutul scaunului rulant. o Pentru a măsura distanța pe care sunt posibile ajustări ale înălțimii suportului de picioare, măsurați intervalul dintre poziția cea mai joasă și cea mai înaltă la care poate fi situat suportul de picioare. o o Măsurați lungimea totală a cadrului scaunului rulant, care este echivalentul distanței dintre marginea posterioară a roților din spate și marginea anterioară a suportului de picioare (sau a roților frontale, dacă acestea sunt situate în fața suportului de picioare). o Măsurați baza roții, care reprezintă distanța dintre centrul roții din spate și centrul roții frontale. Explicați: o Valorile măsurătorilor scaunului rulant și gama de posibilități de ajustare se găsesc în mod frecvent în materialele tipărite ce conțin informații despre produs. o Cu toate acestea, este recomandabil să știm cum se efectuează măsurătorile, deoarece aceste informații nu sunt întotdeauna disponibile. o Verificați întotdeauna dacă un anumit tip de scaun rulant este disponibil într-o gamă mai largă de dimensiuni. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 125. Activitate Groupe: Formați grupe de câte trei participanți. Fiecărei echipe i se va desemna unul din tipurile de scaun rulant disponibile local. Dacă nu sunt disponibile suficiente tipuri diferite, unele grupe vor lucra cu acelați tip de scaun rulant. Instrucțiuni: Cereți fiecărei grupe: o să analizeze cu atenție scaunul rulant cu care trebuie să lucreze; o să completeze formularul de date tehnice din caietul de exerciții practice (acest lucru include efectuarea de măsurători ale scaunului rulant); o să identifice gama de ajustări necesare pentru a testa nivelul minim și nivelul maxim în cazul componentelor care suportă ajustări. Monitorizare: Monitorizați cu atenție activitatea grupelor. Evidențiați toate caracteristicile/componentele pe care participanții nu le-au observat. Asigurați-vă că participanții identifică care sunt ajustările care pot fi efectuate. Răspundeți întrebărilor. Durata: Durata activității este de 20 de minute, plus 20 de minute pentru sesiunea generală de răspunsuri. Dacă sunt disponibile unul sau două tipuri de scaun rulant, acestă sesiune va avea o durată redusă. Feedback: o Cereți fiecărei grupe să prezinte scaunul rulant cu care a lucrat (durata maximă – 5 minute). Asigurați-vă că echipele prezintă caracteristicile esențiale, opțiunile legate de dimensiune, componentele ajustabile și intervalul pe care acestea pot fi reglate. Nu este necesar ca să fie prezentate valorile în sine. o Scoateți în evidență avantajele și dezavantajele diferitelor caracteristici și adăugați orice informație necesară pe care nu au menționat-o participanții. o De exemplu – dacă scaunul rulant are un șezut pliabil din pânză și nu are pernă – explicați că acest tip de scaun rulant nu este recomandat persoanelor cu traumatism vertebro-medular, dar că el poate fi adecvat pentru utilizatorii care au nevoie de scaun rulant pe o perioadă determinată sau scurtă. Explicați: Este posibil ca participanții să dorească să completeze câte un formular de date tehnice pentru fiecare scaun rulant din caietul de exerciții practice (în total sunt incluse trei astfel de formulare). Observații pentru formatori: se recomandă ca la terminarea acestei sesiuni să fie afișat câte un formular de date tehnice pentru fiecare din scaunele rulante descrise. Acestea pot fi de folos în timpul sesiunilor practice la care participă utilizatorii de scaun rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 126. 4. Alegerea scaunului rulant corespunzător și a părților componente adecvate (15 minute) Explicați: o Participanții au exersat modalitățile de aflare a datelor despre utilizatorul de scaun rulant și au informații despre tipurile de scaun rulant disponibile local. Am ajuns la etapa în care vom exersa cum să găsim corespondența cea mai potrivită dintre cerințele utilizatorului și scaunele rulante disponibile. o Vom analiza în continuare două cazuri de utilizatori de scaun rulant. Vom lucra împreună pentru a identifica varianta optimă. o Rețineți – în situațiile reale, utilizatorul este parte a echipei care face selecția scaunului rulant. Citiți primul caz de utilizator de scaun rulant (puteți prezenta și materialul .ppt). Întrebare: Ce fel de scaun rulant și ce fel de componente i s-ar potrivi cel mai bine lui Peter? De ce? Încurajați participanții să răspundă. Peter Scaunul rulant și componentele Motivele Peter trăiește în mediul rural. Este foarte activ și puternic și își menține foarte bine echilibrul. În fiecare zi, pentru a ajunge la serviciu, Peter se deplasează aproape 1 km pe un drum de pământ. Atunci când plouă, traseul devine foarte noroios. Bază a roții lungă (distanță mărită între roțile frontale și roțile spate) Acolo unde este disponibil: triciclu Adecvat pentru utilizarea în exterior Pentru distanțele lungi, triciclul constituie o bună opțiune Roți frontale late Adecvat pentru utilizarea pe teren accidentat/noroios/nisipos Roțile din spate aflate în poziție activă Roțile frontale sunt mai ușor de ridicat când deplasarea are loc pe teren accidentat sau când sunt întâmpinate mici obstacole Menține cu ușurință echilibrul Spătar de înălțime redusă Nu restricționează efectuarea propulsiei Citiți al doilea caz de utilizator de scaun rulant (puteți prezenta și materialul .ppt). Întrebare: Ce fel de scaun rulant și ce fel de componente i s-ar potrivi cel mai bine Natashei? De ce? Încurajați participanții să răspundă. Natasha Scaunul rulant și componentele Motivele Natasha locuiește într-un apartament, într-un oraș. Ea a suferit un accident vascular cerebral și este capabilă să se ridice și să efectueze transferul. Ea nu poate să își împingă singură scaunul rulant, deoarece brațele ei nu sunt suficient de puternice. Uneori, Natasha alunecă înspre partea laterală a scaunului și familia ei este îngrijorată că Suporturi de picioare care pot fi pliate Pentru a permite efectuarea transferului în picioare Pemit/favorizează propulsia cu piciorul Distanța dintre șezutul scaunului rulant și podea – redusă Pentru a-i permite utilizatorului să ajungă ușor la podea atunci când se află poziționat pe partea din față a șezutului scaunului rulant, înainte de a se ridica Pernă pentru reducerea presiunii Reduce presiunea, oferă confort și suport postural Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 127. poziția ei nu este confortabilă. Spătar solid Pentru suport postural adecvat Suporturi pentru brațe situate mai sus Ajută la menținerea posturii Mânere Pentru a facilita propulsia scaunului rulant cu ajutorul unui membru de familie/însoțitor Explicați: Uneori nu este posibilă găsirea unui scaun rulant care să corespundă în totalitate nevoilor utilizatorului. În acest caz, discutați cu utilizatorul pentru a identifica cele mai importante cerințe. 5. Alegerea dimensiunii potrivite a scaunului rulant (25 de minute) Întrebare: De ce este important ca scaunul rulant să aibă dimensiunea potrivită? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o dimensiunea potrivită a scaunului rulant îi permite utilizatorului să mențină poziția corectă; o în cazul unui scaun rulant care are dimensiunea potrivită, greutatea utilizatorului este distribuită în mod egal; o scaunul rulant va oferi un grad mai ridicat de confort și va facilita realizarea propulsiei. Activitate Grupe: Formați grupe de câte doi sau trei participanți. Instrucțiuni: Cereți fiecărei grupe: o să analizeze valorile măsurătorilor efectuate utilizatorului de scaun rulant și notate în formularul din caietul de exerciții practice; o să decidă care ar fi dimensiunea ideală a scaunului rulant pentru fiecare utilizator după care; o să identifice varianta optimă dintre scaunele rulante disponibile. Explicați: o se consideră că înălțimea pernei este de 50 mm. o se consideră că propulsia se realizează cu brațele, nu cu piciorul. Monitorizare: Monitorizați activitatea grupelor și oferiți ajutor acolo unde este cazul. Durata: Durata exercițiului este de 25 de minute. Feedback: Check with each group that they selected the correct “ideal size”, and the best size match of wheelchair from the wheelchairs available. Verificați că fiecare grupă a decis în mod corect în ceea ce privește „dimensiunea ideală” și că a ales scaunul rulant care se potrivește cel mai bine, dintre cele disponibile. Întrebare: Dacă cel de-al doilea utilizator de scaun rulant ar alege să realizeze propulsia cu piciorul, care ar fi distanța ideală dintre șezutul scaunului rulant și podea? (Răspuns: 310 mm.) Întrebare: Dacă în cazul scaunelor rulante disponibile distanța dintre șezutul acestora și podea este mai mare, ce soluție putem găsi? (Răspuns: se recomandă reducerea înălțimii pernei.) Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 128. Explicați: În afară de verificarea adâncimii și lățimii șezutului scaunului rulant, precum și a înălțimii spătarului, personalul furnizor de servicii de scaune rulante trebuie să verifice și posibilitățile de ajustare a înălțimii suporturilor de picioare. Unii utilizatori au coapse mai lungi sau mai scurte decât media. Dacă lungimea coapselor are o valoare care este inclusă în posibilitățile de ajustare, atunci o modificare este posibilă și chiar necesară. Acest aspect va fi discutat în următoarea secțiune. Răspunsuri pentru formatori: 1 Măsurători corp Valori (mm) Transformare măsurători corp în dimensiune ideală scaun rulant Valori scaun rulant A Lățime șold 380 mm Lățime șold = lățime șezut scaun rulant 380 mm B Adâncime șezut S 400 mm B mai mic decât 30–50 mm = adâncime șezut scaun rulant (dacă lungimea este diferită, folosiți valoarea mai mică) 370 mm D 400 mm C Lungime gambă S 420 mm = de la partea superioară a pernei șezutului până la înălțimea suportului de picioare sau = de la partea superioară a pernei șezutului până la podea, pentru propulsia realizată cu piciorul 370 mm (50 mm perna) D 420 mm D Partea inferioară a cutiei toracice - = de la partea superioară a pernei șezutului până la partea superioară a spătarului (măsurați D sau E – în funcție de cerințele utilizatorului) - E Partea inferioară a omoplaților 380 mm 430 mm (50 mm perna) Dimensiunea ideală a scaunului rulant pentru acest utilizator: Lățime șezut: 380 mm Adâncime șezut: 370 mm Înălțime spătar: 430 mm Dintre scaunele rulante disponibile, care sunt tipul de scaun rulant și dimensiunea optime pentru acest utilizator? 2 Măsurători corp Valori (mm) Transformare măsurători corp în dimensiune ideală scaun rulant Valori scaun rulant A Adâncime șezut 420 mm Lățime șold = lățime șezut scaun rulant 420 mm B Adâncime șezut L 460 mm B mai mic decât 30–50 mm = adâncime șezut scaun rulant (dacă lungimea este mai diferită, folosiți valoarea mai mică) 430 mm R 460 mm C Lungime gambă L 360 mm = de la partea superioară a pernei șezutului până la înălțimea suportului de picioare sau = de la partea superioară a pernei șezutului până la podea, pentru propulsia realizată cu piciorul 310 mm (50 mm perna) R 360 mm D Partea inferioară a cutiei toracice 260 mm = de la partea superioară a pernei șezutului până la partea superioară a spătarului (măsurați D sau E – în funcție de 310 mm (50 mm perna) E Partea inferioară a omoplaților - - Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 129. cerințele utilizatorului) Dimensiunea ideală a scaunului rulant pentru acest utilizator: Lățime șezut: 420 mm Adâncime șezut: 430 mm Înălțime spătar: 310 mm Dintre scaunele rulante disponibile, care sunt tipul de scaun rulant și dimensiunea optime pentru acest utilizator? 6. Înregistrarea prescrierii (selecției) (10 minute) Explicați: Prescrierea (selecția) scaunului rulant trebuie înregistrată. Furnizorii de servicii de scaune rulante au nevoie de un formular pentru a nota aspectele legate de această etapă Formularul de prescriere (selecție) folosit în acest pachet de instruire este un model, care poate fi adaptat în funcție de cerințe. Explicați: o Formularul de prescriere (selecție) include patru părți. o Prima parte se referă la informații despre utilizatorul de scaun rulant. Aceste informații pot fi luate din formularul de evaluare. o Există și o rubrică pentru notarea datei la care este planificată probarea produsului (a scaunului rulant). Explicați: o În a doua parte se înregistrează tipul de scaun rulant selectat și dimensiunea acestuia. o Atunci când scaunul rulant are disponibile opțiuni de ajustare (de exemplu, spătar ajustabil sau diferite tipuri de suport de picioare), acestea trebuie înregistrate în formular. o Unii furnizori de scaune rulante au un formular de prescriere (selecție) detaliat pentru echipamentele de mobilitate oferite. Acesta trebuie completat și atașate la formularul de prescriere general. Explicați: o Partea a treia se referă la perna selectată. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 130. Explicați: o La finalul formularului, este prevăzută o secțiune cu semnături, unde toți cei implicați semnează că au căzut de acord în ceea ce privește selecția scaunului rulant. o Lista persoanelor care semnează formularul depinde de fiecare furnizor de servicii de scaune rulante. Totuși, este foarte important ca utilizatorul să semneze acest formular, la fel ca și persoana care a efectuat evaluarea. o Întrebare: Aveți întrebări în ceea ce privește completarea formularului de prescriere (selecție) a scaunului rulant? Răspundeți întrebărilor. Explicați: Prescrierea (selecția) include și stabilirea, împreună cu utilizatorul, a nevoii de instruire a acestuia pentru folosirea și întreținerea scaunului rulant. 7. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 131. B.6: Finanțarea și plasarea comenzii O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să plaseze comanda pentru scaunul rulant prescris, în conformitate cu sistemul aplicat în cadrul serviciului lor de scaune rulante. R E S U R S E Pentru sesiune:  Manualul participantului;  formular de comandă (nu este inclus în pachetul de instruire, folosiți doar dacă există unul disponibil la nivel local). C O N TE X T Adaptați conținutul acestei sesiuni pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții.  Folosiți această sesiune pentru a le vorbi participanților despre pașii din etapa de plasare a comenzii, așa cum vor fi aceștia parcurși în cadrul serviciului de scaune rulante unde își vor desfășura activitatea.  Acolo unde nu există un sistem clar pentru plasarea comenzii, se recomandă formatorilor să ofere asistență furnizorilor de servicii de scaune rulante pentru stabilirea unei astfel de proceduri.  Dați participanților oportunitatea să exerseze etapa plasării comenzilor. Acest aspect include completarea de către participanți a unui formular de comandă (dacă există unul disponibil local). D E P R E G Ă TI T  Pregătiți toate resursele și citiți planul sesiunii. P R E ZE N TA R E 1. Introducere 2. Finanțarea 3. Plasarea comenzii 2 3 10 Total durată sesiune 15 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 132. 1. Introducere (2 minute) Explicați: Finanțarea și plasarea comenzii reprezintă cea de-a patra etapă în livrarea serviciilor de scaune rulante. 2. Finanțarea (3 minute) Explicați: După prescrierea (selecția) scaunului rulant, costul produsului recomandat poate fi estimat cu acuratețe. Este esențial să se cunoască modalitatea de finanțare a scaunului rulant – acesta poate fi plătit de către utilizator sau printr-o subvenție din partea statului, a unei organizații nonguvernamentale sau din partea unui donator. De asemenea, obținerea scaunului rulant poate fi finanțată de către o companie de asigurări. În regiunile în curs de dezvoltare există multe persoane care au nevoie de un scaun rulant, dar nu își permit să îl achiziționeze. Cu toate acestea, toți cei care au nevoie de un scaun rulant au dreptul să îl primească, indiferent de capacitatea lor de a suporta costul. În consecință, trebuie să existe fonduri pentru cei care au nevoie de asistență financiară. În cele mai multe cazuri, sursa de finanțare trebuie identificată înainte de plasarea comenzii pentru obținerea scaunului rulant. Frecvent, această responsabilitate îi revine personalului administrativ sau managerului de program și nu neapărat personalului tehnic sau medical. Includeți orice sistem pentru identificarea surselor de finanțare a scaunelor rulante, dacă acest aspect face parte din îndatoririle personalului de livrare a serviciilor de scaune rulante. Participanții pot nota diferitele oportunități de finanțare a serviciilor de scaune rulante, disponibile în cadrul serviciului lor. 3. Plasarea comenzii (10 minute) După alegerea scaunului rulant corespunzător și pregătirea prescrierii (selecției), etapa următoare este plasarea comenzii. În cazul în care furnizorul de servicii de scaune rulante are echipamentul de mobilitate pe stoc, acest lucru poate însemna completarea unui formular ce trebuie autorizat de către manager. Apoi, scaunul rulant poate fi pregătit de către personalul responsabil de acest lucru. Dacă scaunul rulant nu există pe stocul furnizorului de servicii de scaune rulante, acesta de obicei trebuie comandat de la un alt furnizor. Sistemul de plasare a comenzii va fi diferit de la un furnizor de servicii de scaune rulante la altul. Notați mai jos aspectele de care trebuie să țineți seama atunci când plasați comanda la furnizorul de servicii de scaune rulante local. Explicați: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 133. După alegerea scaunului rulant corespunzător și pregătirea prescrierii (selecției), personalul furnizorului de servicii de scaune rulante trebuie să plaseze comanda. Comanda trebuie făcută cât mai repede posibil, pentru a evita întârzierile. Explicați cum va funcționa sistemul de plasare a comenzii la furnizorii de servicii de scaune rulante unde participanții urmează să își desfășoare activitatea. Participanții pot să noteze aspectele legate de sistemul de plasare a comenzii în spațiul din Manualul participantului, cel rezervat notițelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 134. Sesiunea practică 1: Evaluarea și prescrierea (selecția) O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să demonstreze modalitatea de realizare a unei evaluări (nivel de bază), lucrând în grup și cu sprijin din partea formatorului;  să demonstreze modalitatea de realizare a unei prescrieri (selecții, nivel de bază), lucrând în grup și cu sprijin din partea formatorului. R E S U R S E  Lista de monitorizare și observații pentru formator (sesiunea practică 1);  Formulare de evaluare și prescriere (selecție) scaun rulant necompletate;  Spațiu pentru realizarea evaluării, curat și delimitat, dotat cu pat pentru evaluare, pentru fiecare utilizator de scaun rulant;  Scaune rulante (cu excepția cazului în care evaluarea se realizează pe teren, în comunitate);  Ruletă. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  factorii culturali– de exemplu, dacă este acceptabil din punct de vedere al contextului cultural local ca participanții să formeze echipe mixte pentru realizarea evaluări;  factorii lingvistici – de exemplu, dacă utilizatorii de scaun rulant vorbesc aceeași limbă ca și participanții;  orice document de care furnizorul de servicii de scaune rulante poate avea nevoie în procesul de evaluare și prescriere – de exemplu, orice informație suplimentară referitoare la utilizatorul de scaun rulant de care este nevoie (e.g. sursa de la care a venit trimiterea)  modalitatea prin care formatorii vor gestiona aspectele noi care pot apărea pe parcursul evaluării și care nu pot fi abordate în timpul sesiunii practice sau a părții teoretice a cursului. D E P R E G Ă TI T  Confirmați orarul și detaliile referitoare la deplasarea utilizatorilor de scaun rulant voluntari. Asigurați-vă că ați inclus în comanda pentru pauza de cafea/prânz utilizatorii de scaun rulant, împreună cu membrii de familie sau însoțitorii lor.  Desemnați o persoană care să întâmpine la sosire utilizatorii de scaun rulant și care să le indice locul unde pot aștepta începerea sesiunii.  Pregătiți un pat pentru evaluare, dotat cu un paravan, pentru fiecare echipă formată dintr-un participant la curs și un utilizator de scaun rulant. Aduceți tot echipamentul de care este nevoie pentru evaluare, inclusiv patul pentru evaluare, iar pe acesta plasați formularele de prescriere (selecție) a scaunului rulant.  Asigurați-vă că toate scaunele rulante și pernele folosite ca mostre sunt în bună stare de funcționare.  În cazul în care sunt mai mult de trei echipe, rugați un alt formator să vă asiste la monitorizarea activității.  Decideți care va fi componența grupelor (participanți și utilizatori de scaun rulant). P R E ZE N TA R E 1. Sesiune practică de evaluare și prescriere: o Instrucțiuni și pregătire; o Evaluare o Prescriere (selecție); o Feedback. 5 45 30 10 Total durată sesiune 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 135. 1. Sesiune practică de evaluare și prescriere (90 de minute) Notă pentru formatori: Folosiți lista de verificare și observații pentru formatori de la sesiunea practică 1 pentru a vă asigura că grupele urmează toți pașii și pentru a nota exemple de bună practică sau de erori, pe care să le evidențiați în timpul sesiunii de feedback, cu ajutorul acesteia. Activitate Grupe: o Împărțiți participanții pe grupe (nu mai mult de trei persoane în fiecare grupă). o Numiți câte un responsabil în cadrul fiecărui grup. o Comunicați fiecărei grupe numele utilizatorului de scaun rulant cu care va lucra. o Desemnați spațiul în care va lucra fiecare echipă. o Explicați că tot echipamentul de care au nevoie participanții poate fi găsit pe patul pentru evaluare. Instrucțiuni: Explicați următoarele aspecte: Scopul sesiunii practice: o Scopul acestei sesiuni practice este realizarea unei evaluări și prescrierea unui scaun rulant pentru un utilizator. o Într-o etapă următoare, participanții vor lucra cu același utilizator de scaun rulant, pentru a proba scaunul rulant prescris în cadrul acestei sesiuni și pentru a efectua instruirea utilizatorului. o Dacă în timpul cursului nu este posibilă pregătirea în totalitate a scaunului rulant, se va face o planificare pentru a ne asigura că scaunul rulant va răspunde din toate punctele de vedere cerințelor utilizatorului. Totuși, se recomandă ca participanții să încerce să parcurgă cât mai mulți dintre pașii necesari pe parcursul orelor de curs. Responsabilul: o Persoana care este desemnată să fie responsabilul în cadrul echipei trebuie să se asigure că toți pașii exercițiului au fost parcurși. o Responsabilul este cel care ar trebui să discute cel mai mult cu utilizatorul de scaun rulant, cu membrii de familie sau cu însoțitorul. Acest lucru se recomandă pentru a evita ca mai multe persoane să vorbească în același timp, aspect ce ar putea provoca o stare de confuzie. Formularele: o Fiecare responsabil de grupă va primi un formular de evaluare și un formular de prescriere. Observațiile formatorului și sprijinul oferit de acesta: o Participanții pot cere asistență și clarificări în orice moment, pe toată durata exercițiului. o Pe parcursul sesiunii, formatorii monitorizează fiecare grup și oferă tot sprijinul necesar desfășurării corecte a exercițiului. o După realizarea evaluării, participanții solicită formatorului să verifice rezultatul evaluării și formularele de evaluare completate. o După finalizarea prescrierii (selecției), participanții solicită formatorului să verifice rezultatul prescrierii (selecției) și formularele de prescriere (selecție) completate. Durata exercițiului: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 136. o Durata exercițiului este de 40 de minute pentru evaluare și 20 de minute pentru prescriere (selecție). Întrebați participanții: Care sunt pașii din etapa de evaluare? Evidențiați răspunsurile corecte. Întrebați participanții: Care sunt pașii din etapa de prescriere? Evidențiați răspunsurile corecte. Reamintiți-le participanților că utilizatorul de scaun rulant trebuie să fie implicat în mod activ în fiecare etapă a procesului. Întrebare: Aveți întrebări? Răspundeți întrebărilor participanților. Cereți fiecărei grupe să pregătească spațiul în care se va desfășura exercițiul și să se prezinte utilizatorului de scaun rulant cu care vor lucra. Exercițiul poate începe. Monitorizare și sprijin: Monitorizați cu atenție activitatea echipelor, asigurați-vă că exercițiul se desfășoară în condiții de siguranță, observați și evaluați abilitățile participanților. Utilizați lista de verificare și observații pentru formatori și notați observațiile referitoare la fiecare grupă. Pe parcursul sesiunii: o Periodic, indicați participanților durata de timp rămasă, pentru a-i ajuta să își gestioneze mai bine timpul. o Asigurați-vă că utilizatorii de scaun rulant sunt implicați în mod activ. La sfârșitul sesiunii, cereți participanților să le mulțumească utilizatorilor de scaun rulant pentru prezență și să le explice că scaunul rulant prescris (selectat) va fi pregătit pentru a fi probat în cadrul următoarei sesiuni practice. Durata: Alocați 45 de minute pentru finalizarea evaluării, 30 de minute pentru prescriere (selecție) și 10 minute pentru feedback. Monitorizați timpul folosind Lista de verificare și observații pentru formator. Feedback: Discutați exemplele de bună practică pe care le-ați identificat pe parcursul sesiunilor practice. Notați orice aspect care necesită îmbunătățiri – fără a numi persoana. Întrebare: Aveți întrebări? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 137. B.7: Pregătirea produsului (a scaunului rulant) O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să ajusteze scaunul rulant în așa fel încât acesta să fie în conformitate cu prescrierea (selecția);  folosească lista de verificare preliminară utilizării scaunului rulant, pentru a se asigura că acesta poate fi folosit în condiții în siguranță și că toate componentele sunt funcționale. R E S U R S E Pentru sesiune:  prezentare PPT: B.7 Pregătirea produsului (a scaunului rulant);  Manualul participantului;  Caietul de exerciții practice;  DVD: Demonstrație Listă de verificare preliminară utilizării scaunului rulant;  scaunele rulante selectate pentru fiecare utilizator de scaun rulant, conform evaluării din Sesiunea practică 1  formularul de prescriere completat, pentru fiecare utilizator, conform evaluării din Sesiunea practică 1  lista de verificare preliminară utilizării scaunului rulant (1 exemplar pentru fiecare participant)  rulete și orice alte instrumente necesare pentru efectuarea ajustărilor (1 set per grupă). C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele.  Durata de timp necesară pentru a ajusta scaunele rulante disponibile local. Dacă scaunele rulante disponibile au puține opțiuni de ajustare, durata de timp necesară va fi redusă. Dacă numărul opțiunilor este mai mare, durata de timp de fare este nevoie va crește. Dacă scaunele rulante disponibile local trebuie asamblate înainte de a fi pregătite pentru sesiune. Trebuie să avem în vedere durata de timp necesară asamblării, înainte de începerea sesiunii practice. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii.  Exersați ajustarea scaunelor rulante disponibile local, pentru a vă familiariza cu opțiunile și pentru a putea desfășura demonstrația sau pentru a asista participanții pe parcursul sesiunii practice, dacă acest lucru este necesar. P R E ZE N TA R E 1. Introducere. 2. Pregătirea scaunului rulant. 3. Lista de verificare preliminară utilizării scaunului rulant. 4. Recapitulare puncte cheie. 2 40 30 3 Total durată sesiune 75 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 138. 1. Introducere (2 minute) Explicați: Pe parcursul acestei sesiuni, participanții vor învăța cum trebuie pregătit scaunul rulant pentru ca acesta să poată fi probat de către utilizator. Aceasta este cea de-a cincea etapă în livrarea serviciilor de scaune rulante. Pregătirea scaunului rulant include: o pregătirea scaunului rulant în conformitate cu prescrierea (selecția); o verificarea scaunului rulant pentru a ne asigura că acesta poate fi utilizat în condiții de siguranță și că toate componentele sunt funcționale. 2. Pregătirea scaunului rulant (40 de minute) Explicați: Participanții vor pregăti scaunul rulant prescris utilizatorului cu care au lucrat în sesiunea practică anterioară. Mai jos sunt pașii pentru pregătirea scaunului rulant. Explicați: o Verificați dacă lățimea și adâncimea șezutului scaunului rulant sunt în conformitate cu prescrierea (selecția). o Verificați dacă lățimea și adâncimea pernei se potrivesc șezutului scaunului rulant. Ajustați (acolo unde este posibil): o înălțimea spătarului; o înălțimea suportului de brațe; o poziția roților din spate; o poziția frânelor (frânele trebuie repoziționate de fiecare data când se schimbă poziția roților din spate); o înălțimea suportului de picioare; o înălțimea mânerelor; o orice alte ajustări care pot fi efectuate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 139. Activitate Grupe: Cereți echipelor să se regrupeze în formula în care au lucrat în timpul primei sesiuni practice. Fiecare grupă primește: o formularul de prescriere (selecție) completat pentru utilizatorul de scaun rulant cu care vor lucra; o o ruletă; o scaunul rulant prescris (selectat) pentru utilizatorul de scaun rulant cu care lucrează. Asigurați-vă că toate materialele necesare sunt disponibile în sala de curs, într-un loc desemnat. Instrucțiuni: Cereți fiecărei grupe să analizeze formularul de prescriere (selecție) și să pregătească scaunulu rulant. Reamintiți-le care sunt pașii: o verificarea lățimii și adâncimii șezutului scaunului rulant; o verificarea modului în care se potrivește perna; o efectuarea tuturor ajustărilor pentru ca scaunul rulant să se potrivească utilizatorului de scaun rulant. Reaminți-le că toate materialele de care au nevoie sunt pregătite în sala de curs. Explicați: În cazul în care oricare din grupe trebuie să facă modificări minore pentru ca scaunul rulant să se potrivească cerințelor utilizatorului, acestea vor fi făcute în cadrul unei sesiuni ulterioare. Monitorizare: Monitorizați cu atenție activitatea grupelor. Verificați dacă sunt urmați toți pașii. După finalizarea exercițiului, verificați dacă grupele au pregătit scaunul rulant respectând cât mai mult posibil cerințele din formularul de prescriere (selecție). Dacă sunt necesare modificări minore, discutați despre acestea cu grupa. Explicați că subiectul va fi abordat în detaliu pe parcursul unei sesiuni ulterioare. Durata: Durata exercițiului este de 20 de minute sau mai mult, în funcție de ajustările care pot fi efectuate. Rezervați alte 10 minute pentru feedback. Feedback: Întrebare: o A reușit fiecare echipă să pregătească scaunul rulant în conformitate cu cerințele din prescriere (selecție)? o Dacă nu – care sunt motivele? Cereți echipei să se gândească la posibile soluții. Clarificați și asigurați-vă că toată lumea înțelege. 3. Lista de verificare preliminară utilizării scaunului rulant (30 de minute) Explicați: Cel de-al doilea pas al etapei de pregătire a produsului (a scaunului rulant) este verificarea, pentru a ne asigura că acesta poate fi folosit în condiții de siguranță și că toate componentele funcționează în mod corespunzător. Oferiți fiecărui participant un formular de verificare preliminară a utilizării scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 140. Explicați: o Această listă de verificare ne ajută să ne asigurăm că niciun aspect nu este omis. o Participanții se pot folosi de lista de verificare pe parcursul etapei de pregătire a scaunului rulant. o Furnizorul de servicii de scaune rulante poate decide să folosească lista de verificare ca formular ce trebuie completat pentru fiecare scaun rulant prescris (selectat). Acest lucru rămâne la latitudinea furnizorului. Material video: Listă de verificare preliminară utilizării scaunului rulant. În acest material video se prezintă modalitatea de verificare a scaunului rulant, de așa manieră încât să fim siguri că acesta este gata de a fi folosit de către utilizator în condiții de siguranță. Cereți participanților: o să urmărească cu atenție modul în care se face verificarea scaunului rulant; o ca pe măsură ce urmăresc operațiunile din etapa de verificare, să bifeze în lista de verificare din caietul de exerciții dacă scaunul rulant este pregătit pentru utilizare sau nu. Prezentați materialul video. Verificați dacă există întrebări. Activitate Grupe: Componența echipelor rămâne aceeași. Fiecare grupă va lucra cu câte un scaun rulant pregătit de către o altă echipă de participanți. Instrucțiuni: Cereți fiecărei grupe să verifice scaunul rulant pe care l-a primit, pentru a se asigura că este pregătit în vederea probării de către utilizator, în condiții de siguranță. Se recomandă utilizarea listei de verificare, astfel încât să nu fie omis niciun aspect. Notați toate problemelele, pentru a le discuta mai târziu, cu formatorii. Monitorizare: Monitorizați activitatea grupelor și oferiți sprijin, dacă este necesar. Încurajați participanții să rezolve toate problemele identificate pe parcursul sesiunii, în măsura în care acest lucru este posibil. Dacă nu, orice aspect nerezolvat trebuie notat și rezolvat înainte de a doua sesiune practică. Durata: Durata exercițiului este de 15 minute. Feedback: Cereți fiecărei grupe să comunice întregului grup dacă scaunul rulant este gata pentru utilizarea în condiții de siguranță (2-3 minute pentru fiecare grup). Întrebare: În cazul în care există o problemă, cum se procedează? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o se repară/se soluționează problema; o se trimite scaunul rulant la atelier, pentru reparații; o se contactează furnizorul de scaune rulante pentru a cere asistență în vederea soluționării problemei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 141. 4. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 142. Listă de verificare preliminară : Este scaunul rulant pregătit pentru utilizarea în condiții de siguranță? Scaunul rulant în ansamblu Observații pentru formatori: Nu există margini ascuțite.  Verificați scaunul rulant în ansamblu, vizual și cu mâinile. Nu există părți defecte sau zgâriate.  Traiectoria scaunului rulant aflat în mișcare este dreaptă  Împingeți scaunul rulant în față, pentru a vă asigura că roțile frontale se mențin pe traiectoria corectă. Roțile frontale: Se învârt fără a întâmpina vreo rezistență  Înclinați scaunul rulant pe roțile din spate. Învârtiți roțile frontale. Se învârt fără a atinge furca roții.  Șuruburile sunt strânse.  Verificați. Acestea trebuie să fie imobile la atingere. Nu le strângeți prea mult. Furcile roților frontale: Furca roții frontale se învârte fără a întâmpina vreo rezistență.  Înclinați scaunul rulant pe roțile din spate. Învârtiți furcile roților frontale. Roțile din spate: Se învârt fără a întâmpina vreo rezistență.  Înclinați scaunul rulant lateral, pe una din roțile din spate. Învârtiți cealaltă roată. Verificați și cealaltă parte. Șuruburile axului sunt strânse.  Verificați. Trebuie să fie imobile la atingere. Nu le strângeți prea mult. Anvelopele (dacă sunt pneumatice) sunt umflate în mod corect.  Cu degetul mare, apăsați pe anvelope. Suprafața roții trebuie să cedeze puțin, dar nu mai mult de 5 mm. Inelele de antrenare nu prezintă niciun pericol.  Verificați. Frânele: Funcționează corespunzător.  Acționați frânele. Verificați dacă roata rămâne imobilă. Suporturile de picioare Suporturile de picioare sunt montate corespunzător.  Verificați. Cadrul: În cazul unui scaun rulant pliabil - scaunul rulant se pliază și se depliază cu ușurință.  Pliați scaunul rulant pentru a verifica dacă mecanismele de pliere funcționează corect. În cazul unui scaun rulant cu spătar pliabil - spătarul se pliază și se depliază cu ușurință.  Perna: Perna este introdusă corect în husă.  În general, husa pernei este se închide în partea din spate a pernei, dedesubt. Perna este poziționată corect pe scaunul rulant.  Dacă perna este cu contur, zona de reducere a presiunii de sub oasele bazinului trebuie să fie în spatele șezutului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 143. Materialul textil al pernei este întins pe suprafața acesteia, însă nu mai mult decât este necesar.  Husa pernei nu trebuie să fie foarte întinsă peste partea cu contur a pernei. Perna acoperă în întregime șezutul scaunului rulant.  Verificați că nicio parte a șezutului scaunului rulant nu este vizibilă de sub pernă. Acest lucru este foarte important în cazul șezuturilor de scaun rulant rigide. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 144. B.8: Confecționarea pernei O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere caracteristicile unei perne tipice de reducere a presiunii, care a fost confecționată din spumă/burete.  să confecționeze o pernă tipică de reducere a presiunii, folosind spumă/burete.  să descrie modalitatea de a adăuga pernei o inserție, în cazul utilizatorilor la care nivelul de presiune de sub oasele bazinului reprezintă un risc de apariție a escarelor. R E S U R S E  prezentare PPT: B.8 Confecționarea pernei;  Manualul participantului;  Caietul de exerciții practice;  DVD: Confecționarea pernei;  mostre de perne pentru reducerea presiunii, mostre de huse și de inserție;  trusă pentru confecționarea pernei (pentru detalii, vezi mai sus “Confecționarea pernei – materiale și instrumente”);  mostre de materiale textile disponibile local și care se potrivesc pentru a confecționa huse. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. De exemplu:  confecționarea unei perne potrivite utilizatorului de scaun rulant;  adaptarea dimensiunilor și modelului pernei prezentate, în funcție de tipul de materiale recomandate disponibile și caracteristicile lor (sau raportat la dimensiunile medii ale populației din zonă)  pregătirea unei liste cu perne sau alternative de material textil disponibile local – participanții pot fi rugați să aducă mostre din zonele de unde vin. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii.  Instalați un banc de lucru/masă pentru fiecare grupă formată din trei participanți, cu materialele și instrumentele necesare pentru a testa rigiditatea mostrelor de spumă/burete; materiale pentru tăiat și lipit baza pernei. P R E ZE N TA R E 1. Introducere. 2. Dimensiunile și caracteristicile pernei. 3. Cum se confecționează baza unei perne – demonstrație. 4. Cum se confecționează baza unei perne – parte practică. 5. Întreținerea pernei. 6. Întrebări frecvente cu privire la pernele de reducere a presiunii confecționate din spumă/burete. 7. Recapitulare puncte cheie. 5 20 20 60 5 5 5 Total durată sesiune 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 145. 1. Introducere (5 minute) Explicați: . o Pe parcursul acestei sesiuni, participanții vor învăța cum să confecționeze o pernă de reducere a presiunii simplă, din spumă/burete. Dacă perna este confecționată corect și are dimensiunile corespunzătoare, în cazul multora dintre utilizatorii de scaun rulant, aceasta contribuie la reducerea presiunii sub oasele bazinului. o Este important să reținem că nicio pernă nu va fi potrivită pentru toți utilizatorii. o La furnizarea unei perne de reducere a presiunii, trebuie întotdeauna verificat nivelul presiunii de sub oasele bazinului utilizatorului. Acest lucru are loc în etapa de probarea a produsului (a scaunului rulant). Pot fi necesare modificări, în așa fel încât zona de reducere a presiunii de sub oasele bazinului să aibă lățimea, adâncimea și înălțimea potrivite. Întrebare: Are cineva experiență în confecționarea și furnizarea unei perne de reducere a presiunii? Încurajați participanții să răspundă și notați răspunsurile. 2. Dimensiunile și caracteristicile pernelor (20 de minute) Pregătiți o mostră de bază a unei perne pentru reducerea presiunii, mostră care să circule pe la toți participanții din sală. Partea superioară și husa trebuie să fie la îndemână. Pentru fiecare caracteristică din prezentarea .ppt, participanții trebuie să răspundă la întrebarea: Care este rolul acestei caracteristici a pernei? Reaminți-le participanților că această temă a fost abordată în sesiunea „Pernele”, la începutul progrmului de instruire. Încurajați participanții să răspundă. Pentru fiecare caracteristică prezentată, evidențiați respectiva trăsătura, folosind mostra de pernă. Caracteristică Formatorul: Ce determină această caracteristică? o Determină forma pernei de reducere a presiunii. Zona de reducere a presiunii de sub oasele bazinului o Reduce nivelul de presiune de sub oasele bazinului și coccis. o Ajută la menținerea bazinului în poziție corespunzătoare, în partea din spate a pernei. Explicați: o Oasele bazinului utilizatorului de scaun rulant trebuie să fie poziționate în interiorul zonei de reducere a presiunii – nu pe Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 146. marginea acesteia sau pe partea superioară a pernei. o În timpul probării produsului, verificați întotdeauna dacă oasele șezutului se potrivesc corect. Poziționați mâinile sub oasele bazinului utilizatorului pentru a le simți. Verificați nivelul de presiune cu ajutorul testului prezentat mai devreme. o Dacă perna este destinată unui scaun rulant cu șezut pliabil, se va face o tăietură oblică la baza pernei. o Acest lucru va permite pernei să ia forma șezutului pliant al scaunului rulant, astfel încât partea superioară a pernei să rămână plată. Tăietura oblică se face doar în cazul în care perna va fi folosită pe șezutul unui scaun rulant pliabil. o Pentru șezuturile rigide, baza pernei este dreaptă. o Stratul superior confecționat din spumă/burete oferă confort. o Perna trebuie să circule pe la toți participanții din sala de curs. o Uneori este necesară o reducere suplimentară a nivelului de presiune. o În acest caz, se recomandă personalului furnizor de servicii de scaune rulante să confecționeze un strat de ridicare, din același material care se folosește pentru bază. o Stratul de ridicare se poziționează peste stratul de bază al pernei și sub stratul pentru confort confecționat din spumă. Astfel, va crește nivelul de reducere a presiunii la nivelul zonei de sub oasele bazinului. o După adăugarea stratului de ridicare, efectuați întotdeauna verificarea (fizică), folosind testul pentru identificarea nivelului de presiune de sub oasele bazinului. o Mostra de strat de ridicare trebuie să circule pe la toți participanții din sala de curs. Explicați: Una dintre caracteristicile pernei se referă la husă. Husa este esențială pentru a proteja perna. Întrebare: Ce fel de materiale textile pot fi folosite pentru husa pernei? Încurajați participanții să răspundă și notați materialele „bune” sau „acceptabile”. Explicați care ar fi variantele optime și care ar trebui folosite doar în cazul în care nu există o altă opțiune. Potențiale răspunsuri: o nylon subțire/material pentru umbrele (bun); o material elastic/lycra (bun); o vinil/imitație de piele (nu); o pânză groasă sau nylon gros (nu); Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 147. o material textil pentru tricouri /bumbac tricotat (acceptabil); o neopren/impermeabil (acceptabil); o tafta (acceptabil); o frotir/prosoape (nu); o in/cearșafuri (nu); o saci plastic/polietilenă (nu). Explicați: o Materialul textil recomandat pentru husa pernei de reducere a presiunii este de obicei fie impermeabil la apă, fie elastic. o Materialul textil trebuie să fie subțire (ca cel folosit pentru confecționarea parașutelor sau umbrelelor), astfel încât pliurile să nu lase urme pe suprafața pielii. o Dacă materialul textil nu este impermeabil, peste suprafața spumei/buretelui se poate pune un strat subțire de plastic, pentru a proteja perna. o Husa ar trebui să fie mai largă în partea din spate a pernei, pentru a nu fi prea întinsă peste zona de reducere a presiunii. Mostra de husă pentru perna de reducere a presiunii trebuie să circule pe la toți participanții din sală. Explicați: o Pentru ca zona de reducere a presiunii la nivelul oaselor bazinului să își poată îndeplini rolul în mod corect, ea trebuie să aibă lățimea, adâncimea și înălțimea corespunzătoare. Pentru a calcula dimensiunea zonei de reducere la nivelul oaselor bazinului, participanții trebuie să aibă în vedere următoarele reguli. Explicați fiecare dimensiune a zonei de reducere a presiunii la nivelul oaselor bazinului așa cum apare apare în prezentarea .ppt. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 148. Activitate pentru grupe cu număr redus de participanți Grupe: Alcătuiți echipe de câte doi participanți. Instrucțiuni: Cereți fiecărei echipe: o să completeze tabelul aflat la începutul fișei de lucru, în caietul de exerciții practice. Explicați că trebuie să calculeze lățimea, adâncimea și înălțimea pentru trei utilizatori diferiți (din punct de vedere al lățimii șezutului scaunului rulant). Monitorizare : Monitorizați activitatea grupelor, și oferiți ajutor acolo unde este cazul. În timp ce participanții lucrează, trasați pe tablă următorul tabel – fără a scrie răspunsurile. Lățime Adâncime Înălțime Utilizator scaun rulant adult – lățime șezut 360 mm 180 mm 180 mm 35 mm Utilizator scaun rulant adult – lățime șezut 460 mm 200 mm 200 mm 35 mm Utilizator scaun rulant copil – lățime șezut 280 mm 140 mm 140 mm 20–25 mm Durata: 5 minute. Feedback: Trasați tabelul pe tablă. Întrebare: Care sunt valorile corecte pentru lățimea, adâncimea și înălțimea zonei de reducere a presiunii la nivelul oaselor bazinului, în cazul fiecărui utilizator? Notați răspunsurile corecte în tabelul de pe tablă. Întrebare: Cum pot participanții decide dacă dimensiunea este corespunzătoare în cazul respectivului utilizator? Răspuns: La probarea produsului, verificați dacă zona de reducere a presiunii are dimensiunea corespunzătoare. Plasați mâinile sub oasele bazinului utilizatorului de scaun rulant pentru a identifica poziționarea lor. Verificați nivelul de presiune conform testului deja învățat. Asigurați-vă că oasele bazinului sunt poziționate în interiorul zonei de presiune și nu pe marginea sau pe partea superioară a pernei. 3. Cum se confecționează stratul de bază al pernei – demonstrație (20 de minute) Material video: Confecționarea pernei. Aceasta este o scurtă prezentare a metodei de confecționare a unei perne tipice de reducere a presiunii din spumă/burete. Prezentați materialul video. Verificați dacă există întrebări. Mostrele de spumă rigidă și spumă flexibilă/burete rigid și burete flexibil trebuie să circule pe la toți participanții din sala de curs. Cereți participanților să poziționeze spuma pe o suprafață solidă (de exemplu, pe bancul de lucru) și să compare rigiditatea celor două mostre (rigid versus flexibil). Această comparație se face strângând pumnul și sprijinindu-l de stratul de spumă/burete, exercitând presiune cu proeminențele de la baza degetelor (articulația metacarpo-falangiană). Explicați: o Baza pernei și partea superioară se introduc în husă împreună. o Nu este obligatoriu ca cele două bucăți să fie lipite cu adeziv. o Dacă stratul de deasupra se pătează sau devine uzat, acesta poate fi spălat și uscat sau înlocuit. o Arătați cum poate fi introdus stratul de ridicare, pentru a crește adâncimea zonei de reducere a presiunii la nivelul oaselor bazinului. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 149. 4. Cum se confecționează stratul de bază al pernei – practică (60 de minute) Explicați: Participanții vor exersa modalitatea de decupare a stratului de bază a pernei. Activitate Grupe: Alcătuiți grupe de câte doi sau trei participanți. Fiecare grupă trebuie să aibă la dispoziție un banc de lucru, împreună cu materialele și uneltele necesare pentru a decupa stratul de bază al unei perne din spumă/burete. Instrucțiuni: Cereți fiecărei echipe: o să lucreze împreună pentru a decupa stratul de bază al pernei; o să folosească fișa de lucru în caietul de exerciții practice, pentru a nu omite nicio etapă. Subliniați aspectele legate de lucrul în condiții de siguranță pe parcursul desfășurării exercițiului: o reamintiți-le participanților că obiectele pentru tăierea spumei/buretelui sunt foarte ascuțite și că trebuie mânuite cu atenție sporită. Monitorizare : Monitorizați activitatea grupelor și oferiți ajutor acolo unde este necesar. Durata: Durata exercițiului este de 50 de minute și de 10 minute pentru feedback. Feedback: Întrebați echipele: o Ce tehnici utile pentru tăierea sau lipirea spumei/buretelui ați identificat? o Ce se poate întâmpla dacă tăiem un segment din două direcții diferite? (Răspuns: Este posibil ca cele două porțiuni tăiate să nu se întâlnească, având ca rezultat un prag pe suprafață). 5. Întreținerea pernei (5 minute) Explicați: Utilizatorii de scaun rulant trebuie să știe detalii despre întreținerea pernei. Aici sunt incluse următoarele aspecte: o Perna trebuie menținută curată – poate fi spălată cu apă caldă, cu o cantitate mică de săpun. Înainte de utilizare, trebuie uscată într-un loc ferit de acțiunea directă a razelor de soare. o Verificați stratul superior al pernei – acesta trebuie să își revină la forma inițială după ce se exercită presiune asupra sa. Dacă nu își revine la forma inițială, dacă este tare și aplatizat, stratul superior trebuie înlocuit. o Verificați stratul de bază – acesta nu trebuie să fie deformat și nu trebuie să aibă bucăți lipsă sau să fie uzat. În caz contrar, stratul de bază trebuie înlocuit. o Este posibil ca stratul superior să fie înlocuit de două sau de trei ori înainte ca cel de bază să necesite înlocuire. o 6. Întrebări frecvente cu privire la pernele de reducere a presiunii din spumă/burete (5 minute) Întrebare: Aveți întrebări în legătură cu acest tip de pernă? Răspundeți întrebărilor. Posibile întrebări Răspunsuri Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 150. Cum decid ce material textil să folosesc pentru husa perne? o Dacă este posibil, alegeți un material textil care să fie elastic. Se recomandă material impermeabil, dacă acesta este disponibil. Dacă materialul este rezistent la apă, asigurați-vă că nu este prea gros, în caz contrar, cutele vor lăsa urme pe pielea utilizatorului de scaun rulant, ceea ce poate provoca apariția escarelor. o Alegerea se va face în funcție de materialul textil disponibil. Uneori, variantele sunt limitate. o Dacă există mai multe opțiuni și nu sunteți sigur ce alegere să faceți, rugați utilizatorii de scaun rulant să încerce diferite variante. o Personalul furnizor de servicii de scaune rulante va dobândi mai multă experiență pe măsură ce sunt încercate mai multe tipuri de materiale textile. Această pernă se potrivește oricărui utilizator? o Nu – această pernă nu i se va potrivi oricărui utilizator. o Cu toate acestea, avantajul acestei perne este că poate fi adaptată cu ușurință. Această pernă se poate încălzi sau poate provoca transpirație? o Pernele confecționate din spumă se pot încălzi și pot provoca transpirația. o Cu toate acestea, perna are multe alte avantaje, astfel că acest aspect este un compromis acceptabil. Toți utilizatorii de scaun rulant au nevoie de o pernă pentru reducerea presiunii? o Nu – nu toți utilizatorii de scaun rulant au nevoie de o pernă pentru reducerea presiunii. o Luați în considerare factorii de risc despre care ați învățat în cadrul acestui curs, pentru a decide dacă există sau nu pericolul apariției escarelor la respectivul utilizator de scaun rulant. o Chiar dacă nu este nevoie de o pernă pentru reducerea presiunii, perna poate îmbunătăți confortul și postura, chiar și în cazul utilizatorilor la care nu există riscul apariției escarelor Ce se întâmplă atunci când perna este folosită invers, cu partea anterioară în spate sau cu partea superioară în jos? o Perna nu va funcționa corect și poate chiar să crească riscul apariției escarelor. o Întotdeauna asigurați-vă că utilizatorii de scaun rulant și membrii familiei acestora (acolo unde este cazul) înțeleg cum trebuie folosită perna și o întrețin în mod corect. o Dacă este necesar, marcați perna cu „față”, „spate”, „sus” și „jos”. Este această pernă adecvată pentru copii? o Da, acest tip de pernă li se potrivește și copiilor. Totuși, zona de reducere a presiunii la nivelul oaselor bazinului trebuie să fie mai mică. Vedeți mai sus cum trebuie stabilite dimensiunile unei perne pentru copii. o Mulți copii utilizatori de scaun rulant au nevoie de suport postural suplimentar. Există posibilitatea ca această pernă să nu ofere suficient sprijin postural. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 151. 7. Recapitulare puncte cheie (5 minute) Citiți punctele cheie. Verificați dacă există întrebări. B.9: Probarea produsului (a scaunului rulant) O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere în ordine corectă pașii din etapa de probare a produsului (a scaunului rulant);  să demonstreze modalitatea de verificare a dimensiunii și a celor mai frecvente ajustări pentru utilizatorul de scaun rulant individual. R E S U R S E Pentru sesiune:  prezentări PPT: B.9 Probarea produsului (a scaunului rulant);  Manualul participantului;  DVD: Demonstrație probarea produsului (a scaunului rulant);  câte un scaun rulant pentru fiecare grupă alcătuită din trei participanți;  listă de verificare pentru probarea produsului (a scaunului rulant) -1 per participant. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele aspecte.  Locul unde va avea loc probarea produsului (a scaunului rulant). Dacă probarea produsului (a scaunului rulant) are loc pe teren, în comunitate, formatorii pot să facă recomandări cu privire la uneltele pe care participanții trebuie să le aibă la ei, precum și referitor la alte aspecte. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Bune practici în etapa de probare a produsului (a scaunului rulant). 3. Exercițiu practic probarea produsului (a .scaunului rulant). 4. Recapitulare puncte cheie. 2 30 25 3 Total durată sesiune 60 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 152. 1. Introducere (2 minute) Explicați: o Probarea produsului (a scaunului rulant) este cea de-a șasea din cele opt ale etape ale furnizării serviciilor de scaune rulante. Pe parcursul acestei sesiuni, participanții vor învăța care sunt pașii ce trebuie parcurși. 2. Bune practici în probarea produsului – a scaunului rulant (30 de minute) Explicați: Pe parcursul probării produsului (a scaunului rulant), utilizatorul și personalul furnizor de servicii de scaune rulante se asigură că: o scaunul rulant are dimensiunea potrivită și a fost ajustat corespunzător; o scaunul rulant și perna sprijină utilizatorul pentru ca acesta să poată meține poziția așezat; o dacă a fost prescrisă (selectată) o pernă pentru reducerea presiunii, aceasta este funcțională. Explicați: Bune practici în probarea produsului (a scaunului rulant) înseamnă: o verificarea măsurii și a ajustărilor; o verificarea posturii; o verificarea nivelului presiunii; o verificarea în timpul manevrării scaunului rulant. Verificați dacă scaunul rulant este pregătit pentru utilizare Explicați: o Asigurați-vă că scaunul rulant a fost verificat pentru a vedea dacă este gata de a fi utilizat în condiții de siguranță și dacă toate componentele sunt funcționale. Verificarea dimensiunii și a ajustărilor Explicați: o Am discutat deja despre modul în care scaunul rulant trebuie să se potrivească utilizatorului. Pe parcursul probării produsului (a scaunului rulant), trebuie să verificați (fizic) dacă acesta este adecvat. Respectați următoarele indicații: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 153. Explicați: Pentru a verifica lățimea șezutului scaunului rulant: o treceți degetele prin spațiul dintre partea exterioară a coapselor utilizatorului și lateralele scaunului. Degetele ar trebui să încapă cu ușurință și să aibă suficient spațiu. Pentru a verifica adâncimea șezutului scaunului rulant: o verificați dacă utilizatorul stă în poziția așezat. o treceți mâna prin spațiul dintre pernă și partea posterioară a genunchilor. Distanța ar trebui să fie suficient de mare pentru două degete (30 mm). Distanța poate fi mai mare în cazul utilizatorilor care au picioare lungi. Se acceptă o distanță de până la 60 de mm. o glisați mâna în jos, în spatele gambelor și asigurați-vă că acestea nu ating șezutul scaunului sau perna. o verificați întotdeauna ambele părți. Pentru a verifica înălțimea suportului de picioare: o treceți mâna prin spațiul dintre coapsă și pernă. Presiunea trebuie să fie egală, iar coapsa să nu se ridice de pe suprafața pernei.. o verificați poziția fiecărui picior pe suportul de picioare. Talpa piciorului trebuie să fie așezată pe suport, fără a se ridica în vreun punct. Pentru a verifica înălțimea spătarului: o întrebați utilizatorul de scaun rulant dacă spătarul este confortabil; o observați dacă trunchiul este în echilibru în raport cu șoldurile; o utilizatorul poate efectua propulsia scaunului rulant fără a fi împiedicat de spătar? Pentru a verifica poziția roților din spate, în vederea realizării propulsiei cu brațele: o cereți utilizatorului de scaun rulant să poziționeze mâinile pe partea superioară a inelelor de antrenare – coatele trebuie să formeze un unghi de 90 grade; o verificați împreună cu utilizatorul de scaun rulant dacă roțile din spate sunt poziționate corect pentru echilibru (înainte pentru activ, înspre înapoi pentru mai multă siguranță). Pentru a verifica înălțimea spătarului, în vederea realizării propulsiei cu picioarele: o Cereți utilizatorului să stea cu partea posterioară a bazinului sprijinită de spătarul scaunului rulant și cu piciorul cu care realizează propulsia așezat pe podea. Verificați dacă piciorul atinge podeaua cu toată suprafața talpei. Dacă înălțimea șezutului scaunului este prea mare, personalul furnizor de servicii de scaune rulante poate încerca: o să reducă înălțimea pernei; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 154. o să atașeze un șezut rigid, poziționat mai jos decât șezutul original (apelați la sfatul sau sprijinul unei persoane care are cunoștințele tehnice necesare). Pentru utilizatorii care realizează propulsia cu ajutorul unui singur picior, avându-l pe celălalt poziționat pe suportul de picioare: o verificați ca nivelul presiunii de sub oasele bazinului de pe partea cu piciorul așezat pe suportul de picioare să nu depășească nivelul 3. Verificarea posturii Explicați: După verificarea dimensiunii și a ajustărilor, personalul furnizor de servicii de scaune rulante trebuie să se asigure că postura utilizatorului este cât mai apropiată de poziția așezat corectă. Întrebare: Care sunt aspectele ce trebuie verificate pentru a stabili dacă utilizatorul stă în poziția așezat? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o bazinul este drept și se află în echilibru; o umerii sunt situați la același nivel, brațele au libertate de mișcare; o trunchiul este drept; o spatele urmează cele trei curburi naturale; o capul stă drept și în echilibru în raport cu corpul; o șoldurile flexate la 90 de grade; o coapsele în poziție ușor îndepărtat (în abducție); o genunchii și gleznele flexate într-un unghi de aproape de 90 de grade; o călcâiele pe aceeași linie cu genunchii sau în poziție ușor avansată sau ușor înspre spate; o tălpile poziționate drept pe podea. Explicați: Reamintiți-vă că nu toți utilizatorii stau în aceeși poziție. De exemplu, unii utilizatori de scaun rulant preferă să își țină picioarele îndoite înspre înapoi, într-un unghi diferit de 90 de grade. Verificați nivelul de presiune Explicați: o În cazul fiecărui utilizator de scaun rulant la care există pericolul apariției escarelor – verificați dacă presiunea de sub oasele bazinului se menține în limitele acceptate. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 155. Verificarea cu scaunul rulant aflat în mișcare Explicați: Partea finală a etapei de probare este verificarea scaunului rulant în timp ce acesta este propulsat de utilizator sau manevrat de către însoțitor. Aspecte de verificat: o din punct de vedere al spătarului, există la nivelul umerilor libertatea de mișcare necesară pentru antrenarea scaunului rulant? o spătarul oferă suficient sprijin? o tălpile sunt poziționate pe suportul de picioare? o poziția roților din spate este corectă pentru respectivul utilizator? Explicați: Dacă utilizatorul nu poate propulsa singur echipamentul de mobilitate, rugați un membru de familie/însoțitor să împingă scaunul rulant. Material video: Vom viziona acum în întregime secțiunea care se referă la probarea produsului (a scaunului rulant). Aici sunt incluse: verificarea dimensiunii, a posturii și verificarea scaunului rulant în timpul manevrării acestuia. Împărțiți participanților lista de verificare preliminară utilizării scaunului rulant. Explicați: Participanții pot păstra formularul, pentru a nu omite niciunul din pașii acestei etape. Cereți participanților să urmărească materialul video și să identifice toate tipurile de verificări incluse pe listă. Prezentați materialul video. Verificați dacă există întrebări. Verificați dacă există și alte aspecte de clarificat. 3. Probarea produsului (a scaunului rulant) – probă practică (25 de minute) Activitate Grupe: Alcătuiți grupe de câte doi sau trei participanți. Fiecare grupă trebuie să aibă un scaun rulant și un formular de verificare preliminară utilizării scaunului rulant. Instrucțiuni: o Cereți fiecărei echipe să desemneze o persoană care să joace rolul utilizatorului de scaun rulant. Ceilalți membrii ai echipei trebuie să se asigure că scaunul rulant este adecvat pentru respectivul utilizator. o Reamintiți-le participanților să efectueze verificarea atât cu scaunul rulant aflat pe loc, cât și în timp ce acesta este propulsat de utilizator sau manevrat de însoțitor. Trebuie avute în vedere dimensiunea, postura și nivelul de presiune sub oasele bazinului. Monitorizare: Monitorizați activitatea grupelor și oferiți ajutor dacă este necesar. Durata: Durata alocată pentru feedback este de 10 minute. Feedback: Cereți fiecărei echipe să prezinte pe scurt următoarele aspecte: o dacă scaunul rulant este sau nu potrivit utilizatorului de scaun rulant; o în cazul în care răspunsul este nu, întrebați care au fost problemele; o dacă este posibilă efectuarea unor ajustări sau scaunul rulant trebuie schimbat. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 156. Explicați: Dacă scaunul rulant nu este corespunzător nici după ajustări, trebuie identificate soluții simple pentru a-l modifica. Acestea sunt explicate pe parcursul următoarei sesiuni. 4. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 157. B.10: Soluționarea problemelor O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere cele mai frecvente probleme în ceea ce privește dimensiunile scaunului rulant sau ajustările;  descrie soluții simple pentru cele mai frecvente probleme referitoare la dimensiunile scaunului rulant sau ajustări. R E S U R S E Pentru sesiune:  prezentări PPT: B.10 Soluționarea problemelor;  Manualul participantului;  DVD: Soluționarea problemelor (partea 1 și partea 2);  un scaun rulant;  două plăci spumă/burete (aproximativ 100 mm x 100 mm x 50 mm) pentru demonstrație;  centură glezne/gambe (dacă există). C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  scaunele rulante disponibile local – și orice soluții de ajustare sau modificare ce pot fi puse în practică în cazul lor;  materialele și resursele de care participanții dispun la locul de muncă. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii.  Pregătiți pozele sau prezentările .ppt cu exemplele locale, pentru a ilustra soluțiile descrise în această sesiune. P R E ZE N TA R E 1. Introducere. 2. Adâncimea șezutului scaunului rulant este prea mare sau prea mică. 3. Suportul de picioare este situat prea jos sau prea sus. 4. Picioarele au tendința de a se poziționa înspre interior sau exterior. 5. Picioarele alunecă de pe suportul de picioare. 6. Recapitulare puncte cheie. 3 10 5 10 10 5 2 Total durată sesiune 45 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 158. 1. Introducere (3 minute) Explicați: Se poate întâmpla ca personalul furnizor de servicii de scaune rulante să aibă dificultăți în a face un scaun rulant disponibil să răspundă cerințelor utilizatorului. Problema poate fi cauzată de fapul că: o gama de tipuri și de mărimi de scaune rulante disponibile este limitată; o utilizatorul are nevoie de sprijin suplimentar pentru a menține o poziție așezat confortabilă. o Pe parcursul acestei sesiuni vom analiza câteva soluții simple la cele mai frecvente probleme cauzate de limitările în ceea ce privește gama de dimensiuni și tipuri de scaune rulante disponibile. o Modificările și îmbunătățirea suportului postural sunt abordate în detaliu în modulul de instruire pentru nivelul intermediar. Toate aceste soluții presupun că am ales deja pentru respectivul utilizator scaunul rulant cu mărimea cea mai apropiată de cea recomandată, din cele disponibile. Este bine să verificați întotdeauna acest aspect, înainte de a recurge la modificarea unui scaun rulant. Întrebare: Care sunt unele din cele mai frecvente probleme pe care personalul furnizor de servicii de scaune rulant le-a întâlnit deja sau consideră că pot să apară? Cele mai relevante răspunsuri: o adâncimea șezutului scaunului rulant este prea mare sau prea mică; o suportul de picioare este situate prea jos sau prea sus; o picioarele au tendința de a se poziționa înspre interior sau exterior; o picioarele alunecă de pe suportul de picioare; o scaunul rulant este prea lat. Explicați: Pe parcursul acestei sesiuni, vom analiza la cinci potențiale probleme. 2. Adâncimea șezutului scaunului rulant este prea mare sau prea mică (10 minute) Problemă: Adâncimea șezutului scaunului rulant este prea mică Descrieți potențialele soluții prezentate mai jos. Folosiți un scaun rulant pentru a face demonstrația. o Măriți adâncimea șezutului scaunui rulant prin extinderea cadrului șezutului și înlocuirea materialului textil (tapițeriei). o Dacă scaunul rulant are un cadru pliabil, verificați dacă suportul șezutului scaunului rulant este de sine stătător. Acest lucru înseamnă că el nu este integrat în ansamblul cadrului scaunului rulant. o În acest caz, se poate adăuga o extensie și se aplică un material textil care să aibă lungimea corespunzătoare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 159. o Dacă scaunul rulant are un cadru rigid, acoperit cu material textil, verificați dacă șezutul scaunului rulant este depășit în lungime de cadrul său o În acest caz, materialul textil poate fi înlocuit cu unul nou, de lungimea corespunzătoare, care să fie susținut de cadrul șezutului scaunului rulant. o Măriți adâncimea scaunului rulant adăugând o placă rigidă și o pernă. o Un șezut solid poate fi confecționat din lemn, plastic sau orice alt material rigid care nu se îndoaie sau nu se rupe. o Șezutul poate fi fixat deasupra cadrului șezutului. o Adăugați o pernă care are lățimea și adâncimea egale cu cele ale noului șezut. Explicați: Atunci când înlocuiți șezutului unui scaun rulant, rețineți următoarele. o Asigurați-vă că noul șezut este suficient de puternic pentru a suporta greutatea utilizatorului. o Dacă șezutului scaunul rulant este solid (rigid): o verificați șezutul, acesta nu trebuie să se îndoaie sau să se rupă în porțiunea ce depășește suprafața de ședere existentă. o asigurați-vă întotdeauna că toate șezuturile rigide sunt prevăzute cu o pernă, în cazul fiecărui utilizator de scaun rulant. o în timpul probării scaunului rulant, verificați dacă spătarul și suportul de picioare sunt la înălțimea corectă. Șezutul solid și perna vor ridica utilizatorul în scaunul rulant. Problemă: Adâncimea șezutului scaunului rulant este prea mare. Explicați: Dacă valoarea cea mai mică a adâncimii șezutului în cazul scaunelor rulante disponibile este prea mare, utilizatorului îi va fi imposibil să stea în poziția așezat. Adâncimea șezutului va trebui redusă. Descrieți posibilele soluții prezentate mai jos. Folosiți un scaun rulant pentru a face demonstrația. o Pe șezutul existent, marcați care este adâncimea necesară. o Dacă șezutul este acoperit cu material textil (tapițerie): îndepărtați materialul, scurtați-l (folosind o mașină de cusut industrială) și înlocuiți. o Dacă șezutul scaunului rulant este rigid: îndepărtați șezutul, scurtați și înlocuiți. o Scurtați perna pentru ca aceasta să se potrivească noii dimensiuni a șezutului scaunului rulant. Explicați: Atunci când scurtați șezutul scaunului rulant, rețineți: o atunci când tăiați un șezut rigid – asigurați-vă întotdeauna ca toate marginile sunt netezite și că nu există așchii. o atunci când tăiați o pernă – tăiați întotdeauna din partea frontală, pentru ca zona de reducere a presiunii, aflată în partea din spate a pernei, să nu fie modificată. Explicați: Dacă adâncimea scaunului rulant este mai scurtă cu peste 100 mm decât adâncimea bazinului utilizatorului (în cazul unui utilizator adult), acest lucru poate constitui o problemă. Scaunul rulant nu va oferi suficient suport pentru ca utilizatorul să stea confortabil în scaunul Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 160. rulant. De asemenea, există riscul creșterii nivelului de presiune la nivelul anumitor porțiuni, cum ar fi oasele bazinului. 3. Suportul de picioare este situat prea jos sau prea sus (5 minute) Problemă: Suportul de picioare este situate prea jos Explicați: Dacă suportul de picioare se află prea jos, utilizatorul de scaun rulant nu își va putea poziționa în mod confortabil picioarele pe acesta. Acest lucru poate determina alunecarea în față a utilizatorului sau senzația de instabilitate, iar în acest caz nu va exista suficient sprijin pentru menținerea poziției așezat. Descrieți posibilele soluții prezentate mai jos. Folosiți un scaun rulant pentru a face demonstrația. o Măriți înălțimea suportului de picioare prin scurtarea cadrului pe care este montat acesta. o În cazul celor mai multe scaune rulante cu patru roți, cadrul suportului de picioare poate fi scurtat. o Înălțați suportul de picioare prin adăugarea unor elemente suplimentare. o Folosiți lemn sau un alt material solid pentru a ajusta înălțimea suportului de picioare. Explicați: o Atunci când modificați cadrul suportului de picioare – întotdeauna asigurați-vă că mecanismul de ajustare rămâne funcțional. o Verificați ca această ajustare să nu împiedice plierea suporturilor de picioare (acolo unde ele pot fi pliate). Problemă: Suportul de picioare este situat prea sus Explicați: Dacă suportul de picioare este poziționat prea sus, coapsele utilizatorului nu vor avea o poziție confortabilă pe șezutul scaunului rulant. Suportul de picioare situat prea sus poate crește presiunea pe oasele bazinului. Descrieți posibilele soluții prezentate mai jos. Folosiți un scaun rulant pentru a face demonstrația. o Coborâți suportul de picioare prin lungirea tubului de extensie interior. o Verificați dacă tubul de extensie interior poate fi înlocuit cu unul mai lung. o dacă da, înlocuiți-l cu unul similar, având același diametru și aceeași rezistență. o Măriți înălțimea pernei: o Măriți înălțimea pernei sau ridicați perna prin adăugarea unui element solid sub aceasta. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 161. Explicați: o În cazul în care este coborât suportul de picioare – asigurați-vă că acesta nu este poziționat atât de jos încât să atingă solul. În cazul în care se întâmplă acest lucru, apelați la soluția numărul 2. Dacă nici aceasta nu este adecvată, atunci scaunul rulant nu este corespunzător pentru respectivul utilizator o Atunci când înălțimea pernei devine mai mare: o nu folosiți spumă moale pentru a crește înălțimea pernei. Aceasta se va comprima și, de asemenea, va da senzație de instabilitate; o în timpul probării scaunului rulant, verificați dacă spătarul și suporturile de brațe sunt la înălțimea corectă. Perna mai înaltă va ridica utilizatorul în scaunul rulant; o verificați dacă există probleme funcționale în cazul ridicării pernei. De exemplu – există posibilitatea ca utilizatorul să nu mai poată sta cu picioarele sub masă sau birou. 4. Picioarele au tendința de a se poziționa înspre interior sau exterior. (10 minute) Explicați: o Uneori, picioarele utilizatorului pot avea tendința de a sta înspre interior sau înspre exterior. Acest lucru poate fi cauzat de modul în care utilizatorul este obișnuit să stea sau de alți factori fizici (de exemplu, de forță musculară redusă). Ajustările simple în ceea ce privește șezutul scaunului rulant sau perna pot ajuta la reducerea problemei. Material video: Soluționarea problemelor. Acest material video scurt îl are ca personaj pe Gary, un utilizator de scaun rulant ale cărui picioare au tendința de a se poziționa înspre interior sau exterior. Prezentați materialul video: (partea 1 – Gary) După vizionarea materialului video întrebați: Care a fost soluția găsită de terapeut? Încurajați participanții să răspundă. Explicați că în acest exemplu soluția identificată a fost adăugarea unor inserții la perna existentă, pentru a ajuta coapsele să stea în poziție neutră. A fost mărită porțiunea ridicată, pe partea exterioară a coapselor. Există posibilitatea adăugării unei perne cu contur. Dacă picioarele au tendința de a aluneca înspre interior, porțiunea ridicată dinspre interior ar fi trebuit redusă. Descrieți posibilele soluții prezentate mai jos. o Folosiți un scaun rulant pentru a face demonstrația. o Verificați cu atenție înălțimea suportului de picioare: o asigurați-vă că înălțimea suportului de picioare sprijină în mod corect utilizatorul de scaun rulant (presiunea la nivelul tălpilor și sub coapse trebuie să fie distribuită în mod egal); o Verificați dacă șezutul scaunului rulant este întins în mod corespunzător: o dacă scaunul rulant are șezutul acoperit cu material textil – asigurați-vă că acesta este foarte bine întins; o dacă șezutul se lasă în jos, acest lucru poate determina ca picioarele utilizatorului să alunece înspre interior. o Adăugați elemente suplimentare la perna existentă pentru a menține coapsele în poziție neutră (așa cum este prezentat în Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 162. materialul video și în imagine), furnizați utilizatorului o pernă modelată sau modificați perna, dacă acest lucru este necesar. 5. Picioarele alunecă de pe suportul de picioare (10 minute) Explicați: o Uneori, picioarele utilizatorului alunecă de pe suportul de picioare. Acest lucru poate fi determinat de factori fizici (de exemplu, lipsa forței musculare sau spasme musculare). o Adăugarea unor centuri ajută la reducerea problemei. Descrieți posibilele soluții prezentate mai jos. Folosiți un scaun rulant pentru a face demonstrația. Verificați cu atenție înălțimea la care este situată suportul de picioare: o asigurați-vă că înălțimea suportului de picioare oferă utilizatorului un sprijin adecvat (presiunea la nivelul tălpilor și sub coapse trebuie să fie distribuită în mod egal). o Ajustați unghiul suportului de picioare (acolo unde este posibil). o verificați dacă unghiul suportului de picioare poate fi ajustat. o dacă da – încercați să măriți unghiul suportului de picioare. Acest lucru poate ajuta la menținerea în poziția corectă a piciorului. o Adăugați o centură: o atașați o centură pe cadrul de susținere ale suporturilor de picioare, la nivelul gleznelor. o dacă laba piciorului are tendința să alunece în spate, centura se fixează în spatele picioarelor. o dacă laba piciorului are tendința să alunece în față, centura se fixează în fața picioarelor. Explicați: o Asigurați-vă că centura poate fi îndepărtată cu ușurință, în așa fel încât utilizatorul să poată efectua fără efort transferul în și din scaunul rulant. o Verificați dacă utilizatorul de scaun rulant poate ajunge fără ajutor la centură și dacă poate să o fixeze și să o îndepărteze cu ușurință. Explicați: O altă problemă o constituie picioarele care nu sunt sprijinite în mod egal pe suportul de picioare. Acest lucru este deseori determinat de faptul că piciorul nu poate sta în poziție neutră. Material video: Soluționarea problemelor. Acest material video scurt îl are ca personaj pe Arun, un utilizator de scaun rulant al cărui picioare nu sunt spriijinite în mod egal pe suportul de picioare. Prezentați materialul video: (partea 2 – Arun) După vizionarea materialului video întrebați: Care a fost soluția găsită de terapeut? Încurajați participanții să răspundă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 163. 6. Scaunul rulant este prea lat (5 minute) Explicați: Uneori, chiar și cea mai mică mărime de scaun rulant disponibilă este prea mare pentru utilizatorul căruia i s-a prescris echipamentul de mobilitate. Dacă șezutul scaunului este prea lat, utilizatorului îi va fi greu să stea în poziția așezat și există posibilitatea ca el să alunece într-o parte. Niște simple inserții de spumă pot să ofere utilizatorului sprijinul necesar pentru a sta în poziția așezat. Descrieți posibilele soluții prezentate mai jos. o Folosiți un scaun rulant pentru a face demonstrația. o Adăugați inserții de spumă de ambele părți ale bazinului. o măsurați spațiul dintre utilizator (poziționat pe mijlocul scaunului rulant, cu spatele sprijnit de spătar) și fiecare apăratoare lateral; o tăiați și adăugați inserții de spumă de ambele părți, pentru a umple spațiul dintre utilizator și partea laterală a scaunului rulant; o verificați dacă se potrivește; o aplicați o husă și atașați inserțiile de spumă. Dacă suporturile de brațe sunt rigide, aceste inserții pot fi atașate de suport. Ele pot fi aplicate și pe partea superioară a pernei. Explicați: o Inserțiile nu trebuie să depășească nivelul până la care ajunge trunchiul utilizatorului. o Dacă scaunul rulant este foarte lat, utilizatorul poate avea dificultăți în a ajunge la inelele de antrenare. o Mișcarea forțată pentru a ajunge la inelele de antrenare poate provoca rănirea umărului. o Înainte de a prescrie (selecta) scaunul rulant, asigurați-vă că acesta poate fi folosit în condiții de siguranță de către utilizator. 7. Recapitulare puncte cheie (2 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 164. B.11: Instruirea utilizatorului de scaun rulant O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să enumere care sunt abilitățile pe care utilizatorul le poate dobândi cu ajutorul personalului furnizor de servicii de scaune rulante, la primirea unui scaun rulant nou.  să enumere „bune practici în metoda de instruire”;  demonstreze că pot instrui un coleg cu privire la o abilitate legată de utilizarea scaunului rulant. R E S U R S E Pentru sesiune:  prezentare PPT: B.11 Instruirea utilizatorului de scaun rulant;  Manualul participantului;  Caietul de exerciții practice;  câte un scaun rulant pentru fiecare grupă de câte trei participanți;  lista de verificare pentru instruirea utilizatorului de scaun rulant (1 per participant). C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  grupuri situate la nivel local, care pot oferi utilizatorului instruire suplimentară și consiliere. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Care sunt abilitățile de manevrare a scaunului rulant care sunt de folos utilizatorului? 3. Exercițiu de instruire a utilizatorului de scaun rulant. 4. Recapitulare puncte cheie. 2 10 45 3 Total durată sesiune 60 1. Introducere (2 minute) Explicați: o Instruirea utilizatorului este cea de-a șaptea etapă a procesului de livrare a serviciilor de scaune rulante. Informațiile și instruirea îi ajută pe cei mai mulți utilizatori să beneficieze într-o cât mai mare măsură de avantajele unui scaun rulant. o Fără parcurgerea acestei etape, există posibilitatea ca utilizatorul să nu folosească scaunul rulant la întregul potențial al acestuia. o Pe parcursul acestei sesiuni, vom vorbi despre abilitățile pe care Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 165. utilizatorul le poate dobândi cu ajutorul personalului furnizor de servicii de scaune rulante, la primirea echipamentului de mobilitate. Vom folosi lista de verificare pentru instruirea utilizatorului și vom exersa metodele de instruire. 2. Care sunt acele abilități care pot ajuta utilizatorul de scaun rulant? (10 minute) Întrebare: Care sunt aspectele învățate de participanți în timpul curs și care pot fi transmise utilizatorilor de scaun rulant? Gândiți-vă la elementele care le vor fi de folos utilizatorilor în ceea ce privește: o menținerea stării de sănătate; o utilizarea scaunului rulant în exterior și în interior; o întreținerea scaunului rulant pentru creșterea duratei de viață a acestuia. Reamintiți-le participanților materialul video în care este prezentată Sai, în care vorbește despre ce a ajutat-o pe ea să meargă la școală. Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o metode pentru reducerea riscului apariției escarelor; o tehnici de manevrare a scaunului rulant; o tehnici de transfer în și din scaunul rulant; o mobilitatea în scaunul rulant; o soluționarea problemelor; o întreținerea scaunului rulant și a pernei; o care sunt organizațiile sau serviciile care le pot oferi asistență. Explicați: Cele mai importante șase aspecte care trebuie transmise în timpul instruirii sunt: o modalitatea de manevrare a scaunului rulant; o prevenirea apariției escarelor și ce trebuie făcut în cazul în care acestea se formează; o tehnici de transfer în și din scaunul rulant; Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 166. o mobilitatea în scaunul rulant – în conformitate cu nevoile utilizatorului; o întreținerea la domiciliu a scaunului rulant și a pernei. Explicați: Vom discuta mai multe despre acest subiect în cadrul următoarei sesiuni. o cum trebuie acționat în cazul apariției unor probleme. Fiecare participant va primi câte un scaun rulant și o lista de verificare. Explicați: o Lista de verificare de pe pagina următoare conține abilitățile specifice de care utilizatorul de scaun rulant ar putea avea nevoie. Este posibil ca unii utilizatori să fi dobândit deja aceste abilități; totodată, nu toate abilitățile sunt necesare tuturor utilizatorilor de scaun rulant. o Cu ajutorul acestei liste de verificare, personalul furnizor de servicii de scaune rulante poate identifica punctele care trebuie incluse în instruirea utilizatorului. Acestea se stabilesc prin evaluare și prin discuțiile cu utilizatorul. În acest caz, lista de verificare este utilă și pentru a înregistra temele care au fost incluse în instruirea utilizatorului de scaun rulant. o Verificați întotdeauna împreună cu utilizatorul de scaun rulant dacă acesta dorește ca însoțitorii să fie instruiți pentru a dobândi anumite abilități. O mare parte dintre utilizatori sunt asistați de către familie sau însoțitori, de aceea este benefic pentru toți cei implicați ca aceștia să învețe modalități de utilizare și de întreținere a scaunului rulant. 3. Exercițiu de instruire pentru utilizatorul de scaun rulant (45 de minute) Întrebare: Care sunt aspectele care determină ca intruirea utilizatorului de scaun rulant să fie una eficientă? Participanților li se cere să se gândească la exemple de metode de predare de succes pe care le-au întâlnit (poate chiar în timpul acestui curs de instruire!). Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o identificarea aspectelor pe care utilizatorul le cunoaște deja. o explicarea, demonstrarea abilităților și oferirea oportunității de a exersa cele învățate o folosirea unui limbaj care poate fi înțeles de către toată lumea o folosirea unor alți utilizatori de scaun rulant ca instructori o utilizarea unor bune abilități de comunicare o încurajarea utilizatorul de scaun rulant Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 167. Explicați: Este important ca utilizatorul să exerseze toate abilitățile nou dobândite. Se recomandă să începeți predarea fiecărei manevre cu o demonstrație. Apoi, dați utilizatorului oportunitatea să o exerseze. Activitate desfășurată în grupe mici Grupe: Formați echipe de câte doi sau trei participanți. Instrucțiuni: o Cereți grupelor să citească cazurile din caietul de exerciții practice. Scopul este identificarea a cel puțin trei abilități care ar putea fi de folos în cazul fiecărui utilizator prezentat. o Pentru fiecare caz, grupa ar trebui să exerseze cel puțin una din abilitățile identificate în prealabil. Fiecare membru al grupului ar trebui să aibă, pe rând, rolul utilizatorului de scaun rulant, cel al unui membru de familie și cel al instructorului. o Reamințile-le participanților să țină cont de cerințele referitoare la abilitățile de comunicare și despre bunele practici în instruire. Subliniați importanța demonstrației și a exercițiului practic. Monitorizare: Monitorizați activitatea grupelor și oferiți sprijin dacă este necesar. Durata: Durata exercițiului este de 30 de minute, cu 15 minute alocate pentru feedback. Feedback: Cereți fiecărei grupe să evidențieze o metodă adecvată de predare pe care au aplicat-o sau pe care au observat-o. Moses Observații pentru formatori: Moses are vârsta de 23 de ani. În urmă cu doi ani a căzut din spatele unui camion și a devenit paraplegic. A petrecut un an la spital și s-a întors în satul său cu un scaun rulant vechi, primit donație. Scaunul rulant s-a stricat foarte repede și el nu l-a mai putut utiliza. Moses a avut și o escară, care acum e vindecată. Moses tocmai a primit, de la furnizorul de servicii de scaune rulante, un scaun nou, cu o pernă pentru reducerea presiunii. Acesta este fabricat pentru a putea fi folosit pe teren accidentat. Moses este nerăbdător să se întoarcă acasă cu noul său scaun rulant și speră să devină mai independent. Cele mai importante abilități: o manevrarea scaunului rulant și folosirea pernei pentru reducerea presiunii; o prevenirea apariției escarelor; o transferul în și din scaunul rulant; o abilități de manevrare a scaunului rulant; o întreținerea la domiciliu a scaunului rulant și a pernei; o alte organizații sau servicii care pot oferi asistență. Sian Observații pentru formatori: Sian are 40 de ani și are o amputație bilaterală, de deasupra genunchilor. Este utilizator de scaun rulant de 20 de ani și în această perioadă a avut cinci scaune rulante. În opinia sa, acestea s-au defectat repede. Sian este o persoană foarte activă și lucrează într-un magazin din localitate. El merge de acasă la magazin în fiecare zi, pe un drum accidentat, frecvent acoperit de noroi. El a demonstrat personalului furnizor de servicii de scaune rulante cum știe să stea în echilibru pe două roți. Lui Sian tocmai i s-a recomandat un scaun rulant nou. El speră ca acesta să dureze mai mult de șase luni, cât a rezistat ultimul pe care l-a avut. Cele mai importante abilități: o întreținerea la domiciliu a scaunului rulant și a pernei – efectuarea acestor operațiuni la intervale regulate va mări durata de viață a scaunului rulant. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 168. Zoe Observații pentru formatori: Zoe are vârsta de 16 ani. În copilărie, ea a avut poliomielită și din această cauză nu mai poate merge. Zoe este foarte timidă și nu a mers la școală până acum. Mama ei a învățat-o acasă să scrie și să citească. Ea tocmai am primit un scaun rulant și le-a demonstrat celor care oferă servicii utilizatorilor că poate efectua cu ușurință transferul în și din acesta. Zoe este interesată să urmeze cursurile unei școli profesionale din localitate, dar nu crede că se poate deplasa la școală și înapoi. Există și câteva trepte la intrarea în clădirea școlii. O îngrijorează aspectele legate de accesul la toaletă în timpul cât se află la școală. Cele mai importante abilități: o abilități de manevrare a scaunului rulant – în special urcarea și coborârea treptelor; o transferul – tehnici de transfer din scaun rulant pe toaletă și invers. 4. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 169. B.12: Întreținerea și reparațiile O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să demonstreze modul în care scaunul rulant va fi întreținut la domiciliu;  să identifice problemele tehnice care apar cel mai frecvent și să explice cum pot fi acestea rezolvate la nivel local/în comunitate. R E S U R S E Pentru sesiune:  Prezentare PPT: B.12 Întreținerea și reparațiile;  Manualul participantului;  Caietul de exerciții practice;  DVD: Întreținerea scaunului rulant la domiciliu;  Afiș: Întreținerea scaunului rulant la domiciliu;  scaune rulante care au nevoie de reparații, inclusiv: anvelope cu pană, frâne nefuncționale, pernă deteriorată, pete de coroziune, tapițerie deformată, șuruburi care nu mai sunt strânse adecvat, spițe care nu mai sunt strânse corespunzător sau spițe lipsă, rulmenți deteriorați, inele de antrenare deteriorate. Este posibil ca același scaun rulant să aibă nevoie de mai multe tipuri de reparații.  1 trusă de întreținere a scaunului rulant la domiciliu (vedeți lista de echipamente). C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  unde pot fi reparate scaunele rulante în locurile de unde vin participanții;  subliniați orice cerințe specifice în ceea ce privește reparațiile și întreținerea scaunelor rulante disponibile local;  dacă furnizorii de servicii de scaune rulante de unde provin participanții oferă servicii de reparații – dacă da, cum pot avea utilizatorii acces la acestea și dacă sunt contra cost. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările, parcurgeți materialul video și citiți planificarea sesiunii.  Prezentați afișul Întreținerea scaunului rulant la domiciliu”, în așa fel încât toți participanții să îl poată vedea.  Pregătiți scaunele rulante pentru reparații și etichetați-le cu A, B, C, etc. Pregătiți-le în sala de curs.  Asigurați-vă că în sală există o persoană care stăpânește aspectele tehnice și care poate răspunde întrebărilor detaliate despre reparații (dacă formatorii simt că nu stăpânesc suficient de bine acest subiect). P R E ZE N TA R E 1. Introducere. 2. Prevenirea reparațiilor: întreținerea la domiciliu. 3. Reparații uzuale ale scaunului rulant și ale pernei. 4. Recapitulare puncte cheie. 2 60 55 3 Total durată sesiune 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 170. 1. Introducere (2 minute) Explicați: o Îngrijirea regulată a scaunului rulant și a pernei duce la evitarea costurilor determinate de reparații, crește durata de viață a acestuia și previne producerea de răniri ale utilizatorului sau deteriorările pe termen lung ale stării de sănătate. o Un scaun rulant bine întreținut este mai confortabil, este mai ușor de folosit, iar manevrarea sa necesită un consum de energie mai mic din partea utilizatorului. o Personalul furnizor de servicii de scaune rulante are responsabilitatea de a informa utilizatorul de scaun rulant cu privire la modalitățile de întreținere la domiciliu ale scaunului rulant și ale pernei. o Pe parcursul acestei sesiuni, vom învăța despre modalitatea de întreținere la domiciliu a scaunului rulant și a pernei, precum și despre soluțiile în cazul în care acestea au nevoie de reparații. 2. Prevenirea reparațiilor: întreținerea la domiciliu (60 de minute) Prezentați afișul „Întreținerea scaunului rulant la domiciliu”. Notă pentru formatori: În materialul .ppt de mai jos se explică modalitatea de întreținere a scaunului rulant la domiciliu. Fiecare slide explică de ce respective activitate este importantă și menționează care este intervalul de timp recomandat. Formatorii trebuie să adauge informațiile de mai jos. Explicați: o Există șase lucruri pe care utilizatorii de scaun rulant le pot face acasă pentru a întreține scaunul rulant și perna. o Enumerați (vezi slide). Explicați: o De ce, cu ce frecvență și cum (vezi slide). Adăugați: o Atenție la părțile mobile și la porțiunile unde tapițeria întâlnește cadrul. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 171. Explicați: o De ce, cu ce frecvență și cum (vezi slide). Adăugați: o Nu pulverizați soluții lubrifiante pe rulmenți, acestea pot îndepărta uleiul care face ca rulmenții să funcționeze corespunzător. o Nu folosiți substanțe pentru decapare, deoarece acestea produc deteriorări ale scaunului rulant. Întrebare: Ce tipuri de ulei sunt disponibile în zona de unde provin participanții? Explicați: o De ce, cu ce frecvență și cum (vezi slide). Adăugați: o Verificați dacă anvelopele sunt pneumatice. o Pentru verificarea presiunii – apăsați cu putere pe anvelopă, folosind degetul mare. Aceasta ar trebui să se deformeze puțin sub acțiunea degetului (circa 5 mm). o Presiunea din cele două anvelope trebuie să fie egală. Explicați o De ce, cu ce frecvență și cum (vezi slide). Adăugați: o Nu strângeți exagerat. o Evitați șuruburile cu cap în cruce. Explicați o De ce, cu ce frecvență și cum (vezi slide). o Adăugați: Pentru a verifica spițele – strângeți toate spițele roții cu degetele, două câte două. Dacă o spiță cedează atunci când trageți ușor, este posibil ca aceasta să nu fie strânsă corespunzător. Strângeți cu o cheie pentru spițe. o Cheia pentru spițe este o unealtă importantă pentru utilizatorul de scaun rulant. Aceasta poate fi găsită la cele mai multe magazine de biciclete. o Este posibil ca spițele să fie prea strânse. Dacă sunt prea rigide, acest lucru poate însemna că sunt prea strânse și că trebuie desfăcute Explicați o De ce, cu ce frecvență și cum (vezi slide). Adăugați: Dacă tapițeria s-a uzat sau în cazul în care cusăturile s- au desfăcut, este recomandabil ca aceste probleme să fie rezolvate înainte ca ele să se agraveze. o Dacă există pete de rugină, acestea pot fi îndepărtate cu șmirghel sau cu o perie metalică. Suprafața se acoperă cu vopsea sau se aplică ulei pe părțile metalice. Explicați o De ce, cu ce frecvență și cum (vezi slide). Adăugați: Verificați dacă există zone în care materialul este uzat, murdărie sau găuri în husă și/sau în spumă/burete. o Dacă perna este uzată, aceasta trebuie verificată de personalul furnizor de servicii de scaune rulante. Ar putea fi necesară înlocuirea pernei. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 172. Material video: Întreținerea la domiciliu a scaunului rulant. Acest material video scurt prezintă modul în care un utilizator de scaun rulant desfășoară activități de întreținere a echipamentului de mobilitate. Este important ca utilizatorii de scaun rulant să fie instruiți în acest sens. Prezentați materialul video. Verificați dacă există întrebări. Activitate Grupe: Formați grupe de câte trei participanți. Fiecare grupă va lucra cu un scaun rulant. Plasați în mijlocul sălii de curs suficiente unelte și echipamente necesare pentru întreținerea la domiciliu, asigurându-vă că toți participanții au acces. Instrucțiuni: Cereți fiecărei grupe să desfășoare activitățile specifice întreținerii la domiciliu a scaunului rulant. Reamintiți-le participanților să parcurgă toți pașii prezentați în afiș. Monitorizare: Monitorizați activitatea grupelor. Răspundeți întrebărilor și explicați în detaliu tehnicile, dacă acest lucru este necesar. Durata: Durata exercițiului este de 30 de minute. Feedback: Întrebare: Aveți întrebări cu privire la pașii etapei de întreținere la domiciliu a scaunului rulant? 3. Reparații uzuale ale scaunului rulant și ale pernei (55 de minute) Explicați: Scaunele rulante și pernele necesită uneori reparații. Personalul furnizor de servicii de scaune rulante trebuie să poată efectua aceste reparații sau să sfătuiască utilizatorii de scaun rulant unde să apeleze pentru asistență. Unii utilizatori reușesc foarte bine să rezolve singuri problema reparațiilor, alții au nevoie de ajutor. Toți utilizatorii vor beneficia de pe urma informațiilor cu privire la locurile unde scaunul rulant și perna pot fi reparate. Întrebare: Unde pot beneficia utilizatorii de asistență pentru repararea scaunului rulant? Încurajați participanții să răspundă și notați răspunsurile. Cele mai relevante răspunsuri: o atelier reparații biciclete; o atelier mecanic auto sau motociclete; o ateliere sudare, instalații (părți metalice), tâmplărie, dulgherie (părți de lemn); o utilizatorul de scaun rulant, un membru de familie al utilizatorului de scaun rulant, o rudă sau un vecin al acestuia; o croitor pentru repararea părților din material textil (tapițeriei); o facilități pentru utilizatori scaun rulant. Întrebare: Care sunt cele mai frecvente probleme care apar la scaunul rulant? Încurajați participanții să răspundă și notați răspunsurile. Cele mai relevante răspunsuri: o pernă comprimată sau deteriorată; o tapițerie deformată sau ruptă; o coroziune sau rugină a părților metalice; o spițe largi, lipsă sau spițe deteriorate; o șuruburi, piulițe strânse necorespunzător sau care lipsesc; o distrugerea roților frontale; o anvelope cu pană sau dezumflate; o anvelope și roți frontale uzate; o rulmenți cu depuneri de murdărie, uzați sau deteriorați; o frâne nefuncționale. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 173. Activitate în grupe mici Grupe: Formați grupe de câte trei participanți. Instrucțiuni: Cereți grupelor: o să evalueze fiecare scaun rulant pentru a determina ce fel de reparații sunt necesare o să ia în considerare problemele notate pe tablă o să răspundă, în Caietul de exerciții practice, întrebărilor referitoare la fiecare scaun rulant. Monitorizare: Monitorizați activitatea grupelor. Răspundeți întrebărilor și ajutați participanții să identifice care sunt reparațiile necesare. Unii participanți se vor descurca mai bine, în funcție de gradul de experiență în probleme tehnice. Nu este obligatoriu ca fiecare persoană să aibă abilitatea de a repara ea însăși scaunul rulant. Aspectul cel mai important este capacitatea de a identifica problema și soluția la problemă. Durata: Durata exercițiului este de 30 de minute. Feedback: Cereți grupelor să prezinte care sunt reparațiile necesare în cazul fiecărui scaun rulant. Asigurați-vă că fiecare echipă are ocazia să descrie cel puțin un scaun rulant. Pentru fiecare reparație identificată, întrebați: de ce este asta o problemă pentru utilizatorul de scaun rulant? 4. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 174. Sesiunea practică 2: Probarea produsului (a scaunului rulant) și instruirea utilizatorului O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să demonstreze că știu care sunt pașii din etapa de probare a produsului (a scaunului rulant) - nivel de bază, cu asistență.  să demonstreze că au învățat modalitatea de instruire a utilizatorului în ceea ce privește folosirea eficientă și întreținerea scaunului rulant. R E S U R S E  Lista de verificare și observații pentru formator: sesiunea practică 2.  Formularele de evaluare și prescriere (selecție) completate în sesiunea practică 1  Liste de verificare pentru probarea produsului (a scaunului rulant) și pentru instruirea utilizatorului de scaun rulant (furnizate participanților mai devreme).  Un spațiu curat și liniștit pentru fiecare grupă.  Scaunele rulante pregătite pentru probarea produsului (a scaunului rulant).  Ruletă și unelte pentru ajustarea scaunului rulant – un set per grup. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  factorii culturali – de exemplu, dacă se acceptă formarea de grupe mixte (femei și bărbați) pentru faza de probare a produsului (a scaunului rulant) și de instruire a utilizatorului de scaun rulant;  factorii lingvisitici – de exemplu, dacă utilizatorii de scaun rulant care participă vorbesc aceeași limbă ca și participanții;  toată documentația de care furnizorul de servicii de scaune rulante are nevoie atunci când se furnizează scaunul rulant – de exemplu, număr și serie scaun rulant  modalitatea în care formatorii vor gestiona orice problemă care apare pe parcursul probării produsului (a scaunului rulant) și a instruirii și care nu poate fi abordată în contextul cursului. D E P R E G Ă TI T  Dacă se lucrează cu mai mult de trei grupe, solicitați unui alt formator să vă asiste la monitorizarea activității grupelor.  Confirmați orarul și detaliile referitoare la deplasare ale utilizatorilor de scaun rulant voluntari. Asigurați-vă că ați inclus în comanda pentru pauza de cafea/prânz utilizatorii de scaun rulant, împreună cu membrii de familie sau însoțitorii lor.  Desemnați o persoană care să întâmpine la sosire utilizatorii de scaun rulant și care să le indice locul unde pot aștepta începerea sesiunii.  Pregătiți zona pentru probarea produsului (a scaunului rulant), care constă dintr-un pat pentru evaluare și un paravan. Toate instrumentele necesare probării produsului (scaunului rulant) trebuie să fie disponibile pe pat (sau organizați transportul materialelor, dacă sesiunea practică are loc pe teren, în comunitate).  Asigurați-vă că scaunele rulante care vor fi probate sunt pregătite în totalitate (verificați conformitatea cu formularele de prescriere și asigurați-vă că listele preliminare utilizării scaunului rulant au fost completate): P R E ZE N TA R E 1. Probarea produsului (a scaunului rulant) și instruirea: o Instrucțiuni și pregătire. o Probarea produsului (a scaunului rulant). o Instruirea utilizatorului de scaun rulant. o Feedback. 5 45 50 20 Total durată sesiune 120 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 175. 2. Feedback oferit de utilizatorul de scaun rulant (opțional – în funcție de utilizatorii de scaun rulant și de durata de timp disponibilă). 30 1. Probarea produsului (a scaunului rulant) și instruirea utilizatorului, inclusiv feedback (120 de minute) Notă pentru formatori: Pe parcursul sesiunii practice 2, folosiți lista de verificare și observații pentru formatori. Aceasta vă va ghida în monitorizarea activității echipelor pe durata desfășurării sesiunii practice. Notați toate exemplele de bună practică și toate erorile. Subliniați-le atunci când oferiți feedback (tabelul). Activitate Grupe: o Grupele ar trebui să aibă aceeași componență ca și la sesiunea practică 1. o Numiți câte un responsabil în cadrul fiecărei grupe (acesta poate fi aceeași persoană care a avut rolul de reponsabil în sesiunea practică 1 sau un alt membru al grupei). o Desemnați spațiul în care va lucra fiecare echipă. o Explicați unde pot fi găsite materialele și uneltele. o Asigurați-vă că toate echipele au liste de verificare pentru probarea produslui (a scaunului rulant) și pentru instruirea utilizatorului. Instrucțiuni: Explicați următoarele aspecte: Scopul sesiunii practice: o Scopul acestei sesiuni practice este parcugerea etapelor șase și șapte din procesul de livrare a serviciilor de scaune rulante – probarea produsului (a scaunului rulant) și instruirea utilizatorului – lucrând cu utilizatorii de scaun rulant prezenți la sesiunea practică 1. o Există posibilitatea ca participanții să nu poată termina pregătirea scaunului rulant în perioada de timp alocată. Acest lucru depinde de prima probare a produsului (a scaunului rulant), de modificările/ajustărie care sunt necesare. Totuși, participanții trebuie să încerce să utilizeze cât mai eficient timpul alocat sesiunii practice, pentru a rezolva cât mai multe din aceste aspecte. Dacă scaunul rulant nu poate fi pregătit în totalitate, ne vom asigura că acesta va fi gata după curs. Responsabilul: Persoana desemnată ca fiind responsabilul trebuie să se asigure că toți pașii exercițiului au fost parcurși. o Responsabilul este cel care discută cel mai mult cu utilizatorul de scaun rulant, cu membrii de familie sau cu însoțitorul. Se recomandă această abordare pentru a evita ca mai multe persoane să vorbească în același timp, deoarece se poate crea confuzie. Observațiile formatorului și sprijinul oferit de acesta: o Participanții pot solicita asistență și clarificări în orice moment, pe toată durata exercițiului. o Pe parcursul sesiunii, formatorii monitorizează fiecare grup și oferă tot sprijinul necesar desfășurării corecte a exercițiului. o Dacă sunt identificate orice fel de probleme la probarea produsului (a scaunului rulant), formatorul este rugat să verifice și să discute modificările/ajustările necesare. o După finalizarea etapei de probare a produsului (a scaunului rulant), participanții trebuie să ceară unuia din formatori să verifice rezultatul. NU SE Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 176. VA ÎNCEPE INSTRUIREA UTILIZATORULUI până când scaunul rulant nu a fost verificat de către unul din formatori. o După finalizarea instruirii utilizatorului de scaun rulant, unul din formatori discută cu fiecare grupă și cu utilizatorul de scaun rulant despre rezultatele instruirii. Durata exercițiului: o Durata exercițiului este de 45 de minute pentru probarea produsului (a scaunului rulant) și 50 de minute pentru instruirea utilizatorului. Formularele: o Înmânați fiecărui responsabil de grupă formularele de evaluare și de prescriere scaune rulante, completate în sesiunea practică 1 (ce vor fi folosite în sesiunea practică 2). o Verificați ca la fiecare grupă să existe cel puțin un exemplar din lista de verificare pentru probarea produsului (a scaunului rulant) și din lista de verificare pentru instruirea utilizatorului. Întrebați participanții: Care sunt pașii etapei de probare a produsului (a scaunului rulant)? Notați răspunsurile corecte. Reamintiți-le participanților că utilizatorul trebuie să dobândească prin instruire abilitățile care răspund unor cerințele pe care acesta le are. De exemplu – nu este necesar ca o persoană la care nu există pericolul apariției escarelor să învețe tehnici de reducere a presiunii. Reamintiți-le participanților că utilizatorul de scaun rulant trebuie să fie implicat în mod activ, pe toată durata activității. Întrebare: Aveți întrebări? Răspundeți întrebărilor. Cereți fiecărei grupe să pregătească spațiul în care se va desfășura exercițiul și să se prezinte utilizatorului de scaun rulant cu care va lucra. Exercițiul poate începe. Monitorizare și suport: Monitorizați cu atenție activitatea echipelor, asigurați-vă că exercițiul se desfășoară în condiții de siguranță, observați și evaluați abilitățile participanților. Folosiți lista de verificare și observații pentru formatori pentru a înregistra observațiile pe care le aveți pentru fiecare grupă. Pe parcursul sesiunii: o Periodic, indicați participanților durata de timp rămasă, pentru a-i ajuta să își gestioneze mai bine timpul. o Asigurați-vă că utilizatorii de scaun rulant sunt implicați în mod activ. La sfârșitul sesiunii, cereți participanilor să le mulțumească utilizatorilor de scaun rulant pentru participare. Întrebați utilizatorii de scaun rulant dacă doresc să participe în continuare, pentru a oferi feedback întregului grup cu privire la etapa de evaluare, prescriere (selecție), de probare a produsului (a scaunului rulant) și de instruire a utilizatorului. Durata: Durata exercițiului este de 45 de minute pentru probarea produsului (a scaunului rulant), 50 de minute pentru instruirea utilizatorului și 20 de minute pentru feedback. Feedback: Discutați exemplele de bună practică pe care le-ați identificat pe parcursul sesiunilor practice. Notați orice aspect care necesită îmbunătățiri – fără a numi persoana. Întrebare: Aveți întrebări? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 177. 2. Feedback oferit de utilizatorul de scaun rulant (opțional – în funcție de utilizatorii de scaun rulant și de durata de timp disponibilă - 30 minutes) Notă pentru formatori: Dacă utilizatorii de scaun rulant care au participat la sesiunea practică 2 sunt de acord, puteți să rugați să ofere feedback cu privire la sesiunea care tocmai s-a finalizat. Aceasta se poate face și într-un mod informal – de exemplu, cu băuturi răcoritoare/prăjituri, pentru a marca parcurgerea celor două sesiuni practice. Mai jos aveți exemple de întrebări pentru utilizatorii de scaun rulant. Rugați utilizatorii de scaun rulant să ofere feedback cu privire la următoarele aspecte. o Cum s-au simțit pe durata evaluării? (De exemplu – s-au simțit implicați, cum s-au simțit când au răspuns întrebărilor din interviu, dacă au avut impresia că întrebările îi vor ajuta să primească un scaun rulant mai bun?) o Sunt mulțumiți de scaunul rulant care le-a fost prescris? o Au învățat ceva nou pe parcursul instruirii? Vor folosi ceea ce au învățat acasă/ la locul de muncă? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 178. B.13: Monitorizarea O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să explice ce înseamnă „monitorizarea” și cum se desfășoară aceasta;  să completeze un formular de monitorizare a utilizării scaunului rulant. R E S U R S E Pentru sesiune:  Prezentare PPT: B.13 Monitorizarea;  Manualul participantului;  Caietul de exerciții practice. C O N TE X T Toți utilizatorii de scaun rulant vor beneficia de vizite de monitorizare, de preferat la domiciliu. Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  Modul în care va fi desfășurată monitorizarea în cadrul serviciilor de scaune rulante de unde provin participanții (vizite la domiciliu sau la centru, realizate de persoane din cadrul serviciilor de reabilitare bazate pe comunitate). Adaptați la context. De exemplu, dacă participanții aparțin de un furnizor de servicii de scaune rulante care are un plan de monitorizare, acest plan trebuie explicat participanților. D E P R E G Ă TI T  Pregătiți toate resursele, revedeți prezentările PPT, parcurgeți materialul video și citiți planificarea sesiunii. P R E ZE N TA R E 1. Introducere. 2. Ce este monitorizarea și cum se desfășoară ea? 3. Prezentarea formularului de monitorizare. 4. Exercițiu practic pentru monitorizare 5. Recapitulare puncte cheie. 2 10 5 25 3 Total durată sesiune 45 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 179. 1. Introducere (2 minute) Explicați: Monitorizarea este cea de-a opta etapă a procesului de furnizare de servicii de scaune rulante. Pe parcursul acestei sesiuni vom discuta ce aspecte presupune monitorizarea. Vom exersa folosirea formularului de monitorizare a utilizării scaunului rulant. 2. Ce este monitorizarea și cum se efectuează aceasta? (10 minute) Întrebare: Ce credeți că înseamnă „monitorizarea”? Încurajați participanții să răspundă. Cele mai relevante răspunsuri: o dobândirea de informații de la utilizatorul de scaun rulant; o verificarea faptului că scaunul rulant este în stare corespunzătoare; o verificarea faptului că scaunul rulant se potrivește. Explicați: o Vizita de monitorizare constituie un beneficiu pentru toți utilizatorii de scaun rulant. Cu toate acestea, monitorizarea este o etapă deosebit de importantă în următoarele cazuri: o utilizatori de scaun rulant copii; o utilizatori de scaun rulant la care există pericolul apariției escarelor; o utilizatori de scaun rulant cu o afecțiune degenerativă; o utilizatori de scaun rulant care întâmpină dificultăți la instruire. o Nu există o regulă care stabilește momentul la care trebuie efectuată monitorizarea. Se recomandă totuși o vizită de monitorizare în intervalul de șase săptămâni de la livrare. Monitorizarea depinde de nevoile utilizatorului de scaun rulant. În cazul copiilor, ideal este ca vizita de monitorizare să aibă loc o dată la șase luni, deoarece nevoile copiilor se schimbă mai des, pe măsură ce cresc. o Monitorizarea poate fi făcută: o în decursul unei vizite la domiciliu; o la un centru unde se oferă servicii de scaune rulante; o în orice alt loc pe care utilizatorul și personalul furnizor de servicii de scaune rulante le consideră convenabile. Întrebare: Cum poate fi desfășurată (sau cum se desfășoară) monitorizarea la serviciile de scaune rulante de unde provin participanții? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 180. Încurajați participanții să răspundă și notați. Cele mai relevante răspunsuri: o se stabilește o dată pentru monitorizare la momentul primirii de către utilizator a scaunului rulant; o se efectuează vizita la domiciliul utilizatorului de scaun rulant (acolo unde este posibil); o activitatea de monitorizare se include în vizitele efectuate de către personalul din comunitate, acesta fiind instruit cu privire la desfășurarea monitorizării; o telefonic, acolo unde transportul este dificil de organizat și utilizatorul are acces la telefon. 3. Formularul de monitorizare a utilizării scaunului rulant (5 minute) Explicați: Cunoștințele și abilitățile necesare pentru etapa de monitorizare au fost deja abordate în acest curs de instruire. Vizita de monitorizare înseamnă: o dobândirea de informații de la utilizatorul de scaun rulant; o verificarea faptului că scaunul rulant este în stare corespunzătoare; o verificarea faptului că scaunul rulant se potrivește. Cereți participanților să analizeze formularul de monitorizare din caietul de exerciții practice. Explicați: Formularul de monitorizare va ajuta personalul furnizor de servicii de scaune rulante să nu omită niciunul din pașii din această etapă. Formularul conține și o rubrică în care să fie notate acțiunile recomandate. Acțiuni de monitorizare uzuale o Oferirea de informații sau instruirea suplimentară. De exemplu, dacă un utilizator nu folosește scaunul rulant așa cum era de așteptat, acest lucru poate fi rezultatul faptului că acesta nu are suficientă încredere în propria sa capacitate de a realiza transferul în și din scaunul rulant, atunci când nu se află nimeni în apropierea lui. Instruirea suplimentară ar putea elimina această problemă. o Reajustarea scaunului rulant; o Efectuarea de reparații minore, de exemplu, umflarea roților. Încurajați utilizatorii să desfășoare activitățile de întreținere la domiciliu ale scaunului rulant. o Efectuarea de reparații majore sau oferirea de asistență utilizatorului în rezolvarea problemelor ce țin de repararea scaunului rulant. Întrebare: Dacă utilizatorul de scaun rulant spune că are o escară, cum procedăm? Cele mai relevante răspunsuri: o cereți să vedeți escara și înregistrați unde este localizată, precum și stadiul în care se află o dacă escara se află pe o parte a corpului care este în contact cu scaunul rulant, utilizatorul trebuie să renunțe la folosirea scaunului rulant până la vindecarea escarei; o dacă escara se află în stadiul doi sau într-un stadiu chiar mai avansat, trebuie să apeleze la un specialist; o identificați cauza escarei (de exemplu – utilizatorul nu folosește o pernă sau folosește o pernă care nu reduce presiunea, are o tehnică de transfer defectuoasă, este prezentă incontinență etc) și încercați să soluționați problema. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 181. 4. Exercițiu practic monitorizarea utilizării scaunului rulant (25 de minute) Activitate Grupe: Formați grupe de câte trei participanți. Instrucțiuni: Cereți fiecărei grupe: o să citească fiecare caz de utilizator de scaun rulant din caietul de exerciții practice și să discute acțiunile recomandate; o completeze câte un formular de monitorizare pentru fiecare utilizator (în caietul de exerciții practice există trei formulare de monitorizare). Monitorizare: Supervizați activitatea grupelor și oferiți ajutor dacă e nevoie. Durata: Durata exercițiului este de 20 de minute și 5 minute pentru feedback. Feedback: Întrebare: ce acțiuni au recomandat participanții în cazul utilizatorilor numiți Hala, Daarun și Talha? Aspecte de reținut. Hala locuiește cu fiica ei adultă și cu familia acesteia. În urmă cu șase luni, ea a primit un scaun rulant de la un furnizor de servicii de scaune rulante. Acum un an a suferit un accident vascular- cerebral și nu mai poate merge. Când a primit scaunul rulant, a învățat să facă transferul stând în picioare, cu suportul fiicei sale. Ea spune că își dorea un un scaun rulant pentru a putea ajuta la treburile casei și pentru a putea merge la biserică. La vizita de monitorizare, Hala ne-a spus că nu părăsise casa de câteva luni. Drumul spre casa ei este destul de accidentat și la intrarea în casă există o treaptă. Cu toate acestea, Hala folosește scaunul rulant acasă și își ajută fiica, având grijă de nepoți. Stă în poziția așezat în scaunul rulant, iar acesta este în stare bună. Reușește să efectueze transferul singură, fără asistență din partea fiicei. o Aflați de ce Hala nu merge la biserică atât de des pe cât și-ar dori. o Dacă motivul sunt treapta și terenul accidentat – oferiți sfaturi și instruire, atât pentru Hala, cât și fiicei ei, pentru depășirea obstacolelor. Daarun are un traumatism vertebro-medular. Lucrează într-un atelier de reparații pentru aparate radio aflat în piața din localitate. În urmă cu doi ani, el a primit un scaun rulant și o pernă de reducere a presiunii. La vizita de monitorizare, Daarun a spus că folosește zilnic scaunul rulant, pentru a ajunge la locul de muncă și acasă. Daarun nu are nicio escară. Daarun a avut două anvelope dezumflate pe care le-a reparat chiar el. La verificarea scaunului rulant, reprezentantul furnizorului de servicii de scaune rulante a observant că spițele sunt slăbite și că lipsesc două șuruburi din baza șezutului. Spuma flexibilă din pernă s-a aplatizat foarte mult. El stă bine în scaunul rulant și spune că este foarte mulțumit de acesta. o Asigurați-vă că stratul superior al pernei din spumă va fi înlocuit. o Oferiți sfaturi cu privire la întreținerea la domiciliu a scaunului rulant, inclusiv în ceea ce privește verificarea spițelor și strângerea șuruburilor. Talha are 10 ani și are o formă ușoară de paralizie cerebrală. El merge la școala din localitate. În urmă cu un an, i s-a prescris un scaun rulant cu patru roți, dotat cu o pernă pentru suport postural. La vizita de monitorizare, Talha a menționat că își folosește scaunul rulant în fiecare zi, pentru a merge la școală. Tatăl său este cel care împinge scaunul rulant, deoarece el nu are forța necesară să facă acest lucru. Scaunul rulant este în stare bună. Tatăl său spune că a reparat o dată anvelopa. o Vizitele de monitorizare în cazul utilizatorilor de scaune rulante copii trebuie să aibă loc la intervale de 3–6 luni, dacă acest lucru este posibil. o Copiii cresc repede. Este important ca părinții și însoțitorii să înțeleagă că trebuie să îi aducă pe copii Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 182. Cei din echipa furnizorului de servicii de scaune rulante au observant faptul că Talha a crescut, iar picioarele sale nu sunt susținute corespunzător de șezutul scaunului, pentru că suportul de picioare este situat mult prea sus. la furnizorul de servicii de scaun rulante, dacă personalul acestuia nu poate ajunge la ei. o Talha are nevoie de o nouă evaluare, iar scaunul rulant trebuie ajustat din nou sau înlocuit cu unul de dimensiuni mai mari. 5. Recapitulare puncte cheie (3 minute) Citiți punctele cheie. Verificați dacă există întrebări. Sesiunea practică 3: Monitorizarea O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să demonstreze modalitatea de desfășurare a monitorizării. R E S U R S E  Un spațiu curat, delimitat cu un paravan, un pat de evaluare (excepție cazurile în care monitorizarea are loc pe teren, în comunitate).  Formularul de evaluare și de prescriere (selecție) anterior, completat pentru fiecare utilizator de scaun rulant.  Formular de monitorizare a utilizării scaunului rulant (1 per utilizator de scaun rulant).  Lista de verificare preliminară utilizării scaunului rulant.  Lista de verificare și observații pentru formatori.  Ruletă și unelte pentru ajustarea scaunelor rulante. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  factori culturali relevanți;  factori lingvistici – de exemplu, dacă utilizatorii de scaune rulant implicați vorbesc aceeași limbă cu participanții la curs;  orice documente pe care le utilizează furnizorul de servicii de scaune rulante în desfășurarea monitorizării;  modalitatea prin care formatorii vor gestiona aspectele noi care pot apărea pe parcursul evaluării și care nu pot abordate în timpul sesiunii, de exemplu, dacă scaunul rulant trebuie înlocuit. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 183. D E P R E G Ă TI T  Luați în considerare posibilitatea de a desfășura această activitate pe teren, în comunitate.  Contactați utilizatorii care au primi scaune rulante în ultimele 3-6 luni și care au nevoie de monitorizare. Programați o vizită de monitorizare, fie la domiciliu, fie la centru.  Confirmați orarul și detaliile referitoare la deplasarea utilizatorilor de scaun rulant voluntari. Dacă monitorizarea are loc acolo unde s-a desfășurat cursul, asigurați-vă că ați inclus în comanda pentru pauza de cafea/prânz utilizatorii de scaun rulant, împreună cu membrii de familie sau însoțitorii lor.  Dacă monitorizarea are loc acolo unde s-a desfășurat cursul, pregătiți un pat de evaluare și un paravan pentru fiecare utilizator de scaun rulant voluntar. Puneți toate instrumentele necesare pe pat.  Dacă sunt mai mult de trei grupe de participanți, rugați un formator să vă asiste la monitorizarea activității grupelor.  Decideți care este componența echipelor și care este utilizatorul de scaun rulant cu care va lucra fiecare echipă. P R E ZE N TA R E 1. Monitorizarea: o Instrucțiuni. o Monitorizare. o Feedback. 5 60 25 Total durată sesiune 90 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 184. 1. Monitorizarea (90 de minute) Notă pentru formatori: Pe parcursul sesiunii practice 3, folosiți lista de verificare și observații pentru formatori. Aceasta vă va ghida în monitorizarea activității echipelor pe durata desfășurării sesiunii practice. Notați toate exemplele de bună practică și toate erorile. Subliniați-le atunci când oferiți feedback (tabelul). Activitate Grupe: o Refaceți grupele de la sesiunea practică anterioară (nu mai mult de 3 participanți în fiecare grupă). o Numiți câte un responsabil în cadrul fiecărei grupe. o Comunicați participanților numele utilizatorului de scaun rulant cu care vor lucra și furnizați toate documentele relevante – de exemplu, formularul de evaluare anterior). o Desemnați spațiul în care va lucra fiecare echipă și explicați unde pot fi găsite toate materialele și uneltele (pe patul de evaluare) sau care sunt detaliile deplasării (dacă activitatea are loc pe teren, în comunitate). Instrucțiuni: Explicați următoarele aspecte: Scopul sesiunii practice: Scopul acestei sesiuni este parcurgerea activității de monitorizare. Responsabilul: o Persoana care este desemnată ca fiind responsabilul, trebuie să se asigure că toți pașii exercițiului au fost parcurși. o Responsabilul este cel care discută cel mai mult cu utilizatorul de scaun rulant, cu membrii de familie sau cu însoțitorul. Se recomandă această abordare pentru a evita ca mai multe persoane să vorbească în același timp, deoarece se poate crea o stare de confuzie. Observațiile formatorului și sprijinul oferit de acesta: o Participanții pot solicita asistență și clarificări în orice moment, pe toată durata exercițiului. Durata exercițiului: o Durata exercițiului este de 60 de minute. Formularele: o Înmânați fiecărui responsabil de grup formularele de monitorizare. o Asigurați-vă că fiecare grupă are câte un exemplar din lista de verificare preliminară utilizării scaunului rulant. Reamintiți-le participanților că utilizatorul de scaun rulant trebuie să fie implicat în mod activ, pe toată durata activității. Întrebare: Aveți întrebări? Răspundeți întrebărilor. Cereți fiecărei grupe să pregătească spațiul în care se va desfășura exercițiul și să se prezinte utilizatorului de scaun rulant cu care va lucra. Exercițiul poate începe. Monitorizare și suport: Folosiți lista de verificare și observații pentru formatori pentru a înregistra observațiile pe care le aveți pentru fiecare grupă. Pe parcursul sesiunii: o Periodic, indicați participanților durata de timp rămasă, pentru a-i ajuta să își gestioneze mai bine timpul. o Asigurați-vă că utilizatorii de scaun rulant sunt implicați în mod activ. La finalul sesiunii practice, cereți participanților să le mulțumească utilizatorilor Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 185. de scaun rulant pentru ajutor și explicați cum vor avea loc toate acțiunile necesare identificate (și care nu au fost implementate încă). Durata: Durata exercițiului este de 60 minute pentru monitorizare și de 25 de minute pentru feedback. Feedback: Discutați exemplele de bună practică pe care le-ați identificat pe parcursul sesiunilor practice. Notați orice aspect care necesită îmbunătățiri – fără a numi persoana. Cereți fiecărei grupe să facă un rezumat al aspectelor identificate pe parcursul activității de monitorizare, inclusiv: o în ce măsură scaunul rulant răspunde nevoilor utilizatorului; o orice problemă/aspect negativ; o orice acțiune ulterioară recomandată (câte 5 minute per grupă). Întrebare: Aveți întrebări? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 186. Sesiunea practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului de scaun rulant O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea să lucreze în echipă pentru:  a demonstra că au dobândit abilitățile necesare în ceea ce privește evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului – nivel de bază. R E S U R S E  Scaune rulante disponibile la nivel local.  Spațiu pentru evaluare delimitat și curat și un pat de evaluare (1 per utilizator de scaun rulant).  Formulare: de evaluare, de prescriere (selecție), lista de verificare preliminară utilizării scaunului rulant, lista de verificare pentru probarae produsului (a scaunului rulant), lista de verificare pentru instruirea utilizatorului (1 set per utilizator de scaun rulant).  Lista de verificare și observații pentru formator.  Cameră foto digitală și formulare de acord.  Ruletă. C O N TE X T Adaptați conținutul sesiunii pentru ca informațiile să fie în concordanță cu contextul în care vor lucra participanții. Luați în considerare următoarele:  Factorii culturali și lingvistici.  Tipurile de scaune rulante disponibile – și durata de timp necesară pregătirii lor.  Toate documentele pe care serviciul de scaune rulante le solicită în plus față de informațiile înregistrate în formularele de evaluare și de prescriere (selecție).  Modul în care formatorii vor gestiona aspectele identificate pe parcursul sesiunii practice și care nu pot fi rezolvate pe parcursul acesteia.  Cum va fi gestionată monitorizarea fiecărui utilizator de scaun rulant după încheierea programului de instruire. D E P R E G Ă TI T  Invitați un nou grup de utilizatori de scaun rulant, voluntari, câte unul pentru fiecare grupă.  Confirmați orarul și detaliile referitoare la deplasarea utilizatorilor de scaun rulant voluntari. Asigurați-vă că ați inclus în comanda pentru pauza de cafea/prânz utilizatorii de scaun rulant, împreună cu membrii de familie sau însoțitorii lor.  Desemnați o persoană care să întâmpine la sosire utilizatorii de scaun rulant și care să le indice locul unde pot aștepta începerea sesiunii.  Asigurați-vă că există un spațiu unde utilizatorii de scaun rulant și familiile acestora pot aștepta după etapa de evaluare și de prescriere (selecție), până când scaunul rulant este pregătit.  Asigurați-vă că mostrele de scaune rulante și de perne sunt în stare bună de funcționare.  Pregătiți sala de curs (sau stabiliți detaliile referitoare la deplasare, dacă activitatea are loc pe teren, în comunitate).  Dacă există mai mult de trei grupe de participanți, rugați un formator să vă asiste în monitorizarea activității grupelor.  Decideți componența grupelor și care este utilizatorul de scaun rulant cu care va lucra fiecare echipă. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 187. P R E ZE N TA R E 1. Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului: o Instrucțiuni și pregătire. o Evaluarea. o Prescrierea (selecția). o Pregătirea produsului (a scaunului rulant). o Probarea produsului (a scaunului rulant). o Instruirea utilizatorului. o Feedback. o Durată de timp suplimentară. 5 30 20 60 30 45 30 20 Total durată sesiune 240 1. Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului (240 de minute) Note pentru formatori: 1. Fotografii: o Asigurați-vă că pentru fiecare utilizator de scaun rulant aveți acordul acestuia pentru realizarea de fotografii. Asigurați-vă că utilizatorii înțeleg că acordarea permisiunii este o acțiune voluntară și că acestea vor fi folosite pe parcursul programului de instruire. o Pe parcursul sesiunii practice faceți poze fiecărui utilizator de scaun rulant care și-a dat acordul, după cum urmează: o în scaunul rulant existent (dacă au unul) (vedere din față și vedere laterală); o în timpul evaluării (observarea posturii); o în scaunul rulant prescris, după probarea produsului (vedere din față și vedere laterală). 2. Cerințele utilizatorilor de scaun rulant participanți la sesiunea practică: o Nu toate scaunele rulante vor putea fi pregătite pe parcursul sesiunii practice. o Dacă este nevoie de o nouă programare în cazul oricăruia dintre utilizatorii prezenți la sesiunea practică, formatorul se va asigura că organizația gazdă/furnizorul de servicii de scaune rulante va face acest lucru, având la îndemână toate formularele de evaluare, de prescriere (selecție) și de probare a produsului (a scaunului rulant). 3. Observarea activității participanților: Folosiți Lista de verificare și observații pentru sesiunea practică 4 pentru a vă asigura că grupele parcurg toți pașii din sesiunea practică și pentru a nota exemplele de bună practică și erorile. Toate aceste aspecte vor fi abordate în etapa de feedback (tabelul). o Aceste poze pot fi folosite în sesiunea finală B.14: Sumarizare (dacă permite durata de timp). Activitate Grupe: o Alcătuiți grupele de participanți (2 sau 3 persoane în fiecare grupă). o Numiți câte un responsabil pentru fiecare grupă. o Comunicați participanților numele utilizatorului de scaun rulant cu care vor lucra. o Desemnați spațiul în care va lucra fiecare echipă și explicați unde pot fi găsite toate materialele și uneltele. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 188. Instrucțiuni: Explicați următoarele aspecte: Scopul sesiunii practice: o Scopul acestei sesiuni este să lucreze cu utilizatorul de scaun rulant pentru a parcurge etapele de evaluare, prescriere (selecție), pregătire a produsului (a scaunului rulant), probare a produsului (a scaunului rulant) și instruire a utilizatorului. o Există posibilitatea ca participanții să nu poată termina pregătirea scaunului rulant în perioada de timp alocată. Acest lucru depinde de prima probare a produsului (a scaunului rulant), de modificările/ajustărie care sunt necesare. Totuși, participanții trebuie să încerce să utilizeze cât mai eficient timpul alocat sesiunii practice, pentru a rezolva cât mai multe din aceste aspecte o Responsabilul: Persoana care este desemnată ca fiind responsabilul, trebuie să se asigure că toți pașii exercițiului au fost parcurși. o Responsabilul este cel care discută cel mai mult cu utilizatorul de scaun rulant, cu membrii de familie sau cu însoțitorul. Se recomandă această abordare pentru a evita ca mai multe persoane să vorbească în același timp, deoarece se poate crea o stare de confuzie. Observațiile formatorului și sprijinul oferit de acesta: o Participanții pot cere asistentșă și clarificări în orice moment, pe toată durata exercițiului. o Pe parcursul sesiunii, formatorii monitorizează fiecare grup și oferă tot sprijinul necesar desfășurării corecte a exercițiului. o După finalizarea FIECĂRUI PAS și ÎNAINTE de a trece la următorul, participanții solicită formatorului să verifice completarea exercițiului. Reamintiți-le participanților că utilizatorul de scaun rulant trebuie să fie implicat în mod activ, pe toată durata activității. Întrebare: Aveți întrebări? Răspundeți întrebărilor. Cereți fiecărei grupe să pregătească spațiul în care se va desfășura exercițiul și să se prezinte utilizatorului de scaun rulant cu care vor lucra. Exercițiul poate începe. Monitorizare și suport: Monitorizați cu atenție activitatea grupelor pe tot parcursul sesiunii. Folosiți lista de verificare și observații pentru formatori pentru a înregistra observațiile referitoare la activitatea fiecărui grup. o Indicați durata de timp disponibilă (verbal și/sau în scris, pe tablă, în așa fel încât toți participanții să aibă acces la această informație). Acest lucru îi va ajuta să își gestioneze timpul. o Asigurați-vă că utilizatorul de scaun rulant este implicat în mod activ. o Verificați activitatea participanților după fiecare etapă. La sfârșitul acestei sesiuni, cereți participanților, să le mulțumească utilizatorilor pentru participare și să explice că scaunul rulant prescris (selecționat) va fi pregătit și gata de utilizare în următoarea sesiune practică. Durata: Durata exercițiului: o Evaluarea – 30 de minute; o prescrierea (selecția) – 20 de minute; o pregătirea produsului (a scaunului rulant) – 60 de minute; o probarea produsului (a scaunului rulant) – 30 de minute; o instruire utilizatorului – 45 de minute; o feedback – 30 de minute. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 189. Notă pentru formatori: Se recomandă ca durata de timp alocată să fie atent monitorizată. Timpii menționați mai sus pot varia în funcție de experiența participanților, de cerințele utilizatorilor și de timpul necesar pregătirii scaunelor rulante. Aceste durate de timp pot fi ajustate. o 20 de minute suplimentare pentru rezolvarea problemelor și pentru verificarea de către formatori a fiecărei etape. Feedback: Comentați examplele de bună practică observate pe timpul sesiunii. Subliniați ariile care necesită îmbunătățiri – nu menționați numele persoanelor. Întrebare: Aveți întrebări? B.14: Sumarizare O B IE C TI V E La sfârșitul acestei sesiuni, participanții vor putea:  să facă o prezentare a utilizatorului de scaun rulant cu care au lucrat pe parcursul ultimei sesiuni practice (sesiunea practică 4), inclusiv: evaluare, prescriere (selecție), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant), instruirea utilizatorului și întreținerea scaunului rulant, reparații și monitorizare. R E S U R S E  Caietul de exerciții practice;  DVD: Mesaj pentru participanți  Hârtie pentru notițe. D E P R E G Ă TI T  Pregătiți toate resursele, vizionați materialul video și parcurgeți planificarea sesiunii. P R E ZE N TA R E 1. Introducere și instrucțiuni. 2. Întrebările participanților. 3. Pregătirea participanților. 4. Prezentările participanților. 5. Sesiune de întrebări și răspunsuri. 6. Puncte cheie. 2 5 25 40 20 13 Total durată sesiune 105 1. Introducere și instrucțiuni (2 minute) Explicați: o Pe parcursul acestei sesiuni, participanții vor avea ocazia: o să împărtășească ceea ce au învățat la ultima sesiune practică; o să pună întrebări cu privire la furnizarea serviciilor de scaune rulante – nivel de bază. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 190. 2. Întrebările participanților (5 minute) Activitate în grupe mici Grupe: Formați grupe de câte trei participanți. Dați fiecărei grupe hârtie pentru notițe (de exemplu, hârtie format A4 tăiat în patru). Instrucțiuni: Cereți fiecărei echipe să discute dacă există întrebări cu privire la furnizarea de servicii de scaune rulante și să noteze toate întrebările pe care le au fie unul, fie mai mulți participanți din grupă. Monitorizare: Monitorizați activitatea grupelor. Durata: Durata activității este de 10 minute. Feedback: Cereți fiecărei grupe să înmâneze formatorilor hârtiile cu întrebări. 3. Pregătirea participanților (25 de minute) Activitate în grupe mici Grupe: Cereți grupelor care au lucrat împreună pe timpul ultimelor două sesiuni să păstreze aceeași componență. Instrucțiuni: Cereți fiecărei echipe să pregătească o prezentare de 10 minute despre utilizatorul de scaun rulant cu care au lucrat, în care să specifice aspectele pe care le-au învățat. Scopul trebuie să fie formularea de răspunsuri la întrebările din fișa de lucru din caietul de exerciții practice. Explicați că pozele făcute utilizatorilor de scaun rulant sunt descărcate pe calculator și că pot fi folosite pe parcursul prezentării. Notă pentru formatori: Dacă participanții nu se simt confortabil cu ideea de a utiliza calculatorul, explicați că formatorii vor pregăti pozele și le vor arăta atunci când este necesar. Monitorizare: În timp ce grupele se pregătesc, formatorii trebuie să revadă întrebările adresate în scris. Unele întrebări se pot repeta. Puneți întrebările în ordinea logică a conținutului lor (de exemplu, în ordinea etapelor de furnizare a serviciilor de scaun rulante la care se referă). Pregătiți răspunsurile. Durata: Durata de timp alocată pregătirii participanților este de 25 de minute. Feedback: Vezi punctul 4. Prezentările participanților. 4. Prezentarea participanților (40 de minute) Cereți fiecărei echipe să prezinte pe rând. Încurajați întregul grup să pună întrebări la sfârșitul prezentării. Durata fiecărei prezentări este de 10 minute, plus 5 minute pentru întrebări. Mulțumiți fiecărui participant pentru prezentare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 191. 5. Sesiune de întrebări și răspunsuri (20 de minute) Citiți cu voce tare întrebarea fiecărui participant (vezi 2. Întrebările participanților). NU MENȚIONAȚI cine a pus întrebarea. Oferiți fie un răspuns sau o clarificare, fie întrebați dacă cineva din grup dorește să răspundă la respectiva întrebare. Dacă aceeași întrebare provine de la mai multe persoane/grupe – explicați că mai mulți participanți au pus aceeași întrebare. Explicați: o Furnizarea unui scaun rulant care să răspundă cu adevărat cerințelor utilizatorului presupune abilități care se dobândesc prin practică, muncă de echipă (care implică personalul furnizor de servicii de scaun rulante si utilizator) și un minimum de resurse. o Acest program de instruire a oferit o prezentare a etapelor. Totuși, fiecare utilizator de scaun rulant constituie un caz individual – așadar, este dificilă abordarea tuturor aspectelor în cadrul unui program de acest fel. o Participanții vor învăța ceva nou de la fiecare utilizator de scaun rulant cu care vor lucra. De asemenea, vor învăța atât din greșeli, cât și din ceea ce reușesc să facă bine. o Vor constata că procesul devine mai rapid pe măsură ce capătă experiență. o Cel mai important lucru sunt procesul continuu de aplicare în practică a cunoștințelor și atenția față de ceea ce are de spus utilizatorul de scaun rulant! 6. Puncte cheie (13 minute) Material video: Mesaj pentru participanții la curs. Acest material video scurt va arăta importanța programului de instruire. Prezentați materialul video. Verificați dacă există întrebări. Ceremonia de închidere și înmânare a certificatelor. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 192. Anexa 1 Orar sesiune de instruire pentru furnizare de servicii de scaune rulante - nivel de bază Cinci zile complete Ziua 1 Ziua 2 Ziua 3 Ziua 4 Ziua 5 8:30 Introducere A.6 Scaunul rulant corespunzător B.4 Evaluarea fizică B.9 Probarea produsului(a scaunului rulant) Sesiune practică 3: Monitorizarea 8:45 9:00 A.7 Pernele B.5 Prescrierea (selecția) 9:15 9:30 A.1 Utilizatorii scaun rulant B.10 Rezolvarea problemelor 9:45 10:00 Sesiune practică 4: Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant), instruirea utilizatorului scaunului rulant. 10:15 A.2 Serviciile de scaune rulante A.8 Transferurile B.11 Instruirea utilizatorului 10:30 10:45 A.3 Mobilitatea în scaunul rulant 11:00 – 11:15: Pauză de cafea (adaptați ora pentru a fi în concordanță cu contextul local și cu planul sesiunii) 11:15 A.3 Mobilitatea în scaunul rulant A.8 Transferurile B.6 Finanțarea și plasarea comenzii B.11 Instruirea utilizatorului Sesiune pratică 4 Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant), instruirea utilizatorului scaunului rulant. 11:30 Sesiune practică 1: Evaluarea și prescrierea (selecția) B.12 Întreținerea și reparațiile 11:45 12:00 12:15 12:30 A.4 Poziția așezat B.1 Trimiterea și programarea 12:45 1:00 – 2:00 Prânz (adaptați ora pentru a fi în concordanță cu contextul local și cu planul sesiunii) 2:00 A.4 Poziția așezat B.2 Evaluarea B.7 Pregătirea produsului (a scaunului rulant) B.12 Întreținerea și reparațiile Sesiune practică 4 Evaluarea, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant), instruirea 2:15 2:30 A.5 Escarele B.3 Interviul de evaluare Sesiune practică 2: Probarea produsului și instruirea utilizatorului de scaun rulant 2:45 3:00 Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 193. utilizatorului scaunului rulant. 3:15 – 3:30: Pauză cafea (adaptați ora pentru a fi în concordanță cu contextul local și cu planul sesiunii) 3:30 A.5 Escarele B.3 Interviul de evaluare B.8 Confecționarea pernei Sesiune practică 2: Probarea produsului și instruirea utilizatorului de scaun rulant B.14 Sumarizare 3:45 A.6 Scaunul rulant corespunzător 4:00 4:15 B.4 Evaluarea fizică 4:30 4:45 B.13 Monitorizarea 5:00 5:15 Înmânarea certificatelor sesiuni ce includ prezentări PPT Anexa 2 Formular de trimitere către furnizorul de servicii de scaune rulante Model formular de trimitere: Acest formular poate fi adaptat de către furnizorul de servicii de scaune rulante și transmis către potențiale surse ce pot direcționa utilizatorii de scaun rulant către furnizorul de servicii de scaune rulante. Vă rugăm completați formularul de recomandare și expediați-l către: Numele și adresa furnizorului de scaun rulant: Numele persoanei care face trimiterea: Organizația: Datele de contact ale persoanei care face trimiterea (unde puteți fi contactat cel mai ușor): Numele utilizatorului de scaun rulant: Data nașterii: Numele părintelui/ însoțitorului: Adresa: Cum poate fi contactat utilizatorul de scaun rulant? Poștă Telefon propriu Telefon vecin/prieten Dacă telefonic, vă rugăm precizați numărul de telefon: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 194. Dizabilitatea utilizatorului de scaun rulant, dacă există informația: Motivele pentru care se face trimiterea:  Nu deține un scaun rulant  Deține un scaun rulant defect  Deține un scaun rulant necorespunzător Vă rugăm precizați orice altă informație referitoare la utilizatorul de scaun rulant pe care o considerați relevantă pentru furnizorul de servicii de scaune rulante: Utilizatorul de scaun rulant este de acord să fie trimis către furnizorul de servicii de scaune rulante? Da Nu Semnătura persoanei care face trimiterea: Data: Anexa 3 Formular de evaluare scaun rulant Formular pentru evaluarea utilizatorilor de scaun rulant care pot sta cu ușurintă în poziția așezat. În caz contrar, evaluarea trebuie efectuată de către o persoană care a beneficiat de o instruire de nivel intermediar. Păstrați acest formular în dosarul utilizatorului de scaun rulant. Numele persoanei care efectuează evaluarea: Data efectuării evaluării: 1: Interviu de evaluare Informații despre utilizatorul de scaun rulant Numele: Numărul: Vârsta: Bărbat  Femeie  Numărul de telefon: Adresa: Obiective: Condiția fizică Paralizie cerebrală  Poliomielită  Traumatism vertebro-medular  Accident vascular- cerebral  Constituție fragilă  Spasme sau mișcări involuntare  Amputație: D deasupra genunchiului  D sub genunchi  S deasupra genunchiului  S sub genunchi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 195. Probleme de management urinar  Probleme de management intestinal  Dacă există probleme de management urinar sau de tranzit intestinal, acestea sunt gestionate? Da  Nu  Altele: __________________________________________________________________ Stilul de viață și mediul Descrieți mediul în care va fi utilizat scaunul rulant: ______________________________________________________________________________ Distanța parcursă zilnic: Sub 1 km  1 – 5 km  Peste 5 km  Numărul de ore pe zi de utilizare a scaunului rulant: Mai puțin de 1 oră  1-3 ore  3-5 ore  5-8 ore  mai mult de 8 ore pe zi  Când nu folosește scaunul rulant, unde și cum stă utilizatorul (poziția și tipul de suprafață)? ______________________________________________________________________________ Transfer: Independent  Asistat  În picioare  Așezat  Ridicat  Altele  Tip toaletă (dacă se face transferul la toaletă): La nivelul podelei  Tipică  Adaptată  Utilizatorul de scaun rulant folosește în mod frecvent mijloace de transport în comun / proprii? Da  Nu  Dacă da, de care: Autoturism  Taxi  Autobuz  Altele________________ Scaunul rulant existent ( dacă utilizatorul are deja un scaun rulant) Scaunul rulant răspunde cerințelor utilizatorului? Da  Nu  Scaunul rulant corespunde condițiilor din mediul utilizatorului? Da  Nu  Este scaunul rulant potrivit și oferă suport postural corespunzător? Da  Nu  Este scaunul rulant sigur și durabil? (Există pernă sau nu) Da  Nu  Perna oferă o reducere a presiunii adecvată (previne riscul apariției escarelor)? Da  Nu  Comentarii: __________________________________________________________________ Dacă răspunsul este ”da” la toate întrebările, atunci este posibil ca utilizatorul să nu aibă nevoie de alt scaun rulant. Dacă răspunsul la oricare din aceste întrebări este „nu”, atunci utilizatorul are nevoie fie de un alt scaun rulant, fie de o altă pernă ori scaunul rulant sau perna au nevoie de reparații, respectiv de modificări. 2: Evaluare fizică Prezența escarelor, riscul de formare a acestora sau istoric escare /// = lipsă sensibilitate O = escară anterioară  = escară existentă Sensibilitate normală? Da  Nu  Escară anterioară? Da  Nu  Escară existentă? Da  Nu  Dacă da, este o escară deschisă (faza 1 – 4)? Da  Nu  Durata și cauza: _________________________ _________________________________________ Există riscul* formării de escare? *Se consideră că există pericolul apariției escarelor la persoanele la care sensibilitatea este absentă sau care prezintă 3 sau mai mulți factori de risc. Factori de risc: imobilitatea, umezeala, poziția incorectă, Da  Nu  Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 196. escare anterioare/existente, regim alimentat neadecvat, înaintarea în vârstă, greutatea. Metode de propulsie Cum va realiza utilizatorul propulsia scaunului rulant? Cu ambele brațe  Cu brațul stâng  Cu brațul drept  Cu ambele picioare  Cu piciorul stâng  Piciorul drept  Cu ajutorul unui însoțitor  Comentarii: _____________________________________________________________________ Măsurători Măsurători corp Dimensiune (mm) Transformare măsurători corp în dimensiune ideală scaun rulant Dimensiune scaun rulant A Lățime șold 360mm Lățime șold = lățime șezut scaun rulant 360mm B Adâncime șezut scaun rulant S 400mm B minus 30 – 50 mm = adâncime șezut scaun rulant (dacă lungimea este diferită, folosiți valoarea mai mică) 370mm D 400mm C Lungime gambă S 380mm = de la partea superioară a pernei șezutului* până la înălțimea suportului pentru picioare sau De la partea superioară a pernei șezutului* până la podea, în cazul propulsiei realizate cu piciorul 330mm D 380mm 330mm D Partea inferioară a cutiei toracice 310mm = de la partea superioară a pernei șezutului* până la limita superioară a spătarului (măsurați D sau E – în funcție de necesitatea utilizatorului) 360mm E Limita inferioară a omoplaților 420mm 470mm * verificați înălțimea pernei pe care o va folosi utilizatorul de scaun rulant. Anexa 4 Formular de prescriere (selecție) a scaunului rulant Acest formular de prescriere (recomandare) se utilizează pentru înregistrarea informațiilor referitoare la tipul de scaun rulant, componente și pernă, pentru utilizatorii de scaun rulant care pot sta în poziția așezat. 1. Informații despre utilizatorul de scaun rulant Numele utilizatorului de scaun rulant: Număr: Data evaluării: Data probării produsului (a scaunului rulant): Numele persoanei care efectuează Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 197. evaluarea: 2. Tipul și dimensiunea scaunului rulant recomandat Pentru a alege tipul de scaun rulant: o Discutați cu utilizatorul de scaun rulant; o Luați în considerare aspectele cele mai importante pentru utilizatorul de scaun rulant; o Verificați: cadrul scaunului rulant, roțile frontale și din spate, suporturile pentru picioare, suporturile laterale, înălțimea spătarului (sau opțiunile de ajustare), poziția roților din spate, gradul de sprijin și confort oferit de scaunul rulant. Tipul de scaun rulant Dimensiunea      3. Tipul de pernă selectată Tipul de pernă Dimensiunea E.g. Pernă pentru reducerea presiunii, din spumă / burete  E.g. Pernă plată, din spumă / burete  4. Acordul Semnătura utilizatorului: Semnătura persoanei care efectuează evaluarea: Semnătura managerului: Anexa 5 Formular de date tehnice ale scaunului rulant Denumire scaun rulant: Inserați foto aici: Producător / Furnizor: Dimensiuni disponibile: Greutate totală: Descriere: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 198. Cadru: Fix / rigid Pliabil Lungime cadru: Spătar: Pliabil / pânză Rigid Tensiune ajustabilă Șezut: Pliabil / pânză Rigid Tensiune ajustabilă Pernă: Fără pernă Plată, din spumă / burete Cu contur, din spumă / burete Suport de picioare: Fix Detașabil / pliabil pe lateral Altele: Roți frontale Diametru: Lățime: Roți din spate Pneumatice Diametru: Inele antrenare Solide Lățime: Ax reglabil Tub interior solid Detașabile Frâne: Pârghie scurtă Pârghie lungă Altele: Suporturi laterale: Fixe Detașabile / pliabile lateral Altele: Mânere: Mânere Elemente suplimentare / opțiuni: Centură gambă Bară anti- răsturnare Măsuță Altele: Măsurători, opțiuni modificări și gama de ajustări: Măsurători (dacă scaunul rulant este disponibil în mai multe mărimi, specificați toate mărimile) Este ajustabil? Gamă ajustări (ajustările ce pot fi efectuate pentru acest tip de scaun rulant). Da Nu Lățime șezut: Adâncime șezut: Înălțime șezut: Înălțime spătar: Unghi spătar: Înălțime suport picioare: Unghi suport picioare: Înălțime mânere: Lungime cadru: Lungime bază roți: Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 199. Anexa 6 Listă de verificare preliminară utilizării scaunului rulant: Este scaunul rulant pregătit pentru utilizare? Scaunul rulant în ansamblu Nu există margini ascuțite  Nu există părți defecte sau zgâriate  Traiectoria scaunului rulant aflat în mișcare este dreaptă  Roțile frontale Se învârt fără a întâmpina vreo rezistență  Se învârt fără a atinge furca roții.  Șuruburile sunt strânse  Furcile roților frontale Furca roții frontale se învârte fără a întâmpina vreo rezistență  Roțile din spate Se învârt fără a întâmpina vreo rezistență  Șuruburile axului sunt strânse  Anvelopele sunt umflate în mod corect (la presiunea aplicată cu un deget, anvelopele se deformează mai puțin de 5 mm)  Inelele de antrenare nu prezintă niciun pericol  Frânele Funcționează corespunzător  Suporturile de picioare Suportul de picioare este montat corespunzător  Cadrul Scaunul rulant pliabil se închide și se deschide cu ușurință.  În cazul unui scaun rulant cu spătar pliabil- spătarul se pliază și revine în poziția inițială cu ușurință  Perna Perna este introdusă corect în husă  Perna este poziționată corect pe scaunul rulant  Materialul textil al pernei este întins pe suprafața acesteia, însă nu mai mult decât este necesar  Dacă șezutul scaunului rulant este unul de tip rigid, perna acoperă în întregime șezutul scaunului  Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 200. Anexa 7 Listă de verificare a pașilor pentru probarea produsului (a scaunului rulant) 1. Este scaunul rulant pregătit? A fost scaunul rulant verificat în ceea ce privește siguranța utilizării și funcționarea tuturor componentelor?  2. Verificați dimensiunea și reglajele Lățimea șezutului: Trebuie să se potrivească îndeaproape.  Adâncimea șezutului: Distanță de două degete între porțiunea din spatele genunchiului și șezutul scaunului/ pernă.  Înălțimea suportului de picioare: Coapsa este sprijinită în totalitate pe perne, fără a se ridica. Fiecare picior se sprijină pe suportul de picioare, fără a se ridica.  Înălțimea spătarului: Utilizatorul are suportul necesar și libertate de mișcare la nivelul umerilor în vederea realizării propulsiei scaunului rulant (în cazul în care propulsia se face de către acesta).  Poziția roților din spate (pentru propulsia cu brațele): Atunci când brațul utilizatorului este întins, acesta trebuie să fie pe aceeași linie cu axul posterior. Atunci când mâinile sunt poziționate pe inelul de antrenare, cotul utilizatorului trebuie să formeze un unghi drept.  Frâne: Frânele sunt funcționale?  Înălțimea șezutului (pentru propulsia cu ajutorul piciorului): Atunci când utilizatorul stă în poziție așezat, spatele trebuie să fie sprijinit în mod confortabil de către spătar, iar talpa piciorului trebuie să fie poziționată pe podea.  Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 201. 3. Verificați postura Utilizatorul are poziția așezat și stă confortabil în scaunul rulant?  Verificați postura din lateral.  Verificați postura din față /spate.  Anexa 8 Listă de verificare instruire utilizator scaun rulant Abilități de învățat Abilități învățate Manevrarea scaunului rulant Plierea scaunului rulant Ridicarea scaunului rulant Folosirea roților cu deblocare rapidă Folosirea frânelor Folosirea pernei, inclusiv poziționarea corectă îm scaunul rulant Transferuri Transfer independent Transfer asistat Altele Mobilitatea în scaun rulant Propulsia corectă Urcarea și coborârea unei pante Urcarea și coborârea unei trepte Deplasarea pe teren accidentat Menținerea în echilibru pe două roți Prevenirea apariției escarelor Verificarea existenței escarelor Tehnici pentru reducerea presiunii Alimentație și hidratare corespunzătoare Ce trebuie făcut în cazul apariției unei escare Întreținerea la domiciliu a scaunului rulant Curățarea scaunului rulant; spălarea și uscarea pernei și a husei Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 202. Lubrifierea părților mobile Umflarea anvelopelor, dacă acestea sunt pneumatice Strângerea șuruburilor și a piulițelor (dacă este necesar) Strângerea spițelor (dacă este necesar) Verificarea părților textile (a tapițeriei) Verificarea existenței petelor de rugină Verificarea pernei Ce trebuie făcut în cazul în care există o problemă Scaunul rulant are nevoie de reparații Scaunul rulant nu este corespunzător sau nu este confortabil Anexa 9 Formular de monitorizare a utilizării scaunului rulant Acest formular este destinat înregistrării informațiilor obținute la vizita de monitorizare. 1. Informații utilizator scaun rulant Numele utilizatorului de scaun rulant: Numărul: Data probării produsului (a scaunului rulant): Data efectuării monitorizării: Numele persoanei care realizează monitorizarea: Monitorizarea a avut loc la: Domiciliul utilizatorului  Centru de reparații scaune rulante  Alt spațiu: _____________________________________ 2. Interviu Notați activitatea ce trebuie efectuată: Utilizați scaunul rulant atât de frecvent pe cât vă doriți? Da  Nu  Dacă nu – de ce nu? Întâmpinați vreo dificultate în utilizarea scaunului rulant? Da  Nu  Dacă da – care este aceasta? Aveți întrebări în ceea ce privește utilizarea scaunului rulant? Da  Nu  Dacă da – care sunt acestea. Este nevoie de instruire suplimentară? Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 203. Utilizatorul de scaun rulant prezintă escare? Da  Nu  Dacă da - descrieți (localizare și gravitate) Cum ați nota, pe o scală de la 1 la 5, gradul de satisfacție pe care vi-l oferă scaunul rulant ? (1 deloc satisfăcut, 5 foarte satisfăcut) Notă: Comentarii: 3. Verificare scaun rulant și pernă Scaunul rulant este în stare bună de funcționare și poate fi utilizat în siguranță? Da  Nu  Perna este în stare bună și poate fi utilizată în siguranță? Da  Nu  Dacă răspunsul la oricare din întrebările de mai sus este „nu”, vă rugăm precizați problema. 4. Verificare ajustări Scaunul rulant se potrivește? Da  Nu  Dacă nu – care sunt problemele? Test nivel presiune (1 = sigur, 2 = avertizare, 3 = nesigur) (dacă există riscul producerii de escare ) Stânga: Dreapta: Utilizatorul are o poziție confortabilă în scaunul rulant atunci când stă pe loc, când se deplasează și pe întreg parcursul zilei ? Da  Nu  Dacă nu – care sunt problemele? Anexa 10 Listă de verificare și observații pentru formatori Aceste formulare sunt create pentru a ajuta formatorii în monitorizarea sesiunilor practice. Listă de verificare și observații pentru formatori: Sesiunea practică 1: Evaluarea și prescrierea (selecția). Nume formator: ________________________________________ Data sesiunii practice: ____________________________________________ Monitorizați cu atenție Notați exemplele de bună practică, Notați aspectele practice care au nevoie Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 204. durata sesiunii pentru a oferi feedback: de îmbunătățire, pentru a oferi feedback: Min  Evaluarea 45  Prescrierea (selecția) 30  Feedback 10  Pe durata monitorizării activității, observați modalitatea în care sunt prezente la fiecare grupă abilitățile enumerate mai jos. Notați observațiile pe care le aveți, pentru a oferi feedback. Grupa: Grupa 1 Grupa 2 Grupa 3 Numele participanților: Numele utilizatorului de scaun rulant:  Comentarii  Comentarii  Comentarii Observații generale: Prezența bunelor abilități de comunicare în relaționarea cu utilizatorul și cu familia acestuia    Implicarea utilizatorului de scaun rulant pe parcursul fiecărei etape și în luarea deciziilor    Finalizarea exercițiului în intervalul de timp alocat    Evaluare: Dobândirea de informații relevante pe parcursul interviului    Monitorizarea realizării de către utilizatorul de scaun rulant a transferului pe suprafața de evaluare, pentru a se asigura că transferul are loc în condiții de siguranță    Identificarea prezenței, riscului sau a istoricului escarelor    Identificarea corectă a metodei de realizare a propulsiei    Efectuarea corectă a măsurătorilor    Completarea corectă a formularului de evaluare    Prescriere (selecție): Alegerea tipului de scaun rulant corespunzător și a pernei adecvate    Identificarea tuturor modificărilor minore sau a aspectelor ce necesită îmbunătățiri    Completarea corectă a formularului de prescriere (selecție)    Listă de verificare și observații pentru formatori: Sesiunea practică 2: Probarea produsului (a scaunului rulant) și instruirea utilizatorului. Numele formatorului: ____________________________________ Data sesiunii practice: _______________________________________________ Monitorizați cu atenție durata sesiunii Notați exemplele de bună practică, pentru a oferi feedback: Notați aspectele practice care au nevoie de îmbunătățire, pentru a oferi Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 205. feedback: Min  Probarea produsului (a scaunului rulant) 45  Instruirea utilizatorului de scaun rulant 50  Feedback 20  Feedback oferit de utilizator (opțional) 30  Pe durata monitorizării activității, observați modalitatea în care sunt prezente la fiecare grupă abilitățile enumerate mai jos. Notați observațiile pe care le aveți, pentru a oferi feedback. Grupa: Grupa 1 Grupa 2 Grupa 3 Numele participanților: Numele utilizatorului de scaun rulant:  Comentarii  Comentarii  Comentarii Observații generale: Prezența bunelor abilități de comunicare în relaționarea cu utilizatorul și cu familia acestuia    Implicarea utilizatorului de scaun rulant pe parcursul fiecărei etape și în luarea deciziilor    Finalizarea exercițiului în intervalul de timp alocat    Probarea produsului (a scaunului rulant): Parcurgerea corectă și în condiții de siguranță a procesului de probare a produsului (a scaunului rulant), conform listei de verificare a probării produsului (a scaunului rulant)    Identificarea și gestionarea corectă a tuturor problemelor din etapa de probare a produsului (a scaunului rulant)    Ajustarea și soluționarea corectă pentru a ajunge la dimensiunile corecte ale scaunului rulant    Instruirea utilizatorului de scaun rulant: Selectarea de către grup a setului de abilități optim pentru instruirea utilizatorului de scaun rulant și a familiei acestuia, în conformitate cu formularul pentru instruirea utilizatorului de scaun rulant    Folosirea unor bune tehnici de instruire în timpul procesului de instruire (e.g. explicație, demonstrație, exersare)    Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 206. Desfășurarea în condiții de siguranță a procesului de instruire (e.g. însoțitorul poziționat în spatele scaunului rulant în timpul exersării abilităților de manevrare; instruirea cu privire la realizarea transferului desfășurată în condiții de siguranță)    Listă de verificare și observații pentru formatori: Sesiunea practică 3: Monitorizarea. Numele formatorului: __________________________________________ Data sesiunii practice: ________________________________________ Monitorizați cu atenție durata sesiunii: Notați exemplele de bună practică, pentru a oferi feedback: Notați aspectele practice care au nevoie de îmbunătățire, pentru a oferi feedback: Min  Monitorizare 60  Feedback 25  Pe durata monitorizării activității, observați modalitatea în care sunt prezente la fiecare grupă abilitățile enumerate mai jos. Notați observațiile pe care le aveți, pentru a oferi feedback. Grupa: Grupa 1 Grupa 2 Grupa 3 Numele participanților: Numele utilizatorilor de scaun rulant:  Comentarii  Comentarii  Comentarii Observații generale: Prezența bunelor abilități de comunicare în relaționarea cu utilizatorul și cu familia acestuia    Implicarea utilizatorului de scaun rulant pe parcursul fiecărei etape și în luarea deciziilor    Finalizarea exercițiului în intervalul de timp alocat    Monitorizare: Verificarea de către grup a stării scaunului rulant    Verificarea modului în care scaunul rulant se potrivește utilizatorului    Identificarea și înregistrarea activităților de monitorizare recomandate    Desfășurarea în timpul sesiunii a tuturor activităților specifice monitorizării    Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 207. Listă de verificare și observații pentru formatori: Sesiunea practică 4: Evaluarea utilizatorului de scaun rulant, prescrierea (selecția), pregătirea produsului (a scaunului rulant), probarea produsului (a scaunului rulant) și instruirea utilizatorului. Numele furnizorului: _______________________________________ Data sesiunii practice_____________________________________________ Monitorizați cu atenție durata sesiunii Notați exemplele de bună practică, pentru a oferi feedback: Notați aspectele practice care au nevoie de îmbunătățire, pentru a oferi feedback: Minute1  Evaluare 30  Prescriere (selecție) 20  Pregătirea produsului (a scaunului rulant) 60  Probarea produsului (a scaunului rulant) 30  Instruirea utilizatorului 45  Feedback 30  Pe durata monitorizării activității, observați modalitatea în care sunt prezente la fiecare grupă abilitățile enumerate mai jos. Notați observațiile pe care le aveți, pentru a oferi feedback. Grupa: Grupa 1 Grupa 2 Grupa 3 Numele participanților: Numele utilizatorului de scaun rulant:  Comentarii  Comentarii  Comentarii Observații generale: Prezența bunelor abilități de comunicare în relaționarea cu utilizatorul și cu familia acestuia    Implicarea utilizatorului de scaun rulant pe parcursul fiecărei etape și în luarea deciziilor    Finalizarea exercițiului în intervalul de timp alocat    Evaluare: Dobândirea de informații relevante pe parcursul interviului    Monitorizarea realizării de către utilizatorul de scaun rulant a transferului pe suprafața de evaluare, pentru a se asigura că transferul are loc în condiții de siguranță    1 Notă – în cazul în care este necesar, alocați alte 20 de minute pentru soluționarea problemelor și pentru monitorizare. Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 208. Identificarea prezenței, riscului sau a istoricului escarelor    Identificarea corectă a metodei de realizare a propulsiei    Efectuarea corectă a măsurătorilor    Completarea corectă a formularului de evaluare    Prescrierea (selecția): Alegerea tipului de scaun rulant corespunzător și a pernei adecvate    Identificarea tuturor modificărilor minore sau a aspectelor ce necesită îmbunătățiri    Completarea corectă a formularului de prescriere (selecție)    Pregătirea produsului (a scaunului rulant): Pregătirea corectă a scaunului rulant, în conformitate cu prescrierea (selecția)    Completarea corectă a listei de verificare preliminare utilizării scaunului rulant    Probarea produsului (a scaunului rulant): Parcurgerea corectă și în condiții de siguranță a procesului de probare a produsului (a scaunului rulant), conform listei de verificare a probării produsului (a scaunului rulant)    Identificarea și gestionarea corectă a tuturor problemelor din etapa de probare a produsului (a scaunului rulant)    Ajustarea și soluționarea corectă pentru a ajunge la dimensiunile corecte ale scaunului rulant    Instruirea utilizatorului: Selectarea de către grupă a setului de abilități optim pentru instruirea utilizatorului de scaun rulant și a familiei acestuia, în conformitate cu formularul pentru instruirea utilizatorului de scaun rulant    Folosirea unor bune tehnici de instruire în timpul procesului de instruire (e.g. explicație, demonstrație, exersare)    Desfășurarea în condiții de siguranță a procesului de instruire (e.g. însoțitorul poziționat în spatele scaunului rulant în timpul exersării abilităților de manevrare; instruirea cu privire la realizarea transferului desfășurată în condiții de siguranță)    Servicii pentru utilizatorii de scaun rulant. Pachet de instruire - nivel de bază. Manualul formatorului Pagina 209.

Tekerlekli Sandalye Hizmet Eğitim Paketi Temel düzey Eğitmen Kılavuzu Tekerlekli Sandalye Hizmet Eğitim Paketi Temel düzey Eğitmen Kılavuzu Published by the World Health Organization in 2012 under the title Wheelchair Service Training Package: Basic Level (Dünya Sağlık Örgütü Tarafından 2012 yılında Tekerlekli Sandalye Hizmet Eğitim Paketi-Temel Seviye başlığı altında yayınmalmıştır) © World Health Organization (Dünya Sağlık Örgütü) 2012 Her hakkı saklıdır. Dünya Sağlık Örgütü yayınları şu bağlantılar yoluyla elde edilebilir: WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264; faks: +41 22 791 4857; e-mail: bookorders@who.int). Dünya Sağlık Örgütü yayınlarını çoğaltmak veya tercüme etmek için olan talepler – satışı veya ticari olmayan dağıtımı – WHO Press, yukarıda geçen adrese (faks: +41 22 791 4806; e-mail: permissions@who.int) yönlendirilmelidir. Bu yayında geçen başlıklar ve sunulan içerik, hiç bir şekilde, herhangi bir ülkenin, bölgenin, şehrin ya da sahanın hukuki statüsü ya da bu yerlerin yetkilileri ya da sınırlarının ya da sinir bölgelerinin tahdit edildiği ile ilgili herhangi bir görüsün Dünya Sağlık Örgütü tarafından ifade edildiği anlamına gelmez. Yayında belli başlı şirketlerin ya da imalatçıların ürünlerinin isimlerinin geçmesi bunların, adi geçmeyen ayni nitelikle diğer ürünlerin aleyhine, Dünya Sağlık Örgütü tarafından onaylandığı ya da tavsiye edildiği anlamına gelmez. Hatalar ve eksikler dışında, müseccel markaların isimleri, büyük bas harfleri ile belirtilmiştir. Bu yayında yer alan bilgilerin doğruluğunun teminatı için Dünya Sağlık Örgütü tarafından tüm makul önlemler alınmıştır. Ancak, yayınlanan içerik, sarih ya da zımni, herhangi bir garanti olmadan dağıtılmaktadır. İçeriğin kullanımına ya da yorumlanmasına ilişkin sorumluluk okuyucuya aittir. Dünya Sağlık Örgütü, hiç bir şekilde, bu yayının kullanımından doğabilecek zararlardan sorumlu değildir. The Director General of the World Health Organization has granted translation and publication rights to an edition in Turkish to Latter-day Saint Charities, which is solely responsible for the Turkish edition. (Dünya Sağlık Örgütü Genel Direktörü, Türkçe çeviri ve yayınlama hakkını,Türkçe baskısının tek sorumlusu olarak Son Zaman Azizler Hayır İşleri’ ne vermiştir.) © Latter-day Saint Charities 2012 Wheelchair Service Training Package: Basic Level (Tekerlekli Sandalye Hizmet Eğitim Paketi: Temel düzey) 1. Tekerlekli sandalye - hizmet 2. Tekerlekli sandalye - tedarik ve dağıtım. 3. Tekerlekli sandalye - özellikler. 4. Engelli kişiler - rehabilitasyon. 5. Gelişmekte olan ülkeler. 6. Dünya Sağlık Örgütü Orijinal İngilizce versiyonuna katkıda bulunanlar: Editörler: Chapal Khasnabis ve Kylie Mines Yazarlar: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Değerlendirmeciler: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, ve Isabelle Urseau Çizimler: Melissa Puust Fotoğraf Jeneriği: Chapal Khasnabis and Jesse Moss Video Jeneriği: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Rehber eğitimciler: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri Maddi destek: ABD Uluslararası Kalkınma Ajansı ve Avustralya Uluslararası Kalkınma Ajansı Ortak Kuruluşlar: ASSERT Doğu Timor, Kenya Fiziksel Engelliler Derneği (APDK), Soloman Adaları Sağlık Bakanlığı ve Medikal Hizmetler’in Toplum Temelli Rahabilitasyon Ünitesi, Eğitim Gelişim Merkezi (EDC), Handicap İnternasyonal, Uluslararası Kızıl Haç Komitesi (ICRC), Uluslararsı Protetik Ortetik Derneği (ISPO), Kilimanjaro Omurilik Felçliler Derneği (KASI), Mobility India, Motivasyon Australia, Motivasyon Hayır Vakfı (Motivasyon), Motivasyon Romanya ve Tanzania Ortopedi Teknoloji Uzmanları Merkezi (TATCOT) Terminoloji Eğitim boyunca kullanılan terimler aşağıda tanımlanmıştır. Uygun tekerlekli sandalye Kullanıcının ihtiyaçlarını karşılayan ve çevresel koşullarına uygun; yerinde ve uygun duruş desteği sağlayan ve güvenli, sağlam; ülke içerisinde mevcut olan ve elde edilebilir; ülke içerisinde bakımı ve servis desteği olan ve yine ülke içinde en ekonomik ve karşılanabilir ücreti olan tekerlekli sandalye Manüel tekerlekli sandalye Kullanıcı tarafından veya başka bir kişinin yardımı ile itilerek ilerleyen tekerlekli sandalye. Tekerlekli sandalye Yürüme ya da etrafta dolaşma, hareket konusunda zorlukları olan kişiler için yapılmış, tekerlekleri aracılığı ile hareketlilik sağlayan ve oturma desteği olan araç. Tekerlekli sandalye provizyonu Tekerlekli sandalyenin tasarlanması, üretimi, tedariki, hizmet ve servis sağlanmasını içeren geniş kapsamlı bir terimdir. Tekerlekli sandalye hizmeti ( servisi) Tekerlekli sandalye provizyonunun, her bir kullanıcının uygun tekerlekli sandalye almasının sağlanmasıyla ilgili bölümüdür. Tekerlekli sandalye hizmet personeli Uygun tekerlekli sandalye provizyonu ile konusunda bilgili, yetkin, teknik bilgisi olan kişiler. Tekerlekli sandalye kullanıcısı Yürüme veya etrafta dolaşma, hareket etme konusunda zorlukları olan ve hareketlilik için tekerlekli sandalye kullanan kişi. İçindekiler Tekerlekli Sandalye Hizmet Eğitim Paketi Hakkında: Temel Seviye .............................................. 8 Giriş .............................................................................................................................................................. 8 Hedef Kitle ..................................................................................................................................................... 6 Amaç .............................................................................................................................................................. 6 Kapsam ........................................................................................................................................................ 8 Eğitimciler ................................................................................................. Hata! Yer işareti tanımlanmamış. Nasıl başlıyoruz ........................................................................................ Hata! Yer işareti tanımlanmamış. 1. Eğitimciler İçin Rehberlik Notları ................................................................................. 8 1.1 Eğitime genel bakış ............................................................................ ....................................... 9 1.2 Eğitimin zaman çizelgesi ve süresi .......................................................................................... 10 1.3 Bölüm planları ................................................................................. ........................................ 10 1.4 PowerPoint sunumları ............................................................................................................. 11 1.5 Katılımcıların gelişiminin gözlem ve izlenmesi ......................................................................... 11 1.6 Her bir sunumdan sonra eğitim programının değerlendirmesi ................................................. 11 1.7 Doğru / iyi uygulama eğitim tavsiyeleri / ipuçları ...................................................................... 11 2. Eğitim paketinin sunuma hazırlanması ..................................................................... 13 2.1 Katılımcıların tekerlekli sandalye hizmet ağlarından haberdar olması ..................................... 13 2.2 Katılımcıların hizmet sunumu konusunda görevlerinin netleştirilmesi ...................................... 13 2.3 Her bir bölüm planının gözden geçirilip gerektiğinde düzenlemeler yapılması ......................... 13 2.4 Kullanıacak tekerlekli sandalyenin tanımlanması .................................................................... 13 2.5 Telerlekli sandalye kullanıcılarının uygulama bölümlerine davet edilmesi ............................... 14 2.6 Uygulama bölümleri için grup planlanması .............................................................................. 15 2.7 Tesislerin ayarlanması ............................................................................................................ 15 2.8 Eğitim kaynakları ve materyallerinin ayarlanması .................................................................... 16 3. Detarylı bölüm planları ................................................................................................ 21 Giriş ............................................................................................ Hata! Yer işareti tanımlanmamış. A: Temel bilgi ..................................................................................... ........................................... 25 A.1: Tekerlekli sandalye kullanıcıları ............................................................................................................ 26 A.2: Tekerlekli sandalye hizmetleri .............................................................................................................. 31 A.3: Tekerlekli sandalye hareketliliği ............................................................................................................ 36 A.4: Dik oturuş .............................................................................................................................................. 42 A.5: Basınç yaraları ...................................................................................................................................... 50 A.6: Uygun tekerlekli sandalye .................................................................................................................... 59 A.7: Minderler ............................................................................................................................................... 74 A.8: Transferler ............................................................................................................................................ 82 B: Tekerlekli sandalye hizmet adımları ......................................................................................... 89 B.1: Sevk ve randevu ................................................................................................................................... 90 B.2: Değerlendirme ...................................................................................................................................... 93 B.3: Değerlendirme görüşmesi .................................................................................................................... 97 B.4: Fiziksel değerlendirme ........................................................................................................................ 106 B.5: Reçete (seçim).................................................................................................................................... 115 B.6: Finansman ve sipariş ......................................................................................................................... 123 Birinci Uygulama:Değerlendirme ve reçete (seçim) ................................................................................ 126 B.7:Ürün (tekerlekli sandalye) hazırlığı ...................................................................................................... 128 B.8: Minder yapımı ..................................................................................................................................... 133 B.9: Uygunluk ............................................................................................................................................. 139 B.10: Problem çözme ................................................................................................................................. 144 B.11: Kullanıcı eğitimi................................................................................................................................. 151 B.12: Bakım ve onarım .............................................................................................................................. 155 İkinci Uygulama: Uygunluk ve kullanıcı eğitimi ........................................................................................ 160 B.13: Takip ................................................................................................................................................. 163 Üçüncü Uygulama: Takip ......................................................................................................................... 167 Dördüncü Uygulama:Değerlendirme, reçete (seçim), ürün (tekerlekli sandalye) hazırlığı,uyum ve kullanıcı eğitimi…………………………………………………………………………………………………………………………. ................................................................................................................. Hata! Yer işareti tanımlanmamış. B.14: Sonuç ................................................................................................................................................ 172 Ekler ................................................................................. Hata! Yer işareti tanımlanmamış. Ek 1: Temel tekerlekli sandalye hizmet eğitim paketi için zaman tablosu .................................... 175 Ek 2: Tekerlekli sandalye sevk formu .......................................................................................... 176 Ek 3: Tekerlekli sandalye değerlendirme formu........................... Hata! Yer işareti tanımlanmamış. Ek 4: Tekerlekli sandalye reçete (seçim) formu ........................................................................... 177 Ek 5: Tekerlekli sandalye veri formu ........................................... Hata! Yer işareti tanımlanmamış. Ek 6: Tekerlekli sandalye güvenlik ve kullanıma hazırlık kontrol listesi ................... Hata! Yer işareti tanımlanmamış. Ek 7: Tekerlekli sandalye uygunluk kontrol listesi ........................ Hata! Yer işareti tanımlanmamış. Ek 8: Tekerlekli sandalye kullanıcı kontrol listesi ......................... Hata! Yer işareti tanımlanmamış. Ek 9: Tekerlekli sandalye taip formu ........................................... Hata! Yer işareti tanımlanmamış. Ek 10: Eğitimci gözlem kontrol listeleri ........................................ Hata! Yer işareti tanımlanmamış. Birinci Uygulama: Değerlendirme ve reçete(seçim) ................................. Hata! Yer işareti tanımlanmamış. İkinci Uygulama : Uygunluk ve kullanıcı eğitimi ....................................... Hata! Yer işareti tanımlanmamış. Üçüncü Uygulama : Takip ........................................................................ Hata! Yer işareti tanımlanmamış. Dördüncü Uygulama : Değerlendirme, reçete (seçim), ürün (tekerlekli sandalte) hazırlığı,uyum ve kullanıcı eğitimi ...................................................................................................... Hata! Yer işareti tanımlanmamış. Tekerlekli Sandalye Eğitim Paketi Hakkında: Temel Düzey Giriş Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler’in daha iyi uygulanmasının garanti altına alınması için Dünya Sağlık Örgütü Tekerlekli Sandalye Hizmet Eğitim Paketi – Temel Düzey ‘ini geliştirmiştir. Tekerlekli sandalye çalışanlarına ihtiyaç evrenseldir. Tekerlekli sandalye kişisel hareketliliği sağlamak için en yaygın şekilde kullanılan yardımcı araçlardan biridir fakat tekerlekli sandalye kullanıcılarının olabilecek en iyi düzeyde hareketlilik özgürlüğü kazanmaları, üretken olmaları ve yüksek hayat kalitesine sahip olabilmeleri için, hizmet sağlayıcılarının oldukça az miktarda eğitim imkânı vardır. Temel seviye eğitim paketi, tekerlekli sandalye hizmet eğitim serisinin birinci bölümüdür. Tekerlekli Sandalye Hizmet Eğitim Paketi – Temel Seviye birtakım dokümanları ve tekerlekli sandalye eğitim sağlanması için sunumları içermektedir. Bunlardan en önemlisi Eğitimci Kılavuzu’dur. Pratik sebeplerden dolayı Kullanıcı Kılavuzu sadece elektronik ortamda mevcuttur ( basılı bir şekli yoktur). Kullanıcı Kılavuzu ve tekerlekli sandalye hizmet provizyonu için gerekli olan temel seviye eğitim programı bilgi materyallerinin hepsi diskin içerisindedir. Hedef Kitle Bu eğitim paketi çalışma alanlarında kendilerinden tekerlekli sandalye hizmet sunumu gerçekleştirmesi beklenen bütün personel veya gönüllüler içindir. Bunlar; sağlık, rehabilitasyon ve teknik personeli, halk sağlığı çalışanları, toplum temelli rehabilitasyon (TTR) çalışanları, meslekle ilgili terapistler, fizyoterapistler, prostetistler, ortotistler, yerel esnaf ve tekerlekli sandalye kullanıcılarıdır. Tekerlekli sandalye hizmet sunumunda daha önce edinilmiş bir tecrübeye ihtiyaç yoktur. Ancak katılımcıların aşağıdaki bilgilere becerilere sahip olduğu farz edilerek düzenlenmiştir: o katılımcılar eğitim programının verildiği dili okuyup yazabilmelidirler; o Katılımcılar kişilerin tekerlekli sandalye kullanımını gerektirecek basit fiziksel engeller hakkında temel bilgiye sahip olmaları gerekir; serebral palsi, alt ekstremite ampütasyonu, polyo (çocuk felci), omurilik zedelenmesi ve felç. Katılımcıların bu çok bilinen fiziksel engeller hakkında bilgileri yoksa eğitimciler temel bilgi bölümüne bir ek olarak bu bilgilere yer vermeleri gerekir. Amaç Temel seviye eğitim paketi, hareketlilik noksanlığı çeken ama aynı zamanda ilave duruş desteği olmadan kendi başına oturabilen gençler ve yetişkinlere uygun manüel tekerlekli sandalyeler ve minderler sağlamak amacıyla personel ve gönüllülere eğitim vermek için hazırlanmış bir programdır. Bu eğitim paketinin temel amacı tekerlekli sandalye hizmet sunumu ile ilgili olan personelin bilgi ve becerilerinin geliştirilmesidir. Bu eğitim paketinin sunumu şunlara yardımcı olacaktır: o ihtiyaçlarını karşılayacak tekerlekli sandalye alabilen, tekerlekli sandalye kullanıcıların sayısını artıracak; o tekerlekli sandalye kullanımı ve bakımı ve tekerlekli sandalyelerinde sağlıklı olarak nasıl oturabilecekleri konusunda eğitim alan kullanıcıların sayısını artıracak; o temel düzey tekerlekli sandalye hizmet sunumu konusunda eğitimli personel sayısını artıracak; o tekerlekli sandalye hizmet sunum personelinin yeterliliklerini artıracak; o tekerlekli sandalye hizmet sunumun kalitesini artıracak ve; o rehabilitasyon hizmetleri bünyesinde tekerlekli sandalye hizmet sunumunun daha iyi bir şekilde bütünleşmesi sağlanmış olur. Kapsam Eğitim paketinin kapsamı: o tekerlekli sandalye hizmet sunumu için gerekli temel bilgi; o DSÖ (Dünya Sağlık Örgütü) Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler’ inde (Tablo1) tanımlanan tekerlekli sandalye hizmet sunumundaki kilit adımlara genel bir bakış; o tekerlekli sandalye kullanıcılarıyla beraber çalışarak onların hareketlilikle ilgili ihtiyaçlarını değerlendirmek ve olabilecek en uygun çözümleri belirlemek; o uygun tekerlekli sandalye ve uygun minderi tedarik etmek; o tekerlekli sandalyenin kullanıcısına en uyumlu hale gelmesini garanti etmek için basit modifikasyonlarla problem çözümü; o tekerlekli sandalye bakım ve onarımı; o tekerlekli sandalyesini en iyi şekilde kullanabilmesi için kullanıcının eğitimi ve; o köpük konturlu (biçimli) minder yapımı. Basit bir tekerlekli sandalyede değişiklikler yapılması, mevcut olan manüel sandalyelerdeki çeşitlik ve boyut sınırlamaları gibi şartlara bağlıdır. Tekerlekli sandalye kullanıcısının doğru bir şekilde uyum sağlayabilmesi için sıklıkla basit değişiklikler yapılması gerekir. Bu eğitim programı üç tekerleklilerin provizyonunu detaylı bir şekilde içermez bununla beraber tekerlekli sandalye ile daha uzun mesafeler kat etmeye ihtiyacı olan kullanıcılar için üç tekerleklilerin değeri dikkate alınmıştır. Tablo1. Tekerlekli sandalye hizmet sunumu için kilit adımlar: Adım 1 Sevk ve randevu Adım 2 Değerlendirme Adım 3 Reçete (seçim) Adım 4 Finansman ve sipariş Adım 5 Ürün ( tekerlekli sandalye ) hazırlığı Adım 6 Uygunluk Adım 7 Kullanıcı eğitimi Adım 8 Bakım, onarım ve takip Eğitimciler Beceriler: Bu eğitim paketi, tekerlekli sandalye hizmet sunumunda beceriler edinen ve kendilerine öğretilen yetileri güvenle gösterebilen eğitimcilerin bulunmasına dayanmaktadır. Eğitimci olarak sahip olunan daha önceki tecrübeler de faydalı olacaktır. Tekerlekli sandalye kullanıcıları: Eğitim ekibine bir tekerlekli sandalye kullanıcısının alınması şiddetle önerilir. Tekerlekli sandalye kullanıcıları kendi tecrübelerini diğerlerine öğretmek amaçlı resmedebilirler. Tekerlekli sandalye kullanıcıları aynı zamanda eğitim programında öğretilen pek çok tekniğin gösterimini yapabilirler. Bir tekerlekli sandalye kullanıcısı tarafından eğitilmek katılımcıların kendi tekerlekli sandalyesinin seçiminde merkez rolü oynayan kullanıcıyı anlamalarına yardımcı olacaktır. Eğitmen sayısı: Her 8 – 10 katılımcı için iki eğitimci olması tavsiye edilir. Bu oran özellikle uygulama bölümleri için önemlidir ki bu yolla eğitmenler katılımcılara iyi bir şekilde destek ve geri bildirim sağlayabilirler ve herkesin uygulamaya güvenli bir şekilde katılabildiğinden emin olurlar. Tecrübeli, konu ve eğitim paketi hakkında bilgili olan bir tekerlekli sandalye kullanıcısı eğitim paketi boyunca değerli bir varlık bir kazanç olabilir. Nasıl başlanacak Eğitim paketini uygulamadan önce diski (dosyanın içinde arka tarafta) sabit diskinize kopyalamalısınız. 4GB’lık bir kayıt alanı gerekmektedir ve bir de DVD oynatıcı olmalıdır ki bu eğitim diskini kullanabilesiniz. Eğitim programını elde etmenin en kolay yolu: . 1.1. Kılavuz dosyasından Eğitimci Kılavuz’unu açın. 1.2. Tekerlekli Sandalye Hizmet Eğitim Paketi ve Eğitmenler için Rehberlik Notları bölümlerini okuyun: 1.3. Her bir eğitimci için Eğitimci Kılavuzu’nun bir kopyasını bastırın ve dosyalayın; 1.4. Bir zaman tablosu ve Eğitimci gözlem kontrol listesi bastırın; 1.5. Eğitim programı formları, Eğitim değerlendirme formları ve Tekerlekli sandalye hizmet formları, tekerlekli sandalye hizmet kontrol listesini bastırın. 2. Eğitim paketinin sunuma hazırlanması bölümünde önerilen şekilde gerekli bütün ayarlamaları yapın. 3. Katılımcılara bütün eğitim materyallerini içeren tam bir set veriniz: Referans Kılavuzu (her katılımcıya bir tane ), Katılımcı El Kitabı (her bir katılımcıya bir tane) ve bir set poster (her bir katılımcı için bir set). Eğer bunlar stokunuzda yoksa diskten bastırabilirsiniz. 4. Zaman tablosunu açın ve her bir bölümün köprüsüne tıklayın ki bu sizi ilgili slaytlara ve video konumuna götürecektir. Eğitimi almanın en iyi yolu her bölüme ayrılan zamanda sıralanan şekilde sıkı bir uyumla derslere devam etmektir. 1. Eğitimciler için Rehberlik Notları 1.1 Eğitime genel bir bakış dakika Hoş geldiniz, giriş ve genel bakış. Giriş 60 A: Temel Bilgi Katılımcılara tekerlekli sandalye adımlar bölümlerini alabilmeleri için ihtiyaçları olan bilgilerin altyapısını verecek bölümler. A.1 Tekerlekli sandalye kullanıcıları 45 A.2 Tekerlekli sandalye hizmetleri 30 A.3 Tekerlekli sandalye hareketliliği 90 A.4 Dik oturuş 60 A.5 Basınç yaraları 60 A.6 Uygun tekerlekli sandalye 120 A.7 Minderler 75 A.8 Transferler 120 B: Tekerlekli sandalye hizmet adımları Sevk ve randevu B.1 Sevk ve randevu 30 Değerlendirme B.2 Değerlendirme 30 B.3 Değerlendirme görüşmesi 90 B.4 Fiziksel değerlendirme 90 Reçete (seçim) B.5 Reçete(seçim) 120 Finansman ve sipariş B.6 Finansman ve sipariş 15 Birinci Uygulama Değerlendirme ve reçete(seçim) 90 Ürün (tekerlekli sandalye) hazırlığı B.7 Ürün (tekerlekli sandalye) hazırlığı 75 B.8 Minder yapımı 120 Uygunluk B.9 Uygunluk 60 B.10 Problem çözme 45 Kullanıcı eğitimi B.11 Kullanıcı eğitimi 60 Bakım, onarım ve takip B.12 Bakım ve onarım 120 İkinci Uygulama Uygunluk ve kullanıcı eğitimi 120 Bakım, onarım ve takip B.13 Takip 45 Üçüncü Uygulama Takip 90 Dördüncü Uygulama Değerlendirme, reçete (seçim), ürün (tekerlekli sandalye) hazırlığı, uygunluk ve kullanıcı eğitimi 240 B.14 Sonuç 105 1.2 Eğitimin zaman çizelgesi ve süresi Bu eğitim paketi, ardışık üç gün veya belirli bir süre boyunca bloklar şeklinde sunulabilir. Bütün temel seviye eğitim paketini tamamlamak için gereken minimum zaman süresi 35-40 saattir. Her bir bölümün öğretilmesi için tahmini gereken süre bölüm planında bulunmaktadır. Not: her bir bölümün öğretilmesi için gereken süre aşağıdaki faktörlere bağlı olarak farklılık gösterebilir: o katılımcıların tecrübeleri ve becerileri; o katılımcıların toplam sayısı; o yerel ölçekte mevcut olan tekerlekli sandalyelerin sayısı; o bölümlerin anlatımı sırasında tercümeye ihtiyacın olup olmadığı; o ek materyalin olup olmadığı. Bu faktörlere bağlı olarak eğitim programının tamamlanması için daha az veya fazla zaman gerekebilir. Ek 1 de beş günlük örnek zaman tablosu verilmiştir. Bu zaman tablosu ve aynı zamanda boş zaman tablosu şablonu DVD de mevcuttur. Eğitmenler zaman tablosunu yerel şarlarına göre ve katılımcıların öğrenme ihtiyaçlarına göre değiştirmeye ve adapte etmeye yoğun bir şekilde teşvik edilirler. Örneğin: o eğitim paketindeki bölümler mevcut sağlık ya da rehabilitasyon programları ile birleştirilebilirler; o rehabilitasyon çalışanlarının bu eğitim programının bazı bölümleri ile ilgili daha önceden sahip oldukları eğitim olabilir bu durumda ilgili bölüme gerek yoktur; o tekerlekli sandalyenin hazırlanması için ek zaman gerekebilir (örneğin komple montaj gerektiği durumlar), bu durumda uygulama bölümünde ya tekerlekli sandalye kullanıcılarının sayısı azaltılabilir ya da mevcut süreyi uzatmak gerekir. 1.3 Bölüm planları Her bir bölüm içinde, eğitimcileri bölüm sunumunda yönlendirecek bir bölüm planı mevcuttur. Her bir bölüm baş kısmındaki plan aşağıdaki bilgileri içerir: o Hedefler: katılımcı bölüm sonunda neleri yapmaya yeterli olacak; o Kaynaklar: ilgili bölüm için hangi kaynaklara ihtiyaç var; o İçerik: bölümlerin değişik içerik ve değişik durumlarda nasıl adapte edileceği; o Hazırlık: bölüm için nasıl hazırlanılacak; o Taslak: her bir bölümün temel kısımlarının taslağını çizmek. Bölüm planının geri kalan kısmı konulara ayrılmıştır. Bölüm planında her bir konunun nasıl öğretileceğine dair talimatlar verilmiştir. Not: o Kalın olarak yazılmış kelimeler eğitimciler için olan eylemleri belirtir ( örneğin: sor, göster, açıkla, DVD göster); o Gölgeli kutular eğitimciler tarafından soruları cevaplar fakat katılımcılıları, sorulara kendilerinin cevap vermesi için teşvik ediniz. Her bir bölüm planı sonunda kilit nokta özeti vardır. Katılımcılar, kilit noktaları okumak yerine sorular sorabilirler ve bu yolla kilit noktaları kendileri tanımlayabilirler. Eğitimciler, bölüm planlarını dikkatle takip etmek suretiyle her bir bölümü doğru ve zamanında öğretebilirler. Bölüm planları, kapsamda olması gereken kilit nokta özetleri ve uygulama becerilerini verir. Eğitimciler, kendi bilgilerini, becerilerini ve stillerini bölümlerde göstermeye teşvik edildiler. Ancak mevcut planda verilen konulardan ve metotlardan sapmamak da önemlidir. 1.4 PowerPoint sunumları Hemen her bölüm için PowerPoint slayt gösterimi vardır. Eğitimcilerin dikkat etmeleri gereken şey kilit noktaların sadece slaytlarda yazılı olarak bulunduğudur. Eğitimciler slaytlarda olan her bir bilgiyi Eğitimci Kılavuzundan vermelilerdir ve her bilginin kapsandığından emin olmaları gerekir. Slaytları yüksek sesle okumaktan kaçınmalılardır. Bunun yerine Eğitimci Kılavuzuna yönlendirmelilerdir. 1.5 Katılımcıların gelişiminin gözlem ve izlenmesi Eğitimciler her bir katılımcının gelişimini yakından gözlemlemelidir. En iyi gelişim gözlem imkânı uygulama sırasında olandır. Her bir uygulama bölümü için Eğitimci gözlem kontrol listesi CD de mevcuttur. Eğitimciler bu kontrol listesini şunlar için kullanmalıdırlar: o Her bir uygulama bölümümde her grup katılımcının uygulama sırasındaki gelişimlerini gözlemlemeye yardımcı olması için o İyi yapılan ve daha gelişme ihtiyacı gerektiren uygulama örneklerin kayıt edilmesi içindir ki bunlar daha sonra geri bildirim bölümünde tartışılacaklardır. . Gözlem kontrol listesi, eğitimciler tarafından her bir katılımcıdan daha çok ve detaylı bilgi toplamak amacıyla değiştirilebilir ve/veya daha ileri bir şekilde geliştirilebilir. 1.6 Her bir sunumdan sonra eğitim programının değerlendirilmesi Bu, eğitim programı sunulduktan sonra değerlendirme için yapılan iyi bir uygulamadır. Eğitimciler katılımcılardan program boyunca düzenli olarak geri bildirim toplayabilirler. Eğitimciler eğitim programının sunuluş şekli ile ilgili kendi düşüncelerini de kaydedebilirler. Bu bilgi, programın sonunda eğitim programının zayıflıkları ve güçlü olan tarafları gibi bilgileri de içeren bir değerlendirme yapılmasını sağlar. Bu durum eğitimcilerin daha ileride yapacakları programlar için hem kendi kişisel becerilerini hem de programın kendisi ile ilgili geliştirme çabaları bağlamında yardımcı olur. Eğitim programı değerlendirme formu DVD de mevcuttur. Eğitimciler bu formu kendi ihtiyaçları doğrultusunda adapte edebilir ya da eklemeler yaparak geliştirebilirler. 1.7 Doğru/iyi uygulama eğitim tavsiyeleri/ipuçları Hazırlıklı olun o her bir bölüm planının eğitim başlamadan önce dikkatlice okuyun; o sunduğunuz her bir materyalden emin olun; o eğitimle ilgili kaynakları toplayın ve eğitim alanını iyi hazırlayın. Tekerlekli sandalye hizmetinde doğru uygulamalar için örnek olun o katılımcılara ve tekerlekli sandalye kullanıcılarına saygılı olun; o işinizde özenli olun; o eğitim alanındaki güvenliğe her an dikkat edin; o dakik olun ve bölümleri zaman tablosuna uygun olarak aktarın. Bilgiyi net olarak sunun o açık, net ve sakin konuşun; o odadaki herkesin sizi duyduğundan emin olun; o anlaşılıp anlaşılmadığınızı sorarak emin olun; o tahtaya yazdıklarınızı herkesin okuyabildiğinden emin olun; o önemli noktaları pekiştirmek için tekrarlayın. Bölüm zamanlarını ayarlayın o her bir bölüm için mevcut olan zamanını not alın ve zamanı dikkatli kullanın; o eğer ek zamana ihtiyacınız olma ihtimali varsa bunu baştan planlayın; o o gün için verilmesi planlanan bölümleri zamanında tamamlayın. Dikkatli açık ve net sunumlar yapın o herkesin net bir şekilde gördüğünden emin olun; o yapacağınız şeyin ne olduğunu ve ne yapacağınızı açıklayın; o gösterimi yavaş yapın ve gerekirse tekrarlayın. Kullanıcıların becerilerini geliştirin o katılımcıların pratik yapabilmeleri için her zaman fırsat kollayın; o yeni öğrenenlerin yeni bilgileri öğrenmek ve anlamak için zamana ihtiyacı olduğunu hatırınızdan çıkarmayın.. Küçük grup aktivitelerinde başarı sağlayın o grup aktivitelerini yakından gözleyin ve ihtiyaç varsa yardım edin; o küçük grubun etrafında dolaşın ve her birinin gelişimini kontrol edin Dil farklılıklarına dikkat edin o eğer katılımcılara ders başka bir dille anlatılıyorsa anladıklarından emin olun ve gerekiyorsa yavaşlayın o tekerlekli sandalye kullanıcıları ve bakıcıları arasındaki dil farklılıklarına dikkat edin; o gereken yerlerde tercüman kullanın. Katılımcıları aktif olmaları ve baştan sona eğitimin içinde rol olmaları için teşvik edin o bölüm planlarında verilen değişik metotları ve stilleri kullanın; o çok konuşmaktan kaçının – katılımcıların konuşmalarını ve kendi aralarında görüş alışverişinde bulunmalarını teşvik edin; o kullanıcıların sorularına sürekli cevap vermek yerine soruları hakkında düşünmeye ve kendi kendilerine cevap vermeye teşvik edin; o herkesi konuşmaya teşvik edin bir kişinin baskın çıkmasına izin vermeyin; o katılımcılardan gelen iyi işler için övgüler sunun ve iyi geri bildirim verin; o katılımcıların istedikleri zaman soru sorabileceklerini bilmelerini sağlayın; o gerçek örneklerle bağlantı kurarak katılımcıların farkında olmalarını sağlayın; o eğitimi eğlenceli hale getirin! Kısa “ısınma” aktiviteleri/oyunları kullan o Dikkatleri toplamak için kısa (5-10 dakikalık) ısınma aktiviteleri kullanın. Engelli olan katılımcıları içeren aktiviteleri kullanın. Isınma aktivitelerini, oyunlarından bazı seçmeler eğitim programı araçlar dosyasında vardır. Değişik yetileri olan kişilerin ihtiyaçlarını göz önünde bulundurun o Görme, duyma veya hareketlilikle ilgili zorlukları olan katılımcıların ihtiyaçlarını düşünün. Bazı aktivitelerin ve öğretim yaklaşımlarının bu durumlara göre adapte edilmesi gerekir. 2. Eğitim paketinin sunuma hazırlanması 2.1 Katılımcıların tekerlekli sandalye hizmet ağlarından haberdar olması Eğitimcilerin çalıştıkları yerlerdeki tekerlekli sandalye provizyon sistemini bilmeleri gerekmektedir. Bu durum şunları kapsar: o hangi tip tekerlekli sandalyeler mevcut ve tedarikçileri kim; o bölgede mevcut olan tekerlekli sandalye servisleri ve hangi düzeyde hizmet veriyorlar; alandaki sevk ağları ne durumda; o alandaki kaynak olabilecek kişiler kimlerdir ki bunlara eğitim sunumunda yardımcı olabilecek tekerlekli sandalye kullanıcıları da dahildir; o diğer rehabilitasyon hizmetlerine, ki bunlar tekerlekli sandalye hizmet personeli gerektiğinde tekerlekli sandalye kullanıcısını sevk edebilir 2.2 Katılımcıların hizmet sunumu konusundaki görevlerinin netleştirilmesi Katılımcıların çalıştıkları yerlerde genel görevleri içerisinde tekerlekli sandalye hizmet sunumunun nereye denk geldiğini öğrenin. Örneğin katılımcı sadece tekerlekli sandalye sunumunda mı çalışıyor yoksa başka görevleri de var mı? Katılımcı, tekerlekli sandalye hizmet sunumunda hangi rolü oynayacak bunu belirleyin. Örneğin bazı personeller eğitimde sadece klinik ya da teknik bölümlerin olduğu kısımları yerine getirirler. Başkaları ise her ikisini de hem klinik hem teknik kısımları tamamlarlar. Beklenen roller eğitim başlamadan oluşturulmalıdır. Eğitimciler, eğitimi katılımcılardan beklenen görevlerle bağlantılandırabilirler. Eğitim sunumundan önce yerel eğitmenler, tekerlekli sandalye servisleri bünyesinde eğitimi, katılımcıların rollerine adapte etmek ihtiyacı duyabilirler. 2.3 Her bir bölüm planının gözden geçirilmesi ve gerektiğinde düzenlemeler yapılması Her bir bölüm planını gözden geçirin ve her bir bölüm için bir lider eğitimci belirleyin. Birtakım eğitim bölümleri yerel şartlara uyabilmesi için düzenlenebilir. Değişik şartlara bağlı olarak yapılan düzenleme bölümleri ile ilgili öneriler bütün bölümlerin başlangıcında olan “İçerik” başlığı altında verilmiştir. 2.4 Kullanılacak tekerlekli sandalyenin tanımlanması Eğitimde hangi cins tekerlekli sandalyelerin kullanılacağını belirleyin. Bu sandalyeler katılımcıların çalıştıkları yerlerde bulunabilen sandalyeler olmalıdır. Eğer sandalyelerde çeşitlilik yelpazesi genişse, değişik modellerin arasından en iyi örnekleri ve genellikle bulunabilenleri seçin. Ayarlanabilir duruş desteği sağlayan araçlara sahip (örneğin; omuz bağları, omurilik desteği) “Orta” düzey özellikleri olan tekerlekli sandalyeleri almayın. Her bir tekerlekli sandalyenin özelliklerini tanıdığınızdan emin olunuz. Bir tekerlekli sandalye için veri formu doldurunuz ( bkz. DVD tekerlekli sandalye hizmet formları) ve tedarikçiden ürün bilgilerini elde ediniz. 2.5 Tekerlekli sandalye kullanıcılarının uygulamalı bölümlere davet edilmesi Katılımcılara bu eğitim programında becerilerin öğretilmesi sırasında uygulama yaptırmak için tekerlekli sandalye kullanıcıları ile çalışmaları gereklidir. Eğitim programından önce eğitimcilerin, programa katılmaya istekli ve uygulama bölümlerine devam edebilecek tekerlekli sandalye kullanıcıları belirlemesi ve davet etmesi gerekmektedir. Aşağıdaki tekerlekli sandalye kullanıcısı belirleme konusunda bir kontrol listesidir. Uygulamalı bölümlere katılacak tekerlekli sandalye kullanıcı katılım kontrol listesi: Uygulamalı bölümlere yardımcı olmak amacıyla kendi isteğiyle katılmayı kabul eder Tekerlekli sandalyelerinde iyi durumda oturabilmektedirler ve tekerlekli sandalyelerinde oturabilmek için değişimlere ve duruş desteğine ihtiyaçları yoktur. Bu olabilecek durumlar bu programın içeriğinde yoktur. Bu programa devam edebilecek rahatlıkta, sağlamlıkta ve sağlıktadırlar. Basınç yaraları yoktur. Yakında yaşamaktadırlar ve uygulama bölümüne gelmek için uzağa yolculuk yapmak zorunda değildirler. Uygulama bölümlerine gelmek için müsait zamanları vardır. Eğitimden sonra takiplerinin yapılabilmesi için ev sahibi kuruluşa yakın yaşamaktadır. Tekerlekli sandalye kullanıcısı bay ve bayan sayısı eşittir. Fiziksel ihtiyaç çeşitliliğini temsil etmektedir. Değişik yaşları temsil etmektedir. Tekerlekli sandalye takip bölümü için – en az üç ay tekerlekli sandalye kullanılmalıdır. Kaç tekerlekli sandalye kullanıcısına ihtiyaç var? Uygulamalı bölüm için kaç tekerlekli sandalye kullanıcısına ihtiyaç olduğu katılımcı sayısıyla bağlantılıdır. Ancak herhangi büyüklükteki bir eğitim programı için en az iki ila dört arasında tekerlekli sandalye kullanıcısına ihtiyaç vardır. Katılımcılar genellikle ikili ya da üçlü gruplar halinde bir tekerlekli sandalye kullanıcısı ile çalışırlar. Her bir uygulama bölümü için üçten fazla tekerlekli sandalye kullanıcısı olmayışı en iyisidir çünkü eğitmenler için gözlem ve izlemeyi zorlaştırabilir. Uygulama bölümüne gelen tekerlekli sandalye kullanıcısının bilmesi gereken neler vardır? Uygulama bölümüne gelen tekerlekli sandalye kullanıcısı şunları bilmelidir: o bu bölüme geldiklerinde ne olacak; o ne zaman ve ne kadar süre gelecekler; o aileden birisi ya da yardımcıları ile gelebilirler; o eğitime baştan sona devam ettiklerinde için tekerlekli sandalye alıp almayacaklarını bilmeleri gerekir. Eğitimciler ve ev sahibi kuruluş uygulama bölümlerine devam eden tekerlekli sandalye kullanıcılarına transportlarını sağlama ya da ulaşım masraflarını karşılama ve katılım ücretlerini karşılamayı teklif ettiklerinden emin olmaları konusunda teşvik edilirler. Onlar eğitim programına geldiklerinde ikram için yiyecek ve içecek olması gerekir. Eğitimciler ve ev sahibi kuruluş tekerlekli sandalye kullanıcılarına, katılımcı olarak geçirdikleri zaman için günlük bir ödeme (harcırah) sağlayabilirler. Tekerlekli sandalye kullanıcıları için davet mektubu örneğini ve rıza formunu DVD içindeki eğitim programı formları dosyasında bulabilirsiniz. Bu özel şartlar için adapte edilmeli, ilgili dile çevrilmeli ve tekerlekli sandalye kullanıcısına (gönüllüye) katılımcı olma ilgili seçeneği konusunda bilgilendirmek için gönderilmelidir. Takip o Eğitimciler ya da ev sahibi kuruluş programın bitiminde her şey tamamlanmış olmayacağından dolayı eğitim sırasında görülen tekerlekli sandalye kullanıcısı için hemen bir takip planı yapmalıdır, o Eğitim sırasında tekerlekli sandalye alan her tekerlekli sandalye kullanıcısı ev sahibi kuruluş/eğitimciler tarafından sandalyesini almasının ardından 6-8 hafta içerinde takip edilmelidir. 2.6 Uygulama bölümleri için grup planlaması Her bir grup üç katılımcıdan fazla olmamalıdır. Dörtlü bir grup olmasındansa ikili iki grup olması daha iyidir. Bu şekilde katılımcıların öğrendiklerini uygulama ve becerilerini geliştirme imkânları olmasını garanti eder. Eğitimciler kimin hangi grupta olacağına karar vermelidirler. Bu kararı katılımcılara bırakmayınız. Katılımcıların becerilerine ve şartlarına bağlı olarak eğitimciler gruplarını şu şekilde seçebilirler. o Kendine güveni daha az ve daha yüksek olanlar katılımcılarla bir takım kurun. Kendine güveni yüksek olanlar diğerlerine rehberlik ederek yardımcı olabilirler. Herkesin iştirak ettiğinden emin olmak için grubu yakından gözlemleyin/izleyin. o İleride beraber çalışacak kişilerle bir takım oluşturun ki bu şekilde becerilerini bir takım olarak geliştirebilirler. “Birinci ve ikinci” uygulama için aynı katılımcıları aynı grupta kalmasını sağlayın. “üçüncü ve dördüncü” uygulamalar için ise beraber ne kadar iyi çalıştıklarına bağlı olarak değiştirilebilir. Her bir uygulama bölümü için bir “rehber” kişi belirleyin. Ve her katılımcının rehber olabilme imkânına sahip olduğundan emin olun. Rehber olan kişiye her adımın uygulanmasından sorumlu olduğunu söyleyin. Rehber kişi tekerlekli sandalye kullanıcısı ile ve gerekiyorsa ailesi/bakıcısıyla iletişim kuracak olan kişi olacaktır. 2.7 Tesislerin ayarlanması Eğitimi yapmak için büyük bir eğitim alanı (ya da boşluk) kullanılabilir. Bu alan katılımcıların ve tekerlekli sandalye kullanıcılarının uygulama bölümünde rahatlıkla hareket edebilecekleri ve küçük gruplara ayrılabilecekleri kadar büyük bir salon olmalıdır. Aynı zamanda tekerlekli sandalye hareketlilik becerileri uygulamaları için bir dış mekâna; öğle yemeği ve içecek servisi için ayrı bir bölüme ve temiz tuvaletlere ihtiyaç vardır. Bütün bu alanlar, tuvaletler de dâhil olmak üzere tekerlekli sandalye ile girilebilir alanlar olmalıdır. Aşağıdaki kontrol listesi eğitim alanını belirlemek ve hazırlamak için kullanılabilir. Tesis kontrol listesi: Eğitim alanı Konferans alanı Her bir katılımcı için sandalye: katılımcıların not tutabilmesine imkân sağlayacak türden Katılımcıların 2-3 kişilik gruplara ayrılmasına müsaade edecek büyüklükte bir alan En az üç tekerlekli sandalyenin gösterilebileceği ve etrafta hareket edebileceği kadar büyük bir alan. Tekerlekli sandalye kullanıcılarının uygulama bölümü sırasında mahremiyetlerini korumak için panolar. Minder yapımı bölümü için büyük masalar ya da sıralar. Yeterli ışık & havalandırma Kilitlenebilir/ güvenli Tekerlekli sandalye hareketliliği eğitim alanı Pürüzsüz düzgün yüzey Tek basamak Kısa mesafeli merdivenler Engebeli yüzey Eğimli yüzey Öğle yemeği / ikram alanı Yemek için temiz alan Masalar ve sandalyeler Yakın mesafede el yıkanacak alan - temiz havlu ve sabun Tuvaletler Temiz tuvaletler, su, tuvalet kâğıdı, el yıkama tesisatı ve çöpler. 2.8 Eğitim kaynaklarının ve materyallerinin ayarlanması Basılı kaynaklar Kaynak Miktar  Açıklama /talimatlar Kılavuzlar, el kitapları ve posterler: Eğitimci Kılavuzu Her eğitimciye 1 adet DSÖ’ den sipariş verin ya da basın ve dosyalayın Referans Kılavuzu Her katılımcıya 1 adet DSÖ’ den sipariş verin ya da basın ve dosyalayın Katılımcı El Kitabı Her katılımcıya 1 adet DSÖ’ den sipariş verin ya da basın ve dosyalayın Poster seti Her katılımcıya 1 adet DSÖ’ den sipariş verin ya da basın ve dosyalayın Tamamlayıcı materyal: DSÖ Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler Her bir katılımcı için en az bir kopya Eğer mümkün ise katılımcılar için bir elektronik kopya sağlayın; Elektronik kopyalar ve değişik dil seçenekleri için bkz, : http://www.who.int/disabilities/en/. Birleşmiş Milletler Engelli Haklarına İlişkin Sözleşme Her bir katılımcı için bir kopya Değişik dil seçenekleri için : http://www.un.org/disabilities/default.asp?id=150; http://uncrpdindia.org/about/text/. Eğitim programı formları: Katılımcı kayıt formu Program için 1 adet Bu formu katılımcıların devamlılığını kayıt etmek içim kullanın. Yaka kartı Her katılımcı & eğitmen için 1 adet Zaman tablosu Her bir katılımcı için 1 adet DVD de örnekler mevcuttur; yerel şartlara uyması için ayarlama yapınız Fotoğraf izin formu Her bir katılımcı için 1 adet ve Her bir tekerlekli sandalye kullanıcısı(gönüllü) için 1 adet Bu formu eğitim/ev sahibi kuruluş için adapte ediniz; yerel dile çevirin; fotoğrafı çekilmiş her kişinin bu formu imzalamasını sağlayınız Davet mektubu ve tekerlekli sandalye kullanıcısı izni Her 1 tekerlekli kullanıcısı için 1 adet Örneği verilmiş mektubu uygulama bölümüne kişileri davet etmek için adapte ediniz. Uygulama bölümü için tekerlekli sandalye kullanıcı listesi Her eğitimci için 1 adet Bu formu uygulama bölümüne devam eden kişilerin kayıtları için kullanın ve kimin devam ettiğini ve ne zaman geldiğinin kaydını tutun. Katılımcı sertifikası Her bir katılımcı için 1 adet Katılımcı sertifikalarını hazırlayın ya da verilmiş şablondan adapte edin. Eğitim programı değerlendirme formu: Katılımcılar için eğitim programı değerlendirme formu Her bir katılımcı için 1 adet Örnek eğitim programı değerlendirme formları; bunlar gerekli olduğunda eğitmenler tarafından adapte edilebilir. Eğitmenler için eğitim program bölüm değerlendirmesi Her bir bölüm için 1 adet Eğitmenler için eğitim programı değerlendirme formu Her bir eğitimci için 1 adet Uygulama bölümü için eğitimci gözlem kontrol listeleri formu: Birinci Uygulama Her bir eğitimci için 1 adet Basınız İkinci Uygulama Üçüncü Uygulama Dördüncü Uygulama Tekerlekli sandalye hizmet formları: Tekerlekli sandalye hizmet sevk formu Her bir katılımcı için 1 adet Eğer varsa yerel sevk formunu kullanın veya yerel şartlara uyması için adapte edin. Tekerlekli sandalye değerlendirme formu Her bir tekerlekli sandalye kullanıcısı için 1 adet Yerel şartlara uyması için adapte edin, örneğin tekerlekli sandalye hizmet adı veya yerel hizmetin ihtiyacı olan ilave bilgiyi ekleyin. Tekerlekli sandalye reçete(seçim) formu Her bir tekerlekli sandalye kullanıcısı için 1 adet Tekerlekli sandalye boyutları ve seçeneklerine bağlı olarak sonucu netleştirin. Tekerlekli sandalye veri formu Her bir tekerlekli sandalye kullanıcısı için 1 adet Eğitim programı başlamadan önce yerel olarak bulunabilen her bir tekerlekli sandalye için bir tane doldurun. Tekerlekli sandalye takip formu Her bir tekerlekli sandalye kullanıcısı için 1 adet Yerel şartlara uyması için adapte edin- örneğin tekerlekli sandalye hizmet adı veya yerel hizmetin ihtiyacı olan ilave bilgiyi ekleyin. Kontrol listesi: Tekerlekli sandalye uygunluk kontrol listesi Her bir katılımcı için 1 adet Kontrol listeleri “tekerlekli sandalye hizmet formları” altındaki basılı kaynaklarda bulunabilir. Tekerlekli sandalye kullanıcı eğitim kontrol listesi Tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi Posterler: Tekerlekli sandalye hizmet adımları 1 Tekerlekli sandalye hareketlilik becerileri 1 Basınç yaraları 1 Evde tekerlekli sandalye bakımı 1 Opsiyonel form (lütfen dikkat edin, bu form eğitim paketinin dâhilinde değildir, sadece yerel olarak uygun ise kullanınız): Tekerlekli sandalye sipariş formu Her katılımcı için 1 adet Eğer yerel olarak uygunsa eğitmenlerin kullanacağı sipariş formu Materyaller Madde Miktar Beyaz tahta kalemleri 3–4 Köpük parçaları 4–5 Sunum için örnek parçalar yaklaşık 100x110x50mm Ayak bileği /baldır bantları 2–3 set Eğer mümkünse Ekipman Madde Miktar Geniş beyaz tahta 1 Veri projeksiyon makinesi 1 Bilgisayar 1 Portatif hoparlörler 1 set DVD i duymaya yardımcı olması için Dijital kamera 1 Eğer mümkünse, değişik bölümler için Değerlendirme yatağı Her bir kullanıcı için 1 adet Uygulama bölümünde tekerlekli sandalye kullanıcıları için kullanılacak Bank / değerlendirme sedyesi ya da baza. Yükseklik ortalama bir tekerlekli sandalye yüksekliğinde olmalıdır Mümkünse sert yüzeylerden kaçının- eğer bank kullanılıyorsa ince bir köpük katmanı ve örtü ya da yoga matı koyunuz. Ayak blok seti 1 set Tahta bloklar tekerlekli sandalye kullanıcısının ayaklarının altına değerlendirme yatağında otururken koymak içindir. Bir kaç değişik yüksekliğe ihtiyaç vardır. Transfer tahtası Her 3 katılımcı için 1 adet Eğer mümkünse Mezura Her bir katılımcı için 1 adet Omurga, pelvis ve femurları da olan ½ anatomik iskelet 1 Eğer mümkünse Eğitim için tekerlekli sandalye ve minderler Yerel olarak bulunabilen tekerlekli sandalye ve minderden en az 1’er tane; ideal olarak her bir katılımcı için 1 tekerlekli sandalye ve 2 minder Bütün tekerlekli sandalyelerin düzgün bir şekilde çalıştığından ve minderleri olduğundan emin olun; en az bir tane iyi örnek olacak basınç rahatlatıcı minder sağlayın. Tekerlekli sandalye kullanıcıları gönüllülere sağlanmak üzere tekerlekli sandalyeler ve minderler Uygulama bölümlerine katılan her bir tekerlekli sandalye kullanıcısı için 1 adet. Tekerlekli sandalye ve minder reçete edebilmek için yeteri kadar tekerlekli sandalye ve mindere en azından iyi örnek basınç rahatlatıcı mindere ihtiyaç vardır. Evde bakım alet takımı Her üç katılımcı için 1 adet Takımın içeriği: Kurbağacık, aylan anahtarları, tekerlek pompası, makine yağı, kova, sabun, bez, zımpara Post-it not kâğıdı ya da not kâğıdı Her bir katılımcı için 1 adet Minder yapımı – materyaller ve araçlar Madde Miktar Örnek konturlu köpük basınç rahatlatma minderi ve kılıfı 1 Eğer yoksa eğitimcilerin bunu eğitim programından önce yapmaları gerekecektir. Örnek minder yükseltici 1 Minder yapımı alet takımı Her iki katılımcı için 1 alet takımı Takımın içeriği: o 1 x bilenmiş demir testeresi ağzı ya da uzun bıçak o 1 x siyah keçe kalem; o Köpük yapıştırıcı ve yapıştırıcıyı dağıtmak için karton parçaları Minder materyalleri Her iki katılımcı için 1 set Her birinin içeriği o katı köpük (örn parça köpük) – 50 x 400 x 400 mm; o yumuşak köpük – 50 x 400 x 400 mm. Minder kılıfı yapılabilecek kumaş parçaları örnekleri Her birinden 1 adet Uygun kumaşlarla ilgili daha çok bilgi için minder yapımı bölümüne bakınız. 3. Detaylı bölüm planları Giriş H E D E F LE R Bu bölümün sonunda katılımcılar:  eğitim programının hedeflerini öğrenecekler;  katılımcıların ve eğitmenlerin adlarını öğrenecekler;  eğitim programı zaman tablosuna genel bir bakış yapacaklar;  eğitim programı sırasında hatırlayacakları önemli kuralları öğrenecekler. K A Y N A K LA R Bölümler için:  PPT slaytları: Giriş;  her bir katılımcı için Referans Kılavuzu;  her bir katılımcı için Katılımcı El Kitabı;  DVD: Giriş  her bir katılımcı için zaman tablosu kopyası;  her bir katılımcının ve eğitmenin yaka kartları. İÇ E R İK Bu bölümü eğitimin verildiği yerdeki yerel şartlara göre uyarlayın. Örneğin:  kültürel duruma ve şartlara uygun bir açılış töreni ekleyin;  eğitimcilere ve katılımcılara uygun olacak şekilde “eğitimci ve katılımcıların tanıtımı” bölümünü değiştirin ya da uygun olan şekilde uyarlayın;  ‘katılımcıların “hazırlığı ve beklentileri”’ listesini gerektiği şekilde değiştir, uyarla ve/veya ekle, örnekler eğitim programı taslakta sunulmuştur;  eğitim programında değişiklik yapılmışsa eğitim programı taslak slaydını değiştirin (örneğin hedefler eklenmiş ya da çıkarılmış). H A Z IR LI K  kaynakları bir araya toplayın, PPT slaytlarını gözden geçirin, DVD i izle ve bölüm planını okuyun. T A S LA K 1. açılış töreni (eğer varsa). 2. eğitmenlerin ve katılımcıların tanıtımı. 3. eğitim programına genel bakış. 4. eğitim programı zaman tablosu, Referans Kılavuzu ve Katılımcı El Kitabı 5. “Hazırlık” ve katılımcıların beklentileri. 15 15 10 10 10 Toplam bölüm süresi 60 1. Açılış Töreni (tahmini süre 15 dakika) 2. Eğitmenlerin ve katılımcıların tanıtımı (15 dakika) Eğitmenler: Kendinizi tanıtın. Geçmişinizi, tekerlekli sandalye provizyonu ile ilgili tecrübeleriniz hakkında kısa bir konuşma yapın. Katılımcılara adlarını, hangi kurumlardan geldiklerini ve bu programdan beklentilerinin neler olduğunu sorun. Eğer kayıt sırasında verilmemişse yaka kartlarını verin. 3. Eğitim programına genel bakış (10 dakika ) Açıklayın: Bu programın amacı, düzgün bir şekilde oturabilen ergen ve yetişkinlere uygun manüel bir tekerlekli sandalyenin nasıl sağlanacağını katılımcılara öğretmektir.  Eğitim Paketinin kapsamı: – Tekerlekli sandalye değerlendirmesi; – Seçim, hazırlık, uygunluk; – Tekerlekli sandalye kullanıcısı talimatları; – Bakım ve onarım; – Takip; – Köpük basınç rahatlatma minder yapımı. DVD tanıtımı: Giriş. Bu kısa DVD özet bir şekilde tekerlekli sandalye eğitim programından, amacından, hedef ve beklentilerden bahsedecektir. DVD göster. Soru olup olmadığını öğren. 4. Eğitim programı zaman tablosu, Referans Kılavuzu ve Katılımcı El Kitabı (10 dakika) Her bir katılımcıya zaman tablosunun bir kopyasını verin. Açıklayın: o Eğitim programı teori/sınıf bölümleri ile başlayacak o Bunun ardından katılımcılar teori dersinde öğrendikleri bazı becerileri yardım etmeye gönüllü olan tekerlekli sandalye kullanıcıları ile uygulamaya dökecekler. Her katılımcıya Referans Kılavuzunun bir kopyasını verin. Katılımcılara kılavuzun üstüne isimlerini yazmasını söyleyin. Bu kılavuzlara ek bilgiler yazabilecekleri açıklamasını yapın. Her bir katılımcıya Katılımcı Kılavuzunun bir kopyasını verin. Katılımcılara kılavuzun üstüne isimlerini yazmasını söyleyin. Bu kılavuza ek bilgiler yazabilecekleri açıklamasını yapın. 5. Hazırlık ve beklentiler (10 dakika) Gerektiği şekilde aşağıdaki açıklamaları yapın o Tuvaletlerin yerleri; o Konaklama için kiminle konuşulacak kişi; o Bireysel katılımcıların dönüş yolculukları için kiminle konuşacaklarını söyleyin (ayrıntıya girmeyin); o Acil durumlarda ne yapılacağını anlatın. Eğitim programında katılımcılardan beklenenleri gerektiği şekilde açıklayın: o Her bir oturum zamanında başlayacaktır, katılımcılar her gün eğitime zamanında gelmeliler ve verilen aralardan sonra zamanında geri dönmelidirler; o Katılımcılar emin olmadıkları şeylerle ilgili her zaman soru sormalılardır; o Bütün tekerlekli sandalye kullanıcılarına eşit şekilde davranın onurlarına saygı duyun; o Ders boyunca cep telefonlarınızı kapatın; o Eğlenin! Açıklayın: Program boyunca katılımcılar tekerlekli sandalyeleri kullanacaklar ve itecekler. Bu kullanımlar sırasında aşağıdaki güvenlik kurallarını hatırlayınız: o Tekerlekli sandalyeye binerken ve inerken ayaklıkların üzerinde durmayın; o Parmaklarınızı tekerlek jant tellerinden uzakta tutun; o Eğimli zeminde tekerlekli sandalyeyi kullanırken geri düşme ihtimaline karşı arkanızda bir yardımcı olsun. A: Temel bilgi A.1: Tekerlekli sandalye kullanıcıları H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabiliyor olacaklar:  uygun bir tekerlekli sandalyenin tekerlekli sandalye kullanıcısı için en az yedi faydasını listeleyebilecekler;  tekerlekli sandalye personelinin tekerlekli sandalye kullanıcısın kişisel hareketlilik hakkını nasıl destekleyebileceğini açıklayabilecekler.  tekerlekli sandalye kullanıcılarının tekerlekli sandalye provizyonunda en az beş yolla nasıl aktif bir şekilde katılabileceğini listeleyebilirler. K A Y N A K LA R Bölüm için:  PPT slaytları A.1 Tekerlekli sandalye kullanıcıları;  Referans Kılavuzu  DVD: Uygun tekerlekli sandalyenin faydaları;  Birleşmiş Milletler Engelli Haklarına İlişkin Sözleşme’ nin (UNCRPD) kopyaları, eğer var ise; Ek referans materyalleri (eğitmenler için): o DSÖ Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler (sayfa 23). İÇ E R İK Bu bölümü katılımcıların geldiği şartlara uyarlayın. Örneğin:  Katılımcıların Birleşmiş Milletlerin bu sözleşmesini (UNCRPD) daha önceden biliyor olabilirler – bu durumda UNCRPD ile ilgili ne bildiklerini sorabilirsiniz;  UNCRPD’ nin katılımcının ülkesinde imzalanmış/onaylanmış olduğundan haberiniz olsun. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun. T A S LA K 1. Giriş. 2. Bir tekerlekli sandalyenin faydaları nelerdir? 3. “Uygun tekerlekli sandalye” nedir? 4. Birleşmiş Milletler Engelli Haklarına İlişkin Sözleşme. 5. Tekerlekli sandalye kullanıcıları tekerlekli sandalye hizmet sunumunda eşit ortaklardır. 6. Kilit nokta özeti. 2 10 5 5 20 3 Toplam bölüm süresi 45 1. Giriş (2 dakika) Açıkla: Bu bölümde tekerlekli sandalye kullanıcılarının uygun bir tekerlekli sandalyeden nasıl fayda sağlayabileceklerinden bahsedilecektir. Katılımcıların tekerlekli sandalye sağlama sürecinde kullanıcılar ile nasıl aktif bir şekilde çalışabileceğini düşünün ve bu neden bu kadar önemlidir. Aynı zamanda Birleşmiş Milletler Engelli Haklarına İlişkin Sözleşme’sine kısaca bir bakılacaktır, özellikle Madde 1, Madde 3 ve Madde 20. 2. Tekerlekli sandalyenin faydaları nelerdir? (10 dakika) Uygun tekerlekli sandalye tanımını okuyun. Açıkla: o Bu tanım Dünya Sağlık Örgütü’nün Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergelerinde geçmektedir. Bu eğitim programında bu Yönergeler’ e sıkça atıfta bulunacağız. o Her bir tekerlekli sandalye kullanıcısı için “Uygun tekerlekli sandalye” onların kişisel ihtiyaçlarına ve çevresel şartlarına göre değişecektir. DVD tanıtımı: Tekerlekli sandalyenin faydaları Bu kısa DVD değişik tekerlekli sandalye kullanıcılarının değişik aktivitelerini gösterecektir. Dikkatle izleyin, ardından tekerlekli sandalye kullanıcısının değişik tekerlekli sandalyelerden nasıl faydalar sağladıkları konusunda konuşacağız. DVD göster. Soru olup olmadığını sorun. Sorun: Tekerlekli sandalye kullanıcısının sandalyesi olmasından ne gibi faydalar edindiğini DVD de görüntülenen şekliyle anlatın. Cevaplar vermeye teşvikte bulunun ve bunları tahtaya yazın. Cevaplar: o hareketlilik; o sağlık; o dik oturmaya yardım; o rahatlık; o kendine güven ve konfor ; o itibar; o okula gitmek; o spor yapmak ; o çalışmak; o toplumun ve ailenin bir parçası olmak; o bağımsızlığın artışı. Açıklayın: o Listeden gördüğümüz üzere tekerlekli sandalyenin pek çok faydası vardır. o En önemli olan şudur ki tekerlekli sandalye provizyonu sadece bir ürün olan tekerlekli sandalye ile alakalı değildir. o Tekerlekli sandalye provizyonu engelleri ile beraber hareket özgürlüğüne sahip olabilmekle, sağlıklı kalabilmekle ve tam anlamıyla toplum hayatının içinde olabilmekle alakalıdır. o Videodaki her bir tekerlekli sandalye kullanıcısı farklıdır. Bununla beraber her biri kendileri için “uygun” olan bir tekerlekli sandalyeye sahiptir. 3. Uygun tekerlekli sandalye nedir? (5 dakika) o “Uygun tekerlekli sandalye” şudur ki: – kullanıcısının ihtiyaçlarını karşılar; – kullanıcısının çevresel şartlarına uygundur; – kullanıcısı için doğru seçimdir; – duruş desteği sağlar (kullanıcının dik oturmasına yardımcı olur); – yaşanılan bölgede bakımı ve onarımı yapılabilir. 4. Birleşmiş Milletler Engelli Haklarına İlişkin Sözleşme (5 dakika) Açıkla: o Hepimiz biliyoruz ki tekerlekli sandalyeye ihtiyacı olan pek çok kişinin hala uygun bir tekerlekli sandalyesi yoktur. Ancak şimdi elimizde, tekerlekli sandalyeye ihtiyacı olan insanların haklarını savunmak için kullanabileceğimiz bir aracımız var. o 2006 yılında Birleşmiş Milletler Engelli Haklarına İlişkin Sözleşme imzalandı. (BMEHİS kısaltılmış olarak) 2008 yılında Uluslararası bir kanun haline geldi. (Eğer bu antlaşma katılımcıların ülkelerinde imzalanmışsa bunu belirtin) Sorun: Sözleşmeyi duyan var mı? Duymuş olanları onaylayın. Açıkla: Herkes için geçerli olan insan hakları vardır. BMEHİS’nin odak, noktası herkese tanınan bu hakların engelli kişilere uygulandığından da emin olunması gerekliliğidir. . Açıklayın: o Sözleşmede 50 farklı madde vardır. . o 20. Madde kişisel hareketlilik ile ilgilidir. . o Kişisel hareketlilik şu anlama gelir: o Bir şekilde hareket kabiliyetine kendi tercihi ile sahip olmak. Sor: Katılımcılar, bir tekerlekli sandalye hizmetinde üstlendikleri rolde tekerlekli sandalye kullanıcısının kişisel hareketlilik hakkını nasıl destekleyebilirler? Cevapları teşvik edin ve tahtaya yazın. En önemli cevaplar: o tekerlekli sandalye kullanıcılarının, tekerlekli sandalyeleri hakkında karalara dâhil edin; o tekerlekli sandalye kullanıcısının ihtiyaçlarını anlayın ve bunların karşılanmasına yardımcı olun; o uygun bir tekerlekli sandalye sağlanmasına yardımcı olun; o tekerlekli sandalye kullanıcılarının sandalyelerine kendi kendilerine binip inmeyi öğrenmelerine yardımcı olun; o tekerlekli sandalye kullanıcılarının sandalyelerini kendi başlarına itmeyi öğrenmelerine yardımcı olun; o aile üyelerini, tekerlekli sandalye kullanıcılarının daha bağımsız hareket etmeleri için destek olmaları yönünde teşvik edin; o ülkede gelişmiş hareketlilik ürünlerinin kullanılabilirliğinin artmasının savunucusu olun; o ülke içinde bariyer/engel olmayan bir çevrenin savunuculuğunu yapın. Sorun: Hareket zorluğu olan bir kişinin uygun tekerlekli sandalyesi olduğu takdirde erişilebileceği başka bir insan hakkı var mı? Aklınıza gelen bir şey var mı? Cevapları teşvik edin ve tahtaya yazın (ihtiyaç olursa haklardan örnekler verin). Cevaplar (Sözleşme maddelerini belirtmek gerekliliği yoktur): o bağımsız yaşama ve toplumun bir parçası olmak(madde19); o eğitim hakkı (madde 24); o erişilebilir en yüksek sağlık standartlarından yaralanma hakkı (madde 25); o çalışma ve istihdam hakkı (madde 27); o politik ve sosyal yaşama katılım hakkı (madde 29); o kültürel hayat, eğlence, boş zaman faaliyetleri ve spor aktivitelerine katılma hakkıdır (madde 30). 5.Tekerlekli sandalye kullanıcıları hizmet sunumunda eşit ortaklardır. (20 dakika ) Açıkla: Tekerlekli sandalye kullanıcıları genellikle kendileri için “uygun tekerlekli sandalye” nin ne olduğunu bilirler. Eğer zaten bir tekerlekli sandalye kullanıyorlarsa onlar için neyin uygun olduğu ve neyi değiştirmek istedikleri hakkında fikirleri olacaktır. Daha önce tekerlekli sandalye kullanmamış olanlar daha çok bilgiye ihtiyaç duyacaklardır. Tekerlekli sandalye hizmet personeli tekerlekli sandalye kullanıcısıyla eşit katılımcılar olarak çalışmalıdır. Küçük grup aktivitesi Gruplar: Her bir grupta 2-3 kişi olsun. Talimatlar: Her bir gruba iki dakikalık bir oyun hazırlamaları için beş dakikalık süreleri olduğunu söyleyin. Oyun tekerlekli sandalye almaya gelen bir kullanıcı üzerine olacak. Bir katılımcı tekerlekli sandalye almaya gelen kullanıcı, diğeri hizmet personeli, diğeri ise kullanıcının aile üyesi olacak. Gruptakilerin yarısına, kullanıcının uygun tekerlekli sandalye alma hakkı yokmuş gibi SAYGISIZCA davranan bir tekerlekli sandalye hizmet personeli olmasını ve tekerlekli sandalye hizmet sunumunda kullanıcının aktif katılımcı olmasına ENGEL olmasını söyleyin. Diğer gruba ise kullanıcının uygun tekerlekli sandalye alma hakkına SAYGILI bir tekerlekli sandalye hizmet personeli olmasını ve kullanıcının hizmet sunumunda aktif rol almasına İZİN vermesini söyleyin. İzle: Grupları izleyin/gözlemleyin gerekirse yardım edin. Zaman: 5 dakika hazırlık; 10 dakika oyun ve 5 dakika geri bildirim. Geri bildirim: Tekerlekli sandalye kullanıcısına SAYGISIZ davranan hizmet personelini oynayanlardan ve bir de kullanıcıya SAYGILI davranan hizmet personelini oynayan gruplardan en az birine sorun. Geri bildirim tartışması: o tekerlekli sandalye personelinin; tekerlekli sandalye kullanıcısı ve ailesi ile kurduğu iletişim hakkında konuşun, tartışın; o her gruptaki tekerlekli sandalye kullanıcısına kendini nasıl hissettiğini sorun; o eğer eğitim sırasında orada bulunanlar arasında tekerlekli sandalye kullanıcısı var ise sorun; bu oyundakilere benzer iyi ya da kötü deneyimleri olmuş mu? Sorun: Oyunu düşündüğünüzde, tekerlekli sandalye hizmet personelinin, tekerlekli sandalye kullanıcını, uygun tekerlekli sandalye sağlama işlemine aktif bir şekilde dahil etmesinin yolları nelerdir? Cevap vermeye teşvik edin. En önemli cevaplar: o tekerlekli sandalye kullanıcısı ile doğrudan konuşun; o tekerlekli sandalye kullanıcısına fikrini sorun; o kullanıcıya mümkün olan her durumda seçenekler sunun ve seçimlerine saygı gösterin; o kullanıcıya seçim yapabilmesi için bilgi verin; o kullanıcının hayatı, tekerlekli sandalyesi ile ne yapmak istediği ve yaşadığı, çalıştığı ortamla ilgili konularda bilgi toplayın. 6. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. A.2: Tekerlekli sandalye hizmetleri H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  tekerlekli sandalye hizmetinin ne olduğunun açıklanması;  temel tekerlekli sandalye hizmetinde rollerinin ne olduğunun tanımlanması;  tekerlekli sandalye hizmet sunumunda “temel seviye hizmet” ini tanımlayabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: A.2: Tekerlekli sandalye hizmetleri;  Referans Kılavuzu  poster: Tekerlekli sandalye hizmet adımları Ek referans materyalleri (eğitmenler için):  DSÖ Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler (sayfa 71–72, 76–77). İÇ E R İK Bu bölümü katılımcıların çalışıyor olacakları şartlara uyacak şekilde uyarla. Aşağıdakiler hakkında düşünün.  Tekerlekli sandalye hizmet sunumunda her bir katılımcının çalıştıkları yerlerdeki rollerini düşünün. Örneğin her bir katılımcı tekerlekli sandalye hizmet sunumundaki sekiz adımdan sorumlu olacak mı? Bu bölümü katılımcıların rollerinin ne olacağının ne olacağını açıklamak için kullanın. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD’i seyredin ve bölüm planını okuyun.  Her bir hizmet adımında katılımcıların rollerinin ne olacağı ile ilgili bilgi hazırlayın. T A S LA K 1. Giriş 2. Tekerlekli sandalye hizmetleri 3. Tekerlekli sandalye hizmet personeli rolleri. 4. “Temel düzey hizmet” ne anlama gelir? 5. Kilit nokta özeti 2 10 10 5 3 Toplam bölüm süresi 30 1.Giriş (2 dakika) Açıkla: Bu bölümde yapacaklarımız; o tekerlekli sandalye hizmetinin ne olduğunu açıklanacak ve “temel” seviye hizmet ile “orta” düzey hizmet arasındaki farklar izah edilecek; o tekerlekli sandalye hizmet sunumundaki kilit adımlardan bahsedilecek; o temel seviye tekerlekli sandalye hizmeti sağlanırken her bir katılımcının alacağı rolden bahsedilecek. 2. Tekerlekli sandalye hizmetleri (10 dakika ) Açıklayın: Bir tekerlekli sandalye servisi, tekerlekli sandalye kullanıcısı ile beraber (mevcut olan sandalyeler arasından) kullanıcı için en uygun sandalyeyi sağlamak için çalışır. Sorun: Tekerlekli sandalye personeli her bir tekerlekli sandalye kullanıcısı için en uygun sandalyeyi seçmek amacıyla neler yapmalıdır? Cevap vermeye teşvik edin ve tahtaya yazın. En önemli cevaplar: o tekerlekli sandalye kullanıcısın ihtiyaçlarının neler olduğunu öğrenin (değerlendir); o tekerlekli sandalye kullanıcısı için en iyi sandalyeyi seçin (reçete); o tekerlekli sandalye sağlayın (sipariş, muhtemelen montaj, ayar ve uygunluk). Sorun: Tekerlekli sandalye servisi, tekerlekli sandalye kullanıcısının sandalyesinden en çok faydayı alması için nasıl yardımcı olabilir? Cevap vermeye teşvik edin ve tahtaya yazın. En önemli cevaplar: o tekerlekli sandalye kullanıcılarına tekerlekli sandalyelerini nasıl kullanacaklarını ve bakımını nasıl yapacaklarını öğretin (kullanıcı eğitimi); o tekerlekli sandalye kullanıcılarına tekerlekli sandalyelerinin onarımını nasıl yapacakları konusunda yardımcı olun (evde bakım, onarım ve takip); o tekerlekli sandalyenin, kullanıcının ihtiyaçlarını karşılamaya devam ettiğinden emin olmak için destek sağlayın ve takip edin; o tekerlekli sandalye kullanıcısını onlara yardımcı olabilecek diğer servislere gönderin. 3. Tekerlekli sandalye hizmet personelinin görevleri (10 dakika) Tekerlekli Sandalye Hizmet Adımları posterini takın. Açıkla: Temel tekerlekli sandalye personelinin görevi, duruş desteği almadan dik bir şekilde oturabilen kullanıcıya mevcut olan en iyi tekerlekli sandalyeyi sağlamaktır. Bunu yapmak için personel, kullanıcı ve kullanıcının ailesiyle beraber aşağıdaki kilit hizmet adımlarını takip eder. Aşağıdaki sırayla her bir adımı açıklayın. Sevk ve randevu Sevk ve randevu: o Sevk, tekerlekli sandalye kullanıcılarının tekerlekli sandalye hizmetlerine gelme yoludur. o Kullanıcıların sevk şekilleri çeşitli şekillerde olacaktır. o Kullanıcılar kendileri başvurabilirler kamu veya sivil toplum sağlık ağları aracılığı ile ya da rehabilitasyon çalışanları veya kamusal, yöresel ve bölgesel alanda çalışan gönüllüler aracılığı ile sevk edilebilirler. o Her hizmetin bir randevu sistemi ayarlaması gerekmektedir. Değerlendirme: o Her kullanıcıya bireysel değerlendirme yapılması gerekir. o Burada toplanacak bilgiler şunları içerir; kullanıcı hayat tarzı, ne iş yaptığı, nerede yaşadığı ve fiziksel şartları ve ölçümlerinin yapılması. Reçete (seçim): o Değerlendirmede elde edilen bilgileri kullanarak reçete (seçim), kullanıcı, aile üyeleri veya bakıcı ile beraber geliştirilir. o Reçete (seçim) tekerlekli sandalye cinsini, boyutunu, farklı özellikleri ve değişiklikleri detaylandırır. o Reçete (seçim) aynı zamanda kullanıcının tekerlekli sandalyeye bakım ve daha iyi kullanım için gereken eğitimini de belirtebilir. Finansman ve sipariş: o Bir fon kaynağı tespit edilir ve tekerlekli sandalye hizmeti ya da tedarikçi tarafından düzenlenen bir stoktan sipariş edilir. Ürün ( tekerlekli sandalye) hazırlığı: o Hizmet personeli tekerlekli sandalyeyi hazırlar. o Seçilen ve hazırlık için gereken tesisatın durumuna göre hazırlık şunları da içerebilir; o tekerlekli sandalyenin montajı; o tekerlekli sandalyenin tamamen üretimi; o tekerlekli sandalyede değişiklikler. Uygunluk: o Kullanıcı tekerlekli sandalyeyi dener. o Tekerlekli sandalyenin montajının doğru bir şekilde yapıldığı ve kurulduğundan emin olmak için son kontroller yapılır. o Eğer değişiklikler ve duruş desteği için birtakım parçalar sağlanması gerekiyorsa ek donanıma ihtiyaç duyulabilir. Kullanıcı eğitimi: o Tekerlekli sandalye hizmet personeli; tekerlekli sandalye kullanıcısının, bakıcılarının tekerlekli sandalyenin kullanımı ve bakımı hakkında neler bildiğini ve neleri öğrenmeye ihtiyacı olduğunu kontrol eder. o Hizmet personeli ihtiyaç olan talimatları verir. Bazı kilit konular şunlardır: o tekerlekli sandalye nasıl taşınacak, kaldırılacağı; o tekerlekli sandalyeye nasıl binilip inileceği; o tekerlekli sandalye hareketliliği; o tekerlekli sandalye bakımı; o basınç yaralarının nasıl engelleneceği; o bir problem olursa neler yapılacağı. o bazı tekerlekli sandalye hizmetleri, kullanıcıların sandalye kullanımını kolaylaştırmak için; evlerinde, işyerlerinde veya okullarında ne gibi değişiklikler yapılacağına dair yardımcı tavsiyelerde bulunabilirler. Bu durum bu eğitim programının kapsamında değildir. Bakım, onarım ve takip: o Yaşanılan ortam içinde çözülemeyen teknik sorunlar için bakım ve onarım hizmetleri sağlamak. o Tekerlekli sandalye hizmet sunumunda takip randevuları önemli bir adımı oluşturmaktadır. o Takip sırasında, hizmet personeli tekerlekli sandalye uyumunu kontrol eder daha ileri düzeyde eğitim ve destek sağlar. o Eğer mevcut tekerlekli sandalyenin artık uygun olmadığı düşünülürse 1. Adımdan başlayarak yeni bir tekerlekli sandalye sağlanmalıdır. Açıklayın: Katılımcılar bu eğitim programında her bir adımın nasıl uygulanacağını öğreneceklerdir. Bununla beraber bazı hizmetlerde her bir adım için farklı kişiler sorumlu olabilirler. Örneğin randevular bir yöneticinin sorumluluğunda iken eğitim başka bir kişi tarafından veriliyor olabilir. Sorun: Bir tekerlekli sandalye hizmet sunumu yapan kişi olarak görevleri hakkında soruları var mı? 4. “Temel seviye” hizmeti ne anlama gelir? (5 dakika) Açıklayın: o Tekerlekli sandalye kullanıcılarının farklı fiziksel ihtiyaçları vardır. Oturma ile ilgili zorlukları sıkıntıları veya denge problemi olan kullanıcılara tekerlekli sandalye sağlamak için, oturabilen ve dengesini koruyabilen kullanıcılara gerekli olan bilgilerden ve becerilerden çok daha fazlası gerekmektedir. o Temel seviye hizmet, doğru ve iyi bir şekilde oturabilen tekerlekli sandalye kullanıcılarının fiziksel ihtiyaçlarını karşılayabilir. Temel düzey eğitim programında katılımcılar iyi bir şekilde oturabilen tekerlekli sandalye kullanıcılarına tekerlekli sandalye sağlamayı öğrenirler. o Daha ileri düzey eğitim programında katılımcılar, dik oturamayan ve duruş problemleri olan kişilere tekerlekli sandalye sağlamayı öğrenirler o Duruş problemleri olan kişilere tekerlekli sandalye sağlamadan önce daha çok eğitim almanın önemi büyüktür. Önemlidir çünkü insanların duruş problemlerinin nedenlerini ve nasıl güvenli bir duruş desteği sağlanacağı konusunu anlayabilmek için daha çok bilgi edinilmesi gerekmektedir. Açıkla: Clara Doğu Timor’da yaşamaktadır. Evlerinin hemen önünde olan ailesine ait bir dükkânda çalışmaktadır. Clara’nın polyosu vardır. Evin içinde dolaşmak, dükkânlarında çalışmak ve köylerinde dolaşmak için bir tekerlekli sandalyeye ihtiyacı vardır. Destek olmaksızın dik bir şekilde oturabilmektedir ve ona uyarlanmış ve ona göre ayarlanmış bir manüel tekerlekli sandalyesi vardır. Clara temel düzey hizmet ile tekerlekli sandalye sağlanmış kişilere bir örnektir. Açıkla: Ishade sekiz yaşındadır ve Sri Lanka’da yaşamaktadır. Serebral palsisi vardır. Bu durum Ishade’nin kollarını, bacaklarını kafa ve boynunu kontrol edememe sorunu olduğu anlamına gelmektedir. Destek olmadan dik bir şekilde oturamamaktadır. Ishade tekerlekli sandalyesinde ekstra duruş desteğine ihtiyacı olanlara bir örnektir. Bu durum, bu temel seviye eğitim programında öğretilmemiştir. Ishade’ye orta veya ileri düzey hizmet aracılığı ile tekerlekli sandalye sağlanmalıdır. 5. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. A.3: Tekerlekli sandalye hareketliliği H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler;  Temel tekerlekli sandalye hareketlilik becerilerini güvenli bir şekilde kullanabilecekler; itmek, çekmek, eğimlerde yukarı ve aşağı ilerlemek, yardımla merdiven yukarı çıkmak ve aşağı inmek, arka tekerlekler üzerinde kısmi olarak dengede durmak bu becerilere dâhil olanlardır. K A Y N A K LA R Bu bölüm için:  PPT slaytları A.3: Tekerlekli sandalye hareketliliği;  Referans Kılavuzu (Sayfa no, XX);  DVD: Tekerlekli sandalyemi kullanmayı öğreniyorum;  DVD: Tekerlekli sandalye hareketlilik becerileri;  Poster: Tekerlekli sandalye hareketlilik becerileri;  Her çift katılımcı için bir tekerlekli sandalye.  İÇ E R İK Bu bölümü katılımcıların çalışıyor olacakları şartlara uyacak şekilde uyarlayın.  Eğitmenler bu bölüme dâhil olan kısmi dengede durma becerisini uygularken ve katılımcılara bunu öğretirken sadece kendilerinden emin hissediyorlarsa bunu yapmalıdırlar. H A Z IR LI K  Kaynakları Toplayın, PPT slaytlarına göz gezdirin, DVD’i seyredin ve bölüm planını okuyun.  Tekerlekli sandalye beceri uygulaması için uygun bir yer seçin; düz bir alana, eğimli bir alana, bir ya da iki merdivene ve biraz engebeli bir zemine ihtiyaç vardır.  Bu becerileri öğretirken yardımcı olması için tekerlekli sandalye hareketlilik becerilerinde iyi olan bir tekerlekli sandalye kullanıcısını yanınıza davet edin.  DVD’i kaynak olarak kullanarak tekerlekli sandalye hareketlilik becerilerini kendi kendinize uygulama yapın ki teknikleri gösterebileceğinizden emin olun.  Bütün tekerlekli sandalyelerin kullanım için uygun, iyi durumda ve tekerleklerinin şişirilmiş olduğundan emin olun. T A S LA K 1. Giriş. 2. Tekerlekli sandalye hareketlilik becerileri neden önemlidir? 3. Tekerlekli sandalye hareketlilik becerileri – güvenlik. 4. Tekerlekli sandalye hareketlilik becerileri – gösterim ve uygulama. 5. Kilit nokta özeti. 2 15 5 65 3 Toplam bölüm süresi 90 1. Giriş (2 dakika) Açıkla: Bu bölümde katılımcılar tekerlekli sandalye kullanıcılarına temel hareketlilik becerilerini öğretecekler ki bu tekerlekli sandalyelerinde olabildikleri en üst düzeydeki hareketliliği sağlayacak. 2. Tekerlekli sandalye hareketlilik becerileri neden önemlidir? (15dakika) Açıklayın: Pek çok tekerlekli sandalye kullanıcısı dolaşmaları ve hareket etmeleri zor olan yerlerde yaşamaktadır ve çalışmaktadır. Sorun: Yerel çevrelerinde tekerlekli sandalyelerini kullanmalarını zorlaştıran ne gibi özellikler vardır? Cevap vermeye teşvik edin ve tahtaya yazın. En önemli cevaplar: o merdivenler; o çamurlu zemin; o kumlu zemin; o dik meyil; o dar alanlar (örneğin iç mekanlar); o engebeli ve pürüzlü yüzey; o bozulmuş ve düzgün olmayan kaldırımlar; o kaldırımlardaki park etmiş arabalar ve diğer engeller . Açıkla: Bu hareketlilik becerileri eğitimi tekerlekli sandalye kullanıcılarına bu engelleri/zorlukları çözmelerinde (kendi başlarına ya da yardımla) yardımcı olabilir. DVD tanıtımı: Tekerlekli sandalyemi kullanmayı öğreniyorum videosunda, genç bir kız olan Sai tekerlekli sandalye kullanmayı öğrenmenin hayatında yaptığı değişikliklerden bahsediyor. DVD göster. Soru olup olmadığını öğrenin. Sorun: Sai’nin öğrenmiş olduğu tekerlekli sandalye becerilerinden bazıları nelerdir? En önemli cevaplar: o tekerlekli sandalyeye binmek ve sandalyeden inmek; o bordür ve tümseklerden geçmek – evine girmek ve evinden çıkmak; o eğimli yüzeylerden inmek ve çıkmak; o itmek. Sorun: Bu becerilere sahip olmak Sai’ni hayatında ne değişiklikler yaptı? En önemli cevaplar: o o daha bağımsız hale geldi; o o daha kendine güvenli hale geldi; o o dışarı çıkabiliyor, okula gidebiliyor, yeni arkadaşlar edinebiliyor ve oynayabiliyor. 3. Tekerlekli sandalye hareketlilik becerileri – güvenlik ( 5 dakika) Tekerlekli sandalye hareketlilik becerileri posterini asın. Açıkla: Tekerlekli sandalye hareketlilik becerilerini öğretirken ve öğrenirken güvenlik çok önemlidir. Katılımcılara sorun – tekerlekli sandalye ile çalışırken daha önce konuşmuş olduğumuz ana güvenlik noktaları nelerdir? En önemli cevaplar: o tekerlekli sandalyeye binerken ve inerken ayaklıkların üzerine basmayınız; o parmaklarınızı tekerlek jant tellerinden ve frenlerden uzak tutunuz; o eğim aşağı ya da yukarı gitmeyi öğrenirken arkaya düşme ihtimaline karşı HER ZAMAN arkanızda bir yardımcı olsun. Açıkla: o Bu bölümde rampa yukarı ve aşağı gitmeyi ve kısmi dengede durmayı da (yani sadece arka tekerlekler üzerinde dengede durma) içeren değişik becerileri uygulayacaksınız. Açıkla: o Bu tekerlekli sandalye becerilerini öğrenen tekerlekli sandalye kullanıcısın arkasında her zaman bir yardımcı olduğundan emin olun. o Yardımcı kişi tekerlekli sandalyenin arkasına yakın durmalıdır. . o Yardımcı kişi tekerlekli sandalyenin arkaya düşme ihtimaline karşın hazır olmalıdır ve sağlam durmalıdır. o Tekerlekli sandalye kullanıcısına merdiven iniş çıkışında yardımcı olurken tekerlekli sandalyeyi güvenli bir şekilde kontrol edebilecekseniz yardımcı olun, emin değilseniz yardım isteyin. 4. Tekerlekli sandalye hareketlilik becerileri – gösterim ve uygulama (65 dakika) DVD tanıtımı: Tekerlekli sandalye hareketlilik becerileri. Katılımcılara DVD gösteriminde bulunan değişik hareketlilik becerilerini dikkatli bir şekilde izlemelerini söyleyin. DVD gösteriminin ardından uygulayacakları bu uygulamalara dikkat etmeleri gerekmektedir. DVD göster. Soruları olup olmadığını öğren. Açıkla: o Katılımcılar, tam dengede durma becerisi dışında DVD de bulunan tekerlekli sandalye hareketlilik becerilerinin uygulamasını yapacaklardır. o Tam dengede durma daha çok pratik gerektiren ileri düzey bir beceridir. Bir tekerlekli sandalye kullanıcısı tekerlekli sandalyeyi arka tekerlekler üzerinde dengede tutmayı başarabildiği zaman; bu beceriyi engebeli zeminlerden atlayabilmek, eğimlerden kaldırımlardan ve merdivenlerden geçebilmek için kullanabilirler. Bu beceriyi yanınızda deneyimli bir eğitmen olmada denemeyiniz. o Bu gün uygulamalarını yapacağımız tekerlekli sandalye hareketlilik becerilerini öğrenmek, tekerlekli sandalye kullanıcıları ile çalışanlar için çok kullanışlı olacaktır. Bu becerileri kendiniz yapabiliyorsanız öğretmeniz daha kolay olacaktır. Aktivite Gruplar: Katılımcıları iki grup olarak ayarlayın. Aynı ağırlığa boya ve güce sahip kişileri birbiriyle eşleştirin. Talimatlar: Katılımcılara Referans Kılavuzlarındaki tekerlekli hareketlilik bölümüne başvurmalarını söyleyin. Onlara şu uygulamalar için çiftler halinde çalışmaları gerektiğini açıklayın: 1. itme ve dönme; 2. eğim yukarı çıkma ve inme; 3. yardımla merdiven yukarı çıkmak ve aşağı inmek; 4. kısmi denge uygulaması. Katılımcılara hatırlatın: o Videoda ve Referans Kılavuzunda gösterilen teknikleri kullanarak uygulama yapın; o Eğimlerden ve merdivenlerden aşağı yukarı inip çıkarken ya da kısmi denge becerisini denerken HER ZAMAN arkalarında birisinin olmasını sağlayın; o Merdiven uygulaması yaparken bu manevrayı, kaldırma işleminde zorluk çekmeyecek kişilerin yaptığına emin olun. Güvenlik sağlandığını gözlemleyin. İzle: Gruplar arasında dolaşarak izleyin ve bütün tekniklerin güvenli ve doğru bir şekilde uygulandığına emin olun. Uygulamalardan herhangi birinde tehlikeli bir durum görürseniz grupları durdurun ve güvenlik yöntemleri ile ilgili açıklama yapın. Gerektiği durumlarda gösterin ve teknikleri düzeltin (bkz aşağıdaki teknikler). Süre: Uygulama için 50 dakika geribildirim için 15 dakika müsaade edin. . Geri bildirim: Grubu bir araya getirin. Katılımcıların uygulama sırasında sıklıkla yaptıkları teknik yanlışlıklarını düzeltin. (doğru teknikleri gösterin) Sorun: Katılımcılar hareketlilik becerileri uygulamalarından neler öğrendiler? Açıklayın: Eğitim programı boyunca katılımcılar tekerlekli sandalyelerle daha fazla pratik yapmak isterlerse bunu; bölümlerden önce veya yemek aralarında yapabilirler. Kendilerinden çok emin hale gelene kadar, eğim yukarı aşağı gidip gelmelerde ve kısmi denge pratiğinde arkalarında birisi olduğundan emin olmalıdırlar. Eğitmenler için notlar – Uygulamalar sırasında bu noktaları pekiştirin. İtm e o Doğru itme daha az çaba sarf dilerek yapılandır. o Saat 10 pozisyonundan saat 2 pozisyonuna doğru itiniz. o Uzun ve düzgün bir hareketle itiniz. D ön üş o İtme kasnaklarından birini öne ve diğerini arkaya doğru tutunuz. o Öndeki eli arkaya doğru itiniz ve arkadaki eli öne doğru aynı anda itiniz. E ği m y uk ar ı o Öne doğru eğilin; bu tekerlekli sandalyenin arkaya düşmesini engelleyecektir. o Uygulama yaparken arkanızda güvenlik için bir yardımcınız olsun. o Durmak ya da dinlenmek için tekerlekli sandalyenizi yanlara doğru park edin. E ği m a şa ğı o Arkaya yaslanın. o Ellerinizin arasından itme kasnaklarının yavaşça kaymasını sağlayın. o Tekerlekli sandalyelerini sadece arka tekerlekler üzerinde dengede tutabilen deneyimli kullanıcılar eğim aşağı sadece arka tekerlekler üzerinde inebilirler. Bu çok etkin bir yoldur. Y ar dı m cı il e m er di ve n çı km ak o Geriye doğru çıkın. o Tekerlekli sandalyeyi arka tekerleklere doğru eğin ve ilk basamağa dayayın. o Yardımcı tekerlekli sandalyeyi yukarı doğru sürüklerken aynı zamanda geri ve yukarı doğru çeker. o Tekerlekli sandalye kullanıcısı itme kasnaklarını geriye doğru iterek yardımcı olabilir. o İkinci bir yardımcı tekerlekli sandalyenin önünde, sandalye kasasını tutarak yardımcı olabilir (ayaklıklardan değil) . Y ar dı m cı il e m er di ve n aş ağ ı o Öne doğru inin. o Tekerlekli sandalyeyi arka tekerleklere doğru eğin o Yardımcı, arka tekerlekleri bir seferde bir basamak inecek şekilde indirir. o Tekerlekli sandalye kullanıcısı itme kasnaklarını tutup kontrol ederek yardımcı olabilir. o İkinci bir yardımcı tekerlekli sandalyeyi önden sandalye kasasından tutup sabit kalmasını sağlamak suretiyle yardımcı olabilir ( ayaklıklardan değil). A rk a te ke rle kl er ü st ün de k ıs m i d en ge de d ur m a o Arka tekerlekler üzerinde kısmi dengede durma hareketini yapabilmek bir tekerlekli sandalye kullanıcısı faydalı, kullanışlıdır. o Tekerlekli sandalye kullanıcısı ön tekerleklerini küçük kaldırımlardan, taşlardan ve tepeciklerden geçmek için kaldırabilir. o Tekerlekli sandalyeyi eller saat 10 pozisyonunda olana kadar arkaya doğru sürün ve hızlıca öne doğru itin. o Ön tekerlekler havaya kalkmalıdır. . o Küçük engelleri aşmak için ön tekerlekleri doğru zamanda kaldırmak pratik yaparak mümkün olacaktır. o Tekerlekli sandalye kullanıcısı bu beceri için uygulama yaparken her zaman arkasında birisi olduğundan emin olun. 5. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. A.4: Dik oturuş H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  “Dik oturuşun” en az 10 özelliğini listeleyebilecekler (dengeli oturma duruşu) ;  dik oturmanın en az altı faydasını sayabilecekler;  pelvisin yapabileceği dört hareketi gösterebilecekler;  pelvisin hareketlerinin oturma şeklini nasıl değiştirebileceğini açıklayacaklar;  değişik oturma şekillerini ve bunların dik duruştan farklarını ayırt edecekler. K A Y N A K LA R Bu bölüm için:  PPT: A.4 Di oturuş;  Referans Kılavuzu (Sayfa no, XX);  Kullanıcı Kılavuzu (Sayfa no, XX);  Pelvisli yarım iskelet, omurga ve femurlar (eğer varsa). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara ve öğrenmeye ihtiyaçları olacak durumlara göre uyarla.  Bu bölüm temel pelvis bilgi birikiminin olduğunu farz eder. Eğer katılımcılar pelvisin kemiklerle ilgili önemli noktalarını bilmiyorlarsa eğitim programından önce bu bilgileri programa ekleyin. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarını gözden geçirin ve bölüm planı okuyun. T A S LA K 1. Giriş. 2. Dik oturuş/ dengeli oturma duruşu. 3. Pelvis oturma şeklimizi nasıl etkiler. 4. Değişik oturma şekilleri. 5. Kilit nokta özeti 2 20 10 25 3 Toplam Bölüm süresi 60 1.Giriş (2 dakika) Açıkla: Pek çok tekerlekli sandalye kullanıcısı oturarak saatler geçirir. Onların sandalyesi sadece hareket etmelerine yardımcı olan bir araç değildir. Aynı zamanda onların dik ve rahat oturmalarına da destek olur. Bu bölümde oturma üzerine odaklanacağız. “Dik oturmanın ne anlama geldiği ve nasıl göründüğünü hakkında konuşacağız. Dik oturmanın faydaları üzerine düşüneceğiz. Katılımcılar dik oturuş ve diğer duruşlar arasındaki farkları belirlemek için pratik yapacaklar. Aynı zamanda dik oturmamaktan kaynaklanan problemleri tartışacağız. 2. Dik oturuş /dengeli oturma duruşu (20 dakika) Sorun: Bir kişi “duruş” kelimesinin ne anlama geldiğini açıklayabilir mi? Cevap vermeleri için onları teşvik edin. Açıklayın: Çok çeşitli “oturma duruşları” vardır. Odada oturan katılımcıların oturma şekillerine işaret edin. Açıklayın: o Bir tekerlekli sandalye sağlarken kullanıcıları “dik oturmaya” teşvik etmek önemlidir; o “dik oturuş” bazen “dengeli oturma duruşu” olarak adlandırılır. Bir gönüllüden grubun önünde bir sandalyeye oturmasını isteyin. Ona “dik oturmasını” söyleyin. (onun dik/ dengeli duruşta oturmasını sağlayın) Gruptan gönüllünün duruşunu tarif etmesini isteyin. Cevap vermeleri için onları teşvik edin. En önemli cevaplar: o Pelvis dik ve dengede; o omuzlar dengede, kollar serbest hareket edebilir; o gövde dik; o sırtta üç doğal kavis izlenir; o baş dik ve vücut üzerinde dengede; o kalça eklemleri 90 dereceye yakın durumda; o bacaklar hafif aralık (abdükte); o dizler ve bilekler 90 dereceye yakın durumda; o topuklar hemen dizin arka tarafında veya çok az arkasında ya da önünde; o ayaklar yere değer durumda . Bir kişinin dik oturduğu nasıl anlaşılır Yan taraftan bakın ve kontrol edin:  Pelvis dik;  Gövde dik, sırttaki üç doğal kavis izlenir halde;  Kalça eklemi 90 dereceye yakın kıvrımlı;  Dizler ve bilekler 90 dereceye yakın kıvrımlı;  Topuklar hemen dizin arka tarafında veya çok az arkasında ya da önünde;  Ayaklar yerde veya ayaklık üzerinde düz. Ön taraftan bakın ve kontrol edin:  Pelvis dengede;  Omuzlar dengede, kollar serbest hareket edebilir; o Bacaklar hafif aralık (abdükte); o Baş dik ve vücut üzerinde dengede; Açıkla: o Dik oturuş herkes için tamamıyla aynı değildir o Aşağıdaki slaytlar bakılması gereken özellikleri kilit noktaları gösterecektir – ancak bunlar sadece birer örnektir. o Dik oturuşla ilgili en önemli nokta kişinin ferah, rahat ve iyi bir şekilde dengede olmasıdır. Slaydı klikleyin ve kilit noktaları gösterin. Açıklayın: o Kalça, dizler ve bilekler belki biraz daha açık veya biraz daha bükülmüş olabilir – bu olabilir. o Kişi dengede ve rahat olmalıdır. Slaydı klikleyin ve kilit noktaları gösterin. Bütün katılımcılara dik ve dengeli oturma duruşunda oturmalarını söyleyin. Katılımcılara destek olmaksızın bütün gün bu şekilde oturup oturamayacaklarını sorun. ( örneğin bir arkalık olmadan) ? Cevap genellikle HAYIR olacaktır. Açıklayın: o İyi bir destek olmadan sandalyenizde bütün gün bu şekilde oturmak çok zor olacaktır. Bundan dolayı insanlar oturdukları şekli sürekli değiştirirler. o Tekerlekli sandalyede bütün gün oturan kullanıcının dik oturuşunu devam ettirebilmek için; tekerlekli sandalye koltuğunda, minderinde ve ayaklığında iyi bir desteğe ihtiyacı vardır. Sorun: Dik oturuşun faydaları nelerdir? Cevap vermeye teşvik edin ve tahtaya yazın. En önemli cevaplar: o sağlık; o istikrar; o ağırlığın dağılımı; o rahatlık; o aktivite artışı; o duruşla ilgili problemlerin önlenmesi; o kendine saygı, özgüven. Sorun: Bir personel tekerlekli sandalye kullanıcısının dik oturmasına nasıl yardımcı olabilir? Cevap vermeye teşvik edin ve tahtaya yazın. En önemli cevaplar: o tekerlekli sandalyenin onlara uyduğundan emin olun; o tekerlekli sandalye kullanıcısına dik oturmanın neden önemli olduğunu öğretin (eğer oturabiliyorlarsa); o tekerlekli sandalye kullanıcısına sandalyesinde nasıl dik oturabileceğini gösterin. Açıklayın: Bütün tekerlekli sandalye kullanıcıları dik oturamaz. Bu konudan bu bölümde daha sonra konuşacağız. 3. Pelvis oturma şeklimizi nasıl etkiler (10 dakika) Açıkla: Pelvis dik oturmanın temelidir. Sağlıklı ve sağlam olması için bir binanın sağlam zemini olması gerekir. Aynı şekilde otururken sağlam olabilmek için pelvisin güçlü ve sağlam olması gerekir. Açıkla: Pelvisin gövde ve kalça eklemleriyle bağlantısında farklı hareketleri vardır. Hareketler: o Öne doğru uzanma (pelvisin öne eğilmesi). Açıkla: Slayt üzerindeki resim pelvisin yandan görünüşünü göstermektedir. o Arkaya doğru uzanma (pelvisin arkaya eğilmesi). Açıkla: Slayt üzerindeki resim pelvisin arkadan görünüşünü göstermektedir. o Yanlara doğru eğilme (yanal eğilme). Açıkla: Slayt üzerindeki resim pelvisin yukarıdan görünüşünü göstermektedir. o Rotasyon. Herkesten ellerini pelvislerinin üstüne koymalarını isteyin (iliak çıkıntılarının üstüne). Ellerinizi iliak çıkıntılarınızın üstüne koyun ve her bir pelvis hareketinin gösterimini yapın. Katılımcılardan da aynısını yapmasını isteyin. Katılımcılara her bir hareketten sonra vücutlarında neler hissettiklerini sorun. Hareket Resim Vücuttaki değişimler Öne doğru eğilme: (pelvisin öne eğilmesi). Pelvisin yandan görünüşü o Omuzların geriye çekilmesiyle vücut dikleşir; o Pelvis üzerindeki omurga kavisinde bir yükselme olur. Arkaya doğru eğilme : (pelvisin arkaya eğilmesi). Pelvisin yandan görünüşü o Omuzlar ilerideyken vücut yuvarlanmış hale gelir. Yanlara doğru eğilme: (yanal eğilme ). Pelvisin arkadan görünüşü o Vücut yanlara eğilir. Rotasyon. Pelvisin yukarıdan görünüşü o Vücudun diğer kısmı da döner (rotasyon yapar) Sorun: Değişik pozisyonlarda durmak nasıl hissettirdi? Katılımcılar emin değillerse hareketleri tekrarlamalarını isteyin ve nasıl olduğunu hissetmek için pozisyonda durmalarını söyleyin. Cevap vermeye teşvik edin. En önemli cevaplar: o rahat değil; o hareket etmek zor; o dengesiz yük; o kolları kullanma güçlük ve aktivitelerin zorlaşması; o nefes almada zorluk; o yorgunluk; o içte basınç; o denge zorluğu. Açıkla: Dik otururken pelviste diktir ( ya da hafif öne doğru eğiktir) ve dengelidir. Pelvis dik değilse dik oturmak da mümkün değildir. 4. Değişik oturma duruşları (25 dakika ) Aktivite Gruplar: Her grup 2-3 kişi olmalıdır Talimatlar: Her bir gruba şunları yapmalarını söyleyin: o el kitaplarında bulunan çalışma sayfasındaki her bir değişik duruş örneğine yakından bakın; o duruşun, dik duruştan nasıl farkları var yazın; o dik duruşun, yandan ve önden özelliklerini düşünün. İzle: Grupları izleyin gerektiğinde yardım edin. Süre: 10 dakika müsaade edin. Geribildirim: Slaytla her bir duruşu teker teker gösterin. Her bir gruptan (sırayla) gösterilen duruş ile dik duruş arasındaki farkı söylemelerini isteyin. Katılımcılardan çalışma kâğıtlarına olmayan noktaları eklemelerini isteyin. Eğitmenler için notlar, en önemli cevaplar: o pelvis dengeli değil (sağ taraf daha yüksek); o omuzlar dengeli değil (sol taraf daha yüksek); o gövde bir tarafa doğru kavisli; o sağ bacak içe dönmüş; o sağ bilek içe dönmüş; o sol bilek içe dönmüş. Eğitmenler için notlar, en önemli cevaplar: o pelvis arkaya doğru eğilmiş; o gövde çökmüş (bir taraf öne doğru kavisli ve dönmüş); o omuzlar dengeli değil; o baş arka tarafa doğru eğilmiş ve çene öne doğru çıkmış, pelvis üzerinde denge yok; o dizlerde denge eğilimi yok; o bileklerde denge eğilimi yok; o bir kol bacakların arasında diğer kol itme tutamaklarının arkasına asılmış durumda, tekerlekli sandalye kullanıcısı sandalyede sabit değil. Eğitmenler için notlar, en önemli cevaplar: o pelvis dik değil (arkaya eğilmiş); o gövde öne kavisli; o omuzlar yuvarlanmış ve öne doğru; o baş pelvis üzerinde dengede değil; o çene öne doğru çıkmış. Açıkla: o Katılımcıların gösteride baktığı üç örnek duruşu “dik duruş”tan farklı duruşlardır. Bu duruşlar sabitleşmiş olabilir. Bu bunların düzeltilemeyeceği anlamına gelir. Başkaları için duruş esneklik arz eder. Bu kişiye destek sağlanırsa dik oturabilir anlamına gelmektedir. o Eğer bir kişi (verilen desteğe rağmen) dik oturamıyorsa ve farklı bir duruşta sabit kalmışsa bu durumda tekerlekli sandalyede değişiklikler yoluyla uyarlamalar ve destekler yapılabilir. Bu eğitim programı bu işlemleri içermemektedir. . Sorun: Dik oturmamaktan kaynaklanabilen problemlerden bazıları neler olabilir? Cevap vermeye teşvik edin. En önemli cevaplar: o basınç yaralarına sebep olabilir; o zamanla kullanıcının vücudu bu farklı ve dik olmayan duruşa saplanıp kalır ve hiçbir zaman dik oturamayacak hale gelir; o görebilmek için baş ve boynu hareket ettirmek daha zor hale gelir ve pek çok şeyi yapmak zor hale gelir; o nefes almayı zor hale getirebilir ve sindirimi etkileyebilir; o yorgunluğu artırır; o yutkunmayı zorlaştırır; o rahatsızlık ve ağrı yaratabilir; o dengeyi zorlaştırır; o el ve kolları kullanmayı zorlaştırır; o kaslarda spazm ve gerilme daha başka sorunlara yol açabilir; o kendine güven zayıflar Slaytta gösterildiği gibi dik oturmamaktan kaynaklanan sorunların listesini yapın. 5. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun Soru olup olmadığını öğrenin. A.5: Basınç yaraları H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  basınç yaralarının dört evresini listeleyebilecekler;  bir kişide bir uzmana gönderilmesi gereken basınç yarasını tanıyabilecek duruma gelecekler;  tekerlekli sandalye kullanıcılarının basınç yaralarının tedavi edileceği bölgesel hizmet yerlerinin listesini yapabilecekler;  basınç yaralarına sebep olan üç ana sebebi sayabilecekler;  tekerlekli sandalye kullanıcılarında basınç yarası oluşan ana bölgeleri tanımlayabilecekler;  basınç yarası risk faktörlerini listeleyebilecekler;  tekerlekli sandalye kullanıcısının basınç yaralarını önleme yollarını sayabilecekler;  iki basınç rahatlatma tekniğinin gösterimini yapabilecekler; K A Y N A K LA R Bu bölüm için:  PPT slaytları: A.5 Basınç yaraları;  Referans Kılavuzu  DVD: Basınç yarası belgesi;  Poster: Basınç yaraları;  Bir tekerlekli sandalye (minderi olan ) her iki katılımcı için (iki kişi için bir adet).  İÇ E R İK Bu bölümü katılımcıların çalışıyor olacakları şartlara göre uyarla. Düşünün:  Basınç yarası olmuş olan bir tekerlekli sandalye kullanıcısını hikâyesini katılımcılarla paylaşmak için davet edin. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarını gözden geçirin ve bölüm planı okuyun.  Tekerlekli sandalye kullanıcılarının basınç yaralarını tedavi için gidebilecekleri bölge içinde hizmet veren kurumların listesini hazırlayın. Eğer katılımcılar eğitime başka bölgelerden geliyorlarsa onlardan bu bilgiyi beraberlerinde getirmelerini isteyebilirsiniz.  Basınç yarası olmuş olan bir tekerlekli sandalye kullanıcısını hikâyesini katılımcılarla paylaşmak için davet edin.  Bu bölümün slaytlarında olan 6 numaralı slaydın içine kaynaklar listesini yazın. T A S LA K 1. Giriş. 2. Basınç yaraları. 3. Ne zaman ve nereden yardım alınır. 4. Basınç yaralarına neler sebep olur? 5. Basınç yarası risk faktörleri 6. Basınç yaraları nasıl engellenir? 7. Basınç yarası belgesi. 8. Basınç rahatlatma teknikleri. 9. Kilit nokta özeti 2 5 5 10 10 10 5 10 3 Toplam bölüm süresi 60 1. Giriş(2 dakika) Açıkla: Bu bölümde basınç yaraları hakkında bilgi edineceğiz. Bütün tekerlekli sandalye kullanıcıları basınç yarası geliştirme riski altında değildirler. Ancak basınç yarası geliştirenler için sonuçları çok ciddidir. 2. Basınç yaraları (5 dakika) Basınç yaraları posterini asın. Sorun: Hiç basınç yarası gören var mı? Kısaca tartışın. Açıklayın: o Yara ne kadar büyükse tekerlekli sandalye kullanıcısı için sorun da o kadar fazla olur. o Basınç yaraları uzun süren yatak istirahatı gerektirebilir. o Eğer basınç yarası enfekte olursa (mikrop kaparsa) bu enfeksiyon kana, kalbe ya da kemiğe yayılabilir. Bu çok ciddi hastalıklara ve ölüme sebebiyet verebilir. Açıkla: Basınç yarası oluşumunda dört evre vardır. Açıkla: o 1. Evrede kişinin cildinde kırmızı ve koyu izler olur. Oluşan kırmızılık veya ciltteki renk değişikliği basınç kalktıktan sonra 30 dakika içerisinde yok olmaz. o 2. Evre yüzeysel bir yaradır ve derinin en üst tabakası soyulabilir ya da veziküller (kabarcıklar) oluşabilir. o 3. Evre derin bir yaradır; deri katmanı kaybolur. o 4. Evre çok derindir, kasa ve muhtemelen kemiğe doğru uzanır. Sorun: Basınç yarası çoğunlukla nerede olur? Cevap vermeye teşvik edin En önemli cevaplar: o kalça kemikleri (pelvis); o kuyruk kemiği (koksiks); o kuyruk sokumu kemiği (sakrum); o kalça kemiği; o kürek kemikleri; o omurga. 3. Ne zaman ve nereden yardım alınır (5 dakika) Açıklayın: 1. Evre basınç yarası olan tekerlekli sandalye kullanıcısına personel ne tavsiyede bulunmalıdır? Cevapları teşvik edin. Doğru cevapları pekiştirin ya da siz cevap verin. En önemli cevaplar: o 1. Evre basınç yarası olan bir kişi şunları yapmalıdır: o ilgili bölgeden basınç ivedilikle kaldırılmalıdır; o cilt tamamen iyileşene kadar basınç uzak tutulmalıdır. o Bu yatak istirahatı olabilir ( yaranın nerede olduğuna bağlı olarak). o Sorun tanımlanmalı ve üzerine düşülmelidir. o Tekerlekli sandalye kullanıcısına basınç yaralarının nasıl oluştuğunu ve gelecekte nasıl engellenebileceğini öğret. Sor: 2,3 veya 4. Evre basınç yarası olan tekerlekli sandalye kullanıcısına personel ne tavsiyede bulunmalıdır? Cevapları teşvik edin. Doğru cevapları pekiştirin ya da siz cevap verin. En önemli cevaplar: o Evre 1 için eylemleri takip edin . ve Deneyimli bir sağlık personeli tarafından basınç yarasının tedavisi için sevki yapın. Açık basınç yaralarının, iyileşmesinin ve enfekte olmamasının sağlanması için temizlenmesine pansuman yapılmasına ve yakından izlenmesine ihtiyaç olacaktır. 4. Evre yaralar cerrahi müdahale gerektirebilir. Katılımcılara, Katılımcı El Kitabındaki (sayfa 4)tabloya listeyi kopyalamalarını isteyin. 4. Basınç yaralarına ne sebep olur? (10 dakika) Açıkla: Basınç yaralarının üç ana sebebi aşağıdakilerdir. Slaydı okuyun Açıklayın: Her bir sebebe daha ayrıntılı bakacağız. Açıkla: o Basınç yaraları aynı pozisyonda uzun zaman kıpırdamadan yatmak ya da oturmaktan dolayı ciltteki oluşan basınçtan kaynaklanır. o Basınç yaraları omurilik zedelenmesi olan kişiler için başlıca ölüm sebebidir. Katılımcılara ellerinin üzerine oturmalarını ve kalça kemiklerinin altında basıncı hissetmelerini isteyin. Uzun süre bu pozisyonda kıpırdamadan otururlarsa ne olacağını sorun. Cevap: o Vücudunuzun aynı yerinde basınç olduğu için kısa bir süre içinde rahatsız hissedersiniz. Açıkla: o Friksiyon deri üzerinde sürekli olan sürtünmedir. Örneğin tekerlekli sandalye hareket ettiğinde kolun tekerleğe/kolçağa sürtünmesi basınç yarasına sebep olabilir. o Hissi olmayan tekerlekli sandalye kullanıcıları için friksiyon bilhassa bir problemdir. o Tekerlekli sandalye kullanıcısının transferi sırasında veya sandalye ile hareketleri esnasında çarpmalar olabilir. Açıkla: o Sıyrılma, kaymada deri durur ama kas ya da kemik hareketlerinden dolayı gerginleşir ya da aşınır. Katılımcılara tekrar ellerinin üzerine oturmalarını ve pelvislerini geriye doğru sallamalarını itmelerini söyleyin. Kalça kemiklerinin ellerinin üzerindeki hareketi fark etmelerini isteyin Örneğin tekerlekli sandalye kullanıcısı “yığılmış, çökmüş” şekilde otururken pelvis öne arkaya sallandığı için kalça kemiklerinden dolayı ya da sırttaki kemiklerinin arkalık ile cilt arasında sıkışma yaratmasından dolayı cilt zarar görür. 5. Basınç yaraları risk faktörleri (10 dakika) Açıkla: o Kişinin basınç yarası oluşturması için üç ana risk faktöründen başka pek çok başka unsurlar da vardır Bunlara basınç yarası risk faktörleri denir. Sorun: Risk faktörleri hakkında fikir belirtmek isteyen var mı? Cevapları teşvik edin. En önemli cevaplar: o his olmayışı (duyumun azalmış olması); o hareket edememe; o ter, su ya da idrarını tutamamadan kaynaklanan nem; o kötü beslenme ve yeteri kadar su içmeme; o yaşlanma; o kilo – normalin altında ya da üstünde kiloya sahip olma; o kötü duruş; o daha önce olan ya da şu anki basınç yarası; o travma, çarpmaya da darbeler; o sıcaklık/hararet, ateş; o böcek sokması. Açıkla: Hatırlanması gereken en önemli risk faktörleri şunlardır: o his olmayışı(duyumun azalmış olması); o hareket edememe; o ter, su ya da idrarını tutamamadan kaynaklanan nem; o kötü duruş; o daha önce olan ya da şu anki basınç yarası; o kötü beslenme ve yeteri kadar su içmeme; o yaşlanma; o kilo-normalin altında veya üstünde kiloya sahip olma Açıkla: o En önemli risk faktörü hissedememedir. Hissi olmayan bir kişi basıncı hissedemez. Bu durum basınç rahatlatmak için daha az pozisyon değiştirdiği anlamına gelir. o Hissi olmayan ya da kalçasına, oturma bölgesinde veya bacaklarına his azalması yaşayan kişiler basınç yarası geliştirme riski altındadırlar. o Omurilik zedelenmesi olan pek çok kişinin zedelenmenin seviyesine göre alt kısmında his yoktur. Bu onların basınç yarası riski altında oldukları anlamına gelir. Omurilik zedelenmesi olan kişilerin mesane ve bağırsak kontrollerinde de problemler olabilir. Eğer idrarlarını kontrol ile ilgili sorunları da varsa bu nemin oluşturacağı durumdan dolayı riski artırır. Açıklayın: o Tekerlekli sandalye hizmet personeli basınç yarası risk faktörlerini bilmek durumundadır ki bu yolla kullanıcıların risk faktörlerini belirleyebilsinler. o Risk faktörlerinin kontrolü tekerlekli sandalye değerlendirmesinin bir parçasıdır: o hissedemeyen her kişi basınç yarası geliştirme riski altındadır; o basınç yarası üç ana risk faktörünü ya da daha fazlasını taşıyan herkes basınç yarası geliştirme riski altındadır. Basınç yarası risk faktörlerine aşağıdakiler de dâhildir: o His olmayışı (duyumun azalmış olması); Hissedemeyen ya da kalçasına, oturma bölgesinde veya bacaklarında his azalması olan ( belden aşağısı tutmayan ya da her iki ayağı ve kolu felçli olan) kişiler basınç yarası geliştirme riski altındadırlar. o Hareket edemeyenler: Bir kişi hareket edemediğinde basıncı da rahatlatamaz. o Ter, su ya da idrarını tutamamaktan kaynaklanan nem: Nem cildi yumuşatır ve cilt zedelenmelere açık hale gelir. Eğer kişinin bağırsak ve mesane fonksiyonlarını idare edebilmek için bir yöntemi yoksa dışkı ve idrar cildi yakabilir ve zarar verir o Kötü duruş: Dik olmayan oturuş belli bir bölgede basınç artışına sebep olabilir. o Daha önce olan ya da şu andaki basınç yarası. o Kötü beslenme ve yeteri kadar su içmeme: İyi bir diyet yeteri kadar su içmeyi, vücudun sıvı besin almasını içerir ki vücut sağlıklı bir cilde sahip olsun ve yaraları tedavi edebilsin. o Yaşlanma: Yaşlı kişiler genellikle ince, zayıf çabuk zedelenen bir cilde sahiptirler. o Kilo (normalin üzerinde ya da altında kiloya sahip olma): Normalin üzerinde kiloya sahip kişilerin derideki kan dolaşımları zayıf olabilir ki bu çabuk zedelenmeye ve zor iyileşmeye sebep olur. Normal kilonun altındaki tekerlekli sandalye kullanıcıları basınç yarası riski altındadırlar çünkü kemikleri yeterli derecede korunmamaktadır. Kemiklerin çevresindeki bölgeler çabuk zedelenebilir. Genel basınç hassasiyeti olan bölgeler: Yandan görünüş. Arkadan görünüş 6. Basınç yaraları nasıl engellenebilir? (10 dakika) Açıkla: o Tekerlekli sandalye personeli, kullanıcıya basınç yaralarını engelleme konusunda yardımcı olabilir. o Korunma kişileri uzun süre hastanede yatmaktan, tekerlekli sandalyelerini ullanamamaktan ve ölümden koruyabilir. o Basınç yaralarını engellemenin değişik yolları aşağıdaki gibidir. Açıkla: Basınç rahatlatma minderi kullanın  Basınç rahatlatma minderi basıncı düşürmeye yardımcı olacaktır. Basınç yarası riski altında olan herkese basınç rahatlatma minderi verilmelidir Açıklayın: Dik oturuş  Dik oturuş ağırlığı eşit şekilde dağıtmaya yardımcı olur. Bu durum kemikli bölgelerdeki basıncın azalmasına ve basınçtan kaynaklanan yaraların azalmasına sebep olur.  Dik duruş aynı zamanda sıyrılmanın sebep olduğu basınç yaralarını da engeller.  Tekerlekli sandalyenin doğru bir şekilde uyduğundan emin olun. Bu durum kullanıcının dik oturmasına yardımcı olacaktır.  Tekerlekli sandalye kullanıcılarına dik oturmanın neden önemli olduğunu anlatın. Açıkla: Basınç rahatlatma tekniklerini kullanın.  Düzenli bir şekilde basınç rahatlatma basınç yaralarının engellenmesinde tesirli olabilir.  Bunları bu bölümde daha sonra ayrıntılı olarak göreceğiz. Açıkla: İyi beslenin ve çok su için  Taze sebzelerle ve etle oluşturulan dengeli bir beslenme basınç yaralarının engellenmesine yardımcı olabilir.  Çok su içmek cildin sağlıklı kalması sağlayarak basınç yaralarının engellenmesine yardımcı olacaktır.  Bir tekerlekli sandalye kullanıcısının beslenmesi ile ilgili endişeleriniz varsa kişiyi yardımcı olabilecek bir hizmete (servise) yönlendirin. Açıkla: Sürtünmeden kaçının  Tekerlekli sandalyenin düzgün bir şekilde uyduğundan ve pürüzlü kenarları olmadığından emin olun.  Hissi olmayan tekerlekli sandalye kullanıcılarına tekerlekli sandalyeden kaynaklanabilecek sürtünmelerden korunmaları için vücutlarında kontroller yapmaları gerektiğini öğretin.  Tekerlekli sandalye kullanıcılarına sandalyelerine binerken ve inerken dikkatli olmaları gerektiğini söyleyin. Açıkla: Nemden kaçının  Tekerlekli sandalye kullanıcılarına kirli ya da ıslak çamaşırlarını hemen değiştirmeleri ve ıslak minderde oturmamaları tavsiye edilmelidir.  Mesane ve bağırsak idaresi ile ilgili yapılan planlamalar nemden kaynaklanan problemleri azaltabilir.  İdrarını tutma ile ilgili sorunları olan kullanıcıları onlara yardımcı olabilecek hizmetlere(servislere) gönderin. Açıkla: Cildinizi her gün kontrol edin  Basınç yaraları çık çabuk oluşabilir. Basınç yarasını çabucak fark etmek ve harekete geçmek çok önemlidir.  Risk altında olan kullanıcıları her gün ciltlerini kontrol etmek için teşvik edin. Kendi kontrollerini bir ayna kullanarak yapabilirler ya da aile üyeleri kontrolü yapabilir. Eğer cilt üzerinde kırmızı ve koyu bir bölge görmüşlerse (1. Evre) anında oradaki basıncı rahatlatmaları gerekmektedir. Açıkla: Yatarken ya da otururken pozisyonunuzu düzenli olarak Değiştirin  Düzenli olarak pozisyonu değiştirmek basıncın rahatlamasına yardımcı olacaktır.  Örneğin oturma pozisyonunu yatma yönünde değiştirin.  Bu durum özellikle birden fazla basınç yarası riski taşıyan veya son zamanlarda iyileşmiş basınç yarası olan kişiler için önemlidir  Kendi kendine pozisyonunu değiştiremeyen kişiler risk altındadır. 7. Basınç yarası belgesi (5 dakika) DVD Basınç yarası belgesi video tanıtımı. DVD i göster. Soru olup olmadığını öğren. 8. Basınç rahatlatma teknikleri (10 dakika) Açıkla: o Tekerlekli sandalye kullanıcıları kalça kemiklerindeki basıncı sandalyelerinde oturur iken rahatlatabilirler. o Tekerlekli sandalye kullanıcısının bunu nasıl yapacağı onun sahip olduğu güce ve dengeye bağlım olarak değişir. o Bu eğitim programında iki tane güvenli basınç rahatlatma metodu öğretilmiştir. Bunlar öne eğilme ve yanlara eğilmedir. o Tekerlekli sandalye personeli basınç yarası geliştirme riski altında olan kullanıcılara bu basınç rahatlatma yollarından en az birini öğretmelidirler. Aktivite Gruplar: Katılımcılara ikili gruplara ayrılmalarını söyleyin. Talimatlar: Her bir çifte tekerlekli sandalye verin. Sizi görebilecek şekilde pozisyon almalarını söyleyin Her bir metodu gösterin ve değişik kullanıcılar için değişik metotların işe yaracağını anlatın. Kullanıcılara gösterimin hemen ardından uygulama yapmalarını söyleyin. İzleme: Yakın bir şekilde izleyin ve gerekirse teknikleri düzeltin. Süre: 10 dakika müsaade edin. Eğitmenler için notlar: Bazı tekerlekli sandalye kullanıcıları iki kolları ile kendilerini yükselterek basınç rahatlatırlar. Yeterli kan basıncının cilde dönebilmesi için kullanıcının kendini bu pozisyonda iki dakika tutması gerekir. Bu oldukça fazla güç gerektirir ve omuzlara yük bindirir. Buna ek olarak kullanıcının kilosu üzerinde hâkimiyeti olması gerekir çünkü tekerlekli sandalyesine tekrar dikkatlice oturması gerekmektedir. Eğer sert bir şekilde otururlarsa ciltlerinde hasara sebep olabilirler. Bu sebepten dolayı bu yöntem bu programda öğretilmemiştir. Öne eğilme: Bütün tekerlekli sandalye kullanıcıları için uygun bir yöntemdir. Tekerlekli sandalye kullanıcılarını bu yöntemi gün içerisinde sık sık kullanmaya yoğun bir şekilde teşvik edin. Bağımsız: gücü ve dengesi yerinde olan kişiler için. Yardımla: Güç ve dengesi zayıf olan kişiler için. Yanlara eğilme: Sınırlı güç ve dengesi olan kullanıcılar için uygun bir metottur. Kollar itme tutamaklarına geçirilerek destek alınabilir. 9. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. A.6: Uygun tekerlekli sandalye H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  bir tekerlekli sandalyeyi “uygun” yapan en az dört unsuru tanımlayacaklar;  tekerlekli sandalye kullanıcısının oturmasını etkileyecek parçaları tanımlayacaklar;  tekerlekli sandalyenin farklı parçalarının kullanıcının farklı ihtiyaçlarına nasıl destek sağladığını görecekler;  dış mekanlar/engebeli araziler için uygun olan tekerlekli sandalyeleri diğerlerinden ayırabilecekler;  kişinin ihtiyaçlarını göz önüne alarak kullanıcı için en uygun tekerlekli sandalyeyi tavsiye edebilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: A.6: Uygun tekerlekli sandalye;  Referans Kılavuzu  Katılımcı El Kitabı  DVD: Uygun tekerlekli sandalye benim için ne anlama geliyor;  DVD: Tekerlekli sandalye kullanıcısının ihtiyaçlarını karşılanması;  DVD: Tekerlekli sandalye kullanıcısının çevresel ihtiyaçlarının karşılanması;  yerel olarak bulunabilen tekerlekli sandalyelerin en az birer örneği. İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla.  Eğer katılımcıların bulunduğu bölgede sadece bir ya da iki çeşit tekerlekli sandalye bulunabiliyorsa, bu sandalyelerden birkaç tane sağlayın ki her bir küçük grubun çalışabileceği sandalyeleri olsun.  Eğer gerekiyorsa bu çalışmaları yerel şartlara uyarlayın. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Açık havada engebeli bir alan seçin ( örneğin çakıl, kum ve engellerin olduğu), katılımcıların bu engebeli arazide sandalyeyi kullanma sürecinde birbirlerini görebilecekleri kadar yeterli bir alan olsun. Eğer hava sıcaksa gölge alanlar idealdir.  Bütün tekerlekli sandalyelerin çalışabilecek durumda olduğunu ve minderlerinin olduğunu kontrol edin.  Tekerlekli sandalyelerden birine katılımcılardan birine uyacak şekilde ayarlamalar yapın.  Tekerlekli sandalyeleri eğitim salonunun ön tarafına düzenlice dizin. T A S LA K 1. Giriş. 2. “Uygun tekerlekli sandalye” tanımı 3. Tekerlekli sandalye kullanıcısının ihtiyaçlarını karşılanması. 4. Tekerlekli sandalye kullanıcısının çevresel ihtiyaçlarının karşılanması. 5. Yerinde uygunluk ve duruş desteği sağlama. 6. Tekerlekli sandalye kullanıcısının ihtiyaçlarına göre sandalyenin eşleştirilmesi. 7. Kilit nokta özeti. 2 10 30 30 15 30 3 Toplam bölüm süresi 120 1. Giriş (2 dakika) Açıkla: Bu Bölümde başlıca tekerlekli sandalye çeşitlerine ve bazı tekerlekli sandalyelerde olan değişik özelliklere bakacağız. “Uygun tekerlekli sandalye” nin ne olduğunu daha iyi anlayacağız. Bir tekerlekli sandalye ki: – Kullanıcısının ihtiyaçlarını karşılar; – Kullanıcısının çevresel şartlarına uyar; – Kullanıcısıyla doğru bir şekilde eşleşir; – Duruş desteği sağlar (kullanıcının dik oturmasını sağlar); – Yerel olarak bakımı ve onarımı yapılabilir 2. “Uygun tekerlekli sandalye” tanımı (10 dakika) DVD tanıtımı: Uygun tekerlekli sandalye benim için ne anlama geliyor. Bu kısa DVD tanıtımında deneyimli kullanıcı Faustina uygun tekerlekli sandalyenin onun için ne anlama geldiğini açıklıyor. DVD i göster Soru olup olmadığını öğrenin. 3. Kullanıcının ihtiyaçlarının karşılanması (30 dakika) Sor: Tekerlekli sandalye kullanıcılarının sandalyelerinde neler yapmaya ihtiyaçları vardır? Cevap vermeye teşvik edin En önemli cevaplar: o sandalyeden inmek ve binmek (transfer); o sandalyelerini itmek; o sandalyelerini kaldırmak için katlamak ve transport; o aktivitelerini sürdürmek ( örneğin çalışmak, ev işi yapmak, arkadaşları ile vakit geçirmek, tuvalete gitmek, yıkanmak, giyinmek, kapı aralıklarından geçmek, masa ve sıralara yaklaşmak) Açıkla: Uygun bir tekerlekli sandalye kullanıcının yapmak istediği şeyleri kolaylaştırmalıdır. Haydi, şimdi kullanıcının yapmak istediği şeyleri kolaylaştırmasında ne kadar çok etkili olabilen tekerlekli sandalye özelliklerine bakalım. 3.1 Transferler Tekerlekli sandalyeye binmek ve sandalyeden inmek Açıklayın: Tekerlekli sandalye kullanıcısı sandalyeye farklı şekillerde binebilir ve inebilir. İnsanların nasıl inip bindiğini etkileyen üç tekerlekli sandalye parçası: Açıkla: (her bir parçadaki oku göstermek için tıklayın) o Kolçaklar; o Ayaklıklar; o Frenler. Açıkla: o Çıkarılabilir kolçakları veya arka tekerlek hattını takip eden kolçakları olan tekerlekli sandalyeler yanlardan binip inmeyi kolaylaştıran tekerlekli sandalyelerdir. Açıkla: o Tekerlekli sandalyelerine binip inmek için ayağa kalkan kişiler ayağa kalkmak için kolçaklara ihtiyaç duyabilirler. o Çıkartılarak yoldan çekilebilen ayaklıklar tekerlekli sandalyesine binmek ve inmek için ayağa kalkabilen kişilere kolaylık sağlar. o Yerden transfer yapmak isteyenler için çıkarılabilir ayaklık tercih edebilirler. Açıkla:  Tekerlekli sandalye kullanıcıları için frenler önemlidir. Tekerlekli sandalye kullanıcısı binip inerken sandalyenin hareketsiz kalması için elzemdirler. 3.2 Tekerlekli sandalyeyi itme Açıkla: Tekerlekli sandalye rahatça itmeyi kolaylaştıran parçalar: Açıkla: (her bir parçadaki oku, göstermek için tıklayın) o kolçaklar; o arkalık; o itme kasnakları; o itme tutamakları (kolları); o tekerlekli sandalyenin toplam ağırlığı da kullanıcının sandalyeyi iyi itebilmesini etkileyen etmenlerden olabilir. Açıkla: o Kullanıcı tekerlekli sandalyeyi rahatlıkla itebilmek için itme kasnaklarına kolçaklar üzerinden rahatlıkla ulaşabilmelidir. o Bu slayttaki kullanıcı kolçaklar çok yüksek olduğu için itme kasnaklarına rahatlıkla uzanamamaktadır. Açıkla: o Arkalığın yüksekliği tekerlekli sandalyeyi kolay itmeyi etkileyebilir. o Eğer arkalık çok yüksekse kullanıcının kollarını hareket ettirmesi ve omuzlarıyla itmesi zorlaşır. o Slayttaki tekerlekli sandalye kullanıcısı kendini itmekte zorlanacaktır çünkü arakalık yüksektir. Açıkla: o Arkalık alçak olduğunda kullanıcının sandalyeyi itebilmek için omuzları serbest olur. o Doğru bir şekilde oturabilen ve iyi bir dengesi olan tekerlekli sandalye kullanıcısı için bu arkalık yüksekliği iyidir. Açıkla: o Tekerlekli sandalyesini kolları ile iten bir kullanıcı tekerleklere (itme kasnaklarına) ne kadar kolay ulaşabilirse itmesi de o kadar kolay olur. o Bu bayan yarı itme durumunda. Tekerleklere (itme kasnaklarına) ne kadar kolay ulaşabildiğine dikkate ediniz. Açıkla: o Genel bir talimat olarak arka tekerlek pozisyonu; kullanıcılar itme kasnaklarını tutarken dirseklerindeki açının 90 derecelik olması şeklindedir. o Eğer arka tekerlek saha arkada olursa itme kasnaklarına ulaşmak zorlaşır. Bu da itme işlemi için kullanıcının daha fazla yorulacağı anlamına gelir. Açıkla: o Bazı tekerlekli sandalyelerin arka tekerlek pozisyonları ayarlanabilir özelliktedir. o Arka tekerleklerin ayarlanabilmesi arka tekerlek üzerinde dengede durma hareketini kolaylaştırır. o Bu denge hareketleri engebeli zeminlerde ve kaldırımlarda inip çıkmak için kullanışlı bir harekettir. o Eğer arka tekerlek ileri doğru ayarlanmışsa tekerlekli sandalyeye bu denge hareketini yaptırmak daha kolay olur. Eğer arka tekerlekler geriye doğru ayarlanmışsa bu hareket daha zor olacaktır. Daha stabil olacaktır. Açıkla: o Bazı tekerlekli sandalye kullanıcıları itme işlemini ayaklarıyla yaparlar. o Bu yolla etkin bir şekilde itebilmek için kullanıcıların pelvislerinin arkalıkla iyi bir şekilde desteklenmiş olması ve ayaklarının yere düz değiyor olması gerekmektedir. o Bu kullanıcılar için koltuğun yerden yüksekliği çok önemlidir. (minderin yüksekliği de hesaba katılarak) o Çıkarılabilen ayaklıklar da önemlidir. o Ayakları ile iten bazı kullanıcıların tepsi ya da kolçağa ihtiyaçları vardır ki iterken öne uzanabilsinler. Açıkla: o Ağır bir tekerlekli sandalyeyi itmek için daha fazla enerji gerekir. Eğer bir tekerlekli sandalye iyi tasarlanmışsa ve iyi dengelenmişse ağırlığın etkisi o kadar da kötü olmayabilir. o Tekerlekli sandalyenin ağırlığı özellikle çocuklar için önemlidir. Eğer sandalye ağır ise bir çocuk için sandalyenin kontrolü zorlaşabilir. Açıkla: o Bazı tekerlekli sandalye kullanıcıları kendi sandalyelerini itemezler ve yardıma ihtiyaçları vardır. o Bazı tekerlekli sandalye kullanıcıları kendi sandalyelerini genellikle kendileri iterler ama arada sırada yardıma ihtiyaç duyarlar. Örneğin merdiven inip çıkarken veya engebeli zeminlerde yardıma ihtiyaçları olur. o Güçlü itme tutamakları kullanıcıya yardımcı olan kişilerin işini kolaylaştıracaktır. Çocuk kullanıcılar için; çocuğa yardımcı olan erişkinler için yüksek itme tutamakları itme işlemini kolaylaştıracaktır. 3.3 Tekerlekli sandalyenin katlanması Açıkla: Katlanabilir tekerlekli sandalye saklama ve transport için kullanışlıdır. Tekerlekli sandalyeler iki ana yolla katlanırlar. Açıkla: o Çapraz katlanma iskeleti olan tekerlekli sandalyelerde iskelet katlanır böylece iki taraf bir araya gelerek katlanır. Bazen tekerlekleri çıkarmak da mümkün olabilir. o Çapraz katlanabilen tekerlekli sandalyeler dar kapı aralıklarından geçmeleri gereken kullanıcılar için kullanışlı olabilir. o Bazı kişiler transport edilen sandalyeler için çapraz katlamalı tekerlekli sandalyeleri tercih ederler. o Çapraz katlamalı tekerlekli sandalyelerin bir dezavantajı katlama mekanizmasının zayıflayabilmesidir, sandalye dengesiz hale gelebilir. Bu şekilde itilmesi zor hale gelebilir. Açıkla: o Bazı sabit iskeletli tekerlekli sandalyeler de katlanabilir. Arkalık koltuğa doğru katlanır ve tekerlekler çıkar. o Sabit iskeletli sandalyelerin ve çapraz katlanan sandalyelerin, her ikisinin de avantajları ve dezavantajları vardır. En iyi seçim tekerlekli sandalye kullanıcısının hayat tarzına, transferlerini nasıl yaptıklarına ve transport durumlarına göre yapılacak kişisel seçimdir. Aktivite Gruplar: Her bir grupta üç kişi olmalı. Talimatlar: Her bir gruba odadaki tekerlekli sandalyelerin nasıl katlandığını bulmalarını söyleyin. İzle: Herkesin sandalyeleri katlayabildiklerini ve açabildiklerini kontrol edin.Gerekiyorsa doğru metodu gösterin. Süre: 5 dakika müsaade edin. 3.4 Faaliyetlerin yürütülmesi Açıkla: Tekerlekli sandalye kullanıcısının faaliyetlerini yürütebilmesini kolaylaştıran pek çok tekerlekli sandalye özellikleri vardır. Bunlardan bazıları hakkında şimdiden bahsettik. Örneğin tekerlekli sandalyesini itmek, aktivitelerinde kolaylık sağlamak için ne yollar uygulayabileceklerini söyledik. İşte burada başka örnekler de vardır. Açıkla: o Tekerlekli sandalyenin toplam uzunluğu küçük alanlarda kullanımın zorluğu ya da kolaylığını etkiler. o Uzunluk tekerlekli sandalyenin en arkasındaki bölüm ile en ucundaki bölüm arasındaki uzaklıktır. Katılımcılara sorun: Odada toplam uzunluğu en büyük olan tekerlekli sandalye hangisidir? Açıkla: o Yüksek kolçaklar masa ya da sıraya yaklaşmayı zorlaştırırlar. Açıkla: Hatırlanması gereken en önemli şey, uygun tekerlekli sandalyeyi seçerken kullanıcının ihtiyaçlarını düşünmektir. DVD tanıtımı: Tekerlekli sandalye kullanıcısının ihtiyaçlarının karşılanması. Katılımcılara, farklı özelliklere sahip tekerlekli sandalyelerin kişilerin faaliyetlerini gerçekleştirmelerini nasıl kolaylaştırdığını görmeleri için DVD’i yakından izlemelerini söyleyin. DVD’i seyrettikten sonra bu konuda tartışacağınızı açıklayın. DVD göster Açıkla: DVD de farklı faaliyetlerle bulunan, farklı sandalyeler kullanan farklı kullanıcılar gördük. Sor: Bu aktiviteler nelerdir? Cevapların içeriği: o çalışmak (ofiste, süpermarkette, döşeme atölyesinde); o dans etmek; o arabadan inmek ve arabaya binmek; o yürümek (annesi ve köpekle); o basketbol oynamak. Sor: Roger’a süpermarketteki işini yapmasında yardımcı olan tekerlekli sandalye özellikleri nelerdir? Cevap vermek için teşvik edin (bkz aşağıdaki eğitmen için notlar) Sor: Bu videodan, tekerlekli sandalyenin özelliklerinin kullanıcının ihtiyaçlarına ne kadar iyi cevap verdiğine dair başka bir örnek verebilecek var mı? Cevap vermek için teşvik edin, klipteki kişileri hatırlatın, gerekirse tekrar gösterin. Sor: Birisi bir örnek daha verebilir mi? Cevap vermek için teşvik edin. Eğitmenler için notlar: o Her bir tekerlekli sandalye kullanıcısını gözden geçirmek gerekli değildir; o Katılımcıların sorabileceği sorulara cevap vermelerine yardımcı olabilmek için klipteki her bir tekerlekli sandalye kullanıcısıyla ilgili notlar verilmiştir; Tekerlekli sandalye kullanıcısı Onların yaptıkları aktivite Yardımcı olan tekerlekli sandalye özellikleri. Roger Süpermarkette çalışıyor; rafları düzenliyor. o Kısa akslı, raflara yaklaşmasını kolaylaştırıyor ve dar alanlarda manevra yapabiliyor. o Arka tekerlekler sürüş için uygun pozisyonda ve arkalık kısa ( Roger’ın daha yüksek desteğe ihtiyacı yok) bu Roger’ın sürüşünün verimini artırıyor. o Kolçak yok , Roger’ın bir şeyleri bacağına koymasını kolaylaştırıyor ve aktif hareket etmesini sağlıyor. Ruan Annesiyle ve köpeğiyle yürüyor. o İtme tutamakları, annenin itmesi için iyi bir yükseklikte. o Ruan’ın tekerlekli sandalyesinin onun daha rahat etmesini ve güvende olmasını sağlayan ekstra desteği vardır( ayrıntılara inmeyiniz). James (numara14) ve takım arkadaşları Tekerlekli sandalye basketbolu oynuyor. James ve takım arkadaşları özel Spor Tekerlekli Sandalyeleri kullanıyorlar. Özelliklerin içeriği: o Arka tekerlekler dışa doğru açı verilmiş (stabiliteyi artıran); o İnce arka tekerlekler (hızı artırmaya yardımcı olan); o Küçük ön tekerlekler (ağırlığı azaltıp hızı artırır); o Uyluk ya da baldır şeritleri, tekerlekli sandalye kullanıcısına stabilite ve güvenlik sağlamaya yardımcı; o Kısa arkalık, spor yaparken bolca hareket serbestîsi sağlar; o Arka tekerlekler sürüş için iyi ayarlanmış. Mark Döşeme atölyesinde çalışıyor. Mark tek ayağı ile sürebiliyor ki bu iki kolunu kullanmak zorunda olmadığı anlamına gelir. Bu atölyede bir şeyleri bir koluyla taşıyabilmesini sağlıyor. o Tekerlekli sandalyenin bir ayaklığı çıkarılarak bu duruma olanak sağlanıyor. Dawid ve Pinky Süpermarkette güvenlik görevlisi olarak çalışıyorlar o Her ikisi de kısmen kısa akslı tekerlekli sandalye kullanıyorlar bu onların markette dolaşabilmelerine yardımcı oluyor. o Her biri kendi sandalyelerini kendi başlarına hareket ettirebiliyorlar- bununla beraber Dawid arka tekerlekleri kullanıyor Pinky ise elektrikli bir tekerlekli sandalye kullanıyor. Faizel Ofiste çalışıyor o Arka tekerlekler sürüş için iyi bir pozisyonda. o Arkalık omuz hareketlerine izin verecek kadar alçak ve aynı zamanda doğru ve yeterli destek sağlayacak kadar da yüksektir. o Sürüş eldiveni kullanmaktadır – itme kasnaklarını itmeye yardımcı olur ve daha kolay itmesini sağlar. o Kolçak yoktur– bu Faizel’in tekerlekli sandalyesini masanın altına doğru çekmesini kolaylaştırmaktadır. Keith (üç tekerlekli sandalye ) ve Ralph (dört tekerlekli sandalye) Tekerlekli sandalye montaj atölyesinde çalışıyor. o Ralph ve Keith: Kolçak yok, tezgâh üzerinde aletlerle çalışmak ve dizinin üzerinde eşyaları taşımak kolay. o Keith’in üç tekerlekli sandalyesi gövdeciğinden dolayı diğer eşyaların ve ekipmanların arasında olan ve almak istediği objelere uzanmasını kolaylaştırıyor. o Ralph aks mesafesi kısa olan bir tekerlekli sandalye kullanıyor ve bu onun çalışma alanlarına girebilmesine yaklaşmasına imkân sağlıyor. o Ralph ve Keith: Arka tekerlek pozisyonu sürüş için doğru ayarlanmış ve arkalık hareket serbestisi sağlıyor. Ryan Arabaya binip inmek o Ryan’ın tekerlekli sandalyesi katlanıyor ve arka tekerlekleri çıkıyor( çabuk çıkabilen tekerlek) bu şekilde sandalyesini arabaya kendi koyabiliyor. Bu özellik olmadan arabaya bağımsızca binip inme işlemini yapamazdı. Jenee Dans o Kısa toplam tekerlekli sandalye mesafesi – küçük dönüşler (daire şeklinde) yapmasına izin veriyor. o Kısa dingil mesafesi , manevra kabiliyetini artırıyor. o Alçak arkalık iyi derecede hareket serbestisi sağlıyor. o Emniyet barları (geriye düşmeyi engelleyen) geriye düşmeyi engelliyor (kısa aks mesafesi ile olması muhtemel olan bir durumdur) 4. Tekerlekli sandalye kullanıcısının çevresel ihtiyaçlarının karşılanması (30 dakika) Açıkla: Değişik tekerlekli sandalyeler değişik çevrelere uyumludurlar. Tekerlekli sandalyenin değişik ortamlara çalışmasını etkileyen ana özellikler: o Ön ve arka tekerlek arasındaki mesafe; o Tekerleklerin çapı ve genişliğidir. İşte bazı örnekler: Açıkla: o Ön ve arka tekerlek arasındaki mesafe önemlidir. o Tekerlekler arasındaki uzunluk fazlaysa buna “uzun aks mesafesi” denir. o Tekerlekler birbirine yakın olduğunda ise “kısa aks mesafesi” olarak adlandırılır. Açıkla: o Uzun aks mesafeli tekerlekli sandalyeler daha stabildir ve öne düşme ihtimalleri daha azdır. o Uzun aks mesafeli tekerlekli sandalyeler vaktinin büyük bir kısmını dış mekânlarda geçiren ve engebeli, bozuk zeminlerde hareket eden kişiler için uygundur. o Üç tekerlekli sandalyeler uzun aks mesafeli tekerlekli sandalyelere örnektir. Engebeli araziler için genellikle çok stabil ve uygun sandalyelerdir. o Üç tekerlekli sandalyeler herkes için uygun değildir. o Örneğin üç tekerlekli sandalyeler ayağa kalkarak transferini yapmak isteyen kişiler için uygun değildir çünkü ayaklıklar sabittir ve ön kiriş ayağına engel olabilir. o Dört tekerlekli uzun aks mesafeli tekerlekli sandalyeler de bozuk zeminlerde başarıyla kullanılabilir. o Bu örnekte ön tekerlekler ayaklıkların yanında olacağına ayaklıkların altındadır. Bu tekerlekli sandalyenin uzun aks mesafeli olmasını sağlar ve stabilite kazandırır. Açıkla: o Daha kısa aks mesafesi olan tekerlekli sandalyeler zeminin düz ve makul bir düzeyde pürüzsüz olduğu yerlerde daha uygundur. o Kısa mesafeli aksı olan tekerlekli sandalyeler yokuş aşağı inerken veya ön tekerlek bir engele çarptığında öne düşmeye daha eğilimlidirler. Açıkla: o Bu ortopedik stil, kısa aks mesafeli bir tekerlekli sandalyeye örnektir. o Bu sandalyeyi engebeli arazide itmek pek kolay değildir. Açıkla: o Kısa aks mesafeli tekerlekli sandalyeler zamanının çoğunu iç mekânlarda geçiren kişiler için iti bir seçimdir. Açıkla: o ‘Aktif’ stil dört tekerlekli sandalyeler genellikle kısa aks mesafelidir. o Tekerlekli sandalye hareketlilik becerileri iyi olan bazı tekerlekli sandalye kullanıcıları kısa aks mesafeli tekerlekli sandalyeleri bozuk zeminlerde kullanmada başarılı olabilirler – örneğin tepe aşağı inerken arka tekerlek üzerinde ve engebeli yüzeylerde giderken. Açıkla: o Engebeli yüzeylerde ilerlerken ve taş ya da engeller gibi setleri aşmada tekerlek ne kadar büyükse itmek de o kadar kolay olur. o Geniş arka ve ön tekerlekler sandalyenin kumlu ve çamurlu yüzeylere batmasını engeller. o Standart arka tekerlekler 24” tir. Bununla beraber pek çok yerde 24” tekerlekleri bulmak zordur. Bundan dolayı bazı üreticiler 26” tekerlekler yaparlar. o Çocuk tekerlekli sandalyeleri 20” ya da 22” büyüklüğünde tekerlekler olabilirler. o Arka ve ön tekerlekler havalı (basınçlı tekerlek) ya da dolgu olabilirler. o Hava basınçlı tekerlekler iyi çalışması için şişirilmiş olmalıdır. o Bazı bölgelerde tekerleklerin patlaması çok yaygındır. Bu bölgelerde yaşayan kişiler bu tamiratı kendileri yapabilmelidirler ya da bunu yapabilecek birilerini kolaylıkla bulmaları gerekir. o Dolgu tekerlekler uygun bir alternatiftir. Dolgu tekerlekler delinmezler ve şişirilmeye ihtiyaçları yoktur. Bununla beraber engebeli yüzeylerde dolgu tekerlekler, tekerlekli sandalye kullanıcısı için “sert” hissedilir. o Dış mekânlarda kullanıldığında dolgu lastiklerin hepsi çok uzun ömürlü değildir. Düşük kaliteli dolgu lastikler tekerleklerin kasnaklarının soyulmasına neden olabilirler. o İki çeşit dolgu lastik vardır: o Dolgu kauçuk lastik; ağırdırlar, oldukça serttirler ve iyi kalitede ise oldukça sağlamdırlar. o Poliüretan (PU) lastik; hafiftirler. Ancak çok iyi kaliteli olmadıkları takdirde dış mekânlarda çok çabuk yıpranabilirler ve kullanılmaz hale gelirler. DVD tanıtımı: Tekerlekli sandalye kullanıcısının çevresel ihtiyaçlarının karşılanması Katılımcılara değişik çevresel şartlarda kişilerin hareketliliğimi sağlayan değişik tekerlekli sandalye özelliklerini yakından izlemelerini söyleyin. DVD’i seyrettikten sonra bu konuda tartışacağınızı açıklayın. DVD’i göster. Soru olup olmadığını öğren. Açıkla: DVD’de, iç mekânları ve fazlasıyla engebeli / çamurlu yolları olan dış mekânları da içeren oldukça değişik arazilerde dolaşan birtakım tekerlekli sandalye kullanıcıları vardır. Sorun: İki tekerlekli sandalye kullanıcısı, Venkamarantu ve Sione oldukça engebeli ve çamurlu bir zeminde yolculuk yaptılar. Tekerlekli sandalyelerinin bunu daha kolay yapmalarını sağlayan özellikleri nelerdir? Cevaplar: o Üç tekerlekli sandalye – engebeli arazide onlara stabilite sağladı. o Geniş ön tekerlekler – engellerin üzerinden yuvarlandı ve kuma/çamura batma ihtimali daha azdır. o Arka tekerleğin pozisyonu sürüş için uygundur – tekerlekli sandalyelerini itmeyi kolaylaştırır. Sor: Mutfağında yemek pişiren Jean ve jimnastik salonunda eğitmen olan Jacques iç mekânlardaydılar. İç mekânlarda hareket etmelerini kolaylaştıran tekerlekli sandalye özellikleri nelerdir? Cevaplar şunları içerir: o Kısa aks mesafesi ve toplam uzunluğu kısa. o Daha küçük / daha ince ön tekerlekler – pürüzsüz yüzeylerde daha kolay. Sor: Başka bir tekerlekli sandalye kullanıcısı (Lalithamma)dış mekânlarda sürüyordu. Sandalyesi ile geçtiği yer daha düzgündü ama bir kanalın üzerinden geçmesi gerekiyordu. Tekerlekli sandalyesinin hangi özellikleri bu durumu kolaylaştırdı? Cevaplar şunları içerir: o Uzun aks mesafeli dört tekerlekli sandalye – uzun aks mesafesi stabilite sağlar (aynı zamanda suyla baş etmesine de yardımcı olur) o Geniş ön tekerlekler. o Arka tekerlekler sürüş için iyi bir pozisyondadır – tekerlekli sandalyelerini itmelerine yardımcı olur. Küçük grup aktivitesi Gruplar: Herkesi engebeli araziye üç değişik tekerlekli sandalye ile çıkartın. Talimatlar: Katılımcılara güvenlik kurallarını hatırlatın: ayaklıklar üzerinde durmayın, parmaklarınızı tekerlek jant tellerinden ve frenlerden uzak tutun; yukarı ya da aşağı eğimlerde sürüş yapıyorsanız arkaya düşme ihtimaline karşın arkanızda bir yardımcı olsun. İki gönüllü isteyin: o Katılımcılardan birine engebeli alanlarda kullanmalarının kolay olduğuna inandıkları bir sandalyeyi seçmelerini isteyin; o Başka bir katılımcıya engebeli alanda kullanmanın zor olacağını düşündükleri bir tekerlekli sandalyeyi seçmelerini isteyin; o Her bir katılımcıya engebeli alan üzerinde 5 metre gitmelerini ve dönmelerini söyleyin; o Aynı işlemi herkes bu turu yapana kadar iki katılımcı ile daha yapın. İzle: Bu aktivitenin güvenli bir biçimde yapılmasını sağlayın. Katılımcıları yarışmaya teşvik etmeyin çünkü bu tehlikeli olabilir. Süre: 20 dakika müsaade edin Geri bildirim: Sorun: Engebeli alanlarda hangi tekerlekli sandalyeyi itmenin en kolay olduğu ispatlandı? o Neden? Katılımcıları, tekerlek boyutu ve genişliği; aks mesafesi uzunluğu; tekerlekleri itebilme kolaylığı; arkalık yüksekliği konuları hakkında düşünmeye teşvik edin. Açıklayın: katılımcılardan bazıları yaptıklarının kolay olduğunu düşünebilirler tabii ki kendilerine uygun bir sandalye bulacak kadar şanslı olurlarsa! 5. Yerinde uygunluk ve duruş desteği (15 dakika) Açıkla: o Tekerlekli sandalye kullanıcılarını hepsi farklı bedenlerdedirler. Tekerlekli sandalye kullanıcıya yerinde bir uygunluk ve duruş desteği sağlamak için doğru bir şekilde uymalıdır. Neyse ki pek çok tekerlekli sandalye çeşitli boyutlarda gelmektedir veya boyut ayarlanma özellikleri olmaktadır. Bu birden fazla çeşitlilik durumu kullanıcılara uygun tekerlekli sandalye bulma işlemini kolaylaştırmaktadır. o Aşağıda sıralanan parçalar ve özellikler tekerlekli sandalyenin kullanıcıya uyumuna ve kullanıcının dik oturuşuna yardımcı olacaklardır. Koltuk Slaytları göster: Aynı zamanda odadaki tekerlekli sandalyelerin özelliklerini gösterin. Açıkla: o Tekerlekli sandalye koltukları askı şeklinde ya da yekpare olabilirler. o Yekpare koltuklar tahta ya da plastikten yapılmışlardır. Yekpare koltukların üzerinde her zaman bir minder olmalıdır. o Askı şeklindeki koltuklar (slaytta gösterilmiştir) genelde branda (kanvaz) yapılır. o Bir tekerlekli sandalyenin “boyutu” genellikle koltuk genişliği ile tanımlanır. Açıkla: o Askı şeklindeki koltuklar çoğunlukla brandadan yapılır ve genellikle tekerlekli sandalye iskeletinin iki tarafına bağlanmışlardır. o Düşük kaliteli askı şeklindeki koltuklar daha çabuk esneyip büküleceklerdir. Ve koltuk doğru desteği sağlamayacaktır. o Bu slaytta kullanıcı dik oturamamaktadır çünkü koltuk doğru desteği sağlayamamaktadır. Bu da onun dik oturmasını zorlaştırmaktadır. Açıkla: o Minder rahatlık sağlar ve basıncın rahatlatılmasına yardımcı olur. o Minder aynı zamanda kullanıcının çükmüş bir pozisyona doğru kaymasını da engeller. o Bir sonraki bölümde minderlerle ilgili ayrıntılı olarak konuşacağız. Açıkla: o Arkalık askı şeklinde veya yekpare olabilir. Bütün yekpare arkalıkların yastıklaması/dolgu maddesi olmalıdır. o Tekerlekli sandalyelerin farklı arkalık yükseklikleri vardır. Bazı tekerlekli sandalyelerin arkalık yüksekliği ayarlanabilir. Doğru arkalık yüksekliği kullanıcı tarafından seçilmelidir. Bu daha sonra tartışılacaktır. o Bazı tekerlekli sandalyelerin arkalıkları da ayarlanabilir. Açıkla: o Ayaklıklar kullanıcıya desteklemede yardımcı olur. Ayaklığın doğru ayarlanmış olması çok önemlidir. Bu nedenle ayaklık yüksekliği genellikle ayarlanabilir özelliktedir. o Bazı ayaklıkların açıları ve tekerlekli sandalyeye uzaklıkları da ayarlanabilir. Açıkla: o Kolçaklar da destek sağlamak amacıyla kullanılabilir. o Bazı kolçaklar yükseklik ayarlıdır. o Eğer ayarlanabilir değillerse kullanıcıya ihtiyacı olan desteği vermek amacıyla modifiye edilebilirler. 6. Tekerlekli sandalyelerin kullanıcıların ihtiyaçlarıyla eşleştirilmesi (30 dakika) Aktivite Gruplar: İki, üç kişilik gruplar yapın. Talimatlar: Her bir gruba söyleyin: o el kitaplarındaki çalışma sayfalarında bulunan kullanıcı hikayelerini okumalarını isteyin; o elde bulunan sandalyeler arasından her bir kullanıcının ihtiyaçlarını karşılayan en iyi sandalyenin ne olduğu konusunda tartışın ve nedenini söyleyin; o cevapları yazın. İzleme: Grubu izleyin ve gerekiyorsa yardımcı olun. Süre: 20 dakika müsaade edin ve 10 dakikası geri bildirim için. Geri bildirim: Birer birer her grup öne çıkıp: o elde mevcut olan sandalyelerden bir kullanıcı için hangi tekerlekli sandalyenin en uygun olduğunu bildirsinler; o bu seçimin neden en uygun tekerlekli sandalye olduğunu düşündüklerine dair en az üç sebep söylesinler; o diğer katılımcılara grubun kararına katılıp katılmadıklarını sorun. (her bir geri bildirim için 2-3 dakika müsaade edin ). Geri bildirimin sonunda katılımcılara onların fikirlerinin tekerlekli sandalye kullanıcısı ile beraber alınacak karar için bir tavsiye olacağını hatırlatın. Son karar tekerlekli sandalye kullanıcısının olmalıdır. Kullanıcının hikâyesi Bilgi noktaları Bao kırsal bir bölgede yaşamaktadır. Çift taraflı diz altı ampütasyonu vardır. Kaza geçirmeden önce köy yolundaki bir bakkal dükkânını işletiyordu. Dükkâna giden yol uzun, (yaklaşık 1 km) engebeli ve genellikle de çamurlu olduğu için şimdi işine ancak yardım alarak gidebiliyor. Bu durum hem o hem de ailesi için dükkânın işlemeye devam etmesini zorlaştırıyor. Uzun zaman önce Bao’nun bağış olarak verilmiş ortopedik cins bir tekerlekli sandalyesi oldu. Bu sandalye paslanmış ve döşemesi de parçalanmıştı. Ön tekerlekleri çok küçük ve arka tekerlek o Bao’nun engebeli ve yumuşak zeminde kendi kendine bağımsızca kullanabileceği bir tekerlekli sandalyeye ihtiyacı var. İtebilmek için tekerleklere iyi bir şekilde ulaşması önemli. o İşinde çalışırken her bir gün, tekerlekli sandalyesinde çok uzun zaman geçireceği için uygun ve iyi destek ona yardımcı olacaktır. o Üç tekerlekli sandalyelerin mevcut lastikleri çok ince ve yıpranmıştı. Tekerlekli sandalyeyi kulübesinden köye giden yol boyunca itemiyordu çünkü tekerlekler yola batıyordu. Karısına ya da ona yardım eden diğer kişilere bağımlı kalmadan kendi dükkânına kendi başına gidebilmek istiyordu. olduğu yerlerde eğitimciler şuna işaret edebilirler; eğer kullanıcı uzun mesafelerde yolculuk ediyorsa ve güçlü bir yapıya sahipse bu kişiler için üç tekerlekli sandalyeler hareketlilik açısından çok verimli araçlar olabilirler. Kullanıcının hikayesi Bilgi noktaları Amanthi 24 yaşında bir kızdır ve ailesi ile birlikte küçük bir kasabada yaşamaktadır. 18 yaşındayken bir kaza geçirmiştir ve paraplejik olmuştur (belden aşağısı tutmamaktadır). Amanthi’nin kısa bir süre önce basınç ülseri (yarası) olmuştur ve iyileşmesi altı ay sürmüştür. Amanthi’nin ortopedik bir tekerlekli sandalyesi vardır ancak sandalye ona iyi bir destek sağlamamakta ve o sandalyedeyken çok yorulmaktadır. Sandalyesinin minderi yoktur ve o, basınç yarası geliştirmesinin sebebinin bu durumdan kaynaklandığını düşünmektedir. Amanthi bir sekreterlik kursuna kayıt olması için davet almıştır kendisi de bunu istemektedir. Ancak şu anda sahip olduğu tekerlekli sandalyede bütün gün oturamayacağından korkmaktadır. o Amanthi’nin transferini kolayca yapabileceği, duruş desteği alabileceği ve basınç rahatlatma minderi olan bir tekerlekli sandalyeye ihtiyacı vardır. o Sıranın altına girebilecek bir tekerlekli sandalyesi olması önemlidir. o Ön tekerleğin boyutu ne kadar yol kat edeceğine bağlıdır. Philip 62 yaşındadır ve küçük bir adada yaşamaktadır. Altı ay önce felç geçirmiştir. Evine dönmeden önce hastanede bir ay geçirmiştir ve tekerlekli sandalyesi yoktur. Ya yatağında yatmakta ya da evinin verandasındaki sandalyesinde oturmaktadır. Philip sol kolunu ya da bacağını hareket ettirememektedir. Bununla beraber her geçen gün güçlenmektedir ve aileden birilerinin yardımı ile dik durabilmektedir. Sağ kolunu çalıştırmaktadır ve bir tekerlekli sandalyesi olmasını çok istemektedir ki bu yolla daha hareketli olabilir ailesine daha az bağımlı hale gelebilir. Tek kat olan küçük evinin etrafında dolaşabilmek ve etrafta bulunan komşularını gezebilmek istemektedir. Bölge oldukça kumlu bir yapıya sahiptir. Torunlarından birinin arabası vardır ve onun tekerlekli sandalyesi olduğu takdirde onu gezdireceğini söylemektedir. o Philip’in ayağa dikilerek transfer yapabileceği bir tekerlekli sandalyeye ihtiyacı vardır. Çevrilebilen ayaklıklar bunu kolaylaştırabilir. o Daha büyük ön tekerlekler ve daha kalın arka tekerlekler sandalyesini itmesini ve mahallesinde dolaşmasını kolaylaştıracaktır. o Kısa mesafelerde sandalyesini kendi kendine sağ kol ve bacağıyla itebilir – dolayısıyla tekerlekli sandalye koltuğunun yüksekliği ( minderle beraber) ayağını yere değecek şekilde oturmasına müsaade etmelidir. o Çapraz katlanabilen veya arkalığı katlanabilen ve arka tekerlekleri çıkabilen bir tekerlekli sandalye torununun arabasıyla yolculuk etmesini kolaylaştıracaktır. Sabrina 56 yaşındadır ve küçük bir adada yaşamaktadır. Yıllar önce, dördüncü çocuğunun doğumunun ardından bacaklarının gücünün büyük bir kısmını kaybetmiştir. Biraz olsun ayakta durabilmektedir ama yürüyememektedir. Hiçbir zaman bir tekerlekli sandalyesi olmamıştır. Sabrina deniz kenarında küçük bir köyde yaşamaktadır – ve evinin etrafındaki yüzeyler engebeli ve kumludur. Zamanını torunlarının bakımına yardımcı olarak, yemek o Sabina’nın engebeli ve kulmlu zeminlerde kolaylıkla sürebileceği bir tekerlekli sandalyeye ihtiyacı vardır. Büyük ön tekerleklerin olması çok önemlidir. Uzun aks mesafesi tekerlekli sandalye stabilitesine yardımcı olacaktır. o Çünkü ayakta durabilmektedir, transferini yapabilmek ve sandalyesine binip inebilmek için çıkabilen ayaklıkları tercih edebilir. pişirerek ve örgü örerek geçirmektedir. Evinde tekerlekli sandalye için yeterli alan yoktur ama evinin aşağısında muhafaza edilebilir çünkü evi direkler üzerinde (sütunlar) yapılı bir evdir. ). o Tekerlekli sandalyenin onun dış alanlardaki hayatına uygun olması için sağlam ve dayanıklı olması gerekir. 7. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. A.7: Minderler H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  minderlerin tekerlekli sandalye kullanıcılarına faydalarını sıralayabilecekler;  yerel olarak bulunabilen değişik tipteki minderlerin söyleyebilecekler;  “basınç rahatlatma minderi” nin ne olduğunu açıklayabilecekler;  basınç rahatlatma minderinin basıncı azaltmasının kontrolünü nasıl yapacaklarını gösterebilecekler;  basınç rahatlatma minderinin basıncı azaltabilmesi için köpük bir “kat”ın ekleneceğini açıklayacaklar. K A Y N A K LA R Bu bölüm için:  PPT slaytları: A.7 Minderler;  Referans Kılavuzu (Sayfa no, XX);  Katılımcı El Kitabı (Sayfa no, XX);  DVD: Basınç testi gösterimi;  Yerel olarak bulunabilen minderlerden birer örnek, her üç katılımcı için tekerlekli sandalyelere uyabilen bir basınç rahatlatma minderi, “kat” eklenmiş bir basınç rahatlatma minderi. İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  katılımcıların bulundukları bölgelerde bulunabilen minderler - bu bölüm köpük ve likit/jel minderlerle ilgili bilgi içermektedir, katılımcıların bulundukları bölgede daha başka çeşit minderler de bulunabiliyorsa bu bölüme o minderleri de ekleyin;  eğer basınç mevcutta basınç rahatlatma minderi yoksa bu bölümü anlatmak zor olabilir, aynı zamanda katılımcıların eğitimden sonra da güvenli bir şekilde tekerlekli sandalye reçete etmeleri de zorlaşacaktır, eğitimden önce düşük maliyetli basınç rahatlatma yastıklarını tanıtmanın yollarını bulun, yerel üretimler veya bazı dış kuruluşlardan yardım istemek de buna dahildir. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Mevcut olan sandalyelerden bazılarının basınç rahatlatma minderlerine uymasını sağlayın.  Yerel olarak bulunabilen minderlerin her birinden ve minder yükseltme aparatından eğitim odasında hazır bulundurun. T A S LA K 1. Giriş. 2. Minder ne içindir? 3. Değişik cins minderler. 4. Basınç rahatlatma minderleri. 5. Basınç rahatlatma minderinin işe yaradığı nasıl test edilir. 6. Basıncı rahatlatmak için ne yapılabilir? 7. Kilit nokta özeti. 2 5 5 25 30 5 3 Toplam bölüm süresi 75 1. Giriş (2 dakika) Açıkla: Bu bölümde tekerlekli sandalye minderleri ile ilgili konuşacağız. Minderlerin neden önemli olduğunu, değişik minder çeşitlerini ve bir minderin doğru bir şekilde uyup uymadığını nasıl kontrol edeceğimizi öğreneceğiz. 2. Minderler ne içindir? (5 dakika) Sor: Tekerlekli sandalye kullanıcıları için tekerlekli sandalye minderinin faydaları nelerdir? Cevap vermeye teşvik edin. En önemli cevaplar: o basıncın rahatlatılması; o duruş desteği; o konfor. Açıkla: o Bütün tekerlekli sandalye kullanıcıları için minder tekerlekli sandalyenin elzem bir parçasıdır. o Kullanıcıya en uygun olacak minder tipi kullanıcının ihtiyaçlarına bağlıdır. o Basınç yarası geliştirme riski olan kişiler her zaman basınç rahatlatma minderi kullanmalıdırlar. o Bütün tekerlekli sandalye kullanıcılarının basınç rahatlatma minderine ihtiyacı yoktur. o Bununla beraber bütün tekerlekli sandalye kullanıcıları sandalyelerinde rahat olmalıdırlar ve her tekerlekli sandalye kullanıcısı dik oturmalarına yardım edecek destekten yarar sağlayacaklardır. 3. Değişik minder çeşitleri (5 dakika) Açıkla: Pek çok değişik tekerlekli sandalye minderi vardır. Sor: Katılımcılar hangi çeşit minderleri gördüler ya da duydular? Cevap vermeleri için teşvik edin ve tahtaya yazın. Cevaplar şunları içerebilir: o köpük minderler; o hindistan cevizi lifinden yapılmış minderler); o hava ile doldurulmuş minderler; o likit ya da jel ile doldurulmuş minderler; o düz minderler; o konturlu minderler; o kalıplanmış minderler; o katmanlı minderler. Açıkla: Pek çok çeşit minder vardır. Minderler aşağıdakiler de dâhil olmak üzere pek çok şekilde tanımlanırlar: o yapıldıkları materyal ile (örneğin; köpük, lif); o içlerini dolduran materyal ile (örneğin; hava, likit, jel); o ana fonksiyonları ile (örneğin; basınç rahatlatma, konfor, duruş desteği); o şekilleri ile (örneğin düz ya da konturlu); o nasıl yapıldıkları ile (örneğin; köpük minderler bir parça köpükten “kalıplanarak” ya da “katmanlı” olarak veya farklı köpük katlarından). Yerel olarak bulunabilen minderleri teker teker gösterin. Her bir minderi materyalleri, ana fonksiyonları, şekilleri ve kalıplanmış veya katmanlı oluşuna göre tanımlayın. Her bir minder örneğini grupta elden ele gezdirin. 4. Basınç rahatlatma minderi (25 dakika) Açıkla: Basınç yaraları ile ilgili bölümde, basınç yarası geliştirme riski altında olan herkesin basınç rahatlatma minderi olması gerektiğinden bahsetmiştik. Bu bölümde basınç rahatlatma minderi nedir ona bakacağız. Sor: Minder örneklerinden hangileri basınç rahatlatma görevi yapabilir? Cevap: o konturlu köpük minderlerinden herhangi biri; o hava ile dolu ya da likit ile dolu minderlerden herhangi biri. Basınç rahatlatma minderi basıncı şu yollarla tahliye eder: o tekerlekli sandalye kullanıcısının ağırlığını koltuk yüzeyinin üzerine olabildiğince eşit dağıtarak; o yüksek basınç riski altındaki bölgelerin basıncını azaltarak (kalça kemikleri, kuyruk sokumu/kuyruk kemiği); o tekerlekli sandalye kullanıcısının dik oturmasına yardımcı olarak sıyrılma, kaymayı azaltır. Köpük basınç rahatlatma minderi Açıkla: Öncelikle köpük basınç rahatlatma minderinden bahsedeceğiz. Açıkla: Katı taban tabaka: o Basınç rahatlatma minderinin tabanı katı olmalıdır. o Bu minderin kullanıcıya iyi bir destek vermesini sağlar ve kullanıcı hareket ettiğinde o da hareket etmez. Açıkla: Üst tabaka o Bu kat (birden fazla kat olabilir) daha yumuşak köpüktendir. o Üst tabaka üzerine oturulan kalça kemiklerinin gömüleceği kadar yumuşak olmalıdır ama aynı zamanda çok da yumuşak olmamalıdır ki kalça kemikleri en alt tabana, tekerlekli sandalyenin yekpare tabanına ve koltuğun içine gömülmesin. Açıkla: Pek çok tekerlekli sandalye minderleri oturma yerinde şekillere sahiptir( konturlar). Bu şekillendirme: o kullanıcıya destek sağlamaya yardımcı olur; o kullanıcının ağırlığını koltuk yüzeyinde eşit dağıtmaya yardımcı olur; o kalça kemikleri ve kuyruk sokumu altındaki basıncı rahatlatmaya yardımcı olur. Basınç rahatlatma minderinde görebileceğiniz gibi şekillendirme aşağıdakileri içerebilir (slayttaki okları göstermek için tıklayın): o kalça kemikleri altında bir “çukur” - basıncı rahatlatmak için; o kalça kemikleri önünde bir sahanlık – pelvisi daha dik tutmak öne doğru kaymasını engellemek için; o kilonun dağılımını sağlamak için uyluk kemiklerinin altında bir destek; o uylukların geri kalan kısmı için hendekler ya da oluklar. Hava/Likit/Jel basınç rahatlatma minderleri Açıkla: Şimdi hava/likit/jel basınç rahatlatma minderlerine bakacağız. Açıkla: o Flotasyon minderleri havayla likitle ya da jelle dolu tamponları içerir. o Jel tamponlu minderlerin, köpük konturlu minderlere çok benzeyen sert köpük tabanları olmalıdır. o Alt tabanın üzerinde jel/likit bir tampon vardır. o Jel tampon otomatik olarak tekerlekli sandalye kullanıcısının vücut şeklini alır. Bu tekerlekli sandalye kullanıcısının ağırlığının eşit olarak dağılımını sağlar ve kemikli bölgedeki basıncı azaltır. Hangi minder kullanılmalıdır? Açıkla: Her iki tip minderinde; köpük konturlu minderler ve hava/jel/likit minderlerinin, hem avantajları hem de dezavantajları vardır. Aşağıdaki tabloyu tahtaya üzerinde cevaplar olmadan çizin. Sorun: Dezavantajlar ve avantajlar nelerdir? Katılımcıların önerdikleri avantajları ve dezavantajları yazın. Aşağıdaki listede olan her şeyin yazıldığına emin olun. Avantajlar Dezavantajlar Köpük konturlu minder o Yerel olarak yapılabilir (yüksek kaliteli köpük olan yerlerde) o Değişik ihtiyaçlara uyarlamak için modifiye edilebilir. o “Ani çöküş” söz konusu değildir (havanın ya da jelin tahliyesine neden olan bir delinme minderin “ani çöküşüne” neden olur ve minderin basıncı rahatlatmasını engeller). o Katmanlı bir minderin en üst katmanı kolaylıkla değiştirilebilir ve az masraflıdır (bütün minderi yenilemekten daha kolaydır) o Köpük zamanla sıkışır (düz ve sert bir hale gelir). Bu nedenle köpük minderler düzenli olarak kontrol edilmeli ve her 1-2 yılda yenilenmelidir. o Kuruması zaman alabilir (idrar tutma problemi olanlar için bir problemdir). o Köpük ısı yalıtımı yapar ve doku sıcaklığında artışa sebep olabilir. Hava/likit/jel minderler o Koltuk üzerinde basınç eşit olarak dağıtılır o Tekerlekli sandalye kullanıcısı hareket ettiğinde veya pozisyonunu değiştirdiğinde jel tampon otomatik olarak kullanıcının vücuduna adapte olur. o Hava/likit/jel minderler köpük minderlere oranla daha pahalıdırlar ve çok kolaylıkla hemen bulunmazlar. o Bazı tekerlekli sandalye kullanıcıları hava/likit/jel minderlerinin kendilerini dengesiz hissettirdiğini düşünürler. o “Ani çöküş” söz konusu olabilir. Tekerlekli sandalye kullanıcısının çabuk bir şekilde minder bulamayacağı şartlarda bu problem olabilir. Minder kılıfları Açıkla: Bütün minderlerin bir kılıfı olmalıdır. Kılıf cinsi önemlidir. Mevcut olan değişik minderleri elden ele gezdirin. Katılımcılara kılıflara yakından bakmalarını ve slayttaki soruları dikkate almalarını söyleyin. o Kılıf suya dayanıklı ya da su geçirmez mi? o Kılıf iyi ve dayanıklı mı (uzun ömürlü mü)? o Kılıf elastik mi? o Kılıfın yapıldığı materyal ince veya kalın mı? o Kılıf yıkanmak için kolaylıkla çıkartılıp yeniden takılabiliyor mu? Sor: o Hangi minder kılıfı (eğer varsa) su geçirmez ya da suya dayanıklı? o Bu ne zaman işe yarar bir özellik olur? Cevap: o idrarını tutamayan tekerlekli sandalye kullanıcıları için; o tekerlekli sandalyesini dış mekanlarda bırakmak durumunda olan ya da kendisi sürekli dış mekanlarda olanlar için. Açıkla: o Nem tekerlekli sandalye kullanıcısının basınç yarası geliştirmesine sebep olan risk faktörlerinden biridir. Dolayısıyla minderi kuru tutmak çok önemlidir. o Tekerlekli sandalye kullanıcılarına minderleri ıslandıktan sonra acilen kurutmalarını tavsiye edin. Minderi direk güneş ışıklarından uzak ve kılıfı çıkmış şekilde kurutmalılardır. o Tekerlekli sandalye kullanıcısının idrarını tutma problemi varsa iki minder sağlamayı göz önünde bulundurun. . Eğitmenler için notlar: Katılımcılar, eğer tekerlekli sandalye kullanıcısının idrarını tutma problemi var ise ancak su geçirmez ya da suya dayanıklı minder kılıfı yoksa ne yapacaklarını sorabilirler. Seçenekler şunlardır: o kullanıcının idrarla ilgili problemini azaltmak için nasıl bir yardımda bulunabilir araştırın; o ikinci bir minder verin – dolayısıyla biri kururken kullanıcı diğerini kullanabilsin; o minder kılıfın altına konulacak olan çok ince bir plastik kılıfla korunabilir; eğer plastik kılıf kullanılacaksa: o plastik kılıfın kullanıcının minderin üzerinde “kaymasına” sebep olup olmayacağını kontrol edin; o kullanıcının sıvının plastik kılıf üzerinde “birikmeyeceğinden” emin olması gerekir – bu basınç yarası riskini artırır. o kullanıcının, sıvının plastik kılıf üzerinde “birikmeyeceğinden” emin olması gerekir çünkü bu basınç yarası riskini artırır. o kullanıcının kılıf ıslanırsa bunu kurutması ve plastik kılıfın yenilenmesini sağlaması gerekmektedir. Sor: o Hangi (eğer varsa) minder kılıflarının dayanıklı (uzun ömürlü) olması muhtemeldir? Açıkla: dayanıklı bir kılıf her minder için önemli bir özelliktir. Sor: o Hangi (eğer varsa) minder kılıfı esnektir? o Bu neden önemli bir özellik olur? Cevap: o esnek bir kılıfın konturlara uyma ihtimali daha fazladır, eğer bir kılıf esnek değilse konturlara uyması için içinde daha çok ”yer” vardır. Sor: o Hangisi en ince kumaştır? Hangisi en kalın kumaştır? o Kumaşın inceliği/kalınlığı neden önemlidir? Cevap: o kalın kumaşların ömrü uzun olabilir ama minder konturlarını kolaylıkla saramayabilirler, kalın kumaştaki katlar potansiyel olarak basınç yarası oluşmasına sebep olabilirler; o ince kumaşlar minder üzerindeki konturları sarma ihtimali daha yüksektir ve basınç yarası oluşturma ihtimalleri daha azdır fakat çok uzun ömürlü değildirler, bu kumaşın kalitesine bağlıdır. Sor: Hangi tip kılıflar yıkanmak için çıkartılıp takılacak şekilde tasarlanmıştır? Açıkla: Bu özellik; idrarını tutma problemleri olanlar, tekerlekli sandalyesiyle dış mekânlarda çok vakit geçirenler veya sandalyesini dışarıda bırakmak zorunda olanlar için önemli bir özelliktir. . Açıkla: Tekerlekli sandalyelere gelince, minderler değişik boyutlarda gelir. Tekerlekli sandalye kullanıcısının sandalyesinin koltuğuna uyacak doğru boyutu seçmek önemlidir ki bu kullanıcı için doğru boyut olmalıdır. 5. Basınç rahatlatma minderinin işe yarayıp yaramadığının kontrolü (30 dakika) Açıkla: Bir tekerlekli sandalye kullanıcısına basınç rahatlatma minderi verildiğinde, minderin basıncı rahatlatmak için gerçekten işe yarayıp yaramadığının kontrolü çok önemlidir. Sor: Tekerlekli sandalye kullanıcısı otururken vücudunun basınç yarası geliştirme riski en yüksek olan bölgesi neresidir? Cevap vermeye teşvik edin. En önemli cevaplar: o kalça kemikleri; o kuyruk sokumu – özellikle de tekerlekli sandalye kullanıcısı çökmüş bir pozisyonda oturuyorsa. DVD tanıtımı: Basınç testi gösterimi. DVD basınç rahatlatma minderinin kullanıcının kalça kemiği altındaki basıncı azaltıp azaltmadığına dair küçük bir test göstermektedir. Bu testi DVD den sonra uygulayacağınız için yakından izleyiniz. DVD’i göster. Soru olup olmadığını öğren. Açıkla basıncın aşamaları: Seviye 1: o Parmak uçları yukarı aşağı kıpırdatılabiliyor. Biraz doku sıkışması var ama parmak uçlarındaki kemikleriniz 5 mm ya da daha fazla kıpırdatılabiliyor. Seviye 2 o Parmak uçları kıpırdatılamıyor ama kolaylıkla dışa doğru kaydırılabiliyor. Seviye 3 o Parmak uçları sıkıca sıkışmış. Parmakları çekip çıkarmak oldukça zor. Açıkla: Her zaman bir seferde bir kalça kemiğini kontrol et Seviye Basınç Eylem 1 Güvenli Hayır 2 Uyarı Evet, eğer birtakım risk faktörleri var ise 3 Tehlikeli Evet Açıkla: Ne yapılması gerektiğini bu bölümde daha sonra konuşacağız. Aktivite Gruplar: Her grupta iki ya da üç kişi olacak. Aynı cins kişileri ikili ayırmaya çalışın Her bir gruba basınç minderi olan bir tekerlekli sandalye verin. Talimatlar: Her bir gruba yapmasını söyleyin: o kalça kemiği altındaki basıncın kontrolünün uygulamasını yapın; o gruptaki her bir kişi için basınç seviyelerini el kitaplarına kaydedin. Herkesin hem “test eden” hem de “tekerlekli sandalye kullanıcısı” olarak uygulama yaptığından emin olun. İzleme: o Gruplar arasında dolaşın ve yakından izleyin/gözlemleyin. o Eğer ihtiyaç olursa teknikleri düzeltin Süre: 15 dakika müsaade edin artı 5 dakika geri bildirim için zaman verin. Geri bildirim: Sorun: Bir tekerlekli sandalye kullanıcısı olmak nasıl bir histi? Açıkla: Kullanıcıya ne yaptığınızı, neden önemli olduğunu açıkça anlatmak ve ona bu testi yapmanızın sakıncası olup olmadığını sormak önemlidir. Sorun: Bu teknikle ilgili sorusu olan var mı? Eğitmenler için notlar: Küçük grupları izlerken – adımların takip edildiğinden emin olun. A o Tekerlekli sandalye kullanıcısına basit bir şekilde ne yapacağınızı ve bunun neden önemli olduğunu açıklayın. B o Tekerlekli sandalye kullanıcısına, parmak uçlarınızı onların sağ ya da sol kalçalarının altına koymanıza müsaade edecek şekilde öne eğilmesini ya da kendisini yukarı doğru itmesini söyleyin (el ayası yukarıda olacak). o En iyi yapılış şekli tekerlekli sandalyenin arka tarafından döşemenin altından bir elle uzanmaktır. C o Tekerlekli sandalye kullanıcısından parmaklarınızın üzerine geri oturmasını isteyin. o O dik bir şekilde, yüz karşıya doğru ve elleri bacaklarının (uyluklarının) üzerine koyulmuş bir şekilde oturmalıdır. Bu siz her bir ayrı bölgeyi kontrol ederken onun aynı pozisyonda oturmasını sağlayacaktır. o Eğer parmaklarınız kemiğin altındaki basıncı hissetmek için iyi bir pozisyonda değilse, kullanıcıya kendini tekrar yukarı çekmesini söyleyin ve parmaklarınızı tekrar yerleştirin. D o İlk kalça kemiği altındaki basıncı seviye 1, 2, ya da 3 olarak tanımlayın. Seviye bir = güvenli: Parmak uçları yukarı ve aşağı 5 mm ya da daha fazla kıpırdatılabiliyor. Seviye iki = uyarı: Parmak uçları kıpırdatılamıyor ama kolaylıkla dışa doğru kaydırılabiliyor. Seviye üç =tehlikeli: Parmak uçları sıkıca sıkışmış. Parmakları çekip çıkarmak oldukça zor E İkinci kalça kemiğinde de tekrarlayınız. 6. Basıncın azaltılması için ne yapılmalıdır? (5 dakika) Açıklayın: o Kalça kemiği altında tehlikeli basınç tanımlandığında basıncın azaltılması için eyleme geçilmelidir. o Kalça kemiğinin altındaki basıncı azaltmak için basit bir çözüm katı köpük tabakasına bir katman eklemektir. Bu “kat” (yükseltme) olarak adlandırılır. o Yükseltme yaklaşık olarak 20 mm kalınlığında ve kalça kemiği bölgesinde bir boşluk olacak şekilde olmalıdır. o Bu yükseltme (kat) taban katmanının üstünde ve üzerine oturulan konfor köpük tabakasının altında olmalıdır. Açıkla: Bazen bir katmandan daha fazlası gerekir. Personel bir katman ekleyip sonra basıncı test etmelidir. Eğer basınç halen 2 ya da 3 seviyesinde ise başka bir katman daha eklenmelidir. Bir kat (yükseltme) ve basıncı azaltmak için kat eklenmiş bir minderi örnek olarak elden ele dolaştırın. Açıkla: Eğitimde daha sonra uygulama bölümünde ekstra bir katmanın eklenişini uygulayacağız. 7. Kilit nokta özeti (3 dakika ) Kilit noktaları okuyun. Soru olup olmadığının öğrenin. A.8: Transferler Tekerlekli sandalyeye binmek ve inmek H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  tekerlekli sandalyeye binmek ve inmek düşünüldüğünde, gereken güvenlik noktalarının listesini yapabilecekler; l  bir tekerlekli sandalyeye farklı biniş ve iniş şekillerini gösterebilecekler;  belli bir tekerlekli sandalye kullanıcısı için ona en uygun en az bir transfer metodu seçebilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: A.8: Transferler;  Referans Kılavuzu  Katılımcı El kitabı  DVD: Transfer gösterimi;  tekerlekli sandalyeler – her üç kişilik grup için bir adet;  transfer uygulaması için değerlendirme yatağı – her üç kişilik grup için bir adet  transfer kaydırma tahtası (eğer varsa). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarlayın. Düşünün:  yerel olarak bulunabilen sandalyeler öğretilen teknikleri etkileyebilir – örneğin dört tekerlekli ayaklıkları çevrilebilen bir tekerlekli sandalye yerine üç tekerlekli bir sandalye ile ayakta transfer metotta değişiklikler gerektirir:  katılımcıları bölgelerinde en çok uygulanan transfer metotları nelerdir– eğitmenler öğretilen metotları değiştirebilirler veya yenilerini ekleyebilirler;  eğer üçten fazla metot öğretiliyorsa her bir ek metodun öğretilmesi için 20-25 dakika müsaade edin. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Her bir metottaki tekerlekli sandalyeye inip binme pratiğini yapın ki diğerlerine gösterirken daha rahat olabilesiniz.  Eğer mümkünse transferin gösterimini yapacak ve uygulamada yardımcı olacak bir tekerlekli sandalye kullanıcısını davet edin. T A S LA K 1. Giriş. 2. Tekerlekli sandalye kullanıcıları transfer yapmayı neden öğrenmelidir? 3. Tekerlekli sandalyeye güvenli bir şekilde binmek ve inmek 4. Tekerlekli sandalyeye inip binmenin üç yolu ve kişisel geri bildirim. 5. Yerden tekerlekli sandalyeye bağımsız transfer. 6. Transferleri seçme. 7. Kilit nokta özeti. 2 5 10 60 20 20 3 Toplam bölüm süresi 120 1. Giriş (2 dakika) Açıkla: o Tekerlekli sandalye kullanıcısının, tekerlekli sandalyesine güvenli bir şekilde yardımla ya da yardımsız binip inebilme yetisine sahip olması günlük hayatında ona yardımcı olacaktır. o Tekerlekli sandalyeye binip inebilme bazen “transfer” olarak adlandırılır. o Bu bölümde katılımcılar kullanıcıların sandalyelerine binip indikleri dört transfer yöntemini uygulayacaklar. 2. Tekerlekli sandalye kullanıcıları neden transfer yapmayı öğrenmelidirler? (5 dakika) Sor: Tekerlekli sandalye kullanıcılarının tekerlekli sandalyelerinden inerek ve binerek yaptıkları transfer zamanlarına örnekleri nelerdir? Cevapları teşvik edin ve tahtaya yazın. Cevaplar şunları içerebilir: o yatağa gitmek ve yataktan kalkmak; o tuvalete gitmek; o bir sandalyeden/yataktan/üç tekerlekliden/yerden kalmak ve oturmak vs. o bir arabadan/otobüsten/taksiden/minibüsten/üç tekerlekli araçtan inmek ve binmek vs. Açıkla: o Tekerlekli sandalye kullanıcıları gün içerisinde pek çok defa sandalyelerine binip inmeye ihtiyaç duyabilirler. o Bu nedenle tekerlekli sandalye kullanıcılarının, güvenli, çabuk ve fazla enerji kullanmalarını gerektirmeyen metotlara ihtiyaçları vardır. o Tekerlekli sandalye kullanıcıları yetilerine bağlı olarak değişik metotlar kullanırlar. Bazı kullanıcılar sandalyelerine kendileri binip inebilirler bazılarınınsa yardıma ihtiyacı vardır. Bazı kullanıcılar transfer için ayağa kalkabilirler bazıları için ise bu imkân dâhilinde değildir. o Personel tekerlekli sandalye kullanıcılarına onlar için uygun olan metodu öğrenmelerinde yardımcı olabilirler. 3. Tekerlekli sandalyeye güvenli bir şekilde binip inmek (10 dakika) Açıkla: Transfer yaparken güvenlik önemlidir. Sor: Transfer yaparken dikkate alınması gereken güvenlik noktaları nelerdir? Cevapları teşvik edin ve tahtaya yazın. En önemli cevaplar: o frenleri çekin; o nereye gideceğinizi kontrol edin, yolunuzun üzerinde bir şey olmadığından emin olun; o her zaman yükselin, savrulmayın ya da sürüklenmeyin, bu cildinizde zedelenmeye yol açabilir ve basınç yarasına sebep olabilir; o birisine yardım etmeden önce onun kilosunu kaldırabileceğinizden emin olun; o eğer hamileyseniz ya da sırtınızda problem varsa yardımcı olmayınız. Üç güvenlik noktasını pekiştirin: o frenleri çekin; o nereye gideceğinizi kontrol edin; o her zaman kalkın , savrulmayın ya da sürüklenmeyin. 4. Tekerlekli sandalyeye inip binmenin üç yolu ve kişisel geri bildirim (60 dakika) Açıkla: o Şimdi tekerlekli sandalyeye binip inmenin üç farklı yolunu izleyeceğiz ve uygulamasını yapacağız. o Bir transfer “bağımsız” bir transfer diğer ikisi ise “yardımla” yapılan transfer. Transfer için kullanıcıya öneride bulunmadan ya da uygulamadan önce onun bağımsız transfer yapıp yapamadığını ya da yardıma ihtiyacı olup olmadığını bilmeniz gerekir. Eğer emin değilseniz tekerlekli sandalye kullanıcısıyla kontrol ya da test edin. o Oturarak yapılan bağımsız transferde kullanıcının kendi ağırlığını kolları ile kaldırıp kaldıramadığını kontrol edin. Eğer bunu yapamıyorsa yardıma ihtiyacı vardır. o Ayakta durarak yapılan bağımsız transferde kullanıcının kendi ağırlığını bacakları ile kaldırıp kaldıramadığını kontrol edin. Eğer bunu yapamıyorsa yardıma ihtiyacı vardır. Açıkla: Her transfer için katılımcı şunları hatırlamalıdır: o tekerlekli sandalye kullanıcısı bağımsız transfer yapabiliyor mu veya yardıma ihtiyacı var mı kontrol et; o tekerlekli sandalyenin pozisyonunu kullanıcının transfer yapacağı yere (yatak/yüzey) en yakın olacak şekilde ayarla; o frenleri çek; o tekerlekli sandalyenin yolu kapatan kolçakları var ise – çıkabilen kolçak mı kontrol et. o Ayakta yapılan transfer için ayaklıkları yoldan çekin (eğer mümkünse). o Her zaman yüksel – sürükleme. Sürükleme ciltte zedelenmelere yol açabilir ki bu da basınç yaralarına sebep olabilir. o Yardımla yapılan transferde tekerlekli sandalye kullanıcısını yapabildiği kadar çok kısmını bağımsız yapabilmesi için teşvik et. o Tekerlekli sandalye kullanıcısını kaldırmak için yardımcı olurken – kıyafetlerinden ya da kemer köprülerinden tutmayın. Kıyafetlerinden tutmak tekerlekli sandalye kullanıcısı için çok rahatsız edici olabilir. Aktivite: Gruplar: Her bir grupta üç kişi olacak. Her bir gruba bir tekerlekli sandalye ve bir yatak verin. Talimatlar Açıkla – katılımcılar DVD deki üç değişik transfer gösterimini seyredecekler. Her bir transfer gösteriminden sonra video dondurulacak. Katılımcılar yeni gördükleri transferi ikili gruplarla uygulamasını yapacaklar. Eğer isterlerse Referans Kılavuzlarına başvurabilirler. DVD’i göster Soru olup olmadığını öğren. İzleme: Her bir DVD bölüm gösteriminden sonra aşağıda ana hatları verilen kilit noktaların altını çizin. İzleyin ve gerekirse teknikleri düzeltin. Herkesin transferi ve yardımı yaptığından emin olun. . Süre: 60 dakika müsaade edin. Geri bildirim: Soru olup olmadığını öğrenin. Uygulama sırasında olan genel problemler ya da hataları netleştirin. 1. Oturarak bağımsız transfer (tekerlekli sandalyeden yatağa) DVD gösteriminden sonra ve uygulamadan önce şu noktaların altını çizin. o Tekerlekli sandalyenin pozisyonunu yatağa göre ayarla ve frenleri çek. . o Ayaklıkları çıkar ve ayaklıkları döndür ya da çıkart (uygulanabilen durumlarda). o Yatağa yakın olan kolçağı çıkart. o Eller üzerinde yüksel ve tekerlekli sandalyenin önüne doğru hareket et. . o Bir el yatağın öbür el tekerlekli sandalyenin üzerinde iken kendini yukarı doğru it ve yatağa doğru yüksel. o Eğer kullanıcının dengesi zayıf ise ya da yukarı yeteri kadar kaldıramıyor veya yanlara yeterince uzanamıyorsa bir transfer tahtası kullanabilir. Açıkla: o Eğer yatağa transfer yapılıyorsa bazı tekerlekli sandalye kullanıcıları transferden önce ayaklarını yatağa koymayı tercih ederler. 2. Yardımla oturarak transfer tahtası aracılığı ile yapılan transfer (yataktan tekerlekli sandalyeye) DVD gösteriminden sonra ve uygulamadan önce şu noktaların altını çizin. o Tekerlekli sandalye pozisyonunu yatağa yakın ayarla ve frenleri çek. o Ayaklıkları çıkar ve ayaklıkları döndür ya da çıkart (uygulanabilen durumlarda). o Yatağa yakın olan kolçağı çıkart. o Kullanıcıya ileri hareket etmek için yardımcı ol. o Kalça altına, yatakla tekerlekli sandalye arasına boylu boyunca transfer tahtasını koy. o Kullanıcı tekerlekli sandalyede ve yatakta mümkün olduğunca kollarıyla yükselerek kendi ağırlığını alabilmeye yardımcı olmalıdır. o Yardımcı kullanıcının arkasında durur ve kullanıcının pelvisini yatağa doğru hareket ettirir. 3. Yardımla ayakta yapılan transfer (yataktan tekerlekli sandalyeye) DVD gösteriminden sonra ve uygulamadan önce şu noktaların altını çizin. o Tekerlekli sandalye pozisyonunu yatağa yakın ayarla ve frenleri çek o Ayaklıkları çıkar ve ayaklıkları döndür ya da çıkart (uygulanabilen durumlarda). o Yatağa yakın olan kolçağı çıkart. o Kullanıcının yatağın üzerinde ileriye doğru hareket etmesi için yardımcı ol ve ayaklarını yere koy. o Kullanıcının dizlerini kenarlardan destekle (ön taraftan dizin karşısından itme). o Kullanıcının vücudunu ileri ve yukarı doğru kürek kemiğinden destekleyerek getir. o Kullanıcıyı tekerlekli sandalyeye doğru nazikçe çevirin ve oturmasını sağlayın. 5. Yerden tekerlekli sandalyeye bağımsız transfer (20 dakika) Açıkla: o Bu transfer tekerlekli sandalye kullanıcının güçlü kolları ve iyi bir dengesi olmasını gerektirir. Basınç yarası geliştirme riski altında olan kullanıcılar yerde otururken her zaman basınç rahatlatma minderlerinin üzerinde oturmalıdırlar. Aktivite Gruplar: Her grupta iki kişi olacak. Her bir çifte bir tekerlekli sandalye verin.. Talimatlar: Yapabiliyorsanız transferi gösterin (ya da bu transferi yapabilen bir tekerlekli sandalye kullanıcısına göstermesini söyleyin) Aşağıda ana hatları verilen kilit noktaların altını çizin. Katılımcılara çiftler halinde uygulama yapmalarını söyleyin. İzleme: İzleyin ve gerekirse teknikleri düzeltin. Herkesin uygulamayı yaptığından emin olun. . Süre: 10 dakika müsaade edin. . Geri bildirim: Sorun: Kaç kişi bu transferi yapabildi? Şunu kabul etmek gerekir ki bu işlem güçlü bir üst vücut gerektirmektedir. Aktif ve güçlü kolları olan kullanıcılar içindir, denemeye değer bir beceri uygulamasıdır. Yerden tekerlekli sandalyeye bağımsız transfer Açıkla: Yerden tekerlekli sandalyeye transfer yapılırken: o Tekerlekli sandalyenin önüne oturun ve dizlerinizi vücudunuza doğru çekin; o Yere bakın ve kaldırma hareketi boyunca yere bakmaya devam edin; o Bir elinizi yere diğer elinizi tekerlekli sandalyenin koltuğunun önüne koyun; o Kollarınızla ve omzunuzla yere yeri iterek kalçanızı tekerlekli sandalyenin koltuğunun önüne doğru kaldırın; o Tekerlekli sandalyeye oturun ve minderi almak için yere uzanın; o Ağırlığınızı bir tarafa kaydırarak minderi yerine yerleştirin. Açıkla: Tekerlekli sandalyeden yere transfer yaparken: o Tekerlekli sandalyenin önüne oturun; o Ayaklarınızı ayaklıktan hafifçe yana doğru kaldırın (transfer yapacağınız yönün uzağında olacak şekilde); o Minderinizi yere koyun; o Bir eliniz tekerlekli sandalyenin koltuğundayken, öbür elinizle yere ulaşın; o Omuz ve kollarınızı kullanarak kalçanızı kontrollü bir hareketle yerdeki minderin üzerine yerleştirin. 6. Transfer seçimi (20 dakika) Açıkla: o Tekerlekli sandalye hizmet personeli bir tekerlekli sandalye verdiğinde, tekerlekli sandalye kullanıcısının kolayca ve güvenli bir transfer yapabilmesini sağlamak da onun görevlerinin bir parçasıdır. o Pek çok kullanıcının zaten kullandıkları bir transfer yolu vardır. o Kullanıcılardan her zaman tekerlekli sandalyelerine nasıl binip indiklerini göstermelerini isteyin. o Eğer kullandıkları transfer yolu güvenli ve işe yarayan bir yolsa daha fazla bir şey yapmanıza gerek yoktur. o Eğer değilse, tekerlekli sandalye personeli kullanıcıya daha güvenli ve kolay bir yol öğretebilir. o İlk adım kullanıcı için hangi transfer yolunun en uygun olduğuna karar vermektir. Bu sonraki aktivite kullanıcı için hangi transferin en uygun olacağı düşünmeye yardım etmek içindir. Aktivite Gruplar: Her grupta üç kişi olsun. Talimatlar: Her bir gruba şunları yapmalarını söyleyin: o el kitaplarındaki kullanıcı hikayelerini okuyun; o her bir kullanıcı için onlara en uygun transfer metodu ne olacak karar verin. İzleme: Grupları izleyin gerekirse yardım edin. Süre: 10 dakika müsaade edin. Geri Bildirim: Her bir gruba, kullanıcılar için hangi metotları seçtiklerini sorun ve nedenini kısaca açıklamalarını isteyin. Kullanıcı hikayesi Bilgi noktaları Fridah 60 yaşındadır. Mahallesindeki hastaneden tekerlekli sandalye servisine sevk edilmiştir. Yakın zamanda bir felç geçirmiştir ve yürüyemediğinden dolayı bir tekerlekli sandalyeye ihtiyacı vardır. Fridah biraz da olsun ayağa kalkabilmektedir ve kendi ağırlığını taşıyabilmektedir ancak ayakları üzerinde denge kuramamaktadır. Fridah kızı ve ailesiyle beraber yaşamaktadır. Kızı çalışmamaktadır ve annesine yardım edebilecek durumdadır. Dört tekerlekli ve yanlara dönebilen ayaklıkları olan bir tekerlekli sandalyesi vardır. o Faridah ayağa kalkarak yardımla transfer yapabilmelidir. o Kızı evdedir ve ona yardım edebilmelidir. Kızı da transfer eğitimine dâhil edilmelidir. Jose 45 yaşındadır ve 10 yıldır tekerlekli sandalye kullanmaktadır. Çift taraflı diz üstü alt- ekstremite ampütasyonu vardır ve mahalle pazarında bir radyo tamir atölyesinde çalışmaktadır. Jose tekerlekli sandalye servisine yeni bir sandalye almak için gelmiştir çünkü eski sandalyesi çok yıpranmış durumdadır. o Jose oturarak bağımsız bir şekilde transfer yapabilmelidir. Tahir 14 yaşındadır ve kısa bir süre önce ağaçtan düşüp omurilik zedelenmesi sıkıntısı yaşamıştır ve tekerlekli sandalye için sevk edilmiştir. Tahir kollarını iyi bir şekilde kullanabilmektedir ama henüz çok güçlü değildir. Bacaklarını hiç kullanamamaktadır. o Tahir oturarak yardımla ya da transfer tahtasıyla transfer yapabilmelidir. Pratik yaparak kendi başına transfer yapabilir hake gelebilir 7. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B: Tekerlekli sandalye hizmet adımları B.1: Sevk ve randevu H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  tekerlekli sandalye kullanıcılarının tekerlekli sandalye servisine nasıl sevk edilebileceğini anlatabilecekler;  yerel tekerlekli sandalye hizmetlerindeki randevu sistemini anlatabilecekler; K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.1 Sevk ve randevu  Referans Kılavuzu (Sayfa no, XX);  Tekerlekli sandalye hizmet sevk formu (eğer varsa). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  Tekerlekli sandalye kullanıcıları katılımcıların bölgelerindeki hizmetlere nasıl sevk edilir;  Katılımcıların geldiği bölgede tanımlanmış bir sevk ve randevu sistemi var ise bu bölümün bir parçası olarak bunu da anlatın - kullanımda olan formlar varsa tanıtın ve katılımcılara uygulama yaparak kullanma imkânı verin. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin ve bölüm planını okuyun.  Tekerlekli sandalye kullanıcılarının, tekerlekli sandalye hizmetlerine farklı sevk ediliş yolları ile ilgili bir liste hazırlayın YA DA katılımcılardan isteyin. T A S LA K 1. Giriş 2. Sevk. 3. Randevu. 4. Kilit nokta özeti. 2 12 13 3 Toplam bölüm süresi 30 1. Giriş (2 dakika) Açıkla: Sevk ve randevu tekerlekli sandalye hizmet sunumunda ilk adımdır. Bu bölümde tekerlekli sandalye kullanıcılarının tekerlekli sandalye hizmetlerine sevklerinin değişik yollarını ve değişik randevu sistemlerini göreceğiz. 2. Sevk (12 dakika) Sorun: “Sevk” ne anlama gelir? Cevapları teşvik edin En önemli cevaplar: o Bir kişiyi yardım alması veya hizmet alması için doğru yere göndermek veya yönlendirmektir. Slaydı göster Açıkla: Tekerlekli sandalye kullanıcısının tekerlekli sandalye hizmetlerine sevk edilmesinin farklı yolları vardır. Örneğin tekerlekli sandalye kullanıcıları: o hizmeti duymuş ve kendi kendilerine gelmişlerdir. ; o hizmetlere; yerel hastanelerden, sağlık ocaklarından, toplum kökenli rehabilitasyon merkezlerinden, engelli kişiler için çalışan organizasyonlardan, köy/meclis/kilise liderlerinden ve diğer tekerlekli sandalye kullanıcıları aracılığı ile yönlendirilirler. Sor: Tekerlekli sandalye kullanıcısını hangi kuruluşlar, hizmetler veya kişiler tekerlekli sandalye hizmetlerine sevk edebilirler? Cevapları teşvik edin. Cevaplar şunları içerir: o Doktorlar; o köy/meclis/kilise liderleri; o rehabilitasyon merkezleri; o engelli kişiler için çalışan organizasyonlar; o diğer tekerlekli sandalye kullanıcıları; o sivil toplum örgütleri. Açıkla: Bu kuruluşlar, hizmetler ya da kişilerin hepsi “sevk kaynaklarıdır”. Tekerlekli sandalye hizmetleri, pek çok kullanıcının bu hizmetlere sevkini, bu sevk kaynaklarının hizmet hakkında bilgi edinmelerini sağlayarak artırabilir. Kullanıcılara katılımcı Referans Kılavuzunda olan tekerlekli sandalye sevk formuna bakmalarını söyleyin YA DA var ise yerel bir tekerlekli sandalye sevk formunu onlara verin. Açıklayın: o Bir tekerlekli sandalye sevk formu ile sevk kaynaklarının sağlanması, tekerlekli sandalye hizmetlerine tekerlekli sandalye kullanıcıyla ilgili basit bir ön bilgi verilmesine yardımcı olur. o Her bir tekerlekli sandalye hizmetinin, tekerlekli sandalye hizmet sevk formunun kullanışlı olup olmadığına, hangi bilgileri içereceğine ve nasıl kullanılacağına karar vermesi gerekir (örneğin; hizmet için posta ile mi gönderilecek yoksa kullanıcı elden mi teslim edecek) 3. Randevu (13 dakika) Açıklayın: o Bir tekerlekli sandalye kullanıcısı tekerlekli sandalye hizmetlerine sevk edildiği zaman ona değerlendirme için randevu verilmelidir. Randevu tekerlekli sandalye kullanıcısının hizmetlere/merkeze ziyareti ya da personelin kullanıcıya ziyareti şeklinde olabilir. o Bir randevu sistemi tekerlekli sandalye hizmet personelinin zamanını organize etmesinde yardımcı olur. Bu aynı zamanda tekerlekli sandalye kullanıcısının beklemesine ve etrafta dolanarak personeli aramasına engel olur. o Randevunun nasıl alınacağı tekerlekli sandalye kullanıcısından alınacak iletinin kolaylığına bağlıdır. Sor: Tekerlekli sandalye hizmeti tekerlekli sandalye kullanıcısından hangi yollarla ileti alır? Cevapları teşvik edin. Cevaplar şunları içerir: o telefon; o posta; o topluluk, kamu çalışanı aracılığı ile ileti gönderimi; o radyo; o sevk kaynaklarına tekrar bir ileti göndererek, tekerlekli sandalye kullanıcısı ile irtibata geçmelerini istemek; o arkadaş/aile üyesi aracılığı ile ileti göndermek. Açıklayın: Tekerlekli sandalye kullanıcıları bazen randevusuz gelebilirler. Eğer uzun bir yoldan geliyorlarsa onlarla ilgilenmek için bir çare ayarlamak önemlidir. Katılımcıların yerel tekerlekli sandalye hizmetlerinde belirli bir randevu sistemi var ise bu sistemi açıklayın. 4. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun Sorun olup olmadığını öğrenin. B.2: Değerlendirme H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  değerlendirmenin amacını açıklayabilecekler;  tekerlekli sandalye değerlendirmesinin iki bölümünü söyleyebilecekler;  değerlendirme sırasında toplanan bilgileri listeleyebilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.2 Değerlendirme;  Referans Kılavuzu (Sayfa no, XX). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  Katılımcı hizmetinde değerlendirme nasıl sürdürülecek. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin ve bölüm planını okuyun.  T A S LA K 1. Giriş. 2. Kimin tekerlekli sandalyeye ihtiyacı var? 3. Neden değerlendirme yapmaya ihtiyacınız var? 4. Değerlendirme nerede yapılacak. 5. Basit değerlendirmenin iki kısmı. 6. Kilit nokta özeti. 2 5 10 5 5 3 Toplam bölüm süresi 30 1. Giriş (2 dakika) Açıkla: o Tekerlekli sandalye hizmet sunumunda değerlendirme ikinci adımdır. . o Bu bölümde değerlendirmenin neden önemli olduğundan bahsedeceğiz ve değerlendirmenin iki bölümünü tanıtacağız. o Değerlendirme bölümleri boyunca tekerlekli sandalye kullanıcısının değerlendirmeye aktif olarak katılması gerektiğini unutmayın – onların fikirlerini sorun ve dinleyin. 2. Kimin tekerlekli sandalyeye ihtiyacı var? (5 dakika) Açıkla: Bir kişi tekerlekli sandalye hizmetlerine geldiğinde bu kişinin gerçekten bir tekerlekli sandalyeye ihtiyacı var mı bundan emin olmak çok önemlidir. Sor: Bir kişinin gerçekten tekerlekli sandalyeye ihtiyacı var mı nasıl anlarsınız? Cevapları teşvik edin ve tahtaya yazın. En önemli cevaplar: o kişi yürüyemiyor; o kişi yürüyebiliyor – ancak yürümesi çok zor ya da çok kısa mesafe yürüyebiliyor. Açıkla: o Bir kişinin kısa mesafeleri yürüyebilmesine rağmen uzun mesafeler için tekerlekli sandalyeye ihtiyacı olabilir. o Bir kişinin tekerlekli sandalye kullanması çoğunlukla o kişinin yürüme yetisini kaybedeceği anlamına gelmez. o Doğru olan seçim kullanıcının mümkün olduğu kadar hareketli olması ve en iyi hayat kalitesine sahip olmasıdır. Bu kullanıcının seçme hakkı vardır. 3. Neden değerlendirmeye ihtiyacınız var? (10 dakika) Sor: Neden değerlendirmeye ihtiyacınız var? Cevapları teşvik edin ve tahtaya yazın. En önemli cevaplar: o mevcut tekerlekli sandalyeler içerisinden kullanıcıya en uygun olanı seçmeye yardımcı olmak için; o mevcut olanlar arasından en uygun tekerlekli sandalye parçalarının seçilmesine yardımcı olmak için; o tekerlekli sandalyeden en iyi yararlanabilmek için kullanıcısı ve /veya ailesinin hangi eğitime ihtiyaçlarının olduğunun anlaşılması için. Sor: Katılımcılar bir değerlendirmede hangi bilgilerin toplanması gerektiğini düşünürler? Cevapları teşvik edin ve tahtaya yazın. Cevaplar şunları içerir: o isim, yaş, adres; o kullanıcı nerede yaşıyor – zeminin cinsi, evin büyüklüğü, basamaklar, vs; o kullanıcı nerede çalışıyor ya da okula gidiyor; o kullanıcının yaptıkları ya da yapmak istedikleri (hayat tarzı); o tekerlekli sandalye kullanıcısı her gün ne kadar yol kat ediyor; o tekerlekli sandalye kullanıcısı sandalyesine nasıl binip iniyor (transferler); o kişi kiminle yaşıyor; o tekerlekli sandalye kullanıcısın zayıflığı ya da engeli nedir; o fiziksel yetileri nelerdir; o tekerlekli sandalye kullanıcısı her gün sandalyede ne kadar vakit geçiriyor; o sağlık – basınç yarası riskleri de dahil; o fiziksel boyutu; o tekerlekli sandalye kullanıcısının sandalyesi var mı ve onun ihtiyaçlarını karşılıyor mu;? o kullanıcı çevrede nasıl dolaşıyor – örneğin toplu taşıma araçlarını kullanıyor mu? Açıkla: o Bütün bu bilgi kullanıcıya ve personele şu konuda yardımcı olur: o en uygun tekerlekli sandalye ve minderin seçimine; o en uygun tekerlekli sandalye parçalarının/özelliklerinin seçimine ve; o kullanıcının hangi eğitim ya da desteğe ihtiyacının olduğunun anlaşılmasına. o Örneğin: o bütün gün tekerlekli sandalyesinde vakit geçiren ve uzun mesafeler kat eden bir kullanıcı; rahat, kullanıcıyı iyi bir şekilde destekleyen ve sağlam ve dış mekanlarda kullanılan bir sandalyeye ihtiyaç duyacaktır; o tekerlekli sandalyesine binip inmede etkin bir yolu olmayan kullanıcının transfer yollarını öğrenmeye, eğitimine ihtiyacı olabilir. 4. Değerlendirme nerede yapılacak (5dakika) Açıkla: o Değerlendirme her zaman sessiz ve temiz bir yerde yapılmalıdır. o Bu tekerlekli sandalye hizmetlerinde bir yer, başka bir sağlık ya da toplumsal tesis ya da kullanıcının evi olabilir. Sor: Katılımcılar kendi tekerlekli sandalye hizmetlerinde değerlendirmeleri nerede yapacaklar? Cevapları alın. Eğer katılımcılar bilmiyorlarsa tekrar hatırlatın; tekerlekli sandalye değerlendirmelerini yapacakları alan sessiz ve temiz olmalıdır. 5. Temel değerlendirmenin iki parçası (5 dakika) Açıkla: Değerlendirme iki bölümde yapılır: o Değerlendirme görüşmesi; o Fiziksel değerlendirme. Tekerlekli sandalye değerlendirme formuna kaydedilmektedir. Birkaç bölüm sonra katılımcılar tekerlekli sandalye değerlendirme uygulaması yapmaya başlayacaklardır. 6. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun Soru olup olmadığını öğrenin. B.3: Değerlendirme görüşmesi H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  bir değerlendirme görüşmesi gösterebilecekler;  değerlendirme görüşmesindeki bilgileri değerlendirme formuna kaydedebilecekler;  değerlendirme görüşmesi sırasındaki soruların uygun tekerlekli sandalye seçimine nasıl yardımcı olacağını açıklayabilecek ve kullanıcının neler öğrenmeye ihtiyacı olduğunu tanımlayabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.3 Değerlendirme görüşmesi;  Referans Kılavuzu  Katılımcı El kitabı  He üçlü gruba bir tekerlekli sandalye İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla.  Eğer bulunulan yerel şartlarda çok sıklıkla görülen bir engellilik şekli var ise ve bu tekerlekli sandalye değerlendirme formunda yok ise bu durumu forma ve bölümün içeriğine ekleyin.  Yerel şartlara uymuyorsa kullanıcı hikâyelerini değiştirin. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin ve bölüm planını okuyun.  T A S LA K 1. Giriş 2. Tekerlekli sandalye kullanıcısı ile ilgili bilgi. 3. Fiziksel durum. 4. Hayat tarzı ve çevresel şartlar. 5. Şu anda mevcut olan tekerlekli sandalye. 6. Değerlendirme görüşmesi uygulaması. 7. Kilit nokta özeti. 2 10 15 15 5 40 3 Toplam bölüm süresi 90 1.Giriş (2 dakika) Açıkla: Bu bölümde katılımcılar: o Değerlendirmenin ilk bölümünün nasıl yapılacağını öğrenecekler- görüşme; o Değerlendirme görüşmesinin her bir bölümüne bakın ve alınan cevapların tekerlekli sandalye seçimini nasıl etkilediğini öğrenin. Her bir katılımcı görüşme yapan kişi olarak uygulama yapma şansına sahip olmalıdır. . 2. Tekerlekli sandalye kullanıcısı ile ilgili bilgiler (10 dakika) Açıkla: Görüşme sorularını gözden geçirmeye başlamadan önce, soruları sorarken hatırlamamız gereken bazı şeyler vardır. o Sorularınızı sormaya başlamadan önce her zaman kullanıcıya şunu açıklayın: soracağınız sorular en uygun tekerlekli sandalyeyi seçmek için size ve kullanıcıya yardımcı olmak için sorulmaktadır. o Sorularınızı her zaman tekerlekli sandalye kullanıcısına yönlendirin (ailesine/yardımcısına değil) ancak kullanıcı çocuksa veya sizin sorularınızı anlamayacak durumdaysa aile/ yardımcıyla iletişim kurun. o İyi iletişim teknikleri kullanın. Sorun: İyi iletişim tekniklerine örnekler nelerdir? Cevapları teşvik edin ve tahtaya yazın. En önemli cevaplar: o açık ve net konuşun; o basit terimler kullanın; o bir şey olmadan önce ne olacağını açıklayın; o bir şey izah ettikten sonra kullanıcının anlayıp anlamadığını kontrol edin; o dikkatli bir şekilde dinleyin ve tekerlekli sandalye kullanıcısını doğru bir şekilde anladığınızdan emin olun; o göz teması kurun (uygun olan durumlarda); o saygılı olun; o en iyiyi sizin bildiğinizi düşünmeyin; o ilgili olduğunuzu gösterin. Her bir katılımcıya değerlendirme formu verin. B.3 Değerlendirme görüşmesi PPT slaydını başlat. . Açıkla: o Dört alandaki bilgi, değerlendirme görüşmesinde toplanmıştır. o Şimdi her bir alana bakacağız ve görüşmedeki sorulara verilen cevapların tekerlekli sandalye seçimini nasıl etkilediğini açıklayacağız. o Sorular formda verildiği sıraya göre sorulmak zorunda değildir. Kullanıcılar zaman zaman onlara sorulmadan bazı bilgileri kendileri anlatabilirler ya da konuşmanın doğal olması için sıra takip edilmeyebilir. Açıkla: o “Tekerlekli sandalye kullanıcısı ile ilgili bilgi” kısmındaki sorular kullanıcı ile daha ileride takip için irtibata geçmek içindir. Bunların doğru olduğundan emin olun. o Bu bilgiler aynı zamanda kullanıcıların kabul edildiği hizmet merkezindeki istatistikler için yardımcı olacaktır. 3. Fiziksel durum (15 dakika) Açıkla:  “Fiziksel durum” başlığı altında personel kullanıcının eğer biliniyor ise fiziksel durumunu belirtecekler ve tekerlekli sandalye seçimini etkileyebilecek bir durum var ise bunu kaydedecekler. o Bazı çok görülen durumlar işaret kutusunda belirtilmiştir. Bunlar: serebral palsi, polyo, omurilik zedelenmesi ve felçtir. o Aynı zamanda bir “diğer” kutucuğu da vardır. Eğer bunu işaretliyorsanız kutucuğun yan tarafına durumu yazabilirsiniz. Açıkla: o Her zaman zorunlu olmamakla beraber kullanıcının durumunun bilinmesi yardımcı olmaktadır. o Çünkü bazı durumların sahip olduğu özellikler sandalye seçimini etkileyebilmektedir. o Şimdi bazı farklı durumlarda olanlara tekerlekli sandalye reçete ederken (seçerken) hatırlamamız gereken önemli noktalara bakacağız. o Bu bilgi referans Kılavuzunda vardır. . Açıkla:  Serebral palsi insanları farklı şekillerde etkilemektedir.  Serebral palsisi olan ve dik oturabilen bir kişi için şunu hatırlamak çok önemlidir; pozisyonlarını uzun süre korumaları çok zordur çünkü çabuk yorulurlar. Bu yaptıkları şeyleri zorlaştırır ve bu yorulmayı daha da artırır.  İyi, doğru destek çok önemlidir.  Serebral palsisi olanların tekerlekli sandalyelerinde ilave desteğe ihtiyaçları olabilir. Bunu etkin ve güvenli bir şekilde yapabilmek için orta düzey eğitime ihtiyaç vardır. Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. Açıkla: o Polimiyeliti olan kişilerin güçsüzlükleri ve vücutlarının bazı bölümlerinde “gevşeklikleri olabilir. Polimiyelit bacakları, kolları veya gövdeyi etkilemiş olabilir ama çoğunlukla bacakları etkiler. o Kaslar ve kemikler incelir ve bacaklar iyi gelişmez ve daha kısa kalır. o Gövde etkilendiğinde ise daha kısa görünebilir. o Buna rağmen polimiyeliti olanların hisleri vardır ve rahatlıkları için minderlerinin olması önemlidir. o Yüksek bir minder sandalyeyi itiş pozisyonu açısından rahatlık sağlayabilir. Hatırlanması gereken kilit noktaları vurgulamak için slayta tıklayın. Açıkla: o Omurilik zedelenmesi olan kişilerin basınç yarası geliştirme riski altında olma ihtimalleri oldukça fazladır. o Çünkü pek çok omurilik zedelenmesi olan kişiler zedelenmenin olduğu seviyeden aşağısını hissedemezler. o Onlara her zaman bir basınç rahatlatma minderi reçete edin. Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. Açıklayın: o Felç geçirmiş kişilerin vücutlarının genellikle bir tarafı etkilenir. Bu onların tekerlekli sandalyede bir tarafa doğru düşebilecekleri anlamına gelmektedir. o Felçli olan kişinin vücudunun felçli tarafında normal his olmayabilir. o Felçli kişiler tekerlekli sandalyelerine binip inebilmek için ayakta durabiliyor olabilirler. o İyi, doğru destek önemlidir. . o Kişinin hissedip hissedemediğini kontrol edin ki, basınç rahatlatma minderine ihtiyaçları olabilir. o Felçli bir kişi ayaklıkları hareket eden (çıkabilen veya katlanabilen) bir tekerlekli sandalye tercih edebilir ki bu yolla transferini ayağa kalkarak yapabilir. Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. Açıkla: o Şimdi ise diğer hangi şartların tekerlekli sandalye seçimini nasıl etkileyeceğine bakacağız. Açıkla: o Çift ampütasyonu olan kişilerin tekerlekli sandalyelerinin arkaya düşmesini engelleyecek bacak ağırlıkları yoktur. o Ampütasyonlu bir kişi ilk defa tekerlekli sandalye denerken çok dikkatli olun. o Tekerlekli sandalye dengesini kontrol edin. Ekstra stabilite sağlanması için arka tekerleklerin, arkaya çekilmesi gerekebilir. Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. Açıkla: o Yaşlı insanlar tekerlekli sandalyeye farklı sebeplerden dolayı ihtiyaç duyabilirler. Genellikle yürüme zorluğu çektikleri için ihtiyaç duyarlar. Tekerlekli sandalye onların günlük hayatlarında ailenin ve toplumun bir parçası olmaya devam etmelerine yardımcı olacaktır. o Yaşlı insanlar transferlerini ayakta yapabiliyor olabilirler ve bu durumda çıkan ya da dönebilen ayaklıkları olan tekerlekli sandalyeleri tercih edeceklerdir. o Yaşlı insanlara her zaman rahatlık ve destek sağlayan tekerlekli sandalyeler verilmelidir. Bu onların doğru bir şekilde oturmalarına yardımcı olacak ve kötü duruş pozisyonlarından kaynaklanabilecek problemleri engelleyecektir. o Dönebilen, açılabilen ayaklıklar en iyi seçim olabilir. . Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. Açıkla: o Bazı kişilerin aniden olan sıçrama hareketleri olabilir ve bunları kontrol edemezler(spazmlar) o Spazmlar kişinin ağırlığını arkaya doğru fırlatabilir ve bu tekerlekli sandalyenin arkaya doğru düşmesine sebep olabilir. Bu durumda güvenli arka tekerlek pozisyonu dikkate alınmalıdır. . o Spazmlar ayakların ayaklıktan zıplamasına sebep olabilir, bu durum sürüş için tehlike yaratabilir. Bacak emniyet bantları ayakları uygun pozisyonda tutmak için yardımcı olabilir. o Emniyet bantları yapışkan bantlarla (cırt-cırt bant) bağlanmalıdır çünkü kullanıcının tekerlekli sandalyeden düşmesi durumunda serbest kalabilsin. Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. Açıkla: o Bazı kişilerin mesane ve bağırsaklarını kontrol sorunu vardır. Omurilik zedelenmesi olanlar için bu çok karşılaşılan bir problemdir. o Bu problemler doğru malzemelerle, ilaç tedavisiyle ve mesane bağırsak eğitim programlarıyla üstesinden gelinebilecek problemlerdir. Bulunduğunuz bölgede bu konularla ilgili tavsiye ve eğitim verebilecek doktor ve hemşireleri belirleyin. o Mesane ve bağırsak problemleri olan kişiler nemli ya da kirli minderlerde oturmamalıdırlar çünkü ciltleri çok çabuk zarar görebilir. Ek olarak dışkıdaki mikroplar hızla enfekte olmuş basınç yaralarına sebep olabilirler o Su geçirmez bir minder verin. Kullanıcıya minderi nasıl yıkayıp kurutacağını öğretin. o Genellikle ikinci bir mindere ihtiyaç vardır ki tekerlekli sandalye kullanıcısı bir minderi yıkadığında günlük hayatına devam edebilmesi için diğerini kullanabilsin. Hatırlanması gereken kilit noktaları vurgulamak için slayda tıklayın. 4. Hayat tarzı ve çevresel durum (15 dakika) Açıkla: o Hayat tarzı ve çevresel durum soruları tekerlekli sandalye kullanıcısının nerede yaşadığını ve sandalyesindeyken neleri yapmaya ihtiyacı olduğu ile ilgili bilgi toplar. Her bir soruyu/noktayı sesli oku ve sor: Bu soruların cevapları, en uygun tekerlekli sandalyeyi seçmeye ya da kullanıcının neleri öğrenmesi gerektiğini tanımlamaya nasıl yardımcı olacak? Cevapları alın gerekirse örnekler verin. Soru: En önemli cevaplar Tekerlekli sandalye kullanıcısının sandalyesini nerede kullanacağını tarif edin. o Tekerlekli sandalye onu kullanan kişi için evde, işte veya okulda pratik olmalıdır. Örneğin: o eğer tekerlekli sandalye kullanıcısı sandalyesini evde kullanıyorsa günlük önemli ev işlerini yapabilmesi için evde rahatlıkla dolaşabiliyor olması gerekir; o bir ofiste, büroda çalışan kişinin tekerlekli sandalyesi büro içindeki alanlara kolaylıkla sığabilmelidir; o okula giden bir tekerlekli sandalye kullanıcısının sınıfa uygun ve sıranın altına yanaşabilen bir tekerlekli sandalyesi olmalıdır ya da tekerlekli sandalyede bir tepsi yapmak gerekir; o pazarda engebeli alanlarda çalışan bir tekerlekli sandalye kullanıcısının engebeli zeminlerde iyi bir şekilde gidebilen bir tekerlekli sandalyeye ihtiyacı vardır. Günlük kat edilen yol? o Bazıları kısa mesafeleri yürürken uzun mesafeler için bisiklet kullanır. Aynı şekilde bir tekerlekli sandalye kullanıcısı kısa mesafeleri tekerlekli sandalye ile giderken daha uzun mesafeleri üç tekerlekli ile gidebilir. o Üç tekerlekli, aynı mesafeyi daha az çaba sarf ederek ve daha hızlı gidecektir. Tekerlekli sandalyede günlük geçirilen saat? o Bir kişi tekerlekli sandalyesinde ne kadar çok vakit geçiriyorsa bitkinlik ve basınç yarası riski o kadar fazladır. Kişinin ne derecede desteğe ihtiyacı olduğunu ve minderin basınç rahatlatma ve konfor sağlamada yeterli olup olmadığını düşünün. o Eğer bir kişi tekerlekli sandalyesinde bütün gün “aktif” durumdaysa tekerlekli sandalye, itmek ve diğer aktiviteler için mümkün olduğunca etkin bir hale getirilmelidir. Tekerlek pozisyonları önemlidir. Tekerlekli sandalyenin arkalığının da kontrolü önemlidir; arkalık yeterli desteği vermeli ama hareketleri engellemeyerek omuzların serbestîsini de sağlamalıdır. Transfer o Kolçaklar ve ayaklıklar kullanıcının tekerlekli sandalyeye nasıl binip ineceğini etkileyebilen etmenlerdir: o Ayakta yapılan transferler için, çıkarılabilen ayaklıklar ve kullanıcının kolunu dayayıp itebileceği kolçakların olması kişiye yardımcı olacaktır; o Ayakta olmayan transferler için ise çıkabilen kolçaklar ya da tekerleklerin biçimini takip eden kolçaklar transferi kolaylaştırabilirler. Tuvalet cinsi Tuvaletin şekli ve fiziksel olarak tuvalete ulaşabilme şekli kullanıcının tuvaleti kullanım kolaylığını etkileyecektir. Tasarımından dolayı tuvaleti kullanmak imkânsız olabilir. Örneğin pek çok tekerlekli sandalye kullanıcısı alaturka tuvaletleri kullanmayı çok zor bulmaktadırlar. Hizmet personeli tuvaletin nasıl ve nerede olduğunu sorarak, tuvalete yapılan transferle ilgili önerilerde bulunabilirler. Personel aynı zamanda tuvaletin nasıl uyarlanacağı (adapte) ile ilgili de önerilerde bulunabilir. Tekerlekli sandalye kullanıcısı toplu/özel taşımayı sıklıkla kullanıyor mu? Tekerlekli sandalye kullanıcısı ulaşım araçlarını sıklıkla kullanıyorsa kolaylıkla taşınabilen bir tekerlekli sandalyeye ihtiyaç duyacaktır. Tekerlekli sandalyenin taşınmasını kolaylaştıran farklı özellikler aşağıda sayılmıştır: o hafif tekerlekli sandalyeler içeri ve dışarı taşınmada kolaydırlar; o çıkartılabilen tekerlekler ve katlanabilen iskelet/arkalık tekerlekli sandalyenin taşınmasını kolaylaştıracaktır. Toplu taşıma söz konusu olduğunda çıkartılabilen parçalar yüklemeyi kolaylaştıracağı için avantaj olabilir. Ancak bu çıkarılabilen parçalar ayrılma, çalınma ve kaybolma durumundan dolayı dezavantaj da yaratabilir 5. Mevcut olan tekerlekli sandalye (5dakika) Açıkla: o Eğer tekerlekli sandalye kullanıcısının zaten bir tekerlekli sandalyesi var ise kullanıcının ihtiyaçlarını neden karşılamadığının değerlendirmesi açısından bu sandalyenin görülmesi önemlidir. o Tekerlekli sandalye değerlendirme formundaki “Mevcut olan tekerlekli sandalye” sorularının her birini okuyun. Eğer bu soruların her birinin cevabı “hayır” ise tekerlekli sandalye personeli problemi “Yorumlar” kısmının altına tanımlamalıdırlar. Eldeki kaynakların durumuna bağlı olarak mevcut tekerlekli sandalyenin tadilatı ya da onarımı yolu da reçete (seçim) sürecinde göz önünde bulundurulabilir. Eğer bütün sorulara cevap “evet” ise oldukça muhtemeldir ki tekerlekli sandalye kullanıcısının yeni bir sandalyeye ihtiyacı yoktur. Bu durum tekerlekli sandalye kullanıcısı ile görüşülmelidir. 6. Değerlendirme görüşmesi uygulaması (40 dakika) Aktivite Gruplar: Her bir grupta üç kişi olsun. Talimatlar: Her bir gruptan değerlendirme görüşmesini canlandırmalarını isteyin bunun için el kitabındaki tekerlekli sandalye kullanıcı hikâyelerini kullanmalarını söyleyin. Vurgulayın – eğer mümkün ise sadece tekerlekli sandalye kullanıcısı rolünü yapacak kişi hikâyeyi okumalıdır. Her bir seferinde değişik bir kişi tekerlekli sandalye kullanıcısı rolünü almalı ve kullanıcı hikâyelerindeki bilgileri kullanarak görüşme sorularına cevap vermelidirler. Tekerlekli sandalye kullanıcısı hikâyeyi yüksek sesle okumamalıdır. Diğer iki katılımcı görüşmeyi yapmak için beraber çalışırlar, aldıkları bilgileri el kitabındaki tekerlekli sandalye değerlendirme görüşmesi formlarına kaydederler. İzleme: Grubu izleyin gerekirse yardımcı olun. Süre: Her bir görüşme için 10 dakika ve bütün grubun geri bildirimi için de 10 dakika müsaade edin. Geri bildirim: Hikâyelerde temsil edilmiş kullanıcılar hakkında kısaca tartışın. Her bir kullanıcı için slaydı gösterin ve katılımcılara slayttaki soruları sorun. o Görüşmeciler Felicia/Anton/Chantou için en uygun tekerlekli sandalyeyi seçmek için neler buldular? Görüşmeciler Felicia/Anton/Chantou’nun tekerlekli sandalyelerini kullanabilmeleri için neler öğrenmeleri gerektiğini tanımlayabilmek amacıyla neler buldular? o Anton’un ve Chantou’nun mevcut tekerlekli sandalyeleri onların ihtiyaçlarını karşılıyor mu? Neden/neden değil? Eğitmenler önerilen bilgi noktalarına başvurabilirler. Kullanıcı hikâyesi Önerilen bilgi noktaları Felicia şiddetli artrit (eklem iltihabı) sıkıntıları olan yaşlı bir kadındır. Kollarında, ellerinde ve bacaklarında ağrıları vardır. Birkaç adımdan daha fazla yürüyememektedir çünkü ağrıları vardır ve kendine bakmak çok zor gelmektedir. Felicia kızı ile değerlendirmeye katılmıştır. Küçük bir kasabada yaşamaktadır evinin girişinde üç basamaklı bir merdiven vardır. Artrit dışında başka bir sağlık problemi yoktur. Daha önce düzenli olarak kiliseye giderken artık bunu yapamamaktadır. Evinde alafranga tipi bir tuvaleti vardır. Ailesinin arabası yoktur ve toplu taşıma araçlarını kullanmaktadırlar. Değerlendirmeye gelmek için taksi tutmuşlardır. Ancak bu onlar için pahalı bir yoldur. Hali hazırda bir tekerlekli sandalyesi yoktur Uygun tekerlekli sandalye seçimine yardımcı olacak bilgiler. o Felicia’nın çok ağrısı vardır – tekerlekli sandalyesinin ağrısı yüzünden muhtemelen başkası tarafından itilmesine ihtiyacı vardır. o Felicia birkaç adım yürüyebilmektedir – O o büyük bir ihtimalle ayakta transfer yapabilir ve dönebilen ayaklıkları olan bir tekerlekli sandalyeden fayda görebilir. o Felicia’nın ailesinin arabası yoktur – tekerlekli sandalyesini toplu taşıma araçlarında taşımak durumunda kalabilir dolayısıyla katlanma durumu yararlı olabilir. Felicia’nın ne öğrenmeye ihtiyacı olduğunun tanımlanmasına yardımcı olacak bilgiler. o Felicia’nın kızı ona evde yardım etmektedir – hem Felicia hem de kızının güvenli transfer teknikleri ve tekerlekli sandalye ile merdiven inip çıkmayı öğrenmeye ihtiyaçları vardır. Anton ‘un polyosu (çocuk felci) vardır. 26 yaşındadır ve küçük bir kasabada yaşamaktadır. Bilgisayar eğitimi almaktadır ve gelecekte kendi işini kurmayı çok istemektedir. Değerlendirmeye karısıyla birlikte gelmiştir. Çok uzun zaman önce Anton’a bağış olarak verilmiş ortopedik cins bir tekerlekli sandalyesi vardır. Tekerlekli sandalye paslanmıştır ve döşemesi parçalanmıştır. Ön tekerlekler küçük ve incedir. Arka tekerlekler ince ve yıpranmış durumdadır. Tekerlekli sandalye rahatsız ve itmesi zor bir sandalyedir. Anton ailesi ile aynı tuvaleti kullanmaktadır. Kasabalarındaki yollar engebelidir ve tekerlekli sandalye sıklıkla yere saplanmaktadır. Ancak Anton evinden mesleki eğitim merkezine kendi başına gitmek istemektedir. Gitmesi gereken mesafe 1½ km’dir. Şu an itibariyle onun küçük erkek kardeşinin yardımına ihtiyacı vardır ancak kardeşi oma her zaman yardımcı olamamaktadır. Uygun tekerlekli sandalye seçimine yardımcı olacak bilgiler. o Anton yolları engebeli olan bir yerde yaşamaktadır ve evi ile eğitim aldığı yer arasında kendi başına yolculuk yapabilmek istemektedir – engebeli arazide kendi itebileceği bir tekerlekli sandalyeye ihtiyacı vardır. o Anton tekerlekli sandalyesinde çok zaman harcamaktadır – her gün eğitimi sırasında tekerlekli sandalyesinde uzun zaman geçirdiği için duruş desteği önemlidir. Anton’un ne öğrenmeye ihtiyacı olduğunun tanımlanmasına yardımcı olacak bilgiler. o Anton’un zor zeminde çok hareketli olması gerekir – tekerlekli sandalye hareketlilik becerileri eğitimi ona gerçekten yardımcı olabilir. o Anton tekerlekli sandalyesini engebeli alanlarda oldukça çok kullanmaktadır – tekerlekli sandalyesinin iyi bir şekilde çalışmasını sağlamak için bakımını nasıl yapacağını öğrenmek ona yardımcı olacaktır. Anton’un mevcut tekerlekli sandalyesi. o Anton’un mevcut olan tekerlekli sandalyesi kötü durumda ve onun çevresel ve fiziksel ihtiyaçlarını karşılamıyor. Özel not: Üç tekerleklilerin mevcut olduğu yerlerde eğitmenler üç tekerleklilere işaret edebilirler çünkü eğitim merkezine her gün uzun bir yol kat eden bu kullanıcı için üçtekerlekli iyi bir çözüm olabilir. Chantou 13 yaşındadır. İki Bacağını da (dizinin üstünden) deprem sırasında kaybetmiştir. Ailesi ile beraber kasana yakınlarındaki bir apartman dairesinde yaşamaktadır. Değerlendirmeye annesi ve büyük kız kardeşi ile gelmiştir. Ona bağışlanmış bir tekerlekli sandalyesi vardır. Bu sandalye erişkin boyutunda ortopedik cins bir tekerlekli sandalyedir. Tekerlekli sandalye Chantou’ya göre fazla büyüktür. İtme kasnaklarına ulaşmak için kolçakların üzerinden uzanması gerekmektedir. Bu onun için zor bir durumdur. Arkalık da fazla yüksektir ve minder yoktur. Chantou tekrar okula başlamak istemektedir fakat tekerlekli sandalyede fiziksel olarak rahatsız hissetmektedir. Kendi başına gezinemediği için utanmaktadır. Kendi başına itebileceği ve ona daha fazla destek sağlayacak bir tekerlekli sandalye istemektedir. Eğer tekerlekli sandalyesini de götürebilecekse okula okul servisiyle gidebileceğini söylemektedir. Uygun tekerlekli sandalye seçimine yardımcı olacak bilgiler o Chantou şu andaki tekerlekli sandalyesinde rahatsızdır ve sandalyesinde her gün oldukça çok vakit geçirmektedir, Chantou ona doğru bir şekilde uyan bir tekerlekli sandalyeye ihtiyaç duymaktadır ki bu yolla iyi bir şekilde desteklenebilir, iyi bir duruş desteği onun her gün daha dayanıklı olmasını sağlayacaktır ki o her gün okula devam edecektir. o Chantou her gün okula okul servisiyle gidecektir – onunla beraber okul otobüsünde yolculuk yapacak bir tekerlekli sandalyeye ihtiyacı vardır. Chantou’nun mevcut tekerlekli sandalyesi o Onun şu anki tekerlekli sandalyesi çok büyüktür ve kendi başına dolaşamamaktadır; hafif ve iyi duruş desteği olan bir tekerlekli sandalye onun ihtiyaçlarını karşılayacaktır ki şu anki sandalyesi bunu yapamamaktadır. 7. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B.4: Fiziksel değerlendirme H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  tekerlekli sandalye kullanıcısının şu anki mevcut olan durumunu, basınç yarası riski var mı veya basınç yarası geçmişinin ne durumda olduğunu nasıl kayıt edebilecekler;  bir tekerlekli sandalye kullanıcısının basınç yarası var ise ya da basınç yarası geliştirme riski altındaysa alınması gereken önlemleri açıklayabilecekler;  tekerlekli sandalye kullanıcısının tekerlekli sandalyesini nasıl iteceğini tanımlayabilecekler ya da belirleyebilecekler;  bir tekerlekli sandalye kullanıcısı için tekerlekli sandalye ölçümlerini yapmanın doğru yolunu gösterebilecekler (koltuk genişliği, koltuk derinliği, baldır uzunluğu, sırt yüksekliği);  vücut ölçümlerinin tekerlekli sandalye boyutlarıyla bağlantısını tanımlayabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları B.4: Fiziksel değerlendirme;  Referans Kılavuzu  Katılımcı El Kitabı  DVD: Ölçüm gösterimi;  Ayaklıkları kaldırılabilen tekerlekli sandalye (eğer varsa) – 3 katılımcı için 1 adet;  Tekerlekli sandalye formları – Her bir tekerlekli sandalye kullanıcısı için bir adet;  Ölçüm uygulaması için mezura – her bir katılımcı için bir adet. İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  katılımcılar değerlendirmeyi nerede yapacaklarını düşünün – örneğin kullanıcının evi, halk klinikleri ya da tahsis edilmiş olan tekerlekli sandalye hizmet alanı H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Tekerlekli sandalyeleri oda etrafında düzenleyin  En azından bir tane kaldırılabilen ya da dönebilen ayaklıkları olan tekerlekli sandalye olmasını sağlayın ( ayakla itme egzersizi için) T A S LA K 1. Giriş. 2. Hazırlık. 3. Şu an mevcut olan basınç yarası, basınç yarası riski veya basınç yarası geçmişi 4. İtme metodu 5. Ölçüm yapılması. 6. Vücut ölçümlerinin nasıl alınacağı. 7. Kilit nokta özeti 2 5 10 20 30 20 3 Toplam Bölüm süresi 90 1. Giriş(2 dakika) Açıkla: Bu bölümde tekerlekli sandalye değerlendirmesinin fiziksel bölümünü yapacağız. Yapacaklarımız: o tekerlekli sandalye kullanıcısının mevcut olan, olma riski olan veya geçmişi olan basınç yaralarının nasıl kaydedileceklerini öğrenmek; o tekerlekli sandalye kullanıcısının tekerlekli sandalyesini sürmek için kullanabileceği değişik yolları tartışmak ve ayak sürüşü; o kullanıcı için doğru tekerlekli sandalyeyi seçebilmek amacıyla en önemli vücut ölçümlerinin nasıl alınacağını öğrenmek. 2. Hazırlık (5 dakika) Açıkla: Tekerlekli sandalye kullanıcısına eğer bir tekerlekli sandalyede oturuyorsa değerlendirme sedyesine transfer yapmasını isteyin. Bu tekerlekli sandalye kullanıcısının duruşunu gözlemlemeyi ve ölçümlerin alımını kolaylaştıracaktır. Bu aynı zamanda kullanıcının transferini nasıl yaptığını görmek için bir şans yaratacaktır. Hatırlanması gereken şeyler aşağıda sıralanmıştır. Açıkla: o Görüşmede olduğu gibi değerlendirme de temiz ve sessiz bir alanda yapılmalıdır.. o Eğer basınç yaralarının incelenmesi gerekiyorsa mahremiyet önemlidir. o Tekerlekli sandalye kullanıcısına her zaman ne yapacağınızı ve neden yapacağınızı açıklayın. o Tekerlekli sandalye kullanıcısı transfer yapmadığında kişinin kendi başına güvenli ve kolayca transfer yapamayacağını düşünüyorsanız yardım teklif etmeye hazır olun. o Tekerlekli sandalye kullanıcısı değerlendirme sedyesinde iken: o ayakları yere rahat bir şekilde değmiyorsa ayaklar için bloklar ayarlayın; o tekerlekli sandalye kullanıcısının tek başına rahat, güvenli ve dik bir şekilde oturduğundan emin olana kadar yakınında durun. 3. Halen mevcut olan basınç yarası, basınç yarası riski veya basınç yarası geçmişi (10 dakika) Açıkla: Basınç yaralarının önlenmesinin önemi hakkında ayrıntılı olarak daha önce konuştuk. Sor: Aranızdan bir kişi, bir şahsın basınç yarası geliştirme ihtimalini artıran en önemli risk faktörlerini sayabilir mi? Cevapları teşvik edin. Aşağıda sayılan bütün basınç yarası risklerini ortaya çıkarmaya çalışın. En önemli cevaplar: o his olmayışı (his azalması var); o hareket edememe; o ter,su yada idrarını kontrol edememekten kaynaklanan nem; o kötü beslenme ve yeterli su içmeme; o yaşlılık; o kötü duruş; o daha önceki ya da mevcut olan basınç yarası; o kilo – normalin altında ya da üstünde kiloya sahip olmak. Açıkla: Değerlendirme formu katılımcılara basınç yaralarını belirlemeye yardımcı olacaktır. Slaydı gösterin ve aşağıdaki noktaları açıklamak için tıklayın: o hissi olmayan bir kişi basınç yarası geliştirme riski altındadır; o üç ya da daha fazla ve farklı risk faktörü taşıyan kişiler basınç yarası geliştirme riski altındadırlar. Katılımcılara ellerindeki tekerlekli sandalye değerlendirme formuna nüshasına bakmalarını söyleyin. Açıkla: Katılımcılar tekerlekli sandalye kullanıcılarına formdaki soruları sormalılardır. o Normal bir şekilde hissedebiliyorlar mı? o Daha önce hiç basınç yaraları oldu mu? Eğer olduysa nerede? Formdaki vücuda bunu işaretleyin. o Hâlihazırda bir basınç yaraları var mı? o eğer var ise yarayı görüp göremeyeceğinizi sorun ki bu şekilde yaranın nerede olduğunu ve ne kadar ciddi olduğunu anlayabilirsiniz; o kişinin basınç yarasını görmek istediğinizi söylerken hassas davranın; o değerlendirme alanının etrafına bir perde çekerek kullanıcın mahremiyetini sağladığınızdan emin olun; o yaranın açık ya da açık olmayan bir yara olduğunu belirtin ve formdaki vücut resmine nerede olduğunu işaretleyin; o kullanıcıya yaranın neden kaynaklanmış olabileceğini düşündüğünü ve ne kadar zamandır var olduğunu sorun. o risk faktörlerini daire içine alın. o tekerlekli sandalye kullanıcısının basınç yarası geliştirme riski olup olmadığını işaretleyin. Sorun: Tekerlekli sandalye kullanıcısının 2. Evre ya da daha üst seviye bir açık basınç yarası var ise alınacak önlemler nelerdir? Cevapları teşvik edin. En önemli cevaplar: o tedaviye gönderin; o tekerlekli sandalye kullanıcısına yaranın üzerindeki basıncı kaldırmasını salık verin – bu tekerlekli sandalyesini kullanmaması anlamına gelebilir Sorun: Tekerlekli sandalye kullanıcısının basınç yarası geliştirme riski var ise ne gibi önlemler alınmalıdır? Cevapları teşvik edin. En önemli cevaplar: o basınç rahatlatma minderi verilmesi, kalça kemiği testi yaparak minderin etkili olup olmadığını belirlenmesi; o önleme eğitimi verilmesi, basınç rahatlatma tekniklerinin öğretilmesi, sürekli pozisyon değiştirme ve aktif olmanın önemi; vücuttaki izlerin günlük kontrolü. Eğitmenler için notlar: Bu sorular basınç yarası geliştirme “riski altında” olan kişilerle ilgili sorulardır. Eğer bir kişini basınç yarası var ise farklı önlemler alınacaktır. 4. İtme metodu (20 dakika) Açıkla: o Tekerlekli sandalye kullanıcısın sandalyesini nasıl ittiğini öğrenmek önemlidir. Bu durum tekerlekli sandalye seçimini etkileyebilir. o Tekerlekli sandalye kullanıcıları sandalyelerini farklı şekillerde iterler. o Bazıları kollarıyla, bazıları bacaklarıyla iterler ve bazıları da bunu bir yardımcı aracılığıyla yaparlar. Ask: Tekerlekli sandalye kullanıcısının itmesini etkileyen fiziksel yeterlilikler nelerdir? Cevapları teşvik edin. Cevaplar: o Kolların gücü ve kontrolü; o Bacakların gücü ve kontrolü; o Dik oturma yetisi; o Toplam stabilite ve kontrol, bir kişi eğer stabil değilse ve denge sorunu var ise “tutunmak” için kollarını kullanmak zorunda olabilir ve sandalyesini kendi itemiyor olabilir. . o Kollar ve bacaklardaki güç ve kontrol total stabilite için önemlidir. Stabilitesi ve duruşunda sorunları olan bir tekerlekli sandalye kullanıcısına, uygun duruş desteği sağlayan ve doğru seçilmiş bir tekerlekli sandalye verildiğinde bu durum kişinin sandalyesini sürüşünü de kolaylaştırır. Sor: Kullanıcının tekerlekli sandalyesini kollarıyla itmesiyle bağlantılı olarak arka tekerlek için ideal pozisyonu nedir? Cevap: o Tekerlekli sandalye kullanıcısı itme kasnaklarını üst kısmından tuttuğunda dirseği 90 derecelik açı yapacak şekilde kıvrılmalıdır. Açıkla: o Ayakla sürüş için tekerlekli sandalyede ayarlamalar yapmak gerekir. Pelvis arkalık tarafından iyi bir şekilde desteklenirken kullanıcının ayaklarının yere rahatlıkla ulaşabilmesi gerekir. o Kalkabilen ayaklıkların olması önemlidir. Kullanıcı, daha uzun mesafeler için bir yardımcı onu iterken ayaklıklara ona destek sağlaması için halen ihtiyaç duyacaktır. o Kolçaklar da çok işe yarayacaktır. Kullanıcı sürüş esnasında kolçaklar üzerine doğru eğilebilir. o Eğer tekerlekli sandalye kullanıcısı itme işlemin ayağı ile yapıyorsa ve gerekli olan tekerlekli sandalye ayarlamaları yapılmamışsa, kullanıcı itiş için duruşunu değiştirmek zorunda kalacaktır. Bu da yorgunluğa ve uzun dönemde kalıcı duruş bozukluklarına sebep olabilecektir. Açıkla: Tekerlekli sandalye hareketlilik bölümü sırasında kollarla itme konusunda uygulama yapmıştık. Şimdi herkesin bunu bacaklarıyla deneme imkânı olacak. Aktivite Gruplar: Her grupta üç kişi olmalı (farklı boylarda olmaları ideal olan durumdur zira bu durum yere ulaşabilme meselesini gündeme getirecektir ). Her bir gruba bir tekerlekli sandalye verin. Talimatlar: Her bir gruba sırayla tekerlekli sandalyelerini ayaklarıyla ilerletmelerini söyleyin. İdeal olan pelvislerinin arkalığa değerek oturmalarıdır. Eğer bu mümkün değilse yere ulaşmak için nasıl bir deneyim yaşadıklarını görmeleri gerekir. Eğer tekerlekli sandalye uygun bir şekilde ayarlanmamış ise itme işleminde neler yaşanabileceğini görmelerini sağlayacaktır. Katılımcılara itme işlemini; öne eğilerek, arkaya eğilerek, topuklarıyla ve parmaklarla yapmalarını söyleyin. İzleme: Grupları izleyin. Aktivitenin güvenli bir şekilde yapıldığından emin olun. Süre: Aktivite için 10 dakika ve geri bildirim için de 5 dakika müsaade edin. Geri bildirim: Gruplara sorun: o yere kolaylıkla ulaşamayanlar için – ayaklarının yere değmesi için ne yapmaları gerekti? (Cevap: kambur durmak ya da öne doğru oturmak); o öne ya da arkaya eğilerek itmek kolay mıydı? (Cevap: öne eğilmek – ideal olan pelvisin tam arkalığa dayanması); o bir kişiyi öne eğilmeye ne teşvik eder? (Cevap: öne doğru eğilme durumunda destek sağlayabilecek bir yüzey olan kolçaklar ya da tepsi); o topuk yada parmaklarla itmek kolay mıydı? (Cevap: topukla). Açıkla: o Uygulama sırasında katılımcılar anlayacaklardır ki, eğer tekerlekli sandalyenin ayakla itilebilmesi için gerekli ayarlamaları yapılmamışsa itme işlemi çok zor ve yorucudur. o Tekerlekli sandalyenin doğru ayarlarının yapılması şu anlama gelir; koltuktan zemine kadar olan mesafenin yüksekliği kullanıcı için uygun olan mesafe olmalıdır. Bunu gerçekleştirmenin bazı yolları şunlardır: o koltuktan zemine kadar olan mesafesi kullanıcı için uygun olan sandalyenin seçilmesi (minder yüksekliğinin de hesaba katılması gerekir); o minderin daha ince yapılması – bu toplam yüksekliği düşürecektir; o orijinal koltuktan daha alçak bir yekpare koltuğun eklenmesi. o Tekerlekli sandalye kullanıcısı sandalyesini eğer ayak ile itecekse; ilgili personel kullanıcıya pelvisi arkalığa dayalı bir şekilde nasıl oturması gerektiğini, öne eğilme şeklini ve topuğuyla nasıl “çekeceğini” öncelikle göstermelidir. o Her zaman ileri doğru çekmeyi öğretin arkaya doğru değil. Sor: Tekerlekli sandalye kullanıcısını başka birisi itecekse ya da bu yardımı zaman zaman alacaksa bu durum tekerlekli sandalye seçimini nasıl etkiler? Cevap: o sağlam itma tutamakları önemlidir; o çocuklar için – yüksek itme tutamakları erişkinlerin çocuklarını itmesini kolaylaştıracaktır. Açıkla: İtme metodu aynı zamanda kullanıcının (eğer uygunsa) ailesinin ya da bakıcısının alması gereken eğitimi de etkileyecektir. 5. Ölçü alınması (30 dakika) Açıkla: o Değerlendirme sırasında tekerlekli sandalye personeli kullanıcının ölçülerini alır. Bundan sonra personel mevcut olan tekerlekli sandalyeler arasından kullanıcıya en uygun olanın hangisi olduğunu anlayabilir. o Ölçüler değerlendirme formuna kayıt edilir. o Her bir ölçünün nasıl alınacağının tarifi Referans Kılavuzunda vardır. DVD tanıtımı: Ölçüm gösterimi. Bu DVD size beş temel ölçünün nasıl alınacağını gösterecektir. Katılımcılara bunu dikkatle izlemelerini söyleyin çünkü ardından bu işlemi kendileri de uygulayacaklar. DVD’ yi göster Soru olup olmadığını öğrenin. Aktivite Gruplar: Her bir grupta üç kişi olmalı. Talimatlar: Her bir gruba şunları yapmalarını söyleyin : o her bir kişinin ölçümünü yapın ve bunları kaydedin; o gruptaki her bir kişi diğerinin ölçümünü yapmalıdır, bu şekilde ölçümleri egzersiz sonunda karşılaştırabilirler. o ölçümleri el kitabındaki verilen boşluklara kaydedin. İzleme: Grupların arasında dolaşın ve yakından izleyin. Aşağıda verilen kılavuzu kullanarak katılımcıların doğru teknikleri kullanıp kullanmadıklarını kontrol edin. Katılımcıların ölçümleri doğru yapıp yapmadıklarını değerlendirmek için kontrol edin. Eğitimci ölçüleri farklılıkların altını çizmek adına tahtaya yazabilir. Süre: 15 dakika uygulama ( her bir kişi için 5 dakika)15 dakika da geri bildirim için müsaade edin. Geri Bildirim: o Sor: Aynı kişi için alınan ölçüler aynı mı çıktı? o Sor: Değişikliğe ne sebep olmuş olabilir? (Cevap: doğru tekniğin kullanılmaması; örneğin kullanıcıya dik oturmasının söylenmemiş olması, mezuranın doğru bir şekilde yerleştirilmemiş olması, mezuranın doğru okunmamış olması). o Sor: Yanlış ölçü alındığında ne problemler oluşabilir? (Cevap: tekerlekli sandalye kullanıcıya uymayabilir). Eğitmenler – bu kılavuzu katılımcıların doğru teknikleri uygulamaları için kullanın. Bütün ölçümler için mezuranın düz tutulduğundan ve kullanıcının dik oturduğunsan emin olun. Ayaklar yere değmek suretiyle destekli olmalıdır. Eğer ayaklar yere değemiyorsa ayakların altına bloklar koyularak destek sağlanır. A Ölçümden önce kullanıcının cebinin boş olduğunu kontrol edin. Kalçayı ya da baldırların en kalın olduğu bölgeyi ölçün. Kullanıcının her iki tarafına iki tane not panosu/kitabını dayamak ölçünüzün doğru olmasına yardımcı olur. B Doğru bir ölçü alabilmek için kullanıcının arkasına not panosu/kitap yerleştirin. Pelvisin arkasından dizin arkasını düz bir hat üzerinde olacak şekilde ölçün. Her zaman iki bacağı da ölçün. İki bacak ölçüsü arasında fark var ise tekerlekli sandalye kullanıcısının pelvis seviyesinde dik oturup oturmadığını kontrol edin. Eğer halen bir farklılık varsa kısa tarafa göre bir tekerlekli sandalye reçete edin. C Diz arkasından topuk tabanına doğru ölçün. Kullanıcının ayak bileklerinin 90 derece kıvrıldığından emin olun (eğer mümkünse). Her zaman iki bacağı da ölçün. Eğer kullanıcı ayakkabı kullanıyorsa genellikle kullandığı ayakkabı ile ölçüm yapın (eğer varsa). D Koltuktan göğüs kafesinin altına kadar olan uzunluğu ölçün. Göğüs kafesinin alt kısmını bulmaya yardımcı olması için pelvisin her iki tarafına ellerinizi yerleştirin. Ellerinizi hafifçe sıkın ve yukarı doğru kaydırın. Göğüs kafesinin altı hemen belin üstündedir. E Koltuktan kürek kemiğinin altına kadar olan mesafeyi dik bir hat üzerinde olacak şekilde ölçün. Kürek kemiğinin alt kısmını bulabilmek için kullanıcıdan omuzlarını silkmesini isteyin. 6. Vücut ölçülerinin nasıl alınacağı (20 dakika) Açıkla: Şimdi tekerlekli sandalye kullanıcısının ölçülerinin nasıl alınacağını uyguladık. Şimdi bu ölçülerin tekerlekli sandalye ile bağlantısını göreceğiz. Katılımcılardan tekerlekli sandalye değerlendirme formuna bakmalarını isteyin. Ölçüm tablosundaki üçüncü sütunu işaret edin. Açıkla: Bu kısım vücut ölçülerinin tekerlekli sandalye ile bağlantısını açıklar. Şimdi her birine bakacağız. Açıklayın: o Ölçüm A: Kalça genişliği tekerlekli sandalye koltuk genişliğine eşittir. o Tekerlekli sandalye koltuk genişliği kullanıcının kalçasının genişliğine olabildiğince yakın olmalıdır ama asla daha küçük olmamalıdır. o Eğer kullanıcıda his yoksa tekerlekli sandalyenin kenarlarının pelvise ya da uyluklara baskı yapmadığından emin olun. Açıkla: o Ölçüm B: Yaklaşık olarak 30 mm ‘den aşağı olan koltuk derinliği bir tekerlekli sandalye için ideal olandır. o Doğru uyum baldırlara iyi bir destek verecektir. Bu kalça kemikleri altındaki basıncı azaltacak ve basınç yaralarının oluşmasını engelleyecektir. o Uzun bacaklı tekerlekli sandalye kullanıcılarında daha büyük bir boşluk olabilir. 60 mm’ ye kadar olan boşluk kabul edilebilir. o Koltuk uzunluğu gereğinden uzunsa kullanıcı dik oturamayacaktır. Uyluğun arka tarafı koltuğun ön sınırına sürtünecektir ve bu da rahatsızlık verecek ve/veya basınç yaralarına sebep olabilecektir. o Eğer sağ ve sol bacak arasında bir fark varsa tekerlekli sandalye seçimini kısa bacak ölçülerini temel alarak yapın ve reçete edin. Açıkla: o Ölçüm C için aşağıdaki her ikisi de aynıdır: o koltuk minderinin en üstünden ayaklığa kadar olan mesafe; veya o koltuk minderinin en üstünden zemine kadar (ayakla sürüş için). o Doğru ayarlanmış ayaklık yüksekliği önemlidir. Çünkü uylukların iyi desteklenmesini ve ayakların ayaklık tarafından tam olarak destek almasını garanti eder. o Ayaklık ayarları hemen her zaman en son yapılması gereken ayarlamalardır çünkü kullanıcı oturduğunda yastığın ne kadar bastırılacağı, sıkışacağını tahmin etmek zordur. o İyi bir şekilde destek almaları ve ayakları ile etkin bir şekilde sürüş sağlayabilmeleri açısından tekerlekli sandalyesini ayağıyla iten kullanıcılar için doğru koltuk yüksekliği önemlidir. Açıkla: o Ölçüm D veya E, koltuk minderinin en üst yüzeyinden arkalığın en üst noktası arasındaki mesafeye eşittir. o Doğru bir ayarlama tekerlekli sandalye kullanıcısına destek sağlamalı ve aktif kullanıcılara sandalyeyi itebilmek için omuzlarında hareket serbestîsi sağlamalıdır. Açıkla: o Ölçüm D – tekerlekli sandalye kullanıcısının göğüs kafesinin alt seviyesine gelen arkalık yüksekliğini verecektir. o Bu yükseklik doğru bir yüksekliktir eğer kullanıcı: o zinde ve aktifse; o iyi bir şekilde dengeli ve dik oturabiliyorsa. o Ölçüm E – tekerlekli sandalye kullanıcısının kürek kemiğinin alt kısmıyla arkalık yüksekliğini verecektir. o Bu yükseklik doğru bir yüksekliktir eğer kullanıcı: o tekerlekli sandalye kullanıcısı çabuk yorulabiliyorsa; o dik oturma zorluğu çekiyorsa. Açıkla: Her zaman iki arkalık yüksekliği ölçümünü de yapın çünkü bazen değerlendirme sırasında kullanıcı için hangi arkalık yüksekliğinin en rahat olacağı açığa kavuşturulamayabilir. Açıkla: Şimdi ölçüm tablosunu nasıl tamamlayacağımıza göz atacağız. Ölçüm tablosunu kullanıcının ölçülerini tamamlamış bir şekilde göster. Sor: bu kişi için olabilecekler nelerdir: o tekerlekli sandalye koltuk genişliği? (cevabı göstermek için tıkla); o tekerlekli sandalye koltuk derinliği? (cevabı göstermek için tıkla); o ayaklık yüksekliği? (cevabı göstermek için tıkla); o göğüs kafesinin altı için arkalık yüksekliği (cevabı göstermek için tıkla); o kürek kemiğinin altı için arkalık yüksekliği (cevabı göstermek için tıkla). Sor: Eğer koltuk derinliği sağ ve sol tarafta farklı olsaydı katılımcılar ne yapacaklardı? Cevapları teşvik edin. En önemli cevaplar: o koltuk derinliğinde bir tarafta bir farklılık var ise ihtiyaç olduğu kadar kısa taraf kadar olmalıdır. Açıkla: Unutmayın – bunların hepsi ideal ölçümlerdir. Personel mevcut olan tekerlekli sandalyelerin boyutlarını bilmelidir ki kullanıcının boyutuna en yakın olanı seçebilsin. Bu konudan bir sonraki bölümde daha çok bahsedeceğiz. 7. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B.5: Reçete (seçim) H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  reçete etme (seçim) sürecinin neleri içerdiğini listeleyebilecekler;  yerel olarak bulunabilen tekerlekli sandalyelerin ana özelliklerini tanımlayabilecekler;  yerel olarak bulunabilen tekerlekli sandalyelerle kullanıcının ihtiyaçlarını karşılayabilen en uygun sandalyeyi eşleştirebilecekler;  tekerlekli sandalye kullanıcısı için doğru seçimi yapabilecekler;  tekerlekli sandalye reçete(seçim) formuna reçete etme ile ilgili kararlarını yazabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.5 Reçete (seçim);  Referans kılavuzu  Katılımcı El kitabı (Katılımcı El kitabında iki tane B5 Bölümü vardır lütfen dikkat edin);  Eğer mümkünse, yerel olarak bulunabilen tekerlekli sandalyelerden, minderlerden ve tekerlekli sandalye broşürü ya da özellikleri anlatan özetlerden en az birer örnek;  Mezuralar ve gevşeyebilen ayarlanabilir parçaları için aletler (örneğin ayaklıklar). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  zamanın durumuna göre yerel olarak bulunabilen tekerlekli sandalyelerin ayarlanmaları;  özellikli tekerlekli sandalye reçete (seçim) ve veri formlarının hazırlanması, ayarlanma seçenekleri sunulabilen tekerlekli sandalyeler için yararlı olabilir. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin ve bölüm planını okuyun.  Müsait durumda olan her kullanıcı için referans olması amacıyla tekerlekli sandalye veri formu hazırlayın.  Mevcut olan tekerlekli sandalyeleri gözden geçirin ve bu sandalyelerin özelliklerine ayarlanma aralıklarına ve seçeneklerine ve nasıl ayarlandıklarına tam anlamıyla aşina olun.  Tekerlekli sandalye reçete formunu; yerel olarak bulunabilen sandalyelerin sahip oldukları seçenekleri ve ayarlamaları da içerecek bir şekilde uyarlayın ( bir ürün için ona özel bir reçete etme-seçme formu varsa bunu ayrı tutun)  Tekerlekli sandalyeleri odanın etrafına üretici tarafından sağlanan materyallerle beraber dizin ( örneğin broşür ya da ürün bilgileri) T A S LA K 1. Giriş. 2. ‘Reçete/seçim’ nedir? 3. Yerel olarak bulunabilen tekerlekli sandalyeler ve minderler 4. Doğru tekerlekli sandalye ve parçalarının seçimi 5. Doğru tekerlekli sandalye boyutunun seçimi 6. Reçete(seçim) kaydı. 7. Kilit nokta özeti. 2 5 60 15 25 10 3 Toplam bölüm süresi 120 1.Giriş (2 dakika) Açıkla: o Reçete(seçim) hizmet sunumundaki sekiz adımdan üçüncüsüdür. o Bu bölümde katılımcılar değerlendirmede elde edilen bilgilerle nasıl tekerlekli sandalye reçete edileceğini(seçileceğini) öğrenecekler. 2. Reçete (seçim) nedir? (5 dakika) Açıkla: o Reçete(seçim) kullanıcının ihtiyaçları ile tekerlekli sandalye ve minderler arasındaki en iyi eşleşmeyi yapabilmektir. o Reçete(seçim) her zaman tekerlekli sandalye kullanıcısı ile beraber verilmesi gereken bir karardır bu sürece eğer uygunda aile üyesi ya da kişinin bakıcısı da dâhil edilmelidir. o Reçete(seçim)şunları içerir: o doğru boyutlardaki tekerlekli sandalye ve minder seçimi; o doğru tekerlekli sandalye ve minder ve doğru tekerlekli sandalye parçalarının seçimi; o tekerlekli sandalye kullanıcısının ihtiyaçları doğrultusunda tekerlekli sandalye ve minderinin bakımı ve kullanımı için hangi eğitimin verileceği konusunda fikir birliğine varmak. Açıkla: Bunu yapabilmek için personelin ihtiyacı olanlar şunlardır: o tekerlekli sandalye kullanıcısının ihtiyaçlarını; tekerlekli sandalye değerlendirmesini yaparak,ve kullanıcının söylediklerini dikkatle dinleyerek anlamak; o mevcut olan tekerlekli sandalye ve minderler hakkında bilgi sahibi olmak; o seçenekleri tekerlekli sandalye kullanıcısı ile tartışmak. 3. Yerel olarak bulunabilen tekerlekli sandalyeler ve minderler (60 dakika) Açıkla: Personel yerel olarak bulunabilen tekerlekli sandalye ve minderlerle ilgili iyi derecede bilgi sahibi olmalıdır. o İskelet – örneğin, uzun ya da kısa akslı oluşu; iskelet uzunluğu; çapraz katlanabilen mi yoksa sabit iskelet mi oluşu. o Özellikler – koltuğun cinsi de dâhil olarak, arkalık, ayaklıklar, kolçaklar, ön tekerlekler, arka tekerlekler. o Tekerlekli sandalye boyutu: Bu genellikle tekerlekli sandalye koltuk genişliği ve bazen de derinliği ile tanımlanır. Koltuktan yere olan mesafeyi bilmek de yararlı olur. o Ayarlanabilirlik seçenekleri: Hangi parçalar ayarlanabilir ve ayarlanabilme aralıkları nelerdir? Ayarlanabilirlik genellikle iki ya da daha fazla pozisyon için mümkündür. Örneğin bir çok tekerlekli sandalyenin farklı yüksekliklere eşit aralıkları ayrılabilen ayalıkları vardır. Ayarlanma “aralığı” en küçükten en büyük ölçülere kadardır. o Minder: Tekerlekli sandalye ile beraber (eğer varsa) ne cins bir minder verilmektedir ya da ayrıca verilmekte midir? o Bazı tekerlekli sandalye tedarikçileri şunları sağlarlar: a. broşür ya da ürün özet bilgileri b. ürün (tekerlekli sandalye) teknik özellikleri tanıtımı. o Tekerlekli sandalye ölçümleri, ağırlıkları, özellikleri ve bazen de seçenekli parçaları bu bilgilerde listelenmektedir. o Reçete ederken (seçerken) tekerlekli sandalye ile ilgili bu bilgilerin olup olmadığını her zaman kontrol edin. Bu bilgileri okuyun ki ürüne aşina olabilesiniz. o Eğer tedarikçi bu bilgileri vermiyorsa sorunuz. Açıkla: Bu bölümde katılımcılar yerel olarak bulunabilen tekerlekli sandalyelere çok yakından bakabilecekler. Katılımcılar el kitaplarında olan tekerlekli sandalye veri formunu dolduracaklar. Bu tekerlekli sandalye ölçümünü de içerecektir. Tekerlekli sandalye ölçümü bu şekildedir. Açıkla o Tekerlekli sandalye koltuk tırabzanının birinden diğerine doğru uzanan koltuk genişliğini ölçün. o Eğer kolçaklar koltuk tırabzanının üstünde ise kolçakların arasını ölçün. o Koltuk derinliği için arkalık tabanından koltuğun önüne kadar olan mesafeyi ölçün. o Koltuk yüksekliği için koltuğun önünden direk yere kadar olan mesafeyi ölçün. o Arkalık yüksekliği için (mindersiz) koltuğun arkasının orta yerinden arkalığın en üstüne kadar olan mesafeyi ölçün. o Ayaklık yüksekliği için ayaklığın arka tarafından tam yukarı koltuğa kadar olan mesafeyi ölçün. o Ayaklık yükseklik aralığını ölçmek için; ayaklıkları en alçak ve en yüksek ayarlara getirerek ölçün. o Toplam tekerlekli sandalye iskelet uzunluğunu ölçmek için arka tekerleklerin arka kısmından ayaklıkların en ön kısmına kadar olan mesafeyi ölçün ( eğer ön tekerlekler ayaklıklardan önde ise ön tekerlek mesafesini temel alın). o Tekerlekli sandalye aks aralığın için arka tekerleğin ortasıyla ön tekerleğin ortası arasında kalan mesafeyi ölçün. Açıkla: o Tekerlekli sandalye ve ayarlanma aralıkları ürün hakkında basılı olan bu materyallerde bulunabilir. o Buna rağmen kendi başınıza bu bilgileri ölçerek edinebilmek de iyidir çünkü bunları her zaman bulmak mümkün olmayabilir. o Tedarikçinin farklı boyutlarda özel tekerlekli sandalyeleri olup olmadığını her zaman kontrol edin. Aktivite Gruplar: Her bir grupta üç kişi olsun. Her bir gruba yerel olarak bulunabilen bir tekerlekli sandalye tahsis edin. Her gruba yetecek yeterli farklı tekerlekli sandalye cinsi yoksa bazı gruplar aynı tip sandalyeleri alabilirler. Talimatlar: Her bir gruba şunları söyleyin: o kendilerine verilen tekerlekli sandalyelerle dikkatli bir şekilde çalışmalarını söyleyin; o çalıştıkları tekerlekli sandalye için el kitaplarındaki tekerlekli sandalye veri formunu doldurmalarını isteyin (tekerlekli sandalye ölçümleri de buna dahil); o her bir parça için ayarlanma aralıklarını bulmak amacıyla tekerlekli sandalyeyi en büyük ve en küçük ayarlara getirerek ayar aralığını bulmalarını söyleyin. İzleme: Gruplar arasında dolaşın ve yakından izleyin. Katılımcıların fark etmedikleri her bir özelliğe/parçaya dikkat çekin. Katılımcıların ayarlanma aralıklarını çözdüklerinden emin olun. Soruları cevaplayın. Süre: 20 dakika müsaade edin, artı olarak 20 dakika bütün grup geri bildirimi için müsaade edin. Eğer sadece bir veya iki çeşit tekerlekli sandalye var ise bu bölüm için bu kadar çok zaman gerekmeyecektir. Geri Bildirim: o Her bir gruba gözden geçirdikleri tekerlekli sandalyeyi takdim etmelerini isteyin. (maksimum 5 dakika). Kilit özellikleri, parçaları, boyut seçeneklerini, ayarlanabilir parçaları ve ayarlanabilirlik aralıklarını işaret ettiklerinden emin olun. Gerçek ölçüleri vermeleri gerekli değildir. o Değişik özelliklerin avantaj ve dezavantajlarını pekiştirin ve grup tarafından söylenmeyen bilgileri ekleyin. o Örneğin; eğer bir tekerlekli sandalye askı şeklinde kanvaz koltuklu ise ve minderi yoksa bu sandalye omurilik zedelenmesi olan bir kişi için uygun değildir ama sandalyeyi geçici veya kısa süreli kullanacak bir kullanıcı için uygundur. Açıklama: Katılımcılar el kitaplarındaki tekerlekli sandalye veri formunu her bir tekerlekli sandalye kullanıcısı için doldurmak isteyebilirler (toplamda üç veri formu verilmiştir) Eğitmenler için notlar: Bölüm sonunda her bir tekerlekli sandalye için doldurulmuş bir veri formu asmak iyi bir fikirdir. Tekerlekli sandalye kullanıcılarıyla uygulama bölümüne Bu daha sonra tekerlekli sandalye kullanıcıları ile uygulama bölümüne sevk edilebilir. 4. Doğru tekerlekli sandalye ve parçalarının seçimi (15 dakika) Açıkla: o Katılımcılar şimdi tekerlekli sandalye kullanıcısı ve yerel olarak bulunabilen tekerlekli sandalyeler ile ilgili bilgi edinme uygulamasını yaptılar. Şimdi en iyi tekerlekli sandalye ile kullanıcı eşleştirme uygulama sırasıdır. . o Şimdi bakacağımız iki tane kullanıcı hikayesi vardır. Her bir kullanıcı için en iyi tekerlekli sandalyeyi ve parçalarını eşleştirmek için beraber çalışacağız. o Unutmayın – gerçek bir durumda tekerlekli sandalye kullanıcısı sandalyeyi seçen takımın bir parçası olmalıdır. i İlk tekerlekli sandalye kullanıcısının hikâyesini okuyun ( ve isterseniz bu hikâyenin slaydını gösterin). Sor: Ne tür bir tekerlekli sandalye ve parçaları Peter’a en uygun olacaktır? Neden? Cevapları teşvik edin Peter Tekerlekli sandalye ve parçaları Nedeni Peter kırsal alanda bir köyde yaşamaktadır. Çok aktif ve güçlüdür. İyi bir dengesi vardır. Peter her gün işten dönmek için toprak yol üzerinde 1 km yol yapmaktadır. Yağmur yağdığında yol oldukça çamurlu olmaktadır. Uzun aks mesafeli (ön ve arka tekerlekleri arası uzun) Mevcut olan yerlerde: üç tekerlekli Dış mekanlara uygun Üç tekerlekliler uzun mesafeler için iyi bir seçenektir. Geniş ön tekerlekler Toprak/çamur/kum için uygundur. Aktif arka tekerlek pozisyonu Ön tekerlekleri engebeli zeminlerde/küçük engellerde kaldırmak daha kolaydır. Onun iyi bir dengesi vardır. Alçak arkalık Sürüşünü kısıtlamayacaktır. İkinci tekerlekli sandalye kullanıcısı hikâyesini okuyun (ve eğer arzu ederseniz onun hikâyesinin slaydını gösterin). Sor: Ne tür bir tekerlekli sandalye ve nasıl parçalar Natasha’ya en uygun olacaktır? Neden? Cevapları teşvik edinç Natasha Tekerlekli sandalye ve parçaları Nedeni Natasha bir kasabada bir dairede yaşamaktadır. Felç geçirmiştir ve transferini yapmak için ayağa kalkabilmektedir. Kolları çok güçsüz olduğu için tekerlekli sandalyeyi kendisi itememektedir. Natasha bazen koltuğun bir tarafına doğru kaymaktadır ve ailesi onun rahat olmadığından endişe etmektedirler. Kalkabilen ayaklıklar. Ayakta transferine imkân tanımak için Ayakla itmeye imkan sağlaması/teşvik etmesi için Koltuk yüksekliği yerden itibaren – fazla yüksek değil Natasha’nın koltukta ileriye doğru oturup ayağa kalkmaya hazır durumdayken yere rahatlıkla ulaşabilmesi için. Basınç rahatlatma minderi Basınç tahliyesi, rahatlık ve duruş desteği sağlanması Sabit/sert arkalık Duruş desteği sağlamak için Yüksek kolçaklar Duruşa yardımcı olabilir İtme tutamakları Aile/yardımcının itmesini kolaylaştırmak için Açıkla: Bazen tekerlekli sandalye kullanıcısının bütün ihtiyaçlarını karşılayacak tekerlekli sandalye bulmak imkân dâhilinde değildir. Bu durumda kullanıcı ile görüşün ve en önemli ihtiyaçları karşılamaya çalışın. 5. Doğru tekerlekli sandalye boyutunun seçimi (25 dakika) Soru: Tekerlekli sandalyenin doğru boyutta olması neden önemlidir? Cevapları teşvik edin. En önemli cevaplar: o doğru boyut tekerlekli sandalye kullanıcısının tekerlekli sandalyede doğru oturmasını sağlar; o doğru boyuttaki bir tekerlekli sandalye ile kullanıcının ağırlığı eşit olarak dağıtılır; o tekerlekli sandalye daha rahat olacaktır ve kullanıcısı için sandalyeyi itmek daha kolay olacaktır. . Aktivite Gruplar: Her grupta iki üç kişi olmalı Talimatlar: Her bir gruba şunları yapmalarını söyleyin: o el kitaplarında bulunan çalışma sayfasındaki tekerlekli sandalye kullanıcı ölçümlerine bakmalarını söyleyin; o her bir kullanıcı için ideal tekerlekli sandalye ölçümü ne olabilir karar vermelerini ve sonra; o mevcut olan tekerlekli sandalyelerden hangisi en uygun onu seçmelerini. Açıkla: o Minder yüksekliğini 50 mm olarak kullanabilirler. o Tekerlekli sandalye kullanıcısının sandalyesini ayağıyla ittiğini farz etmeliler. İzleme: Grupları izleyin ve gerekirse yardım edin. . Süre: 25 dakika müsaade edin Geri Bildirim: Her bir grubun doğru “ideal boyutu” ve mevcut tekerlekli sandalyelerin arasından en iyi boyutu seçtiğini kontrol edin. Sor: Eğer ikinci tekerlekli sandalye kullanıcısı sandalyesini kendisi ayağıyla itmek isterse tekerlekli sandalyenin koltuğundan yere olan ideal yükseklik ne olurdu? (Cevap: 310 mm.) Sor: Eğer mevcut olan tekerlekli sandalyenin koltuktan yere olan mesafesi daha büyük olsaydı ne yapabilirlerdi? Cevap: minderin yüksekliğini azalt. Açıkla: Personel; koltuk derinliğini, koltuk genişliğini ve arkalık yüksekliğini kontrol etmenin yanı sıra ayaklık yüksekliği ayarlamalarını da kullanıcıya uyması için kontrol etmelidir. Bazen tekerlekli sandalye kullanıcısının özellikle kısa ya da uzun baldırları olabilir. Bunlar ayarlanabilir aralığın dışındaysalar bir modifikasyon gerekli olabilir ve mümkündür. Bu bir sonraki bölümde tartışıldı. Eğitmenler için cevaplar: 1 Vücut ölçümü Ölçü(mm) Vücut ölçülerini ideal tekerlekli sandalye boyutuna çevir Tekerlekli sandalye ölçümleri A Basen genişliği 380 mm Basen genişliği = koltuk genişliği 380 mm B Koltuk derinliği Sol 400 mm B koltuk derinliği = 30 – 50 mm’ den daha küçük ise. (eğer uzunluk farklı ise daha kısa olanını kullanın) 370 mm Sağ 400 mm C Baldır uzunluğu Sol 420 mm = koltuk minderinin üstünden* ayaklık yüksekliğine kadar Ya da = koltuk minderinin üstünden* yere kadar ayakla itmek için 370 mm (50 mm minder) Sağ 420 mm D Göğüs kafesinin alt kısmı - = koltuk minderinin üstünden * arkalığın üstüne kadar ( D ya da E’ i ölçün – kullanıcının ihtiyaçlarına bağlı olarak ) - E Kürek kemiğinin alt kısmı 380 mm 430 mm (50 mm minder) Bu tekerlekli sandalye kullanıcısı için ideal tekerlekli sandalye boyutu: Koltuk genişliği: 380 mm Koltuk derinliği: 370 mm Arkalık yüksekliği: 430 mm Mevcut olan tekerlekli sandalyelerden hangisi ve hangi boyut kullanıcıya en uygun olandır? 2 Vücut ölçümü Ölçü(mm) Vücut ölçülerini ideal tekerlekli sandalye boyutuna çevir Tekerlekli sandalye ölçümleri A Basen genişliği 420 mm Basen genişliği = koltuk genişliği 420 mm B Koltuk derinliği Sol 460 mm B koltuk derinliği = 30 – 50 mm’ den daha küçük ise. (eğer uzunluk farklı ise daha kısa olanını kullanın) 430 mm Sağ 460 mm C Baldır uzunluğu Sol 360 mm = koltuk minderinin üstünden* ayaklık yüksekliğine kadar Ya da = koltuk minderinin üstünden* yere kadar ayakla itmek için 310 mm (50 mm minder) Sağ 360 mm D Göğüs kafesinin alt kısmı 260 mm = koltuk minderinin üstünden * arkalığın üstüne kadar ( D ya da E’ i ölçün – kullanıcının ihtiyaçlarına bağlı olarak ) 310 mm (50 mm minder) E Kürek kemiğinin alt kısmı - - Bu tekerlekli sandalye kullanıcısı için ideal tekerlekli sandalye boyutu: Koltuk genişliği: 420 mm Koltuk derinliği: 430 mm Arkalık yüksekliği: 310 mm Mevcut olan tekerlekli sandalyelerden hangisi ve hangi boyut kullanıcıya en uygun olandır? 6. Reçetenin (seçimin) kayıt edilmesi (10 dakika) Açıkla: Tekerlekli sandalye reçetesinin (seçiminin) yazılması gerekir. Tekerlekli sandalye hizmetlerinin reçete (seçim) kararlarının yazılması için bir forma ihtiyaçları vardır. Eğitim paketinde kullanılan tekerlekli sandalye reçete (seçim) formu, değişik tekerlekli sandalye hizmetleri tarafından uyarlanması gereken bir örnektir. Açıkla: o Tekerlekli sandalye reçete (seçim) formu dört bölümdür. o İlk bölüm tekerlekli sandalye kullanıcısı hakkında bilgilerdir. . Bu bilgi değerlendirme formundan da alınabilir. o Planlanmış olan uygunluk tarihinin yazılacağı bir boşluk da vardır. Açıkla: o Kayıtların ikinci bölümü seçilmiş olan tekerlekli sandalyenin cinsi ve boyutudur. o Bir tekerlekli sandalyede seçenekler var ise (örneğin ayarlanabilir arkalık ya da değişik cins ayaklıklar) seçilen seçenekler yazılmalıdır. o Bazı tekerlekli sandalye tedarikçilerinin kendi tekerlekli sandalyeleri için ayrıntılı reçete(seçim) formları vardır. Bu form da doldurulmalıdır ve genel forma eklenmelidir. Açıkla: o Üçüncü bölüm seçilmiş minderi belgeler. Açıkla: o Son olarak, konuya dâhil olan herkesin anlaştıklarına dair imzalamaları için reçete(seçim) formunda bir boşluk vardır. o İmzalayan kişilerin sayısı ilgili hizmete göre değişir. Bununla beraber tekerlekli sandalye kullanıcısı ve değerlendirmeyi yapan kişinin imzalaması çok önemlidir. Sor: Tekerlekli sandalye reçete(seçim) formunun doldurulması ile ilgili sorusu olan var mı? Soruları cevaplayın. Cevapla: Tekerlekli sandalye reçete(seçim) formu tekerlekli sandalye kullanıcısına verilecek eğitim ya da sandalyeye bakım tavsiyelerini de içerir. 7. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun Soru olup olmadığını öğrenin. B.6: Finansman ve sipariş H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  reçete edilmiş tekerlekli sandalyeyi tekerlekli sandalye hizmetlerinin sipariş sistemine göre sipariş edebilecekler K A Y N A K LA R Bu bölüm için:  Referans Kılavuzu  Sipariş formu (eğitim paketi bunu içermemektedir, sadece yerel olarak varsa kullanınız). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla.  Katılımcılara, çalışıyor olacakları hizmette tekerlekli sandalye siparişi verirken kullanacakları hizmet adımlarını öğretmek için bu bölümü kullanın.  Tekerlekli sandalye siparişi için net bir sistemin olmadığı yerlerde, katılımcılar tekerlekli sandalye hizmetleri ile sipariş yöntemi oluşturmak için teşvik edilmektedir.  Katılımcılara sipariş vermek için bir uygulama imkânı verin. Bu onların bir sipariş formu doldurmalarını içerebilir (eğer yerel olarak bir form varsa) H A Z IR LI K  Kaynakları toplayın ve bölüm planını okuyun.  T A S LA K 1. Giriş 2. Finansman 3. Sipariş 2 3 10 Toplam bölüm süresi 15 1.Giriş (2 dakika) Açıkla: Finansman ve sipariş tekerlekli sandalye hizmet sunumunda dördüncü adımdır. 2. Finansman (3 dakika) Açıkla: Tekerlekli sandalye reçete edildiğinde önerilen ürünün ücreti tam olarak tahmin edilebilir. Tekerlekli sandalyeyi kimin finanse edeceğini bilmek zorunludur. Finansman; cepten ödemeyle, devlet desteği ile sivil toplu örgütü ya da bağış temsilciliğinden ya da sigorta kuruluşundan sağlanabilir. Gelişen dünyada tekerlekli sandalyeye ihtiyacı olan pek çok kimsenin bunu alabilecek maddi güçleri yoktur. Buna rağmen tekerlekli sandalyeye ihtiyacı olan herkesin maddi alım güçlerine bağlı olmaksızın bir sandalye sahibi olmaya hakları vardır. Dolayısıyla maddi yardıma ihtiyacı olan kullanıcılar için fonlar oluşturulmalıdır. Pek çok servis için tekerlekli sandalye sipariş edilebilmesi için bir finans kaynağı tanımlama zorunlu olacaktır. Bu sorumluluk klinik veya teknik personelden daha çok idari personele düşmektedir. Eğer bu tekerlekli sandalye hizmeti personelinin görevinin bir parçası ise tekerlekli sandalye ücretinin nasıl ödeneceğini belirleyen herhangi bir sisteminin tanımlanmasını kapsar. Katılımcılar kendi programlarındaki farklı finansman imkânlarını yazabilirler. 3. Sipariş (10dakika) Tekerlekli sandalye kullanıcısı için en uygun sandalye seçildiğinde ve reçete (seçim) hazırlandığında, tekerlekli sandalyenin siparişinin verilmesi gerekmektedir. Bir tekerlekli sandalye hizmeti tekerlekli sandalyeleri stokta tutuyorsa bu servis müdürü tarafından onaylanması amacıyla bir sipariş formunun tamamlanması anlamına gelebilir. Bu durumda tekerlekli sandalye, sorumlu personel tarafından kişinin ihtiyaçlarını karşılayacak şekilde hazırlanmış olur. Tekerlekli sandalye hizmetleri stokta tekerlekli sandalye tutmuyorsa bu dışarıdan bir üreticiye sipariş ettiği anlamına gelebilir. Tekerlekli sandalye sipariş sistemleri farklı hizmetlerde değişik sistemlerde olacaktır. Yerel tekerlekli sandalye hizmetlerine sipariş verirken hatırlamanız gerekenleri yazınız. Açıkla: Tekerlekli sandalye kullanıcısı için en uygun iyi tekerlekli sandalyenin seçiminden ve reçetenin hazırlanmasının ardından tekerlekli sandalye personeli siparişi vermelidir. Bir sipariş, her zaman gecikmelere meydan vermeyecek şekilde mümkün olan en çabuk haliyle verilmelidir. Katılımcıların bu eğitimden sonra dönecekleri tekerlekli sandalye hizmetinin sipariş sistemini açıklayınız. Katılımcılar sipariş sistemlerini Referans Kılavuzlarındaki verilmiş boşluğa yazabilirler. Birinci Uygulama: Değerlendirme ve reçete(seçim) O B JE C T IV E S Bu bölümün sonunda katılımcılar şunları yapabilecekler:  Grupta temel düzeyde bir tekerlekli sandalye değerlendirme çalışması yardımınızla gösterebilecekler  Grupta temel düzeyde bir tekerlekli sandalye reçete (seçim) çalışması yardımınızla gösterebilecekler  R E S O U R C E S  Eğitmen gözlem kontrol listesi: birinci uygulama;  Boş, doldurulmamış değerlendirme ve reçete(seçim) formu;  Her bir tekerlekli sandalye kullanıcısı için içinde değerlendirme sedyesi olan temiz ve sessiz bir alan;  Örnek tekerlekli sandalyeler (değerlendirme toplum önünde yapılmadığı takdirde );  Mezuralar ve ayaklar için destek bloklar. C O N T E X T Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  kültürel faktörler – örneğin kadın erkek karışık değerlendirme yapmanın uygun olup olmadığı;  dil faktörü – kullanıcıların katılımcılarla aynı dili kullanıp kullanmadığı;  hizmetlerin, değerlendirme ve reçete etme işlemini yaparken ihtiyacı olabilecek her türlü doküman - örneğin tekerlekli sandalye kullanıcısının tekerlekli sandalyeye erişimi ile ilgili ihtiyaçları olabilecek ilave bilgiler( örneğin referans bilgileri).  Değerlendirme sırasında doğabilecek ve bölüm ya da eğitim sırasında değinilememiş olan problemleri katılımcılar nasıl çözecekler. T O P R E P A R E  Tekerlekli sandalye gönüllülerinin zaman ve seyahat ayrıntılarının teyit edilmesi. Kullanıcılar ve aileleri ve onlara yardıma gelenler için ikramlar olmasını sağlamak.  Kullanıcılar geldiği zaman onları karşılayacak ve bölüm başlayana kadar nerede bekleyeceklerini gösterecek bir kişinin tahsis edilmesi.  Her bir çift katılımcı ve gönüllü kullanıcının kullanacağı bir değerlendirme sedyesi ve mahremiyeti korumak için bir perde sağlanması. Her bir değerlendirme için kullanılacak bütün malzemeleri (değerlendirme ve reçete formu da dahil olmak üzere) değerlendirme sedyesinin üstüne koymak. .  Tekerlekli sandalye kullanıcılarına gösterilecek sandalyelerin ve minderlerin iyi ve çalışır durumda olduklarından emin olmak.  Eğer üç çift katılımcıdan daha fazlası varsa başka bir eğitmenin gözlem ve yardım için gelmesini söylemek.  Hangi katılımcıların beraber çalışacağına ve hangi tekerlekli sandalye kullanıcısı ile ilgileneceğine karar vermek. O U T LI N E 1. Değerlendirme ve reçete uygulaması: o Talimatlar ve düzenleme; o Değerlendirme; o Reçete(seçim); o Geri bildirim. 5 45 30 10 Toplam bölüm süresi 90 1. Değerlendirme ve reçete uygulaması (90 dakika) Eğitmenler için notlar: Birinci Uygulamada grupların bütün adımları uyguladıklarından emin olmak için “Eğitmen gözlem kontrol listesi”ni kullanın ve iyi ve kötü olan uygulamaları, genel örnekleri not alın ki bunlar daha sonra geri bildirim bölümünde kontrol listesinde altı çizilecek noktalar olacaktır. (kutucuk verilmiştir) Aktivite Gruplar: o Katılımcıları gruplara ayırın (bir grupta üç kişiden fazla kişi olmasın) o Her gruba bir lider belirleyin. o Gruba çalışacakları tekerlekli sandalye kullanıcısının adını söyleyin. o Her grubun çalışacağı bir yer belirleyin. o Gerekli olan her materyalin değerlendirme sedyesi üzerine bırakıldığını açıklayın. Talimatlar: Aşağıdakileri açıklayın: Bölümün amacı: o Bu uygulama bölümünün amacı tekerlekli sandalye kullanıcısı için değerlendirme ve reçete işleminin yapılması. o Katılımcılar bu gün aynı tekerlekli sandalye kullanıcısı ile çalışacaklar, daha sonra kursta seçilmiş tekerlekli sandalyenin uyumunu ve kullanıcı eğitimini yapacaklar. o Eğer kurs sırasında kullanıcının tekerlekli sandalyesinin ayarlamalarının tamamını yapmak imkanı olmazsa tekerlekli sandalye kullanıcısı ile bunun tamamlanmasını sağlamak için gerekli düzenlemeler yapılmalıdır. Bununla beraber katılımcıların mümkün olduğu kadar çok işi bitirmek için çaba göstermeleri gerekir. Lider kişi: o Lider olan kişi bütün adımların yapıldığından emin olmak için sorumluluğu olan kişidir. o Lider kişi kullanıcı, aile/bakıcı ile konuşacak olan esas kişidir. Bu herkesin bir anda konuşmasını ve oluşabilecek kafa karışıklığını engelleyecektir. Hizmet formları: o Her bir grubun takım liderlerine değerlendirme ve reçete formu dağıtın. . Eğitimcilerin gözlemi ve desteği: o Katılımcılar her an yardım ve açıklama isteyebilirler. o Bütün bölüm boyunca eğitmenler her grubu izleyecekler ve olabildiğince çok destek ve ihtiyaç olduğu kadar da tavsiye vereceklerdir. o Değerlendirmenin ardından katılımcıların bir eğitmenin gelip değerlendirmeyi ve değerlendirme formunu kontrol etmesini istemeleri gerekir. o Reçete (seçim) ardından katılımcıların bir eğitmenin gelip reçete(seçim) işlemini ve reçete(seçim) formunu kontrol etmesini istemeleri gerekir. . Müsaade edilen zaman: o Değerlendirmeyi 40 dakikada ve reçete(seçim) işlemini 20 dakikada bitirmeyi amaçlamaları gerekir. Katılımcılara sor: Değerlendirme adımları nelerdir? Doğru cevapları onayla. Katılımcılara sor: Reçete adımları nelerdir? Doğru cevapları onayla. Tekerlekli sandalye kullanıcılarının süreç içerisindeki her adıma dahil edilmeleri gerektiğini katılımcılara hatırlatın. Sor: Sorusu olan var mı? Bütün soruları cevaplayın. Her bir gruba çalışacakları bölgeyi hazırlamalarını ve çalışacakları tekerlekli sandalye kullanıcısına kendilerini tanıtmalarını söyleyin. İzleme ve destek: Grupları yakından izleyin, uygulamaların güvenli bir biçimde yapıldığından emin olun ve katılımcıların becerilerini değerlendirin. Her bir grupla ilgili gözlemlerinizi kayıt etmek için Eğitimci gözlem kontrol listesini kulanın. Bütün bölüm boyunca: o Katılımcıları zamanlarını iyi kullanmaları için uyarın. o Tekerlekli sandalye kullanıcılarının sürece aktif bir şekilde dahil edildiklerinden emin olun. Bölümün sonunda katılımcılara; tekerlekli sandalye kullanıcılarına katılımlarından dolayı teşekkür etmelerini, reçete edilen (seçilen) tekerlekli sandalyenin onlar için bir sonraki bölümde denenmek üzere hazırlanacağını söylemelerini isteyin. Süre: Değerlendirmeyi tamamlamak için 45 dakika, reçete etme (seçim) için 30 dakika ve geri bildirim için de 10 dakika müsaade edin. Zaman kullanımını Eğitmen Gözlem kontrol listesini kullanarak takip edin. Geri Bildirim: Uygulama esansında gördüğünüz iyi örnekler ile ilgili yorumlar yapın. Katılımcıların kendilerini geliştirebilecekleri alanlara işaret edin, kişilerle ilgili değil grupla ilgili konuşun. Sor: Soru var mı? B.7: Ürün (tekerlekli sandalye) hazırlığı H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  bir tekerlekli sandalyeyi reçete (seçim) ile eşleşecek şekilde ayarlayabilecekler;  “tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi ” ni tekerlekli sandalyenin güvenliliğini ve bütün parçaların kullanıma hazır olduğunu anlamak için kullanacaklar. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.7 Ürün(tekerlekli sandalye) hazırlığı;  Referans Kılavuzu  Katılımcı el kitabı  DVD: Tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi gösterimi;  birinci uygulamada değerlendirilerek kullanıcı için seçilmiş olan tekerlekli sandalyeler;  birinci uygulamada doldurulmuş olan reçete formları;  tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi (her katılımcı için bir nüsha);  mezuralar ve ayarlamalar için gereken her türlü el aleti (her çift için 1 adet) İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  Yerel olarak bulunabilen tekerlekli sandalye ayarlamaları için gereken zaman. Eğer bu tekerlekli sandalyelerin seçenekleri az miktarda ise zaman da kısa olacaktır, eğer fazla ayarlanma seçenekleri varsa daha fazla zaman gerekecektir.  Bu yerel olarak mevcut tekerlekli sandalyelerde hazırlıktan önce montaj gereken bir durum var ise bölümden önce montaj için gereken zaman verilmelidir. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Yerel olarak bulunabilen bu sandalyelerin ayarları için pratik yapın ki nasıl yapıldıklarını öğrenebilesiniz ve ihtiyaç olduğunda katılımcılara gösterebilip onlara yardımcı olabilesiniz. T A S LA K 1. Giriş 2. Tekerlekli sandalye hazırlama 3. Tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi 4. Kilit nokta özeti. 2 40 30 3 Toplam bölüm süresi 75 1.Giriş (2 dakika) Açıkla: Bu bölümde katılımcılar tekerlekli sandalye kullanıcılarının denemeleri için tekerlekli sandalyeyi nasıl hazırlayacaklarını öğrenecekler. Bu adım tekerlekli sandalye hizmet sunumunda beşinci adımdır. Tekerlekli sandalye hazırlığı şunları içerir: o Montajı yapılmış tekerlekli sandalyenin kullanıcının reçetesiyle eşleşecek şekilde hazırlanması; o Tekerlekli sandalyenin güvenli ve kullanıma hazır olduğunun ve bütün parçaların doğru olarak çalışıyor olmasının kontrolü . 2. Tekerlekli sandalyenin hazırlanması (40 dakika) Açıkla: Kullanıcılar daha önceki uygulamada kendisi ile çalışılmış olan kullanıcı için reçete edilmiş tekerlekli sandalyeyi hazırlayacaklar. Uygulayacakları adımlar şunlardır. Açıkla: o Sandalye koltuk genişliğinin ve derinliğinin reçete edilmiş sandalyeye uygun olup olmadığını kontrol edin. o Minder genişliği ve derinliği koltuğa uyuyor mu kontrol et. Ayarla (imkân olan durumlarda): o arkalık yüksekliği; o kolçak yüksekliği; o arka tekerlek pozisyonu; o fren pozisyonu (arka tekerlek pozisyonunu değiştirdikten sonra her zaman fren pozisyonunu yeniden ayarla); o ayaklık yüksekliği; o itme tutamakları yüksekliği; o yapılması mümkün olan diğer ayarlamalar. Aktivite Gruplar: Birinci uygulamada beraber çalışan gruplara tekrar beraber çalışmalarını söyleyin. Her bir gruba şunları verin: o ilgilendikleri kullanıcı için doldurulmuş olan tekerlekli sandalye reçete(seçim) formu; o mezura; o kullanıcı için reçete edilmiş olan tekerlekli sandalye. Sandalye ayarlamaları için ihtiyaç olan aletlerin salonda önde bir yerde bulunmasını sağlayın. Talimatlar: Her bir gruba reçeteye bakmalarını ve tekerlekli sandalyeyi hazırlamalarını söyleyin. Takip edilecek adımları hatırlatın: o sandalye koltuk genişliğini ve derinliğini kontrol edin; o minder uyuyor mu kontrol edin; o kullanıcı için tekerlekli sandalye ayarlamalarının yapımını kontrol edin. İhtiyaçları olan aletlerin salonun ön kısmında olduğunu hatırlatın. Açıkla: Kullanıcının ihtiyaçları için sandalyede modifikasyon yapması gereken gruplar olursa bu daha sonraki bölümde yapılacaktır. . İzleme: Grupları yakından izleyin Adımların uygulandığını kontrol edin. Her bir grup işini bitirdiğinde kullanıcının reçetesine (seçim) en yakın olacak şekilde ayarlamalar yapılmış mı kontrol edin. Süre: Ayarlamaların durumuna göre, yapılıp yapılamadığına bakarak 20 dakika ya da daha fazla süre müsaade edin. 10 dakika geri bildirim için verin. Geri Bildirim: Sorun: o Her bir grup kullanıcının reçetesindeki ihtiyaçları karşılayacak şekilde sandalyeleri hazırlayabildi mi? o Eğer cevap hayırsa sorun nedir? Gruba bu problemin çözümünün ne olabileceğini sorun. Herkesin anlayana kadar açıklama yapın , netleştirin. 3. Tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi (30 dakika) Açıkla: Ürün(tekerlekli sandalye) hazırlığının ikinci kısmı; tekerlekli sandalyenin güvenli, kullanıma hazır ve bütün parçalarının doğru bir şekilde çalışıyor olmasının kontrolüdür. Bürün katılımcılara tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi verin. Açıkla: o Bu kontrol listesi hiç bir şeyin unutulmamasını sağlar. o Katılımcılar bu listeyi her tekerlekli sandalye hazırladıklarında kolay bir referans olarak saklayabilirler. o Hizmetler, bu kontrol listesini reçete edilmiş (seçilmiş) her bir sandalye için bir form olarak kullanmayı seçebilirler. DVD tanıtımı: Tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi gösterimi. Bu DVD kullanıcının sandalyeyi denemesi için güvenli ve kullanıma hazır olup olmadığının nasıl kontrol edileceğini gösterecektir. Katılımcılara söyleyin: o tekerlekli sandalyede kontrollerin yapılışını yakından izlemelerini; o her bir kontrolü yaptıklarında sandalyenin kontrolden geçtiğini düşünüyorlarsa el kitaplarında olan kontrol listesindeki kutucuklara tik atmalıdırlar. Show DVD. Soru olup olmadığını öğrenin. Aktivite Gruplar: Birinci uygulamadaki aynı gruplar. Her bir grupta hazırlanan sandalyeleri diğer gruba verin. Talimatlar: Her bir gruptan kendilerine verilmiş tekerlekli sandalyelerin güvenli ve kullanıcı için kullanıma hazır durumda olup olmadıklarını kontrol etmelerini isteyin. Hatırlanması gereken her noktayı hatırlamaları için ellerindeki kontrol listesini kullanmaları gerekecektir. Olabilecek her problem için not alın ve bunları eğitmenlerle tartışın. İzle: Grupları izleyin ve ihtiyaç olduğunda yardımcı olun. Katılımcılara tanımlanmış bazı problemleri eğer mümkünse bu bölüm içinde tamir etmelerini için teşvik edin. Eğer mümkün değilse problemler not alınmalı ve ikinci pratikten önce çözülmelidir. Time: 15 dakika müsaade edin. Geri bildirim: Her bir gruptan, diğer bütün gruplara tekerlekli sandalyenin güvenli ve kullanıcı tarafından kullanıma hazır olduğuna dair geri bildirimde bulunmalarını isteyin (her bir gruba 2-3 dakika müsaade edin) Sor: Bir problem olsaydı ne yaparları? Cevapları teşvik edin. En önemli cevaplar: o problemin tamir/onarımını yaparlardı; o sandalyenin tamiri için tekerlekli sandalye tamir atölyesine göndererek; o tedarikçi firma ile bağlantıya geçilir ve problemin çözümü için yardım istenir. . 4. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. Kontrol listesi: Tekerlekli sandalye güvenli ve kullanıma hazır mı? Bütün tekerlekli sandalyeler için: Eğitmenler için notlar Keskin kenarlar bulunmamaktadır  Tekerlekli sandalyenin her yerini gözle ve elle kontrol et. Çizilmiş ve zarar görmüş parça bulunmamaktadır  Tekerlekli sandalye düz bir hat üzerinde yol almaktadır  Tekerlekli sandalyeyi kendinizden uzağa doğru itin ve ön tekerleklerin “izleme” pozisyonunda olduğundan emin olun. Ön küçük tekerlekler: Serbest dönmektedir  Tekerlekli sandalyeyi arka tekerleklerin üzerine doğru eğin ve ön tekerlekleri döndürün. Tekerlek tutma çatalına dokunmadan dönmektedir.  Cıvatalar sıkılmış durumdadır  Kontrol edin. Sabit durmalı. Gereğinden fazla sıkmayın. Ön tekerleklerin oturduğu aksam(boru): Tekerlekleri tutan çatal serbestçe dönmektedir.  Tekerlekli sandalyeyi arka tekerleklerin üzerine doğru eğin. Ön tekerlek çatalını etrafında döndürün. Arka büyük tekerlekler: Serbestçe dönmektedir.  Tekerlekli sandalyeyi yanlara bir büyük tekerleğe doğru eğin. Diğer tekerleği çevirin. Diğer tarafı da kontrol edin. Aks cıvataları sıkılmış durumdadır.  Kontrol edin. Sabit durmalı. Gereğinden fazla sıkmayın. Lastikler doğru bir şekilde şişirilmiştir (eğer hava basınçlı ise)  Tekerleklere başparmağınızla basınç uygulayın. Lastikler bir miktar içe girmeli ama 5 mm den daha fazla değil. İtme kasnakları güvenlidir.  Kontrol edin Frenler: Düzgün bir şekilde çalışmaktadır.  Frenleri çekin. Tekerlekli sandalyenin hareket edemediğini kontrol edin. Ayaklıklar: Ayaklıklar güvenli bir şekilde takılmıştır.  Kontrol edin. İskelet: Çapraz katlanabilir sandalye kolaylıkla açılıp kapanabilmektedir.  Katlanma mekanizmasının doğru bir şekilde çalışıp çalışmadığını kontrol etmek için sandalyeyi katlayın. Arkalığı yatan – arkalık rahatlıkla yatıp kalkabilmektedir.  Minder: Minder kılıfın içinde düzgün bir şekilde durmaktadır.  Genellikle minder kılıfı minderin arkasına, altına kadar yapılır. Minder tekerlekli sandalyenin üzerinde düzgün bir şekilde durmaktadır.  Eğer minder konturlu minder ise kalça kemikleri için olan “çukur” koltuğun arka tarafında olmalıdır. Minder kılıfının kumaşı gergin ama gereğinden fazla gergin değildir.  Minder kılıfı minder üzerindeki konturların üzerinde gergin halde sarmış olmamalıdır. Minder koltuğun tamamını kaplamaktadır.  Koltuğun hiçbir bölümü minderin altından görünmemelidir. Bu özellikle yekpare koltuklar için önemlidir. B.8: Minder yapımı H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  temel bir basınç rahatlatma minderinin özelliklerini gösterebilecekler.  basit bir köpük basınç rahatlatma minderi yapabilecekler.  kalça kemikleri altında tehlikeli düzeyde basınç olan kullanıcılar için mindere “kat, yükseklik” nasıl eklenir bunu tarif edebilecekler. K A Y N A K LA R  PPT slaytları: B.8 Minder yapımı;  Referans Kılavuzu  Katılımcı El Kitabı  DVD: Minder yapımı;  örnek basınç rahatlatma minderi, minder kılıfı ve minder katı, yükseltmesi;  minder yapımı araç kiti (“Minder yapımı – materyaller ve aletler” bütün detaylar için yukarı bkz);  minder kılıfı olmaya uygun olan yerel olarak bulunabilen kumaş örnekleri. . İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Örneğin:  tekerlekli sandalye kullanıcısı için uygun bir minder yapmak;  verilen minderin ölçülerini ve dizaynını, mevcut olan malzemelerin durumuna göre veya toplumdaki kişilerin ortalama bedenlerine göre uyarlayın;  yerel olarak bulunabilen minderler ve alternatif materyallerin bir listesini hazırlayın – katılımcılardan kendi bulundukları bölgelerden örnek getirmeleri istenebilir. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Her üç kişilik gruplar için bir çalışma masası ayarlayın, köpük örneklerin dayanıklılığının denenmesi için ihtiyaç duyulabilecek aletler ve materyaller; minder tabanını kesme ve yapıştırma. T A S LA K 1. Giriş. 2. Minder özellikleri ve ölçüleri. 3. Minder tabanı nasıl yapılır – gösterim 4. Minder tabanı nasıl yapılır – uygulama. 5. Minder bakımı. 6. Basınç rahatlatma minderi ile ilgili sıklıkla sorulan sorular. 7. Kilit nokta özeti. 5 20 20 60 5 5 5 Toplam bölüm süresi 120 1. Giriş (5 dakika) Açıkla: o Bu bölümde katılımcılar temel bir köpük basınç rahatlatma minderinin nasıl yapılacağını öğrenecekler. Eğer doğru bir şekilde ve uygun yapılırsa bu minder tekerlekli sandalye kullanıcıları için basınç rahatlatmaya yardımcı olabilir. o Her minderin her kullanıcı için uygun olmayacağını hatırlamak önemlidir. o Bir basınç rahatlatma minderi sağlarken, uygunluk sırasında kullanıcının kalça kemikleri altındaki basıncı her zaman kontrol edin. Kalça kemiği çukurunun genişliği, derinliği ve yüksekliğinin doğru olması için bazı ayarlamalar gerekebilir. Sor: Aranızda daha önce basınç rahatlatma minderi yapan ya da tedarik eden oldu mu? Cevapları teşvik edin ve cevapları onaylayın. 2. Minder özellikleri ve ölçüleri (20 dakika) Örnek basınç rahatlatma minderi tabanını elden ele dolaştırın. Üst katmanı ve kılıfı yakınınızda bulundurun. Slaytta gösterilen her bir minder özelliği için katılımcılara sorun: Bu minderde bu özelliğin amacı nedir? Katılımcılara bunun, eğitim programının başlangıcında “Minderler” bölümünde olduğunu hatırlatın. Cevapları teşvik edin. Slaytta gösterilen her bir özelliği örnek minderde işaret edin. Özellik Eğitmen notları: Bu özellik ne yapar? o Mindere şeklini verir. Kalça kemiği çukuru o Kalça kemikleri ve kuyruk sokumu (kuyruk kemiği) altındaki basıncı rahatlatır. o Minderin arka tarafında pelvisin dik durmasını sağlar. Açıkla: o Tekerlekli sandalye kullanıcısının kalça kemiği çukurun üzerine oturmalıdır, yastığın sınırına ya da üstüne değil. o Uygunluk sırasında kalça kemiği çukurunun doğru yerde olduğunu her zaman kontrol edin. Elinizi kullanıcının altına yerleştirin ve kalça kemiklerinin nerede olduğunu hissedin. Bu eğitim programında size öğretilen basınç testini kullanarak basıncı kontrol edin. o Eğer minder askı şeklindeki bir sandalye koltuğunda kullanılacaksa, eğimli bir kesim yapılır. o Bu minderin askı şeklinde olan tekerlekli sandalye koltuğunun şeklini almasın kolaylaştırır ve minderin üzeri düz kalır. o Bu “eğimli” kesim minder sadece askı şeklinde sandalye koltuğunda kullanılacaksa yapılır. o Yekpare koltuklar için minderin tabanı düzdür. o Minderin üst kısmı konfor sağlar. o Üst katman örneğini elden ele dolaştırın. o Bazen daha çok basınç azaltmaya ihtiyaç olur. o Bu durumlarda personel taban için kullanılan köpüğün aynından bir “kat” yükseltme yapabilir. o Bu kat, yükseltme minder taban katmanının üstüne ve köpük konfor katmanının altına yerleştirilir. Bu kalça kemiği çukurundaki basınç rahatlatmayı artıracaktır. o Bir kat eklediğinizde her zaman fiziksel kontrolü, kalça kemiği basınç testini kullanarak yapın. o Minder kat örneğini elden ele dolaştırın. Açıklayın: En son özellik minder kılıfıdır. Minderi korumak için kılıf zorunludur. Sor: Ne tür bir kumaş minder kılıfı olarak kullanılabilir? Cevapları teşvik edin ve tahtaya: söylenen kumaşları “iyi” ve “idare eder” olarak yazın. Hangi kumaşın iyi olacağını hangilerinin eğer alternatif yoksa kullanılabileceğini açıklayın. Muhtemel cevaplar: o ince naylon/şemsiye kumaşı (iyi); o esnek kumaş/likra (iyi); o “Tişört kumaşı/örgü keten (idare eder); o suni kauçuk/dalgıç kıyafeti kumaşı (idare eder); o tafta (idare eder); o ince naylon/şemsiye kumaşı (iyi); o esnek kumaş/likra (iyi); o “Tişört kumaşı/örgü keten (idare eder); o suni kauçuk/dalgıç kıyafeti kumaşı (idare eder); o tafta (idare eder); Açıkla: o Basınç rahatlatma minderi için iyi bir kumaş genellikle ya suya dayanıklı ya da esnek kumaştır. o Suya dayanıklı kumaş çok ince (paraşüt ya da şemsiye kumaşı gibi) olmalıdır böylece katlanmalar ciltte iz bırakmayacaktır. o Eğer esnek ve suya dayanıklı olmayan bir kumaş kullanılıyorsa ince bir parça plastik (plastik torba) köpüğün üstüne ve minder kılıfının altına kaplanarak minder kılıfının korunması sağlanabilir. o Kılıf arka tarafta daha gevşek olmalıdır ki kalça kemikleri boyunca bir tambur etkisi yaratmasın. Örnek minder kılıfını elden ele gezdirin. Açıkla: o Doğru bir şekilde işlev görebilmesi için kalça kemiği çukurunun doğru genişlikte, derinlikte ve yükseklikte olması gerekir. Kalça kemiği çukurunun boyutunun doğru hesaplanması için kullanıcılar aşağıdaki kuralları uygulayabilirler. Her bir kalça kemiği çukuru ölçüsünü slaytlarda gösterildiği şekilde açıklayın. Küçük grup aktivitesi Gruplar: Her bir grupta iki kişi olmalı Talimatlar: Her bir gruba söyleyin: o el kitaplarının çalışma sayfasının başında bulunan tabloyu doldurmalarını söyleyin. Değişik koltuk genişlikleri olan üç farklı kullanıcı için farklı kalça kemiği çukuru genişliği, derinliği ve yüksekliği hesaplamaları gerektiğini açıkla. İzleme: Grupları izle ve ihtiyaç olduğunda yardım et. Onlar çalışırken aşağıdaki tabloyu tahtaya üzerinde cevaplar olmadan çiz. Genişlik Derinlik Yükseklik Erişkin t. sandalye kullanıcısı – 360 mm koltuk genişliği 180 mm 180 mm 35 mm Erişkin t. sandalye kullanıcısı – 460 mm koltuk genişliği 200 mm 200 mm 35 mm Çocuk t. Sandalye kullanıcısı– 280 mm koltuk genişliği 140 mm 140 mm 20–25 mm Süre: 5 dakika Geri bildirim: Tabloyu tahtaya çiz Sor: Her bir tekerlekli sandalye kullanıcısı için kalça kemiği çukuru genişlik, derinlik ve yüksekliği nedir? Doğru cevapları tahtadaki tabloya yaz. Sor: Katılımcılar boyutların tekerlekli sandalye kullanıcısı için doğru olıp olmadığını nasıl söyleyebilirler? Cevap: Uygunluk sırasında kalça kemiği çukurunun uyumunu her zaman kontrol et. Ellerini kullanıcının kalça kemiklerinin altına yerleştir ve kemiklerin nerede olduğunu hisset. Bu programda öğretilmiş olan basınç testini kullanarak basıncı kontrol et. Kalça kemiklerinin minder sınırına ya da üstüne değil kalça kemik çukuruna oturduğuna emin olun. 3. Minder tabanı yapımı – gösterim(20dakika) DVD tanıtımı: Minder yapımı. Bu temel bir basınç rahatlatma minderi yapımının kısa bir gösterimidir. DVD’i göster Soru olup olmadığını öğren. Sert köpük ve yumuşak köpük örneklerini elden ele dolaştırın. Katılımcılara köpüğü sert bir yüzeye koymalarını (örneğin çalışma masasına) ve her iki örneğe yumruklarını ve parmaklarının eklem boğumlarını bastırmalarını ve farkı hissetmelerini söyleyin. Açıkla : o Hem taban hem de üst katmanın ikisi de minder kılıfının içerisindedir. o Bu iki katmanın birbirine yapıştırılması gerekmez. . o Eğer üst katman kirlenirse ya da yıpranırsa, yıkanabilir kurutulabilir, ya da yenisi ile değiştirilebilir. o Pelvik çukuru yükseltmek için kılıfın içerisine nasıl bir kat eklenebileceğini gösterin. 4. Minder tabanı yapımı – uygulama (60 dakika) Açıkla: Katılımcılar şimdi minder tabanının kesiminin uygulamasını yapacaklar.. Aktivite Gruplar: Her grupta iki, üç kişi olmalı. Talimatlar: Her bir gruba söyleyin: o minder tabanını kesmek için beraber çalışmalarını; o her bir adımı hatırlamak için el kitaplarındaki çalışma sayfasını kullanmalarını söyleyin. Güvenlik noktalarının altını çiz: o katılımcılara köpük kesmek için kullanılan aletlerin çok keskin olduklarını ve kullanırken dikkatli olmaları gerektiğini hatırlatın. İzleme: Grupları izle ve ihtiyaç olduğunda yardım et. Süre: 50 dakika müsaade et ve 10 dakika geri bildirim için zaman ver. Geri bildirim: Gruplara sor: o Köpüğü kesmek ya da yapıştırmak için keşfettiğiniz kullanışlı teknikler nelerdir? o İki taraftan bir parça keserseniz ne olur? (Cevap:Her iki kesilen taraf birleşmeyebilir ve yüzeyde bir kademe oluşabilir.) 5. Minder bakımı (5 dakika) Açıkla: Tekerlekli sandalye kullanıcıları minderlerine nasıl bakacaklarını bilmeleri gerekir. Bu durum aşağıdakileri içerir. o Minderi temiz tutun; minder ılık ve hafif sabunlu su ile yıkanabilir. Yerine takılmadan önce güneş ışığından uzak bir şekilde kurutulmalıdır. o Üst katmanı kontrol edin; üst katman üzerine basıldıktan sonra tekrar eski haline gelmelidir. Eğer basıldıktan sonra düzelmiyorsa ve sert ve düz bir hale gelmişse yenilenmesi gerekir. o Taban katmanını kontrol edin; tabanın halen şeklini muhafaza ettiğini ve yıpranıp aşınmadığını kontrol edin. Eğer aşınmış ise yenilenmesi gerekebilir. o Üst katmanın alt katmandan önce iki ya da üç kere değiştirilmeye ihtiyacı olabilir. 6. Köpük basınç rahatlatma minderi ile ilgili sıkça sorulan sorular (5 dakika) Sor: Bu minderle ilgili soru var mı? Soruları cevaplayın. Muhtemel sorular Cevapları Minder kılıfı için kullanacağınız mindere nasıl karar veriyorsunuz? o Mümkünse esnek bir kumaş seçin. Eğer varsa suya dayanıklı kumaş çok iyidir. Eğer kumaş su geçirmez ise kalın olmamasına dikkat ediniz çünkü kalın kumaş katlanabilir ve bu ciltte izlere yol açabilir bu da basınç yaralarına sebep olabilir. o Seçim elde mevcut olan kumaşlara bağlıdır. Bazen seçenekler sınırlıdır. o Eğer değişik seçenekler var ve siz emin değilseniz tekerlekli sandalye kullanıcılarına değişik seçenekleri denemelerini söyleyiniz. o Tekerlekli sandalye personeli değişik seçeneklerin denenmesi ile deneyimlerini geliştireceklerdir. Bu minder herkeste işe yarar mı? o Hayır; bu minder her kullanıcı içim işe yaramayacaktır. o Anka bu minderin bir avantajı vardır ki, kolayca adapte edilebilir. Bu minder sıcak mıdır ve terlemeye sebep olur mu? o Köpük minderler sıcaklık yaratabilir ve terlemeye sebep olabilirler. Bununla beraber minder başka şekillerde iyidir ve işe yarar dolayısıyla sıcaklık bir ödün vermedir. Bütün tekerlekli sandalye kullanıcılarının basınç rahatlatma minderine ihtiyacı var mıdır? o Hayır; bütün kullanıcıların basınç rahatlatma minderine ihtiyacı yoktur. o Bu eğitim programında öğretilmiş olan risk faktörleri göz önünde tutularak bir kullanıcının basınç yarası geliştirme riski var mı yok mu karar verilir. o Bu mindere basınç rahatlatma için ihtiyaç duyulmuyor olabilir ancak basınç yarası riski olmayan kullanıcılar bile rahatlığı artırmak ve duruş için kullanabilirler. Peki, minder önü arkaya doğru ya da tersyüz olarak kullanılırsa ne olur? o Minder doğru bir şekilde işe yaramayacaktır ve hatta basınç yarası oluşmasına bile sebep olabilir. o Her zaman tekerlekli sandalye kullanıcısının ve aile üyelerinin (ilgili olan) minderi nasıl kullanacakları ve bakımını nasıl yapacakları konusunu anladıklarından emin olun. o Eğer gerekli ise minderin üzerine “ön” “arka” “yukarı” “aşağı” işaretleri ekleyin. Minder çocuklarda işe yarar mı? o Evet bu minder doğru bir şekilde oturabilen ve basınç yarası riski olan çocuklar için işe yarar. o Tekerlekli sandalye kullanan pek çok çocuğun sadece bu yastıkla sağlanamayacak ekstra duruş desteğine ihtiyaçları vardır. 7. Kilit nokta özeti (5 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B.9: Uygunluk H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  uygunluk adımlarını doğru sırasıyla listeleyebilecekler;  bireysel bir tekerlekli sandalye kullanıcısı için bir tekerlekli sandalyenin boyutunun kontrolünü ve genel ayarlarını gösterimini yapabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.9 Uygunluk;  Referans Kılavuzu  DVD: Uygunluk gösterimi;  her üç kişilik gruplar için bir tekerlekli sandalye;  tekerlekli sandalye uygunluk kontrol listesi (her bir katılımcı için bir adet). İÇ E R İK  Bu bölümü katılımcıların çalışacakları şartlara uyarla. Aşağıdakiler hakkında düşünün:  Uygunluk nerede yapılacak. Eğer katılımcılar uygunluğu toplum önünde gerçekleştireceklerse, eğitmenler uygunluk ziyareti ve diğer hususlarla ilgili alınması gereken araçlar hakkında tavsiye ekleyebilirler. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  T A S LA K 1. Giriş. 2. Uygunlukta iyi uygulama. 3. Uygunluk pratiği. 4. Kilit nokta özeti. 2 30 25 3 Toplam bölüm süresi 60 1. Giriş (2 dakika) Açıkla: o Uygunluk tekerlekli sandalye hizmet sunumunda sekiz adımın altıncısıdır. Bu bölümde katılımcılar uygunluk uygulaması sırasında ne yapacaklarını öğrenecekler. 2. Uygunlukta iyi uygulama (30 dakika) Açıkla: Uygunluk sırasında tekerlekli sandalye kullanıcısı ve personel beraber şunları kontrol edecekler; o tekerlekli sandalye doğru boyuttadır ve ayarları doğru yapılmıştır; o tekerlekli sandalye ve minder, kullanıcıyı dik oturmasında desteklemektedir; o eğer bir basınç rahatlatma minderi reçete edilmişse (seçilmişse) minder basıncı rahatlatmaktadır. Açıkla: Uygunlukta iyi uygulama şu anlama gelir: o boyut ve ayarlamaların kontrolü; o duruşun kontrolü; o basıncın kontrolü; o tekerlekli sandalye kullanıcısı hareket halinde iken uyum kontrolü. . Tekerlekli sandalye hazırsa kontrol edin Açıkla:  Tekerlekli sandalyenin güvenli ve kullanım için hazır ve bütün parçalarının çalışır halde olduğunun kontrolü yapılmış mı kontrol edin. Boyut ve ayarlamaları kontrol et Açıklama: o Tekerlekli sandalyenin uyması gerekliliği ile ilgili bir miktar olsun konuştuk. Uygunluk sırasında fiziksel olarak uygunluğu doğrulamak gerekmektedir. Nasıl yapılacağını şöyledir. Açıkla: Koltuk genişliğinin kontrolü: o Parmaklarınızı tekerlekli sandalye kullanıcısının uylukları ile tekerlekli sandalyenin kenarları arasına doğru uzatın. Parmaklarınızın rahatlıkla sıkışmadan geçebilmesi gerekmektedir. Koltuk derinliğinin kontrolü: o Kullanıcının dik oturduğunu kontrol edin. o Elinizi minderle dizin arkasında kaydırın. İki parmağınızın gireceği kadar bir boşluk olmalı (30 mm). Uzun bacaklı kullanıcılar için daha büyük bir boşluk olabilir. 60 mm ye kadar kabul edilebilir. o Elinizi baldırın arka tarafından aşağı doğru kaydırın ve mindere dokunmadığınızdan emin olun. o Her iki tarafı kontrol edin. Ayaklık yüksekliğinin kontrolü: o elinizi uyluk ile minder arasında kaydırın, uyluk boyunca eşit basınç olması gerekir ve boşluk olmamalıdır. o ayaklık üzerindeki ayağa bakın. Ayak önde ve arkada boşluk olamadan desteklenmiş olmalıdır. Arkalık yüksekliğinin kontrolü: o tekerlekli sandalye kullanıcısına arkalığın rahat olup olmadığını sorun; o vücut kalça üzerinde dengede mi gözlemleyin; o tekerlekli sandalye kullanıcısı sandalyeyi arkalığın engeli olmadan itebiliyor mu? Arka tekerleklerin, sandalyeyi elle itebilmek için kontrolü: o tekerlekli sandalye kullanıcısına itme kasnaklarını tekerleğin üzerinden tutmalarını isteyin, dirsek 90 derecelik bir açıyla bükülüyor olmalıdır; o aynı zamanda denge pozisyonunu da kontrol edin (etkin hareket için öne, güvenlik için arkaya). Arkalık yüksekliğinin sandalyeyi ayakla itebilmek için kontrolü: o Tekerlekli sandalye kullanıcısına pelvisinin arkası arkalığa yaslanmış, ayak yerde düz itecek şekilde oturmasını isteyin. Ayak yere düz bir şekilde değiyor mu kontrol edin. o Eğer koltuk çok yüksekse personel şunları deneyebilir: o minderin yüksekliğini azaltmak; o orijinal koltuktan daha alçak yekpare bir koltuğun takılması (bunu yapmak için teknik destek ya da tavsiye alın). Tek ayağı ile iterken ve öbür ayağını ayaklığa koyan bir kullanıcı için: o ayaklığın üzerindeki ayak tarafında kalan kalça kemiğinin altındaki basıncın 3. seviye olmadığını kontrol edin. Duruşu kontrol edin Açıkla: Boyut ve ayarlamaların kontrolünden sonra personel kullanıcının duruşunu kontrol etmelidir, bu duruş kullanıcı için olabildiği en üst düzeyde dik duruş olmalıdır. Sor: Bir kişinin dik oturup oturmadığını kontrol için bakılması gereken şeyler nelerdir? Cevapları teşvik edin. En önemli cevaplar: o pelvis dik ve dengede; o onuzlar dengeli,kollar hareket serbestisine sahip; o gövde dik; o sırt üç doğal kavisi takip ediyor; o baş dik ve vücut üzerinde dengede; o uyluklar 90 dereceye yakın bükülmüş; o bacaklar hafif aralık (abdükte); o dizler ve ayak bilekleri 90 dereceye yakın bükülmüş; o topuklar tam olarak dizin arkasında ya da hafif önünde veya arkasında; o ayak yere düz bir şekilde değer şekilde. Açıkla: Herkesin tamamıyla aynı şekilde oturamayacağını unutmayın. Örneğin; bazı kullanıcılar ayaklarını geriye doğru çekerek oturmayı severler, dizler 90 dereceden daha fazla bükülür. Basıncı kontrol edin Açıklayın: o Basınç yarası geliştirme riski taşıyan her kullanıcı için kalça kemiğinin altındaki basıncın güvenli bir düzeyde olup olmadığını kontrol edin. Tekerlekli sandalye kullanıcısı hareket halinde iken uygunluğu kontrol edin. Açıkla: Uygunluğun en son aşaması tekerlekli sandalye kullanıcısının hareket halinde iken yapılan kontroldür. Bakılması gereken şeyler: o arkalık kullanıcının sandalyeyi itmesi için omuzlara hareket serbestisi sağlıyor mu? o arkalık kullanıcıya yeterli destek sağlıyor mu? o kullanıcının ayakları ayaklık üzerinde duruyor mu? o arka tekerlek pozisyonu kullanıcı için doğru pozisyon mu? Açıkla: Eğer tekerlekli sandalye kullanıcısı sandalyesini kendi kendine itemiyorsa aile üyesi/bakısına itmesini söyleyin. DVD tanıtımı: Şimdi bütün uygunluk dizisini seyredeceğiz. Buna dahil olanlar; uygunluk kontrolü, duruş kontrolü ve tekerlekli sandalye hareket halinde ilen yapılan kontrol. Tekerlekli sandalye uygunluk kontrol listesini dağıtın. Açıklayın: Katılımcılar bu kontrol listesini saklayabilirler ve bu liste uygunluk adımlarını hatırlamalarına yardımcı olacaktır. Katılımcılara DVD’i seyretmelerini söyleyin ve her bir uygunluk kontrolünün ellerindeki kontrol listesindeki gibi yapılıp yapılmadığına bakmalarını isteyin. DVD’i göster. Soru olup olmadığını öğrenin Yapılması gereken daha başka şeyler var mı kontrol edin. 3. Uygunluk pratiği (uygulaması) (25 dakika) Aktivite Gruplar: Her grupta iki, üç kişi olmalıdır. Her bir gruba bir tekerlekli sandalye ve bir tekerlekli sandalye uygunluk kontrol listesi verin. Talimatlar: o Her gruba bir kişiyi tekerlekli sandalye kullanıcısı olarak görevlendirmelerini söyleyin. Gruptaki diğer kişiler kullanıcı ile uygunluk kontrolü yapmak üzere çalışacaklar. o Katılımcılara tekerlekli sandalyeyi dururken ve hareket halindeyken kontrol etmeleri gerektiğini hatırlatın. İzleme: Grupları izleyin ve gerekirse yardımcı olun. Süre: Geri bildirim için 10 dakika müsaade edin. Geri Bildirim: Her bir gruptan diğer gruplara kısaca rapor vermelerini isteyin: o tekerlekli sandalyenin kullanıcısına uyup uymadığını; o eğer sandalye uymadıysa, hangi parçanın uymadığını; o sandalyenin uyması için ayarlamalar yapmak mümkün mü ya da tekerlekli sandalye değiştirilmeli mi? Açıklama: Eğer bir tekerlekli sandalye ayarlamalardan sonra da uymuyorsa modifiye etmek için basit çözümler olabilir. Bu sonraki bölümde açıklanacaktır. 4. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B.10: Problem çözme O B JE C T IV E S  Bu bölümün sonunda katılımcılar şunları yapabilecekler  sıklıkla görülen tekerlekli sandalye uygunluk ve ayarlama problemlerini sayabilecekler.  sıklıkla görülen tekerlekli sandalye uygunluk ve ayarlama problemlerine basit çözümler bulabilecekler. R E S O U R C E S Bu bölüm için:  PPT slaytları: B.10 Problem çözme;  Referans Kılavuzu  DVD: Problem çözme uyum ve ayarlama (bölüm 1 ve 2);  bir tekerlekli sandalye;  gösterim için iki köpük tampon (yaklaşık olarak 100 mm x 100 mm x 50 mm);  bilek/bacak emniyet bantları (eğer var ise). C O N T E X T Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  yerel olarak bulunabilen sandalyeler ve bu sandalyelere uygulanabilen belirli çözümler;  katılımcıların çalıştıkları yerdeki materyaller ve tesisat. T O P R E P A R E  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun.  Bu bölümde tanımlanan yerel örneklerle ilgili fotoğraflar ve slaytlar hazırla. O U T LI N E 1. Giriş 2. Koltuk derinliği çok kısa veya çok uzun. 3. Ayaklık yüksekliği çok alçak veya çok yüksek. 4. Bacaklar içe ya da dışa dönmeye eğilimli. 5. Ayaklar ayaklıktan kaymaya eğilimli. 6. Tekerlekli sandalye çok geniş. 7. Kilit nokta özeti. 3 10 5 10 10 5 2 Toplam bölüm süresi 45 1. Giriş (3 dakika) Açıkla: Personel bazen mevcut tekerlekli sandalyenin kullanıcıya uygunluğunda bir problem bulacaktır. Bu problemler şu sebeplerden dolayı olabilir: o tekerlekli sandalyelerde bulunması mümkün olan boyut aralığı sınırlıdır; o tekerlekli sandalye kullanıcısının dik ve rahat oturabilmesi için ekstra desteğe ihtiyacı vardır. o Bu bölümde, tekerlekli sandalye boyut aralığının limitli olmasından kaynaklanan ve sıklıkla karşılaşılan sorunlara bulunabilecek basit çözümlere bakacağız. o Modifikasyonlar yapmak ve ekstra duruş desteği sağlamak daha detaylı bir şekilde orta düzey eğitim programının dâhilindedir. . Bu bölümde tartışacağımız bütün çözümler tekerlekli sandalye kullanıcısına en yakın boyuttaki tekerlekli sandalyenin seçilmiş olduğunu farz eder. Sor: Personelin görmüş olduğu sıklıkla karşılaşılan problemlerden bazıları nelerdir ya da neler olabilir? En önemli cevaplar: o koltuk derinliği çok uzun ya da çok kısa; o ayaklık yüksekliği yeteri kadar yükseğe çıkamıyor ya da yeteri kadar alçağa inemiyor; o bacaklar içe ya da dışa yuvarlanma eğiliminde; o ayaklar ayaklıktan kayma eğiliminde; o tekerlekli sandalye çok geniş. Açıkla: Bu bölümde olması muhtemel beş probleme bakacağız. 2. Koltuk derinliği fazla kısa ya da fazla uzun (10 dakika) Problem: Koltuk derinliği çok kısa Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Koltuk derinliğini, koltuk rayını (tırabzanını) uzatarak ve kaplamayı (döşemeyi) değiştirmek suretiyle uzatın: o Eğer tekerlekli sandalye katlanabilen bir tekerlekli sandalye ise rayların “ayrılmış” olup olmadığını kontrol edin. Bu şu anlama gelir ki, koltuk rayları sandalyenin iskeletinin bir parçası olmayabilir de. o Bu durumda uzatma işlemi koltuk raylarına yapılabilir ve yeni bir döşeme yapılır. o Koltuk derinliğini, kaplamayı (döşemeyi) değiştirmek suretiyle uzatın: o Eğer tekerlekli sandalye sert iskeletli ve döşemesi olan bir sandalye ise, koltuk raylarının koltuk ötesine uzanıp uzanmadığını kontrol edin. o Bu durumda koltuk döşemesini değiştirerek mevcut olan raylarla desteklenecek şekilde doğru uzunlukta yapılabilir. o Koltuk derinliğini sert bir tahta ve minder ekleyerek uzatın: o Yekpare bir koltuk kırılmayacak veya eğilmeyecek şekilde tahtadan, plastikten veya sert herhangi bir materyalden yapılabilir. o Koltuk, koltuk raylarının üstüne sabitlenebilir. . o Yeni koltuğun genişliğinde ve derinliğinde bir minder ekleyin. Açıkla: Bir tekerlekli sandalye koltuğunu değiştirirken şunları hatırlayın. o Yeni koltuğun kullanıcının ağırlığını taşıyacak kadar sağlam olduğundan emin olun. o Eğer koltuk sert (kompakt) ise: o koltuğun esnemediğini ve bükülmediğini veya mevcut tekerlekli sandalye koltuğunun dışına doğru uzanmadığını kontrol edin; o kullanıcı için, sert (kompakt ) koltuğun minder ile beraber tedarik edildiğinden her zaman emin olun; o uygunluk sırasında arkalığın ve ayaklıkların doğru yükseklikte olduğunu kontrol edin, yekpare koltuk ve minder kullanıcıyı tekerlekli sandalyede yükseltecektir. Problem: Koltuk derinliği çok uzun Açıkla: Eğer mevcut olan tekerlekli sandalyelerden koltuk derinliği en kısa olan sandalyenin koltuğu kullanıcı için fazla uzun geliyorsa, bu onun dik oturmasını imkânsız hale getirecektir. Koltuk derinliği kısaltılmalıdır. Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Mevcut koltukta gerekli olan derinliği işaretleyin ve kısaltmayı yapın. o Eğer koltuğun döşemesi varsa döşemeyi çıkartın, kısaltın (bunu yaparken sanayi tipi bir makine kullanın) ve yerine takın. o Eğer koltuk sert (kompakt) ise koltuğu çıkartın, kısaltın ve yerine takın. o Minderi yeni koltuk derinliğine denk gelecek şekilde kısaltın. Açıkla: Koltuk derinliğini kısaltırken şunları unutmayın: o Sert (kompakt) bir koltuğu keserken her zaman bütün kenarların pürüzsüz ve kıymıksız olduğundan emin olun; o Minderi keserken her zaman önden kesin ki, minderin arkasındaki basınç rahatlatma aynı şekilde kalsın. Açıkla: Eğer bir tekerlekli sandalye koltuğu, kullanıcının koltuk derinliğinden 100mm (erişkinler için) daha kısa ise bu bir problem olabilir. Tekerlekli sandalye kullanıcısı, dik ve rahat oturabilmek için yeterli desteğe sahip olamayacaktır. Bu aynı zamanda risk oranı yüksek bölgelerde (örneğin kalça kemiklerinde) basınç yarası oluşmasına sebep olabilir. 3. Ayaklık yüksekliği fazla yüksek veya fazla alçak (5 dakika) Problem: Ayaklık yüksekliği çok alçak Açıkla: Eğer ayaklık yüksekliği çok alçaksa kullanıcı ayaklarını ayaklığın üzerine rahatlıkla koyamayacaktır. Bu durum onun tekerlekli sandalyesi üzerinde öne doğru kaymasına ya da dengesiz hissetmesine sebep olabilir. Kullanıcı, sandalyesinde dik ve rahat oturabilmek için ihtiyacı olan desteğe sahip olamayacaktır. Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Ayaklıkların yüksekliğini ayaklık askılarını kısaltarak yükseltin. o Pek çok dört tekerlekli olan tekerlekli sandalyede ayaklık askıları kısa kesilmiştir. o Ayaklık yüksekliğini, ayaklıklara destek koyarak yükseltin. o Yüksekliği artırmak için tahta ya da onun gibi dayanıklı materyaller kullanın. Açıkla: o Ayaklık askılarını değiştirirken ayar mekanizmasının çalışmaya devam ettiğini kontrol edin. o Ayaklık destekle yükseltildiyse yapılan montajın ayaklığın çalışmasına engel olmadığını kontrol edin. Problem: Ayaklık yüksekliği çok yüksek Açıkla: Eğer ayaklık yüksekliği çok yüksekse Kullanıcının uylukları koltuğun üzerinde rahat bir şekilde durmayacaktır. Ayaklıkların çok yüksek olması kalça kemikleri üzerindeki basıncı artırabilir. Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Ayaklıkları, iç uzatma borularını uzatarak alçaltın. o iç uzatma borularının daha uzunları ile değiştirilebilir mi kontrol et. o eğer yapılabiliyorsa aynı çapta ve sağlam bir boruyla değiştir. o Minder yüksekliğini artırın: o minderin yüksekliğini artırın ya da minderin altına sert bir şey ekleyin. Açıkla: o Ayaklıklar alçaltılıyorsa çok fazla alçaltılıp yere değmediğinden emin olun. Eğer ayaklık yere değiyorsa bunun yerine 2. seçeneği deneyin. Eğer bu olmazsa tekerlekli sandalye kullanıcı için uygun değildir. o Minderin yüksekliğini artırırken: o minderi yükseltmek için yumuşak köpük kullanmayın, bu sıkışacaktır ve aynı zamanda dengesiz olacaktır. o uygunluk sırasında arkalığın ve kolçakların da doğru yükseklikte olduğunu kontrol edin, yüksek minder kullanıcının tekerlekli sandalye içinde yükselmesine sebep olacaktır; o minderi yükseltme nedeniyle işlevsel problemler oluşmayacağına dair kontrolü yapın, örneğin tekerlekli sandalye kullanıcısı masaların ya da sıraların altına yaklaşamaz hale gelebilir. 4. Bacaklar içe ya da dışa yuvarlanma eğiliminde (10 dakika) Açıkla: o Bazen tekerlekli sandalye kullanıcılarının bacakları içe ya da dışa yuvarlanır. Bu durum o kişinin oturma şeklinden ya da sahip olduğu fiziksel durumdan kaynaklanabilir (örneğin kas zayıflığı). o Minder ya da tekerlekli sandalyede yapılacak küçük ayarlamalar bu problemi azaltacaktır. DVD tanıtımı: Problem çözme uyum ve ayarlama. Bu kısa video Gary adında bacakları dışa yuvarlanmaya eğilimli bir tekerlekli sandalye kullanıcısını göstermektedir. DVD göster: (bölüm 1 – Gary) Videodan sonra sorun: Terapistin sağladığı çözüm neydi? Cevapları teşvik edin. Açıklayın: Bu sorunda çözüm, bacakları destekleyerek dengede tutmak için mindere takozlar eklenmesi olmuştur. Bacakların dışarıdaki yükselişi artmıştır. Bu sorunu çözmek için konturlu minder de eklenebilirdi. Eğer bacaklar içe doğru yuvarlanıyor olsaydı iç taraftaki yükseklik artırılabilirdi. Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Ayaklık yüksekliğini iki defa kontrol et: o ayaklık yüksekliğinin kullanıcıyı doğru bir şekilde desteklediğinden emin olun (ayaklar ve uyluklar altında eşit basınç hissedilmelidir) o Tekerlekli sandalye koltuğunun doğru bir şekilde gergin olması gerekir: o eğer tekerlekli sandalyenin koltuğu kaplamalı ise koltuğun düzgün bir şekilde gergin olması gerekir. o eğer koltuk bel vermişse (eğrilmişse) bu tekerlekli sandalye kullanıcısının bacaklarını içe doğru yuvarlanmaya teşvik edecektir. o Bacakları dengede tutmak için mindere takozlar ekleyin (DVD gösteriminde olduğu gibi) ya da konturlu minder sağlayın ve gerekiyorsa minderi modifiye edin. 5. Ayaklar ayaklıktan dışarı kaymaya eğilimli (10 dakika) Açıkla: o Bazen tekerlekli sandalye kullanıcısının ayakları ayaklıktan dışarı kayar. Bu genellikle fiziksel sebeplerden olur (örneğin kas güçsüzlüğü ya da kas spazmları) o Basit emniyet bantlarının eklenmesi bu problemi azaltabilir. Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Ayaklık yüksekliğini iki defa kontrol et: o ayaklık yüksekliğinin kullanıcıyı doğru bir şekilde desteklediğinden emin olun (ayaklar ve uyluklar altında eşit basınç hissedilmelidir) o Eğer mümkünse ayaklık açısını ayarlayın. o ayaklık açıları ayarlanabiliyor mu kontrol edin; o eğer yapılabiliyorsa ayaklık açılarını azaltmaya çalışın. Bu kullanıcının ayaklarını yerinde tutmasına yardımcı olabilir. o Bant ekleyin: o ayaklık askılarına bilek düzeyinde bir bant takın; o eğer ayaklar arkaya düşme eğiliminde ise bant bacakların dolansın; o eğer ayaklar öne düşme eğiliminde ise bant bacakların önünden dolansın. Açıkla: o Tekerlekli sandalye kullanıcısının, sandalyeye binmeyi ve inmeyi çaba sarf etmeden yapabilmesi için bandın kolayca çıkarılabileceğinden emin olun. o Tekerlekli sandalye kullanıcısının yardım olmadan banda ulaşabilmesi, kolaylıkla kaldırabilmesi ve açabilmesini denetleyin. Açıkla: Başka bir problem de ayakların ayaklık üzerinde eşit olarak desteklenmemesi olabilir. DVD tanıtımı: Problem çözme uyum ve ayarlama. Bu kısa DVD Arun adında ayakları ayaklık üzerinde eşit olarak desteklenmeyen bir tekerlekli sandalye kullanıcısını göstermektedir. DVD göster: (bölüm 2 – Arun) Videodan sonra sorun: Terapistin sağladığı çözüm neydi? Cevapları teşvik edin. 6. Tekerlekli sandalye çok geniş (5 dakika) Açıkla: Bazen mevcut sandalyeler arasından en küçük boyutta olanı bile tekerlekli sandalye kullanıcısı için çok geniştir. Eğer tekerlekli sandalye koltuğu çok genişse, tekerlekli sandalye kullanıcısı için dik oturmak zor olacak ve bir tarafa düşmesi olası hale gelecektir. Bazı köpük ekler tekerlekli sandalye kullanıcısının dik oturmasına yardımcı olabilir. Aşağıda sayılmış olan muhtemel çözümleri anlatın. Göstermek için bir tekerlekli sandalye kullan. o Pelvisin her iki tarafına köpük tamponlar ilave edin. : o tekerlekli sandalye kullanıcısı sandalyenin ortasında otururken ve sırtı arkalığa yaslanmış durumdayken; kullanıcı ile kolçaklar arasında yanlarda kalan boşluğun mesafesini ölçün. o köpük ekleri kesin ve kullanıcının yan tarafı ile tekerlekli sandalyenin yan tarafı arasında kalan boşluğu dolduracak şekilde ekleyin. o uyumu kontrol edin; o köpük tamponları kaplayın ve ekleyin. Eğer kolçaklar yekpare ise ekler kolçaklara bağlanabilir. Aynı zamanda minderin üstüne de bağlanabilir. Açıkla: o Tamponlar kullanıcının sadece gövdesine kadar uzanacak şekilde olmalıdır. o Minderin koltuk genişliği ile eşleştiğinden emin olun. o Tekerlekli sandalye çok geniş ise kullanıcı itme kasnaklarına ulaşmak için de sorunlar yaşayacaktır. o İtme kasnaklarına uzanmaya çalışmak, omuzlarda hasarlara sebep olabilir. Tekerlekli sandalyeyi reçete etmeden önce sandalyenin kullanıcı için güvenli olup olmadığını göz önünde bulundurun. 7. Kilit nokta özeti (2 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B.11: Kullanıcı eğitimi H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  bir tekerlekli sandalye kullanıcısı yeni bir tekerlekli sandalye aldığında tekerlekli sandalye personelinin onlara öğretebilecekleri becerileri listeleyebilecekler;  “iyi uygulama eğitim yöntemleri” ni sayacaklar;  bir meslektaşlarına bir tekerlekli sandalye becerisini öğretmeyi gösterecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.11 Kullanıcı eğitimi;  Referans Kılavuzu  Katılımcı el kitabı  Her üç kişilik grup için bir tekerlekli sandalye;  Tekerlekli sandalye kullanıcısı eğitim kontrol listesi (1 her bir katılımcı için bir tane). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  tekerlekli sandalye kullanıcılarına daha çok eğitim ve öneri sunan yerel gruplar. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin ve bölüm planını okuyun.  T A S LA K 1. Giriş. 2. Bir tekerlekli sandalye kullanıcısının işine yarayacak beceriler nelerdir? 3. Tekerlekli sandalye eğitim uygulaması. 4. Kilit nokta özeti. 2 10 45 3 Toplam bölüm süresi 60 1. Giriş (2 dakika) Açıkla: o Kullanıcı eğitimi tekerlekli sandalye hizmet sunumunda yedinci adımdır. Tekerlekli sandalye hakkında bilgi ve eğitim tekerlekli pek çok sandalye kullanıcısının sandalyesinden daha çok fayda sağlamasına sebep olabilir. o Bu adım olmadan, tekerlekli sandalye, kullanıcısına yeteri kadar yardımcı olamayabilir. o Bu bölümde, kullanıcı sandalyesini yeni aldığında personelin onlara öğretebilecekleri becerilerden bahsedeceğiz. Tekerlekli sandalye kullanıcı eğitim kontrol listesini tanıtacağız ve kullanıcıya eğitim verme uygulaması yapacağız. 2. Tekerlekli sandalye kullanıcıları için faydalı beceriler nelerdir? (10dakika) Sor: Bu eğitim programında katılımcılar tekerlekli sandalye kullanıcılarına öğretebilecekleri neler öğrendiler? Tekerlekli sandalye kullanıcılarına yardımcı olacak şeyleri düşünün: o sağlıklı kalmak; o tekerlekli sandalyelerini evde ve dışarıda kullanmak; o tekerlekli sandalyelerine bakım yaparak ömrünü mümkün olduğunca uzatmak. Kullanıcılara Sai’nin okula gitmesine yardımcı olan şeylerden bahsettiği videosunu hatırlatın. Cevapları teşvik edin. En önemli cevaplar: o basınç yaralarını durdurma yolları; o tekerlekli sandalyenin nasıl taşınacağı; o tekerlekli sandalyeye nasıl binileceği ve nasıl inileceği; o tekerlekli sandalye hareketliliği; o bir problem olduğunda ne yapılacağı; o tekerlekli sandalye ve minderin bakımı; o onlara yardımcı olabilecek organizasyonlar ve hizmetler. Açıkla: Tekerlekli sandalye kullanıcılarına öğretmek için hatırlanması gereken altı önemli nokta: o tekerlekli sandalye nasıl taşınacak. o basınç yaraları nasıl önlenir ve basınç yarası oluşursa ne yapılmalıdır. o tekerlekli sandalyeye nasıl binilir ve inilir (transfer). o tekerlekli sandalye hareketliliği, kullanıcının ihtiyaçlarının karşılanması o tekerlekli sandalyenin ve minderin evde bakımı Açıkla: Bu konu hakkında bir sonraki bölümde bahsedeceğiz. o bir problem olursa ne yapılacak. Her bir katılımcıya tekerlekli sandalye kullanıcı eğitim kontrol listesi verin. Açıklama: o Kontrol listesi tekerlekli sandalye kullanıcısının öğrenmesinin faydalı olabileceği belli başlı becerileri listeler. Bununla beraber bazı tekerlekli sandalye kullanıcıları bu becerilerin nasıl uygulandığını zaten bilmektedirler ve bütün beceriler bütün kullanıcılar için önemli değildir. o Bazı hizmetler bu kontrol listesini bir form olarak kullanabilirler ve kullanıcıların dosyalarında saklarlar. Personel tekerlekli sandalye kullanıcısının hangi talimatlara ihtiyacı olduğunu kayıt edebilirler. Buna değerlendirme ve kullanıcı ile konuşma aracılığı ile karar verilir. Kontrol listesi aynı zamanda hangi eğitimim verildiğini kayıt etmek için de kullanılabilir. o Tekerlekli sandalye kullanıcılarının bakıcılarının da bu becerileri öğrenmesini isteyip istemediklerini de kontrol edin. Pek çok tekerlekli sandalye kullanıcısı aileleri ya da bakıcıları tarafından desteklenir ve bu becerilerin öğrenilmesine ve tekerlekli sandalye bakımına dahil olmaları herkes için yararlı olacaktır. 3. Tekerlekli sandalye kullanıcı eğitim uygulaması (45 dakika) Sor: Eğitimi başarılı yapabilecek şeyler nelerdir? Katılımcılar tecrübe edindikleri bazı iyi öğretim metotları hakkında düşünebilirler (belki eğitim programı sırasında olan !). Cevapları teşvik edin. En önemli cevaplar: o Tekerlekli sandalye kullanıcılarının zaten bildikleri şeyleri bulun. o Açıklayın, gösterin ve sonra da kullanıcıların uygulamalarına izin verin. o Herkesin anlayabileceği bir dil kullanın. o Tekerlekli sandalye kullanıcılarının diğer kullanıcılarına öğretmelerini sağlayın.. o İyi iletişim becerileri kullanın. o Teşvik edici olun. Açıklayın: Yeni bir beceri öğrenirken uygulama önemlidir. Bir beceriyi öğretirken her zaman önce gösterin ve daha sonra öğrenen kişilere uygulama fırsatı tanıyın. Küçük grup aktivitesi Gruplar: Her grupta iki, üç kişi olmalı. Talimatlar: o Her gruptan el kitaplarındaki hikâyeleri okumalarını isteyin. Hikâyedeki kullanıcının öğrenmekten fayda sağlayacağı en az üç beceriyi tanımlamalarını isteyin. o Her bir kullanıcı için, gruplar bu becerilerden en azından bir tanesinin uygulamalı öğretimini yapmalılar. Gruptakiler sırasıyla; kullanıcı, aile üyesi ve eğitmen olacaklar. o Katılımcıların “iyi iletişim” ve “iyi öğretme” ile ilgili düşünmelerini hatırlatın. Uygulama tarafından takip edilen gösterimin önemini vurgula. İzleme: Grupları izleyin ve gerekirse yardımcı olun. Süre: 30 dakika müsaade edin ve 15 dakika geri bildirim için müsaade edin. Geri bildirim: Her bir gruba yapmayı denedikleri ya da gözlemledikleri bir iyi öğretim yolunun altını çizmelerini söyleyin. Moses Eğitmenler için notlar: Moses 23 yaşındadır. İki yıl önce bir kamyonun arkasından düşmüş ve paraplejik olmuştur. Bir yıl hastanede kaldıktan sonra köyüne bağışla edinilmiş eski bir tekerlekli sandalye ile gelmiştir. Tekerlekli sandalye çok çabuk bozulmuştur ve dolaşamamaktadır. İyileşmiş olan bir basınç yarası geliştirmiştir. Moses tekerlekli sandalye servisi aracılığı ile bir tekerlekli sandalye ve basınç rahatlatma minderi edinmiştir. Bu tekerlekli sandalye, engebeli zeminlerde kullanılması için yapılmıştır. Eve bu sandalyeyle gideceği için çok heyecanlanmıştır ve artık daha bağımsız hareket edebileceğini umut etmektedir. En önemli beceriler: o tekerlekli sandalyenin taşınması ve basınç rahatlatma minderinin nasıl kullanılacağı, özellikle o yeni bir tekerlekli sandalye kullanıcısı olduğu için; o basınç yaralarının nasıl önleneceği; o tekerlekli sandalyeye nasıl binilip inileceği (transfer); o tekerlekli sandalye hareketlilik becerileri; o tekerlekli sandalye ve minderin evde bakımı; o yardımcı olabilecek diğer organizasyonlar ve hizmetler. Sian Eğitmenler için notlar: Sian 40 yaşındadır ve çift taraflı diz üstü ampütasyonu vardır. 20 yıldır tekerlekli sandalye kullanmaktadır ve bu süre içerisinde beş tane tekerlekli sandalyesi olmuştur. Kullandığı tekerlekli sandalyelerin çabuk bozulduğu kararına varmıştır. Çok aktif bir kişidir ve yerel bir dükkânda çalışmaktadır. Evinden işine her gün; engebeli, tümsekli ve genellikle de çamurlu olan bir yoldan gitmektedir. Tekerlekli sandalye servis personeline arka tekerlekler üzerinde nasıl dengede durabildiğini göstermiştir. Ona daha şimdi yeni bir tekerlekli sandalye reçete edilmiştir. Yeni sandalyesinin, en son kullandığından daha uzun ömürlü olmasını umut etmektedir ki en son sandalyesi aldıktan altı ay sonra bozulmuştur. En önemli beceriler: o tekerlekli sandalye ve minderin evde bakımı; düzenli bakım Sian’ın sandalyesinin daha uzun süre çalışmasına yardımcı olabilir. Zoe Eğitmenler için notlar: Zoe 16 yaşındadır. Genç bir kızdır polyosu vardır ve yürüyememektir. Çok çekingendir ve hiç okula gitmemiştir. Annesi ona evde ders vermiştir ve çok iyi bir şekilde okuyup yazabilmektedir. Daha yeni bir tekerlekli sandalye almıştır ve tekerlekli sandalye personeline nasıl transfer yapabildiğini ve tekerlekli sandalyesine nasıl kolayca binip indiğini göstermiştir. Zoe yerel bir meslek okuluna gitmek istemektedir fakat okula gidip gelmeyi beceremeyeceğini düşünmektedir. Okul binasında birkaç basamak vardır. Aynı zamanda okulda tuvalete nasıl gideceği konusunda da endişeleri vardır En önemli beceriler: o tekerlekli sandalye hareketlilik becerileri; özellikle merdiven çıkmak ve inmek; o transferler; tuvalete ve tuvaletten transfer. 4. Kilit nokta özeti (3dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. B.12: Bakım ve onarım H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  evde tekerlekli sandalye bakımını gösterebilecekler;  bir tekerlekli sandalyede sıklıkla görülebilen teknik problemleri belirleyebilecekler ve bu problemlerin yerel şartlar/topluluk çerçevesinde nasıl çözümlenebileceğini açıklayabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.12 Bakım ve onarım;  Referans Kılavuzu  Katılımcı El Kitabı;  DVD: Evde tekerlekli sandalye bakımı nasıl yapılır;  Poster: Evde tekerlekli sandalye bakımı nasıl yapılır;  bakıma ihtiyacı olan tekerlekli sandalyeler, şunlar da dahil olarak; patlak tekerlek lastiği, çalışmayan frenler, hasarlı minder, paslanma, gevşemiş koltuk kaplaması, gevşemiş cıvatalar, gevşek ya da kopuk jant telleri, hasarlı rulman, hasarlı itme kasnakları. Herhangi bir tekerlekli sandalyede birden fazla tamirat ihtiyaç duyulabilir.  1 ev bakım alet kiti (bkz malzeme listesi). İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  katılımcıların bölgelerinde onarım nerede yapılır;  yerel olarak bulunan tekerlekli sandalyelerin belirli bakım ve onarımlarının altı çizilmelidir ;  katılımcıları tekerlekli sandalye hizmetleri tekerlekli sandalye hizmeti sağlıyor mu; eğer sağlıyorsa, kullanıcılar buraya nasıl ulaşabilirler ve ücret ödemeleri gerekiyor mu H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD’i seyredin ve bölüm planını okuyun.  “Evde tekerlekli sandalye bakımı nasıl yapılır” posterini katılımcıların hepsinin görebileceği bir yere asın.  Onarılacak tekerlekli sandalyeleri hazırlayın ve A, B, C vs gibi etiketleyin. Odanın etrafına dizin.  Teknik deneyimi olan birinin tekerlekli sandalye onarımı ile ilgili sorulara ayrıntılı cevaplar vermesi ve yardımcı olması amacıyla bölüme katılması için ayarlayın (eğer eğitmenler bu konuda kendine güvenmiyorsa). T A S LA K 1. Giriş. 2. Onarımın önlenmesi: evde bakım. 3. Sıklıkla karşılaşılan tekerlekli sandalye ve minder onarımı. 4. Kilit nokta özeti. 2 60 55 3 Total session time 120 1.Giriş (2 dakika) Açıkla: o Tekerlekli sandalye ve mindere yapılan düzenli bakım onarım masraflarını azaltacak ve kullanıcının vücudunda meydana gelecek yaralanmaları önleyecek ve uzun dönemde oluşacak zararı engelleyecektir. . o Bakımı yapılan bir tekerlekli sandalye daha rahat olacak ve kullanımı kolay olacaktır. o Bakımı yapılan bir minder basınç rahatlatmaya ve destek vermeye devam edecektir. o Tekerlekli sandalye hizmet personelinin, kullanıcıya, sandalyesine ve minderine evde nasıl bakım yapacağını öğretmek konusunda sorumlulukları vardır. o Bu bölümde; tekerlekli sandalye ve mindere evde bakım için neler yapılacağını öğreneceğiz ve sandalye veya minderin onarıma ihtiyacı varsa ne yapılması gerektiğini göreceğiz. 2. Onarımın önlenmesi: evde bakım (60dakika) Evde tekerlekli sandalye bakımı nasıl yapılır posterini asın. Eğitmenler için notlar: Aşağıdaki slaytlar Evde tekerlekli sandalye bakımı nasıl yapılırı açıklamaktadır. Her bir slayt bu işin neden önemli olduğunu ve ne sıklıkla yapılması gerektiğini anlatmaktadır. Eğitmenler aşağıda listelenmiş ek noktaları eklemelilerdir. Açıkla: o Tekerlekli sandalye kullanıcılarının tekerlekli sandalyelerinin ve minderlerinin bakımı için evde yapabilecekleri altı şey vardır.. o Liste (slayda bak). Açıkla: o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Hareketli parçalara ve iskeletin döşeme ile birleştiği yerlere dikkat edin. Açıkla: o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Rulmanların üzerine kayganlaştırıcı sprey sıkmayınız çünkü bu rulmanın iyi çalışmasını sağlayan gres yağını temizleyebilir. o Tekerlekli sandalyeyi yağlamak için nüfuz eden yağlar kullanmayın çünkü bunlar tekerlekli sandalyede hasar yaratabilir. Sor: Katılımcıların bölgelerinde hangi yağ bulunabilir? Açıkla: o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Tekerlekler hava basınçlı ise kontrol et. o Basıncı kontrol ederken, başparmağınızla tekerleğin üzerine sertçe basın. Lastik çok hafif bir şekilde çökmeli( 5 mm kadar) o Her bir lastikte basınç aynı olmalı. Açıkla: o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Fazla sıkmayın. o Somunları sıkarken “diş atlatmadan” kaçının. Açıkla o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Jant tellerini kontrol ederken; Bütün tekerlek çevresinde iki teli birlikte sıkın. Eğer hafifçe dokunduğunuzda tel “esniyorsa” fazla gevşek olabilir. o Jant teli anahtarı bir tekerlekli sandalye kullanıcısı için önemli bir araçtır. Kullanıcının bu anahtardan yoksa pek çok bisiklet tamir dükkânında bunlar satılmaktadır. o Jant telleri fazla sıkılmış olabilir. Eğer tel dokunulduğunda çok sert hissediliyorsa muhtemelen çok sıkıdır ve gevşetilmesi gerekmektedir. Açıkla: o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Eğer bir döşeme zayıflamışsa ya da dikişleri bozulmuşsa daha kötü olmadan onarılması iyi olacaktır. o Eğer pas varsa, bu zımpara ile ya da çelik fırçası ile temizlenebilir. Ardından yeniden boyayın ya da parçayı yağlayın. Açıkla: o Neden, hangi sıklıkla ve nasıl (slayda bak). Ekle: o Kılıfta ve/veya köpükte aşınmış noktalar, kir ve delikleri kontrol edin. o Eğer minder yıpranmışsa tekerlekli sandalye hizmet personeli tarafından kontrol edilmesi gerekir. Yenilenmesi gerekebilir. DVD tanıtımı: Evde tekerlekli sandalye bakımı nasıl olur. Bu kısa video bir tekerlekli sandalye kullanıcısının tekerlekli sandalye bakımını evde nasıl yaptığını gösterecektir. Tekerlekli sandalye kullanıcılarına bu işlerin evde nasıl uygulandığının gösterilmesi önemlidir. DVD göster. Soru olup olmadığını öğren. Aktivite Gruplar: Her bir grupta üç kişi olmalı. Her bir gruba bir tekerlekli sandalye verin. Bütün grupların paylaşabilmesi için ortaya yeteri kadar araç koyunuz (evde bakım için gereken araçlar). Talimatlar: Her bur gruba `` Evde tekerlekli sandalye bakımı nasıl yapılır `` işlerinin nasıl uygulandığını sorun. Evde tekerlekli sandalye bakımı nasıl yapılır posterini gösterin ve katılımcılara takip edilmesi gereken adımları hatırlatın. İzleme: Grupları izleyin. Soruları cevaplayın ve gerekirse teknikleri daha detaylı olarak gösterin. Süre: 30 dakika müsaade edin. Geri Bildirim: Sor: evde bakım işleri ile ilgili sorusu olan var mı sorun. ? 3. Genel tekerlekli sandalye ve minder onarımı (55 dakika) Açıkla: Tekerlekli sandalyelerin bazen onarıma ihtiyaçları olacaktır. Tekerlekli sandalye hizmet personeli bunları ya kendisi tamir edebilmeli ya da kullanıcıyı yardım alabileceği bir yere yönlendirebilmelidir. Bazı tekerlekli sandalye kullanıcıları kendi tamirlerini yapmada çok iyilerdir. Bazılarınınsa yardıma ihtiyacı olur. Bütün tekerlekli sandalye kullanıcıları tekerlekli sandalyelerinin nerede tamir edileceğini bilmenin faydasını göreceklerdir. Sor: Tekerlekli sandalye kullanıcıları sandalyelerini nerede tamir ettirebilirler? Cevapları teşvik et ve tahtaya yaz. En önemli cevaplar: o bisiklet tamircileri; o motosiklet ya da araba tamircileri; o atölyeler; kaynakçı, tesisatçı (metal parçalar), marangoz, mobilya atölyesi(tahta parçalar); o döşeme tamiri için terzi; o tekerlekli sandalye hizmet tesisleri. Sor: Tekerlekli sandalyede sıklıkla bozulabilecek şeyler? Cevapları teşvik et ve tahtaya yaz. En önemli cevaplar: o yassılmış veya hasarlı minder; o esnemiş ya da yırtık döşeme; o metal parçalarda korozyon ya da paslanma; o gevşemiş ya da kopmuş jant telleri; o ön tekerleklerin kırılması: o patlak/inik lastikler; o yıpranmış lastikler ve ön tekerlekler; o kirli, yıpranmış ya da hasarlı rulman; o hasarlı itme tutamakları; o çalışmayan frenler. Küçük grup aktivitesi Gruplar: Her grupta üç kişi olmalı. Talimatlar: Her bir gruba sorun: o her bir tekerlekli sandalyeyi sorunun nerede olduğunu ve neyin onarımına ihtiyacı olduğunu bulmak için değerlendirin o tahtada yazan değişik problemleri göz önünde bulundurmaları gerektiğini hatırlatın o el kitaplarındaki her bir tekerlekli sandalye için sorulara cevap vermelerini söyleyin. İzleme: Grupları izleyin Sorulara cevap verin. Ve ihtiyaç olan onarımlar için yardımcı olun. Teknik tecrübeleri doğrultusunda bazıları diğerlerinden daha iyi olabilir. Herkesin tekerlekli sandalyelerini tamir edebilmesi gerekmez. En önemli beceri sorunun ne olduğunu tayin edebilmek ve tamiri için ne yapılması gerektiğini anlamaktır. Süre: 30 dakika müsaade edin. Geri bildirim: Gruplara her bir sandalyede tamir edilmesi gereken şeylerle ilgili geri bildirimlerde bulunmalarını söyleyin. Her grubun en az bir sandalye ile ilgili geri bildirimde bulunmasını sağlayın. Her tamir edilen parça için; bu tekerlekli sandalye kullanıcısı için neden sorun oluyor sorusunu sorun. 4. Kilit nokta özeti (3 dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. İkinci pratik: Uygunluk ve kullanıcı eğitimi H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  Yardım aracılığı ile temel seviye uygunluk gösterimi yapabilecekler.  Bir tekerlekli sandalye kullanıcısına, tekerlekli sandalyesini etkili bir şekilde kullanması ve bakımını yapabilmesi için verilen eğitimin gösterimini yapabilecekler. K A Y N A K LA R  Eğitmenler gözlem kontrol listesi: ikinci uygulama.  Birinci uygulamadaki tamamlanmış tekerlekli sandalye değerlendirme ve reçete(seçim) formları.  Tekerlekli sandalye uygunluk ve kullanıcı eğitim kontrol listesi (katılımcılara daha önce verilmişti).  Katılımcıların kullanıcılarla çalışmaları için her bir katılımcıya temiz ve sessiz bir alan.  İlk uygunluk için hazır tekerlekli sandalyeler.  Mezura ve ayarlamalar için aletler ( her bir grup için bir set. İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  kültürel faktörler – örneğin kadın erkek karışık değerlendirme yapmanın uygun olup olmadığı;  dil faktörü – kullanıcıların katılımcılarla aynı dili kullanıp kullanmadığı;  hizmetlerin, değerlendirme ve reçete etme işlemini yaparken ihtiyacı olabilecek her türlü doküman - örneğin tekerlekli sandalye kullanıcısının tekerlekli sandalyeye erişimi ile ilgili ihtiyaçları olabilecek ilave bilgiler( örneğin tekerlekli sandalye seri numaraları).  Değerlendirme sırasında doğabilecek ve bölüm ya da eğitim sırasında değinilememiş olan problemleri katılımcılar nasıl çözecekler. H A Z IR LI K  Katılımcılar üç çiftten fazla ise bir başka eğitmeninde grupları izleme ve yardım etme için bulunmasını isteyin.  Tekerlekli sandalye gönüllüleri ile seyahat ayarlamalarını teyit edin. Tekerlekli sandalye kullanıcıları, aileleri ve yardımcıları için ikramlar olmasını sağlayın.  Tekerlekli sandalye kullanıcılarını karşılamak ve bölüm başlayana kadar nerede bekleyeceklerini gösterecek birini tahsis edin.  Her bir grup için uygunluk pratiği alanı hazırlayın (değerlendirme sedyesi ve mahremiyet için perde). İhtiyaç olan bütün araçları değerlendirme sedyesinin üzerine yerleştirin. (ya da bulundukları yerlerde değerlendirme yapılacaksa seyahat ayarlamaları yapın)  Uygunluğu yapılacak tekerlekli sandalyelerin tam olarak hazırlanmış olduğundan emin olun ( reçete formlarına göre kontrol edin ve güvenlik ve kullanıma hazır kontrollerinin tamamlanmış olduklarından emin olun) T A S LA K 1. Uygunluk ve kullanıcı eğitimi: o Talimatlar ve kurulum. o Uygunluk. o Kullanıcı eğitimi. o Geri bildirim. 5 45 50 20 Toplam bölüm süresi 120 2. Tekerlekli sandalye kullanıcı geri bildirimi (tekerlekli sandalye kullanıcılarının zamanı ve müsaitlik durumlarına bağlı olarak seçenek dâhilindedir). 30 1. Geri bildirimi de kapsayan Uygunluk ve kullanıcı eğitimi (120 dakika) Eğitmen için notlar: Bu İkinci Uygulama sırasında katılımcıları gözlemlerken size rehberlik etmesi için eğitmen gözlem kontrol listesini kullanın. İyi ya da kötü olan genel örnekleri daha sonra geri bildirimde altlarını çizebilmek için kontrol listesine yazın (kutucuk verilmiştir). Aktivite Gruplar: o Birinci Pratikteki aynı gruplar olmalıdır. o Her bir grup için bir lider seçin ( Birinci pratikteki aynı lider ya da başkası olabilir). o Her bir gruba çalışmaları için bir yer tahsis edin. o Materyalleri ve araçları nerede bulacaklarını açıklayın. o Her bir grupta tekerlekli sandalye uygunluk ve tekerlekli sandalye kullanıcı eğitim kontrol listesinin olduğundan emin olun. Talimatlar: Bütün bu aşağıda bulunanları açıklayın: Bölüm amacı: o Bu uygulama bölümünün amacı tekerlekli sandalye hizmet sunumunun sekiz adımının, altı ve yedinci adımının uygulanmasıdır (uygunluk ve kullanıcı eğitimi). Bu uygulamada daha önceki uygulama sırasında bulunan tekerlekli sandalye kullanıcıları ile beraber çalışılacaktır. o Katılımcının mümkün olan zaman içerisinde tekerlekli sandalyeyi tamamlayamamış olabilirler. Bu, ilk uyuma ve hangi modifikasyonlar / ayarlamaların yapılmasının gerekli olduğu duruma göre değişecektir. Bununla beraber katılımcılar bölüm zamanlarını mümkün olduğu kadar çok şey yapacak şekilde en uygun olarak kullanmalıdırlar. Eğer tekerlekli sandalye tamamlanamamışsa kullanıcı ile kurs sonrasında tamamlanmak üzere gerekli ayarlamaların yapılması sağlanmalıdır. Lider kişi: o Her grupta lider olan kişi bütün adımların uygulanmasını sağlamaktan sorumlu kişidir. o Lider kişi kullanıcı ve ailesi/yardımcısı ile konuşmaları yapacak olan kişi olmalıdır. Bu yolla herkesin bir arada konuşması ve karışıklık çıkması engellenmiş olur. Eğitimcilerin gözlemi ve destekleri: o Katılımcılar her an yardım ve açıklamalar isteyebilirler. o Bütün bölüm boyunca eğitmenler izlemeli ve ihtiyaç olduğunda olabildiğince destek vermeli ve yardım etmelilerdir. o Eğer uygunlukla ilgili herhangi bir problem olursa eğitmenlerin gelmesini ve kontrol etmesini isteyiniz. İhtiyaç duyulabilecek modifikasyon /ayarlamalar ile ilgili görüşünüz. o Uygunluğu tamamladıktan sonra katılımcıların bir eğitmeni çağırarak kontrol etmesini istemeleri gerekmektedir. Bir eğitmen tarafından uygunluğun kontrolü yapılmadıkça KULLANICI EĞİTİMİNE BAŞLAMAYINIZ. Müsaade edilen zaman:  Uygunluğu 45 dakikada ve kullanıcı eğitimini 50 dakikada tamamlama hedefinde olmalıdırlar. Hizmet formları: o Her bir grup liderine birinci uygulamadaki tekerlekli sandalye değerlendirme ve tekerlekli sandalye reçete(seçim) formlarını (ikinci uygulamada kullanılan) dağıtın. o Her bir grubun, tekerlekli sandalye uygunluk ve tekerlekli sandalye kullanıcı eğitim kontrol listesinden en az bir nüsha aldığına emin olun. Katılımcılara sorun: Uygunluk için adımlar nelerdir? Doğru cevapları onaylayın. Katılımcılara hatırlatın: sadece onlarla bağlantısı olan tekerlekli sandalye becerilerini onlara öğretmelilerdir. Örneğin; basınç yarası geliştirme riski altında olmayan bir kullanıcıya basınç rahatlatma teknikleri öğretmeye gerek yoktur. Katılımcılara hatırlatın: Sürecin her aşamasına kullanıcıların aktif katılımını sağlamaları gerekir. Sor: Soru var mı? Soruları cevaplayın. Her gruba çalışacakları alanı hazırlamalarını ve beraber çalışacakları tekerlekli sandalye kullanıcısına kendilerini tanıtmalarını söyleyin. İzle ve destekle: Grupları yakından izleyin, güvenli uygulama yaptıklarından emin olun, katılımcıların becerilerini gözlemleyin ve değerlendirin. Her bir grup hakkındaki izlenimleriniz için Eğitmen gözlem kontrol listesini kullanın. Bütün bölüm boyunca: o Katılımcıların zamanlarını ayarlamaları için uyarılarda bulunun (konuşarak ve / bütün katılımcıların göreceği şekilde tahtaya yazarak). o Tekerlekli sandalye kullanıcılarının aktif bir şekilde katılımını sağlayın. Bölümün sonunda katılımcılardan; tekerlekli sandalye kullanıcılarına teşekkür etmelerini, bütün gruba değerlendirme, reçete(seçim) uygunluk ve kullanıcı eğitimi ile ilgili tecrübelerinin geri bildirimi için kalmak isteyip istemediklerini sormalarını isteyin. Süre: 45 dakika uygunluğu tamamlamak, 50 dakika kullanıcı eğitimini tamamlamak ve 20 dakika da geri bildirim için müsaade edin. Geri Bildirim: Uygulama esansında gördüğünüz iyi örnekler ile ilgili yorumlar yapın. Katılımcıların kendilerini geliştirebilecekleri alanlara işaret edin, kişilerle ilgili değil grupla ilgili konuşun. Her bir gruba tekerlekli sandalyenin uygun hale gelmesi için yaptıkları değişikler hakkında kısa bir özet bildirmelerini söyleyin (her grup için 3 dakika müsaade edin) Sor: Soru var mı? 2. Tekerlekli sandalye kullanıcısı geri bildirimi (seçeneğe bağlı: tekerlekli sandalye kullanıcılarının zamanlarına ve müsaitlik durumuna göre yapılabilir) Eğitmenler için notlar: Eğer Birinci ve İkinci uygulamaya katılmış olan tekerlekli sandalye kullanıcıları istekli ise, bir kullanıcıyı, burada yaşadıkları süreçle ilgili geri bildirim vermek için davet edin. Bu daha samimi bir ortamda da yapılabilir örneğin; ilk iki uygulamanın bitimini kutlamak amacıyla verilen ikramlar sırasında yapılabilir. Kullanıcıya sorulacak örnek sorular aşağıdadır. Tekerlekli sandalye kullanıcısına aşağıdaki alanlarda geri bildirim vermesini isteyin. o Değerlendirme sırasında neler hissetti? (örneğin; kendini olaya dahil hissetti mi, görüşme sorularını cevaplarken neler hissetti, soruların daha iyi bir tekerlekli sandalye sahibi olmasını sağlayacağını düşündü mü?) o Kendilerine reçete edilmiş tekerlekli sandalyelerden memnunlar mı? o Kullanıcı eğitiminden yeni bir şeyler öğrendiler mi? Bunları gelecekte evde/işte kullanacaklar mı? B.13: Takip H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  “Takip” ne anlama geldiğini ve nasıl olduğunu açıklayabilecekler  bir tekerlekli sandalye takip formu doldurabilecekler. K A Y N A K LA R Bu bölüm için:  PPT slaytları: B.13 Takip;  Referans Kılavuzu  Katılımcı El kitabı İÇ E R İK Bütün tekerlekli sandalye kullanıcıları takip ziyaretlerinden (tercihan yaşadıkları yerde) yarar sağlayacaklardır. Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  Katılımcının geldiği hizmetlerde takip nasıl yapılacak ve buna bağlı olarak eğitim nasıl uyarlanacak(ev ziyaretleri, merkez tabanlı, toplum temelli rehabilitasyon merkezleri tarafından). Örneğin; eğer katılımcı takip için planı olan bir tekerlekli sandalye hizmetinden geliyorsa bu plan katılımcıya açıklanmalıdır. H A Z IR LI K  Kaynakları toplayın, PPT slaytlarına göz gezdirin ve bölüm planını okuyun. T A S LA K 1. Giriş. 2. Takip nedir ve nasıl olur? 3. Takip formunun tanıtımı. 4. Takip uygulaması. 5. Kilit nokta özeti. 2 10 5 25 3 Toplam bölüm süresi 45 1.Giriş (2dakika) Açıkla: “Takip” tekerlekli sandalye hizmet sunumunun sekizinci adımıdır. Bu bölümünde takibin içeriğinden bahsedeceğiz. Tekerlekli sandalye takip formunu tanıtacağız ve nasıl kullanıldığının uygulamasını yapacağız. 2. Takip nedir ve nasıl olur? (10 dakika) Sor: Katılımcılar ”takip” in neyi içerdiğini düşünüyorlar? Cevapları teşvik edin. En önemli cevaplar: o tekerlekli sandalye kullanıcısından bilgi toplamak; o tekerlekli sandalyenin iyi çalışır halde olduğunu kontrol etmek; o tekerlekli sandalyenin uygunluğunu kontrol etmek. Açıkla: o Bütün tekerlekli sandalye kullanıcıları takipten yarara göreceklerdir. Bununla beraber takibin en çok önem taşıdığı kişiler: o çocuklar; o basınç yarası geliştirme riski olan tekerlekli sandalye kullanıcıları; o hastalığı ilerleyen tekerlekli sandalye kullanıcıları; o kendilerine verilen eğitim ile sıkıntıları olan tekerlekli sandalye kullanıcıları.  Takip tarihi ile ilgili belli bir kural olmamasına rağmen teslim tarihinden itibaren altıncı haftada yapılan takip faydalı olacaktır. Bu kullanıcının ihtiyaçlarına bağlıdır. Bununla beraber çocuklar için her altı ayda yapılan takip idealdir. Bunun sebebi çocuk büyüdükçe ihtiyaçlarının değişmesidir. o Takip randevuları: o tekerlekli sandalye kullanıcısının evinde; o tekerlekli sandalye hizmetlerinde; o tekerlekli sandalye kullanıcısına ve personele uyan herhangi başka bir yerde yapılabilir. Sor: Katılımcının tekerlekli sandalye hizmetlerinde takip nasıl olur (ya da yapılır)? Cevapları teşvik edin ve tahtaya yazın. En önemli cevaplar: o tekerlekli sandalye kullanıcısı sandalyesini aldığında bir takip randevusu verin. o tekerlekli sandalye kullanıcısını takip için evde ziyaret edin (uygun olan durumlarda) o takip ziyareti, takip ziyareti için eğitilmiş, toplum-temelli çalışan bir personelin rutin ziyaretlerinin bir parçası olarak yapılabilir. o tekerlekli sandalye kullanıcısının yolculuk yapmasının zor olduğu ve telefonla ulaşılabildiği durumlarda telefonla takip ayarlanabilir. 3. Tekerlekli sandalye takip formunun tanıtımı (5 dakika) Açıkla: Takip için geren bilgi ve beceriler eğitim içerisinde mevcuttur. Takip ziyareti yapmak için personelin yapması gerekenler: o tekerlekli sandalye kullanıcısından bilgi toplayın; o tekerlekli sandalye iyi ve kullanılır durumda mı kontrol edin; o kullanıcının uygunluğunu kontrol edin. Katılımcılardan el kitaplarındaki tekerlekli sandalye takip formuna bakmalarını isteyin. Açıkla: Tekerlekli sandalye takip formu personele takipte ne yapmaları gerektiği ve hangi soruları sormaları gerektiği konusunda hatırlatmalar yapar. Bu formda aynı zamanda “yapılması gerekenler” kısmı da vardır ve gerekenler buraya yazılabilir. Takiplerde bazı genel yapılması gerekenler listesi aşağıdadır. o Daha çok tavsiye ve eğitim vermek. Örneğin bir kullanıcı tekerlekli sandalyesini beklendiği şekilde kullanmıyor olabilir, kullanıcı yalnızken güvende hissetmediği için sandalyeye binip inme işlemini yapamıyor olabilir bu durumda transfer eğitimi yardımcı olabilir. o Tekerlekli sandalyenin yeniden ayarlanması. o Küçük tamirlerin yapımı. Örneğin lastiklerin şişirilmesi. Tekerlekli sandalye kullanıcısını evde bir tekerlekli sandalye bakımı yaparak sandalyesine bakım yapmaya teşvik edin. o Tamiratların yapımı ya da tamiratların yapımı için tekerlekli sandalye kullanıcısına yardımcı olmak. Sor: Eğer bir tekerlekli sandalye kullanıcısı bir basınç yarası olduğunu belirtirse ne yapılması gerekir? En önemli cevaplar: o basınç yarasını görmeyi isteyin ve yerini ve hangi evrede olduğunu tespit edin; o eğer basınç yarası tekerlekli sandalyenin dokunduğu bir bölgede ise tekerlekli sandalye kullanıcısı yarası iyileşene kadar sandalyesini kullanmayı bırakmalıdır; o eğer basınç yarası 2. evre ya da daha üzeri bir aşamadaysa tedavi için bir uzmanın araştırılması gerekir. o basınç yarasının neden oluştuğunu belirleyin (örneğin minder kullanmama ya da minderin basıncı rahatlatmayı yapamaması, kötü transfer metodu, idrar tutamama problemi v.s.) ve çözmeye çalışın. 4. Takip uygulaması (25 Dakika) Aktivite Gruplar: Her grupta üç kişi olmalı Talimatlar: Her gruptan şunları isteyin: o el kitaplarından her bir kullanıcının hikayesini okusunlar ve ne yapılması gerektiği konusunda tartışsınlar; o her bir kullanıcı için bit takip formu doldursunlar (el kitabında üç tane takip formu vardır). İzleme: Grupları izleyin ve ihtiyaç olduğunda yardımcı olun. Süre: 20 dakika müsaade edin ve 5 dakika geri bildirim için izin verin. Geri bildirim: Sor: Hala, Daarun ve Talha için katılımcılar neler öneriyorlar. Bilgi noktaları Hala yetişkin kızı ve ailesiyle beraber aynı evde yaşamaktadır. Altı ay önce tekerlekli sandalye hizmetleri aracılığı ile bir tekerlekli sandalye edinmiştir. Daha bir yıl önde felç geçirmiştir ve yürüyememektedir. Tekerlekli sandalyesi olduğunda, kızının yardımı ile dikilerek transfer yapmayı öğrenmiştir. Bir tekerlekli sandalye istediğini ve böylece evde daha çok yardımcı olabileceğini ve kiliseye gitmek istediğini söylüyordu. Bir takip ziyaretinde Hala evinden birkaç ay ayrılmadığını söylemişti. Evine gelen yolun oldukça engebeli olduğunu ve eve doğru bir merdiven olduğunu söyledi. Bununla beraber o tekerlekli sandalyesini evde kullanmaktadır ve evde kızının çocuklarına bakarak kızına yardım etmektedir. Tekerlekli sandalyede dik oturmaktadır ve sandalye iyi durumdadır. Tekerlekli sandalyesine ve sandalyeden başka yere kızının yardımı olmadan kendi transferini yapabilmektedir. o Hala’nın istediği halde neden kiliseye gidemediğini bulunuz. o Eğer bu engebeli yüzeydeki basamaktan dolayı ise Hala ve kızına engebeli arazi ve basamak için tavsiyede bulunun ve eğitim verin. Daarun ’un omurilik zedelenmesi vardır. Yerel pazarda bir radyo tamir atölyesinde çalışmaktadır. Tekerlekli sandalyesini ve basınç rahatlatma minderini iki yıl önce almıştır. Takip ziyaretinde tekerlekli sandalyesini her gün işe gidip gelmek için kullandığını söylemiştir. Basınç yarası yoktur. Daarun’un iki patlak lastiği olmuştur ve kendisi tamir etmiştir. Tekerlekli sandalye kontrol edilirken servis çalışanı jant tellerinin gevşek olduğunu ve koltuk kaidesine ait iki cıvatanın kayıp olduğunu fark etmiştir. Minderindeki yumuşak köpük oldukça yassılmıştır. Tekerlekli sandalyesinde iyi bir şekilde oturmaktadır ve sandalyesinden çok memnun olduğunu söylemektedir. o Minderin üzerine yumuşak katman eklemek için ayarlamalar yapın. o Evde tekerlekli sandalyesine bakım için tavsiyelerde bulunun. Bu bakıma jant tellerinin kontrolü ve cıvataların sıkılması da dahildir. Talha 10 yaşındadır. Hafif serebral palsisi vardır ve mahalle okuluna gitmektedir. Bir yıl önce kendisine dört tekerlekli ve ekstra duruş destek minderi olan bir tekerlekli sandalye reçete edilmiştir. Takip ziyaretinde Talha tekerlekli sandalyesini her gün okula gidip gelmek için kullandığını söylemiştir. Kendini itecek güce sahip olmadığından dolayı sandalyesini babası itmektedir. Tekerlekli sandalyesi iyi durumdadır. Babası tekerleği bir defa tamir ettiğini söylemiştir. Tekerlekli sandalye servis çalışanı fark etmiştir ki; Talha büyümüştür ve ayaklıklar onun için fazla yüksek olduğundan o Çocuklar için yapılan takip ziyaretleri eğer mümkünse 3 ila 6 ay arasında olmalıdır. o Çocuklar çok çabuk büyüyebilirler. Ebeveynleri ve bakıcıları, (eğer hizmetler onları ziyaret edemiyorsa) çocukların durumunu gözden geçirmek için eğitmek çok önemlidir. dolayı bacakları tekerlekli sandalye koltuğunda yeteri kadar desteklenmemektedir. o Talha’nın yeniden değerlendirilmesi gerekmektedir ve tekerlekli sandalyesinin ayarlanması ya da yenisiyle değiştirilmesi gerekmektedir. 5. Kilit nokta özeti (3dakika) Kilit noktaları okuyun. Soru olup olmadığını öğrenin. Üçüncü Uygulama: Takip H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  takip gösterimini yapabilecekler. K A Y N A K LA R  Temiz ve mahrem bir bölge ve bir değerlendirme sedyesi ( eğer bölüm toplum içinde yapılmayacak ise)  Her bir tekerlekli sandalye kullanıcısı, için önceki değerlendirme ve reçete (seçim) formu  Tekerlekli sandalye takip formu ( her kullanıcı için bir adet)  Tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi.  Eğitmen gözlem kontrol listesi.  Mezura ve tekerlekli sandalye ayarlarını yapmak için aletler. İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  kültürel faktörler göz önünde bulundurulmalıdır;  dil faktörü – kullanıcıların katılımcılarla aynı dili kullanıp kullanmadığı;  takip sırasında hizmetlerin gerek duyabileceği her türlü doküman;;  takip sırasında doğabilecek ve bölüm ya da eğitim sırasında değinilememiş olan problemleri katılımcılar nasıl çözecekler. H A Z IR LI K  Bu bölümün toplu önünde yapılacağını göz önünde bulunurun.  Son 3-6 ayda tekerlekli sandalye almış ve takibe ihtiyacı olan kullanıcılarla irtibata geçin. Onları bir takip ziyareti planlaması yapmak için davet edin. Bu ziyaret kullanıcının evinde ya da klinikte olabilir.  Zaman ve yolculuk ayarlamalarını yapın. Eğer kullanıcı ve ailesi/bakıcısı eğitim alanına yolculuk yaparak gelmişlerse onlar için ikramlar olmasını sağlayın.  Eğer takip eğitim alanında olacaksa her bir çift katılımcı ve gönüllü tekerlekli sandalye kullanıcıları için değerlendirme sedyesi ve mahremiyet için perde hazırlayın. İhtiyaç olabilecek bütün ekipmanları sedyenin üzerine yerleştirin.  Eğer üç çift katılımcıdan daha fazlası var ise başka bir eğitmeni daha gruplara yardımcı olması ve gözlem yapması için çağırın.  Hangi tekerlekli sandalye kullanıcısıyla ve hangi katılımcılar beraber çalışacaklar karar verin. T A S LA K 1. Takip: o Talimatlar. o Takip. o Geri bildirim. 5 60 25 Toplam bölüm süresi 90 1. Takip (90 dakika) Eğitmen için notlar: Bu Üçüncü Uygulama sırasında katılımcıları gözlemlerken size rehberlik etmesi için eğitmen gözlem kontrol listesini kullanın. İyi ya da kötü olan genel örnekleri daha sonra geri bildirimde altlarını çizebilmek için kontrol listesine yazın (kutucuk verilmiştir). Aktivite Gruplar: o Katılımcıları aynı gruplar olacak şekilde ayarlayın ( bir grupta üç kişiden fazlası olmasın). o Her bir gruba bir lider atayın. o Katılımcılara beraber çalışacakları tekerlekli sandalye kullanıcısının adın söyleyin ve bağlantılı notları verin; örneğin, önceki tekerlekli sandalye değerlendirme formu. o Her bir gruba çalışmaları için bir yer verin ve ihtiyaç olacak bütün malzemelerin değerlendirme sedyelerinin üzerine bırakıldığını açıklayın ( ya da eğer toplum içinde yapılacaksa ulaşım ayarlamalarını açıklayın) Talimatlar: Herkese şunları açıklayın: Bölüm amacı: o Bu bölümün amacı takibi yapmaktır. . Lider kişi: o Lider olan kişi bütün adımların yapıldığından emin olmak için sorumluluğu olan kişidir. o Lider kişi kullanıcı, aile/bakıcı ile konuşacak olan esas kişidir. Bu herkesin bir anda konuşmasını ve oluşabilecek kafa karışıklığını engelleyecektir. Eğitmenlerin gözlem ve desteği: o Katılımcılar her an yardım ve açıklamalar isteyebilirler. Müsaade edilen zaman: o Takibi 60 dakikada bitirmeyi hedeflemelilerdir. Hizmet formları: o Her bir grup lideri için tekerlekli sandalye takip formu dağıtın. o Her grubun en azından bir tane tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi olduğundan emin olun. Katılımcılara hatırlatın: Sürecin her aşamasına kullanıcıların aktif katılımını sağlamaları gerekir. Sor: Soru var mı? Soruları cevaplayın. Her gruba çalışacakları alanı hazırlamalarını ve beraber çalışacakları tekerlekli sandalye kullanıcısına kendilerini tanıtmalarını söyleyin. İzleme ve destek: Grupları yakından izleyin, güvenli uygulama yaptıklarından emin olun, katılımcıların becerilerini gözlemleyin ve değerlendirin. Her bir grup hakkındaki izlenimleriniz için Eğitmen gözlem kontrol listesini kullanın. Bütün bölüm boyunca: o Katılımcıların zamanlarını ayarlamaları için uyarılarda bulunun (konuşarak ve / bütün katılımcıların göreceği şekilde tahtaya yazarak). o Tekerlekli sandalye kullanıcılarının aktif bir şekilde katılımını sağlayın. Bölümün sonunda katılımcılardan; tekerlekli sandalye kullanıcılarına katılımları için teşekkür etmelerini ve takip edilecek kaç tane eylem belirlendiğini (ve daha değinilmemiş olan) açıklamalarını söyleyin. Süre: Takibin tamamlanması için 60 dakika ve geri bildirim için 25 dakika müsaade edin. Geri bildirim: Uygulama esansında gördüğünüz iyi örnekler ile ilgili yorumlar yapın. Katılımcıların kendilerini geliştirebilecekleri alanlara işaret edin, kişilerle ilgili değil grupla ilgili konuşun. Her bir gruba takip randevusunda neler buldukları ile ilgili kısa bir özet bildirmelerini söyleyin, (bunları da içerecek şekilde): o tekerlekli sandalye kullanıcısının ihtiyaçlarını ne derecede karşılıyor; o sorunlar/endişeler; o takip önerileri (her grup için 5 dakika müsaade edin) Sor: Soru var mı? Dördüncü uygulama: Değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlık, uygunluk ve kullanıcı eğitimi H E D E F LE R Bu bölümün sonunda katılımcılar bir takım üyesi olarak şunları yapabilecekler:  Değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlık, uygunluk ve kullanıcı eğitiminin temel düzeyde gösterimini yapabilecekler. K A Y N A K LA R  Yerel olarak bulunabilen tekerlekli sandalyeler.  Temiz ve mahremiyeti olan değerlendirme sedyesi (her kullanıcı için bir adet).  Formlar: tekerlekli sandalye değerlendirme formu, tekerlekli sandalye reçete (seçim) formu, tekerlekli sandalye güvenli ve kullanıma hazır kontrol listesi, tekerlekli sandalye uygunluk kontrol listesi, tekerlekli sandalye kullanıcı eğitim kontrol listesi (her tekerlekli sandalye kullanıcısı için bir set)  Eğitmen gözlem kontrol listesi  Dijital fotoğraf makinesi ve fotoğraf onay formu  Mezura İÇ E R İK Bu bölümü katılımcıların çalışacakları şartlara uyarla. Düşünün:  Kültür ve dil faktörleri.  Mevcut olan tekerlekli sandalye tipleri ve onları hazırlamak için gereken zaman süresi.  Tekerlekli sandalye değerlendirme ve tekerlekli sandalye reçete (seçim) formunda toplanmış bilgilere ek olarak, hizmet tarafından istenen her türlü ek doküman.  Uygulama sırasında doğabilecek ve bölüm ya da eğitim sırasında değinilememiş olan problemleri katılımcılar nasıl çözecekler.  Tekerlekli sandalye kullanıcıları için takip bu eğitim programından sonra nasıl halledilecek. H A Z IR LI K  Yeni bir grup gönüllü tekerlekli sandalye kullanıcısı çağırın, bu her grup için bir kişi olacak şekilde olmalı. Zaman ve seyahat ayarlamalarını teyit edin ve ikramların hazır olduğundan emin olun.  Kullanıcılar geldiğinde onları karşılayacak bir kişi tahsis edin.  Tekerlekli sandalye kullanıcıları ve aileleri için; değerlendirme ve reçete (seçim) işleminden sonra tekerlekli sandalyeleri hazırlanana kadar bekleyebilecekleri bir yer ayarlayın.  Örnek tekerlekli sandalye ve minderlerin iyi, çalışabilir durumda olduklarından emin olun.  Eğitim alanını hazırla ( eğer toplum içinde yapılacaksa seyahat ayarlamalarını yapın).  Eğer üç çift katılımcıdan daha fazlası var ise başka bir eğitmeni daha gruplara yardımcı olması ve gözlem yapması için çağırın.  Hangi tekerlekli sandalye kullanıcısıyla ve hangi katılımcılar beraber çalışacaklar karar verin. T A S LA K 1. Değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlık, uygunluk ve kullanıcı eğitimi o Talimatlar ve kurulum. o Değerlendirme. o Reçete (seçim) o Ürün (tekerlekli sandalye) hazırlığı. o Uygunluk o Kullanıcı eğitimi. o Ek zaman. 5 30 20 60 30 45 30 20 Toplam bölüm süresi 240 1. Değerlendirme, reçete (seçim), ürün(tekerlekli sandalye)hazırlığı, uygunluk ve kullanıcı eğitimi (240 dakika) Eğitmenler için notlar: 1. Fotoğraflar: o Tekerlekli sandalye kullanıcılarının fotoğraflarını çekmek için imzalı izin alınıp alınmadığını kontrol edin. Tekerlekli sandalye kullanıcılarına fotoğraflarının çekilmesine gönüllü olarak izin verdiklerini ve bunların ilerideki eğitimlerde kullanılacağını anladıklarından emin olun. o İzin vermiş olan bütün tekerlekli sandalye kıllanıcılarının fotoğraflarını şu şekilde çekin: o eski tekerlekli sandalyelerinde (eğer varsa) (önden ve yandan görünüş) o değerlendirme sırasında (postural gözlem); o reçete edilmiş tekerlekli sandalye ile uygunluktan sonra (ön ve yandan görünüş). 2. Uygulama bölümüne katılan tekerlekli sandalye kullanıcılarının ihtiyaçlarının karşılanması: o Uygulama sırasında mevcut olan zamanın içerisinde bütün tekerlekli sandalyelerin tamamlanması mümkün olmayabilir. o Uygulama sırasında görülen tekerlekli sandalye kullanıcılarından herhangi biri ile başka bir randevunun icap ettiği durumlarda, eğitmen randevunun ev sahibi kuruluş/hizmet tarafından alındığına ve bütün değerlendirme, reçete (seçim) ve uygunluk bilgilerinin teslim edildiğine emin olmalıdır. 3. Katılımcının uygulamasının gözlemlenmesi: Dördüncü Uygulama sırasında “Eğitmen gözlem kontrol listesini” grupların bütün adımları uyguladıklarından emin olmak için kullanın ve iyi ya da kötü olan genel örnekleri daha sonra geri bildirim bölümünde altlarını çizebilmek için kontrol listesine yazın (kutucuk verilmiştir). o Bu fotoğraflar son bölüm B.14: Sonuç ’da kullanılabilir (eğer izin verilmiş ise). Aktivite Gruplar: o Katılımcıları gruplara ayırın (her grupta 2 ya da 3 kişi olacak şekilde) o Bir grup lideri belirleyin. o Her bir gruba beraber çalışacakları tekerlekli sandalye kullanıcısının adını söyleyin. o Her bir gruba çalışacak bir yer ayarlayın ve bütün malzemelerin değerlendirme sedyesinin üzerine bırakıldığını açıklayın. Talimatlar: Herkese şunları açıklayın: Bölüm amacı: o Bu uygulama bölümünün amacı tekerlekli sandalye kullanıcısı ile beraber değerlendirme, reçete (seçim), ürün(tekerlekli sandalye) hazırlığı, uygunluk ve kullanıcı eğitimi yapmaktır. o Tekerlekli sandalye kullanıcısının tekerlekli sandalyesini bölüm sırasında tamamlamak mümkün olmaz ise, tekerlekli sandalyenin tamamlanması için kullanıcısı ile ayarlamaların yapıldığına emin olun. Bununla beraber katılımcı olabildiğince çok işin tamamlanması için çaba göstermelidir. Lider kişi: o Lider olan kişi bütün adımların yapıldığından emin olmak için sorumluluğu olan kişidir. o Lider kişi kullanıcı, aile/bakıcı ile konuşacak olan esas kişidir. Bu herkesin bir anda konuşmasını ve oluşabilecek kafa karışıklığını engelleyecektir. Eğitmenlerin gözlem ve desteği: o Katılımcılar her an yardım ve açıklamalar isteyebilirler. o Eğitmenler bürün bölüm boyunca her bir grubu izleyecekler ve mümkün olduğu kadar çok destek ve ihtiyaç olduğu kadar tavsiye vereceklerdir. o Katılımcılar HER BİR HİZMET ADIMINI tamamladıktan sonra bir sonraki adıma geçmeden ÖNCE eğitmenin gelip kontrol etmesini istemeleri gerekir.. Katılımcılara hatırlatın: Sürecin her aşamasına kullanıcıların aktif katılımını sağlamaları gerekir. Sor: Soru var mı? Soruları cevaplayın. Her gruba çalışacakları alanı hazırlamalarını ve beraber çalışacakları tekerlekli sandalye kullanıcısına kendilerini tanıtmalarını söyleyin. İzleme ve destek Bütün uygulama bölümü boyunca grupları yakından izleyin. Her bir grup hakkındaki izlenimleriniz için Eğitmen gözlem kontrol listesini kullanın. Bütün bölüm boyunca: o Katılımcıların zamanlarını ayarlamaları için uyarılarda bulunun (konuşarak ve / bütün katılımcıların göreceği şekilde tahtaya yazarak). o Tekerlekli sandalye kullanıcılarının aktif bir şekilde katılımını sağlayın. o Katılımcıların yaptıklarını her adımda takip edin. Bölümün sonunda katılımcılardan; tekerlekli sandalye kullanıcılarına katılımları için teşekkür etmelerini ve onlar için reçete edilmiş tekerlekli sandalyenin bir sonraki bölümde denemeleri için hazırlanacağını söyleyin. Time: Süreler aşağıdaki gibi olmalıdır: o Değerlendirme: 30 dakika; o Reçete (seçim): 20 dakika; o Ürün (tekerlekli sandalye ) hazırlığı: 60 dakika; o Uygunluk: 30 dakika; o Kullanıcı eğitimi: 45 dakika; o Geri bildirim: 30 dakika. Eğitmenler için notlar: Uygulama sırasında gözünüzü saatte tutmanız önemlidir. Yukarıda verilen zaman süreleri bir rehberdir. Bununla beraber bu durum katılımcıların tecrübelerine, kullanıcıların ihtiyaçlarına ve ürünün hazırlanması için gereken zamana göre farklılıklar gösterebilir. Eğitmenlerin ayarlamalar yapmaları gerekebilir.  ek bir 20 dakika: oluşabilecek herhangi bir problemi çözmek ve eğitmenlerin her bir adımı kontrolleri için. Geri bildirim: Uygulama esansında gördüğünüz iyi örnekler ile ilgili yorumlar yapın. Katılımcıların kendilerini geliştirebilecekleri alanlara işaret edin, kişilerle ilgili değil grupla ilgili konuşun. Sor: Soru var mı? B.14: Sonuç H E D E F LE R Bu bölümün sonunda katılımcılar şunları yapabilecekler:  Son uygulama bölümünde beraber çalıştıkları tekerlekli sandalye kullanıcısının verilerini şunlar da dahil olarak özetleyebilecekler (Dördüncü uygulama): değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlığı, uygunluk, kullanıcı eğitimi ve bakım, onarım ve takip. K A Y N A K LA R  Katılımcı El Kitabı  DVD: Alınacak mesajlar  Yapışkanlı not kâğıtları ya da not kağıtları İÇ E R İK  Kaynakları toplayın, PPT slaytlarına göz gezdirin, DVD i seyredin ve bölüm planını okuyun. H A Z IR LI K 1. Giriş ve talimatlar. 2. Katılımcıların soruları. 3. Katılımcıların hazırlığı. 4. Katılımcıların sunumları. 5. Soru cevap bölümü. 6. Kilit noktalar. 2 5 25 40 20 13 Toplam bölüm süresi 105 1. Giriş ve talimatlar (2 dakika) Açıkla: o Bu bölümde katılımcıların şunları yapma imkânları olacak: o son uygulama bölümünde neler öğrendiklerini herkesle paylaşabilecekler o temel seviye tekerlekli sandalye hizmet sunumu ile ilgili halen soruları varsa sorabilecekler 2. Katılımcı soruları (5 dakika) Küçük grup aktivitesi Gruplar: Her grupta üç kişi olmalı. Her bir gruba post-it not kâğıtları verin ya da not kâğıtları verin (örneğin dörde bölünmüş A4 kâğıtları) Talimatlar: Her bir gruptan tekerlekli sandalye hizmet sunumu hakkında soruları var mı tartışmalarını isteyin. Bir kişi ya da gruba ait bu soruları kâğıtlara yazmaları gerekmektedir. İzleme: Grupları izleyin Süre: Toplamda 10 dakika müsaade edin. Geri Bildirim: Her gruptan sorularını eğitmene vermelerini isteyin. 3. Katılımcıların hazırlığı (25 dakika) Küçük grup aktivitesi Gruplar: Son iki uygulama bölümünde beraber çalışan grupların tekrar beraber çalışmalarını isteyin. Talimatlar: Gruplara beraber çalıştıkları tekerlekli sandalye kullanıcısı hakkında 10 dakikalık bir sunum hazırlamalarını ve neler öğrendiklerini anlatmalarını isteyin. El kitaplarındaki çalışma sayfasında bulunan sorularını cevaplama amacında olmaları gerekir. Bilgisayarda bulunan tekerlekli sandalye kullanıcı resimlerini sunumlarını resimlendirmek için kullanabilirler. Eğitmenler için notlar: Eğer katılımcılar bilgisayarı kullanma konusunda rahat hissetmiyorlarsa onlara eğitmenlerin yardımcı olabileceğini açıklayın. İzleme: Gruplar hazırlanana kadar eğitmenler grup tarafından yazılan soruları gözden geçirmelilerdir. Bazı sorular aynı olabilir. Soruları mantıksal bir sıralamaya koyunuz (örneğin hizmet adımlarıyla bağlantılı olarak. Soruların cevaplarını hazırlayın). Süre: Katılımcılara hazırlanmaları için 25 dakika müsaade edin. Geri Bkz 4. Katılımcı sunumları. Bildirim: 4. Katılımcı sunumları (40 dakika) Her gruba sırayla sunum yapmalarını söyleyin. Bütün grubu sunum sonunda soru sormaları için teşvik edin. Her bir sunum için 10 dakika ve sorular için 5 dakika müsaade edin. Her katılımcıya sunumu için teşekkür edin. 5. Soru cevap bölümü (20 dakika) Her bir katılımcının sorusunu sesli okuyun (bkz 2. Katılımcı soruları). Bu soruyu kim sordu diye SORMAYIN. Soruyu cevaplayın ya da açıklama yapın veya grupta soruyu cevaplamak isteyen var mı diye sorun. Eğer bir soruyu birden fazla kişi/grup sorduysa bu sorunun birkaç kişi daha tarafından sorulduğunu açıklayın. Açıklayın: o Tekerlekli sandalye kullanıcısının ihtiyaçlarını gerçekten karşılayacak bir tekerlekli sandalye sağlama; pratik, iyi takım çalışması (kullanıcı ve personel arasında) becerileri ve en azından bazı temel kaynakları gerektiren bir iştir. o Bu eğitim programı bu sürece dahil adımlara genel bir yapmıştır. Bununla beraber her tekerlekli sandalye kullanıcısı değişiktir dolayısıyla her durumun bunun gibi bir programa dâhil edilmesi zordur. o Katılımcılar her çalıştıkları tekerlekli sandalye kullanıcısından bir şey öğreneceklerdir. İyi yaptıkları şeylerden öğrendikleri gibi aynı zamanda hatalarından da dersler alacaklardır. o Pratik yaptıkça süreç onlar için çabuklaşacaktır. o En önemli şey pratik yapmaya devam etmek ve tekerlekli sandalye kullanıcısını dinlemeye devam etmektir. 6. Kilit noktalar (13 dakika) DVD tanıtımı: Alınacak mesajlar. Bu kısa video tekerlekli sandalye eğitim programının önemini vurgulayacaktır. DVD ‘yi göster. Soru olup olmadığını öğren. Kapanış töreni ve sertifikaların takdimi. Ekler Ek 1: Temel seviye tekerlekli sandalye hizmet eğitim paketi için zaman tablosu Beş tam gün 1. Gün 2. Gün 3. Gün 4. Gün 5. Gün 8:30 a.m. Giriş A.6 Uygun tekerlekli sandalye B.4 Fiziksel değerlendirme B.9 Uygunluk Üçüncü Uygulama: Takip 8:45 9:00 A.7 Minderler B.5 Reçete (seçim) 9:15 9:30 A.1 Tekerlekli sandalye kullanıcıları B.10 Problem çözme 9:45 10:00 Dördüncü Uygulama: Değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlığı, uyguluk ve kullanıcı eğitimi 10:15 A.2 Tekerlekli sandalye hizmetleri A.8 Transferler B.11 Kullanıcı eğitimi 10:30 10:45 A.3 Tekerlekli sandalye hareketliliği 11:00 – 11:15: Sabah çayı (zamanı yerel şartlara ve bölüm planına uyacak şekilde ayarlayın) 11:15 A.3 Tekerlekli sandalye hareketliliği A.8 Transferler B.6 Finansman ve sipariş B.11 Kullanıcı eğitimi Dördüncü Uygulama: Değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlığı, uyguluk ve kullanıcı eğitimi 11:30 Birinci uygulama: Değerlendirme ve reçete (seçim) B.12 Bakım ve onarım 11:45 12:00 12:15 p.m. 12:30 A.4 Dik oturuş B.1 Sevk ve randevu 12:45 1:00 – 2:00 Öğlen yemeği (zamanı yerel şartlara ve bölüm planına uyacak şekilde ayarlayın) 2:00 A.4 Dik oturuş B.2 Değerlendirme B.7 Ürün (tekerlekli sandalye ) hazırlığı B.12 Bakım ve onarım Dördüncü Uygulama: Değerlendirme, reçete(seçim), ürün(tekerlekli sandalye) hazırlığı, uyguluk ve kullanıcı eğitimi 2:15 2:30 A.5 Basınç yaraları B.3 Değerlendirme görüşmesi İkinci Uygulama: Uygunluk ve kullanıcı eğitimi 2:45 3:00 3:15 – 3:30: Öğleden sonra çayı(zamanı yerel şartlara ve bölüm planına uyacak şekilde ayarlayın) 3:30 A.5 Basınç yaraları B.3 Değerlendirme görüşmesi B.8 Minder yapımı İkinci Uygulama: Uygunluk ve kullanıcı eğitimi B.14 Sonuç 3:45 A.6 Uygun tekerlekli sandalye 4:00 4:15 B.4 Fiziksel değerlendirme 4:30 4:45 B.13 Takip 5:00 5:15 Sertifikaların takdimi Ek 2: Tekerlekli sandalye hizmet sevk formu Bir sevk formunun hizmetler için açık bir irtibat ayrıntısı olması gerekir(hizmet adı, posta adresi ve telefon numarasını da içeren bir şekilde olmalı) .Tekerlekli sandalye kullanıcısının hizmet hakkında bilgilendirilmesi ve sevkin yapıldığı konusunda anlaşmaya varılması önemlidir. B.1.’i yürütmek için bir sevk formu gerekmektedir. Tekerlekli sandalye sevk formu olmayan yerlerde, eğitmenler bu formu adapte edebilirler. Bu formun Word versiyonu eğitim paketi CD sinde mevcuttur. Sevk formu ile servis, tekerlekli sandalye kullanıcısı ile randevu için irtibata geçecektir. Bu her zaman imkân dâhilinde olmayabilir. Bu durumda hizmetler başvuranları randevusuz kabul ederler. Ek 3. Tekerlekli Sandalye Değerlendirme Formu Tekerlekli sandalyede dik şekilde kolaylıkla oturabilen tekerlekli sandalye kullanıcıları için yapılan bir değerlendirmedir. Tekerlekli sandalyede dik bir şekilde oturamayan kullanıcılar için “orta düzey” eğitim almış bir kişi tarafından değerlendirme yapılmasına ihtiyaç olabilir. Bu formu tekerlekli sandalye kullanıcısının dosyasında saklayınız. Değerlendirme yapan kişinin adı: Değerlendirme tarihi: 1: Değerlendirme Görüşmesi Tekerlekli sandalye kullanıcısı hakkında bilgi Adı: Numara: Yaşı: Bay  Bayan  Telefon numarası: Adres: Hedefler: Fiziksel durum Beyin felci (serebral palsi) Çocuk felci (polyo)  Omurilik zedelenmesi  Felç (inme)  Zayıf, güçsüz  Spazmlar ya da kontrolsüz hareketler  Ampütasyon: Sağ diz üstü  Sağ diz altı  Sol diz üstü  Sol diz altı Mesane problemleri  Bağırsak problemleri  Eğer tekerlekli sandalye kullanıcısının mesane ya da bağırsak problemleri varsa ilgilenilmiş mi? Evet  Hayır  Diğerleri__________________________________________________________________ Hayat tarzı ve çevresel durum Tekerlekli sandalye kullanıcısının bu sandalyeyi nerelerde kullanacağını tanımlayın: ______________________________________________________________________________ Günlük kat edilen yol: 1 km  ‘ye kadar. 1 – 5 km  5 km  ‘den fazla Günlük tekerlekli sandalye kullanımı nedir? 1  saatten az. 1-3  3-5  5-8  8 saatten fazla  Tekerlekli sandalye kullanıcısı sandalyede oturmuyor iken nerede oturuyor ya da uzanıyor ve nasıl bir yüzeyde oturuyor ve duruşu nasıl? ______________________________________________________________________________ Transfer: Kendi kendine  Yardım ile  Ayakta  Ayakta değil  Kaldırılarak  Diğer  Tuvalet cinsi (eğer tuvalete transfer yapılıyorsa ): Alaturka  Alafranga  Uyarlanmış  Tekerlekli sandalye kullanıcısı sıklıkla toplu / özel taşıma araçlarını kullanıyor mu? Evet  Hayır  Cevap evet ise, ne cins bir: Araba  Taksi  Otobüs  Diğer _________________________________________________________________________ Mevcut tekerlekli sandalye (eğer şahsın zaten tekerlekli sandalyesi var ise) Tekerlekli sandalye kullanıcının ihtiyaçlarını karşılıyor mu? Evet  Hayır  Tekerlekli sandalye kullanıcının çevresel şartlarına uygun mu? Evet  Hayır  Tekerlekli sandalye şahıs için yerinde ve uygun mu ve duruşu için destek sağlıyor mu? Evet  Hayır  Tekerlekli sandalye sağlam ve güvenli mi? (Minder olup olmadığını göz önünde bulundurun) Evet  Hayır  Minder uygun basınç rahatlatması sağlıyor mu? (eğer şahıs basınç yarası riski taşıyorsa) Evet  Hayır  Yorumlar: _____________________________________________________________________ Soruların hepsinin cevabı evet ise kullanıcının yeni bir sandalyeye ihtiyacı olmayabilir. Eğer bu sorulardan bazılarının cevabı hayır ise kullanıcının yeni bir sandalyeye ya da mindere ihtiyacı vardır; ya da mevcut sandalyenin ya da minderin tamire ya da modifikasyona ihtiyacı vardır. 2: Fiziksel Değerlendirme Şimdiki durum, basınç yaralarının geçmişi ya da risk durumu /// = hissetmiyor. O = önceki basınç yarası  = mevcut basınç yarası Normal hissedebiliyor mu? Evet  Hayır  Önceden basınç yarası var mıydı? Evet  Hayır  Halen basınç yarası var mı? Evet  Hayır  Evet ise, açık bir yara mı? (evre 1 – 4)? Evet  Hayır  Süresi ve sebebi: _________________________ _________________________________________ Bu kişi basınç yarası riski* taşıyor mu? *Bir şahıs hissedemiyor ise ya da 3 ve daha fazla risk faktörü taşıyorsa risk altındadır. Risk faktörleri: hareket edilememesi, ıslaklık, kötü duruş, önceki / hali hazırdaki basınç yarası, kötü beslenme, yaşlanma, normal kilonun altında ya da üstünde olmak. Evet  Hayır  İtme metodu Tekerlekli sandalye kullanıcısı sandalyesini nasıl itecek? İki kolla  Sol kolla  Sağ kolla  İki bacağıyla  Sol bacakla  Sağ bacakla  Bir yardımcı aracılığı ile  Yorum: _____________________________________________________________________ Ölçümler Vücut Ölçümü Ölçüm (mm) Vücut ölçülerini ideal tekerlekli sandalye boyutuna çevir Tekerlekli sandalye ölçümleri A Basen genişliği 360mm Basen genişliği = koltuk genişliği 360mm B Koltuk derinliği Sol 400mm B koltuk derinliği = 30 – 50 mm’ den daha küçük ise. (eğer uzunluk farklı ise daha kısa olanını kullanın) 370mm Sağ 400mm C Baldır uzunluğu Sol 380mm = koltuk minderinin üstünden* ayaklık yüksekliğine kadar Ya da = koltuk minderinin üstünden* yere kadar ayakla itmek için 330mm Sağ 380mm 330mm D Göğüs kafesinin alt kısmı 310mm = koltuk minderinin üstünden * arkalığın üstüne kadar ( D ya da E’ i ölçün – kullanıcının ihtiyaçlarına bağlı olarak ) 360mm E Kürek kemiğinin alt kısmı 420mm 470mm *Kullanıcının kullanacağı minderin yüksekliğini ölçün. Ek 4. Tekerlekli Sandalye Reçete (Seçim ) Formu Bu reçete (seçim) formu, tekerlekli sandalye kullanıcısının dik ve rahat oturabilmesi amacıyla tekerlekli sandalye tercihinin, tekerlekli sandalye parçalarının ve minderinin seçiminin kayıt edildiği bir formdur. 1. Tekerlekli Sandalye kullanıcı bilgileri Tekerlekli sandalye kullanıcısının adı: Numara: Değerlendirmenin yapıldığı tarih: Uygunluk ölçümünün yapıldığı tarih: Değerlendirmeyi yapan kişinin adı: 2. Tekerlekli sandalyenin cinsi ve boyutunun seçimi Tekerlekli sandalyenin cinsinin ve boyutunun seçilmesi: o Tekerlekli sandalye kullanıcısıyla görüşünüz, tartışınız; o Tekerlekli sandalye kullanıcısının en önemli ihtiyaçlarını düşününüz; o Kontrol edilecek hususlar: tekerlekli sandalye iskeleti, ön ve arka( büyük) tekerlekler, ayaklıklar, kolçaklar, koltuk arkalığının yüksekliği (ya da ayarlanabilirliği), arka tekerleklerin pozisyonu, destek ve rahatlık. Tekerlekli sandalye cinsi Boyut      3. Minderin cinsinin seçimi Minderin cinsi Boyut Örn. Köpük basınç rahatlatma minderi  Örn. Yassı köpük minderi   4. Anlaşma Sağlandı Kullanıcının imzası: Değerlendirmeyi yapan kişinin imzası: Yöneticinin imzası: Ek 5. Tekerlekli Sandalye Veri Formu Tekerlekli Sandalye Adı: Resmi buraya yerleştirin: Üretici / Sağlayıcı: Mevcut olan boyutlar: Toplam ağırlık: Tanımlama: İskelet: Sabit / Sert Katlanabilir İskelet yüksekliği: Arkalık: Askı şeklinde/ Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Koltuk: Askı şeklinde / Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Minder: Minderi yok Yassı köpük Konturlu köpük (şekillendirilmiş) Ayaklıklar: Sabit Çıkartılabilir/dönebilen Diğer: Ön tekerlekler: Çap: Genişlik(en): Arka(büyük) tekerlekler: Hava basınçlı Çap: İtme kasnakları Dolgu Genişlik(en): Ayarlanabilir aks İç lastikli Çıkartılabilir Frenler: Kısa kaldıraçlı Uzun kaldıraçlı Diğer: Kolçaklar: Sabit Çıkartılabilir/dönebilen Diğer: İtme tutamakları: İtme tutamakları Ekstra parçalar / seçenekler: Destek bandı Arka destek barları Tepsi Diğer: Ölçümler, ayarlama seçenekleri ve ayarlanabilirlik aralığı (sınırları) : Ölçüm (Eğer tekerlekli sandalye değişik boyutlarda mevcutsa bütün boyutları listeleyin ) Bu ayarlanabilir mi? Ayarlanabilirlik aralığı, sınırları (bu sandalye için ayarlanabilirlik aralığı). Evet Hayır Koltuk genişliği(eni): Koltuk derinliği: Koltuk yüksekliği: Arkalık yüksekliği: Arkalık açısı: Ayaklık yüksekliği: Ayaklık açısı: İtme tutamakları yüksekliği: İskelet mesafesi (uzunluğu): Dingil mesafesi (uzunluğu): Ek 6. Kontrol Listesi: Tekerlekli Sandalye Güvenli ve Kullanıma Hazır mı? Tekerlekli sandalye hizmet adı: Tekerlekli sandalye kullanıcısının adı: Tekerlekli sandalye cinsi: Tekerlekli sandalye seri numarası: Bütün tekerlekli sandalyeler Keskin kenarlar bulunmamaktadır.  Çizilmiş ve zarar görmüş parça bulunmamaktadır.  Tekerlekli sandalye düz bir hat üzerinde yol almaktadır.  Ön küçük tekerlekler Serbest dönmektedir.  Tekerlek tutma çatalına dokunmadan dönmektedir.  Cıvatalar sıkılmış durumdadır.  Ön küçük tekerleklerin oturduğu aksam (boru) Tekerlekleri tutan çatal serbestçe dönmektedir.  Arka büyük tekerlekler Serbestçe dönmektedir.  Aks cıvataları sıkılmış durumdadır.  Lastikler doğru bir şekilde şişirilmiştir (başparmakla basınç uygulandığında 5 mm den daha az bir içeri girme olabilir.)  İtme kasnakları güvenlidir.  Frenler Düzgün bir şekilde çalışmaktadır.  Ayaklıklar Ayaklıklar güvenli bir şekilde takılmıştır.  İskelet Katlanabilir tekerlekli sandalye için – tekerlekli sandalye kolaylıkla açılıp kapanmaktadır.  Arkalığı katlanabilir tekerlekli sandalye için – arkalık kolaylıkla katlanıp açılmaktadır.  Minder Minder kılıfının içinde düzgün bir şekilde durmaktadır.  Minder tekerlekli sandalyenin üzerinde düzgün bir şekilde durmaktadır.  Minder kılıfının kumaşı gergin bir şekilde ama gereğinden fazla gergin değildir.  Tekerlekli sandalyenin yekpare bir koltuğu var ise: minder yekpare koltuğun tamamını kaplamaktadır.  Tekerlekli sandalyeyi kontrol eden kişinin adı: İmza: Tarih: Ek 7. Tekerlekli sandalye uygunluk kontrol listesi 1. Tekerlekli sandalye hazır mı? Tekerlekli sandalyenin bütün parçalarının güvenli bir kullanıma hazır olduğuna dair kontroller yapıldı mı?  2. Boyut ve ayarların kontrolü Koltuk genişliği (eni) : Oldukça uygun olmalı.  Koltuk derinliği: Koltuk/minder ile dizin arkası arasında iki parmaklık bir mesafe olmalı.  Ayaklık yüksekliği: Uyluklar minderin üzerine tam destekli ve altında boşluk olmadan durmalı. Ayaklar, ayaklığın üzerinde arada boşluk olmadan tam destekli bir şekilde durmalı.  Arkalık yüksekliği: Tekerlekli sandalye kullanıcısının omuzlarının desteklenmeye ve itmek için hareket serbestliğine ihtiyacı vardır (eğer tekerlekli sandalyesinin ilerlemesini kendisi sağlıyorsa).  Arka (büyük) tekerleklerin pozisyonu (el ile itmek için): Tekerlekli sandalye kullanıcısı kolunu sarkıttığı zaman, arka büyük tekerlek ekseni ile aynı hatta olmalıdır. Eller itmek için tekerleklerin itme kasnaklarına konulduğunda kullanıcının dirseği doğru bir açıda olmalıdır.  Frenler: Frenler çalışıyor mu?  Koltuk yüksekliği (ayak ile itmek için): Tekerlekli sandalye kullanıcısı dik bir şekilde oturuyor iken sırtı koltuk arkalığı tarafından rahat bir şekilde destekleniyor ve ayak yere düz bir şekilde dayanıyor olmalı.  3. Oturma pozisyonu kontrolü Tekerlekli sandalye kullanıcısı dik bir pozisyonda rahat oturabiliyor mu?  Oturuş pozisyonunu yandan kontrol ediniz.  Oturuş pozisyonunu önden/arkadan kontrol ediniz.  4. Basınç kontrolü Bütün tekerlekli sandalye kullanıcılarının basınç yarası geliştirme riski olduğu için kalça kemiklerinin altındaki basıncı kontrol edin. A Tekerlekli sandalye kullanıcısına testi açıklayın. B Tekerlekli sandalye kullanıcısına öne eğilmesini ya da kendisini yukarı doğru itmesini söyleyin. Parmak uçlarınızı tekerlekli sandalye kullanıcısının kalça kemiğinin altına koyun. C Tekerlekli sandalye kullanıcısından parmaklarınızın üzerine geri oturmasını isteyin. Dik bir şekilde ve elleri bacaklarının (uyluklarının) üzerine koyulmuş olarak oturduklarından emin olun. D Basıncın tanımlanması: Seviye bir = güvenli: Parmak uçları yukarı ve aşağı 5 mm ya da daha fazla kıpırdatılabiliyor. Seviye iki = uyarı: Parmak uçları kıpırdatılamıyor ama kolaylıkla dışa doğru kaydırılabiliyor. Seviye üç =tehlikeli: Parmak uçları sıkıca sıkışmış. Parmakları çekip çıkarmak oldukça zor E İkinci kalça kemiğinde de tekrarlayınız. 5. Uygunluğun tekerlekli sandalye hareket halinde iken kontrolü Arkalıklar, tekerlekli sandalye kullanıcısına omuzlarını itebilmek için gerekli hareket imkânını sağlıyor mu?  Arkalıklar, tekerlekli sandalye kullanıcısına yeterli desteği sağlıyor mu?  Tekerlekli sandalye kullanıcılarının ayakları ayaklıkların üzerinde mi duruyor?  Arka büyük tekerleklerin pozisyonu kullanıcı için doğru pozisyon mu?  6. Eylem? Gerekli olan daha ileri düzey bir eylem var mı? Tekerlekli sandalye kullanıcısının dosyasında her ne eylem var ise yazınız. .  Hatırlatma: Uygunluktan bir sonraki aşama kullanıcı talimatıdır. Ek 8.Tekerlekli Sandalye Eğitim Kontrol Listesi Öğretme Becerileri Öğrenme Becerileri Tekerlekli sandalye kullanımı Tekerlekli sandalyeyi katlama Tekerlekli sandalyeyi kaldırma Çıkarılabilir tekerleklerin kullanımı Frenlerin kullanımı Minderin doğru yerleştirme de dâhil kullanımı Transferler Kendi kendine transfer Yardımla transfer Diğer Tekerlekli sandalye hareket kabiliyeti Uygun bir şekilde itme Yukarı aşağı eğimler Yukarı aşağı basamaklar Engebeli yüzeyler Sadece büyük tekerleklerin üzerinde kısmi olarak dengede durabilme Basınç yaralarını önleme Basınç yaralarının kontrolü Basınç rahatlatma için yükselme İyi beslenmek ve bol su içmek Basınç yarası gelişirse nelerin yapılacağı Tekerlekli sandalyenin evde bakımı Tekerlekli sandalyeyi ve minderi temizleyin Hareketli parçaları yağlayın Tekerlekleri şişirin Somunları ve cıvataları sıkılayın (eğer gevşekse) Tekerlek jant tellerini sıkılayın (eğer gevşekse) Kaplamaları kontrol edin Paslanmayı kontrol edin Minderi kontrol edin Problem var ise yapılacaklar Tekerlekli sandalyenin tamire ihtiyacı var Tekerlekli sandalye uygun değil ya da rahat değil Ek 9. Tekerlekli Sandalye Takip Formu Bu form takip ziyaretinde elde edilen bilgileri kaydetmek içindir. 1. Tekerlekli sandalye kullanıcısı bilgileri Tekerlekli sandalye kullanıcısının adı: Numara: Uygunluk tarihi: Takip tarihi: Takibi gerçekleştiren kişinin adı: Takibin uygulandığı yer: Tekerlekli sandalye kullanıcısının evi  Tekerlekli sandalye servis merkezi  Diğer: ________________________________________ 2. Görüşme Alınacak önlemleri kaydet: Tekerlekli sandalyenizi istediğiniz kadar çok kullanabiliyor musunuz? Evet  Hayır  Cevap hayır ise – neden? Tekerlekli sandalyenizi kullanırken hiç problem yaşıyor musunuz? Evet  Hayır  Cevap evet ise – bu problemler nelerdir? Tekerlekli sandalyenizin kullanımı ile ilgili sorularınız var mı? Evet  Hayır  Cevap evet ise – bu sorular nelerdir? Daha ileri düzey bir eğitime ihtiyaç var mı? Kullanıcının basınç yarası mevcut mu? Evet  Hayır  Eğer cevap ise - tanımlayınız (nerede ve ne düzeyde) Tekerlekli sandalyenizle ilgili memnuniyetinizi 1 ile 5 arasında değerlendirirseniz kaç verirsiniz? (1 çok memnun ve 5 hiç memnun değil) Değer: Yorum: 3. Tekerlekli sandalye ve minder kontrolü Tekerlekli sandalye iyi çalışır vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Minder kullanımı uygun vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Her biri için cevap hayır ise, problem nedir? 4. Uygunluk kontrolü Tekerlekli sandalye doğru bir şekilde uyuyor mu? Evet  Hayır  Cevap hayır ise – problem nedir? Basınç testi düzeyi (1 = güvenli, 2 = uyarı, 3 = tehlikeli) (eğer kullanıcı basınç yarası geliştirme riski altındaysa) Sol: Sağ: Tekerlekli sandalye kullanıcısı hareketsizken, hareket ederken ve gün boyunca rahat ve dik oturabiliyor mu? Evet  Hayır  Eğer cevap hayır ise – problem nedir? Ek 10: Eğitmen gözlem kontrol listesi Bu form eğitmenlere her bir uygulama bölümünün gözleminde yardımcı olmak için tasarlanmıştır. Eğitmen gözlem kontrol listesi: Birinci uygulama: Değerlendirme ve reçete (seçim) Eğitmenin adı: ________________________________________ Uygulama tarihi: ________________________________________________ Bölüm süresini yakından izle İyi ve kötü uygulama örneklerini geri bildirim için yaz: Gelişme kaydetmek için uygulama yapılması gereken örnekleri geri bildirim için yaz: Dak  Değerlendirme 45  Reçete(seçim) 30  Geri bildirim 10  Grubun gösterim yaptığı ve gözlemlediğiniz aşağıdaki becerileri kontrol et. Grup geri bildirimi için sahip olduğunuz geri bildirimi yaz. Grup: Bir İki Üç Katılımcının adı: Tekerlekli sandalye kullanıcısının adı:  Yorum  Yorum  Yorum Genel gözlem Tekerlekli sandalye kullanıcısı ve ailesi ile iyi iletişim becerileri var    Tekerlekli sandalye kullanıcısı her bir adıma ve kararlara dâhil oldu    Uygulama zamanında tamamlandı    Değerlendirme: Görüşme sırasında anahtar noktalarla ilgili bilgi elde edildi.    Kullanıcının değerlendirme sedyesine transferinin güvenli bir şekilde sağlanması izleniyor    Şu anda olan, riski olan ya da geçmişte olan basınç yaraları tanımlandı    İtme metodu doğru bir şekilde tanımlandı    Ölçüler doğru şekilde alındı    Tekerlekli sandalye değerlendirme formu doğru bir şekilde dolduruldu.    Reçete (seçim): En uygun tekerlekli sandalye ve minder (boyut ve cins olarak) seçildi    Küçük modifikasyonlar / problem çözme ihtiyacı belirlendi    Tekerlekli sandalye reçete (seçim ) formu doğru bir şekilde tamamlandı    Eğitmen gözlem kontrol listesi: İkinci uygulama: Uygunluk ve kullanıcı eğitimi. Eğitmen adı: ________________________________________ Uygulama tarihi: ___________________________________________________ Bölüm süresini yakından izle İyi ve kötü uygulama örneklerini geri bildirim için yaz: Gelişme kaydetmek için uygulama yapılması gereken örnekleri geri bildirim için yaz: Dak  Uygunluk 45  Kullanıcı eğitimi 50  Geri bildirim 20  Seçenekli kullanıcı geri bildirimi 30  Grubun gösterim yaptığı ve gözlemlediğiniz aşağıdaki becerileri kontrol et. Grup geri bildirimi için sahip olduğunuz geri bildirimi yaz. Grup: Bir İki Üç Katılımcının adı: Tekerlekli sandalye kullanıcısının adı:  Yorum  Yorum  Yorum Genel gözlem Tekerlekli sandalye kullanıcısı ve ailesi ile iyi iletişim becerileri var    Tekerlekli sandalye kullanıcısı her bir adıma ve kararlara dâhil oldu    Uygulama zamanında tamamlandı    Uygunluk: Uygunluk sürecinin her adımı güvenli bir şekilde (örn. transferler) ve doğru bir şekilde uygunluk kontrol listesi takip edilerek tamamlandı.    Uygunlukla ilgili problemler tanımlandı ve belirtildi.    Tekerlekli sandalyeyi doğru uygunluğa getirmek için grubun problemi çözmesi ve sandalyeyi ayarlaması.    Kullanıcı eğitimi: Grup kullanıcı eğitim kontrol listesini bir rehber olarak kullanarak, kullanıcıya ve ailesine öğretilecek en uygun tekerlekli sandalye becerilerini seçti.    Beceriler öğretilirken iyi öğretme teknikleri gösterildi.(örn. uygulama, gösterim, açıklama).    Eğitim güvenli bir şekilde yürütüldü (örn. tekerlekli sandalye hareketlilik becerileri öğretilirken arkada yardımcı bulundu, transfer güvenli bir şekilde öğretildi).    Eğitmen gözlem kontrol listesi: Üçüncü pratik: Takip. Eğitmen adı: __________________________________________ Uygulama tarihi: ________________________________________________ Bölüm süresini yakından izle İyi ve kötü uygulama örneklerini geri bildirim için yaz: Gelişme kaydetmek için uygulama yapılması gereken örnekleri geri bildirim için yaz: Dak  Takip 60  Geri bildirim 25  Grubun gösterim yaptığı ve gözlemlediğiniz aşağıdaki becerileri kontrol et. Grup geri bildirimi için sahip olduğunuz geri bildirimi yaz. Grup: Bir İki Üç Katılımcının adı: Tekerlekli sandalye kullanıcısının adı:  Yorum  Yorum  Yorum Genel gözlemler: Tekerlekli sandalye kullanıcısı ve ailesi ile iyi iletişim becerileri var    Tekerlekli sandalye kullanıcısı her bir adıma ve kararlara dâhil oldu    Uygulama zamanında tamamlandı    Takip: Tekerlekli sandalyenin fiziksel durumu grup tarafından kontrol edildi.    Tekerlekli sandalyenin kullanıcıya ne kadar uyduğu fiziksel olarak kontrol edildi.    Uygun takip eylemleri tanımlandı ve kayıt edildi.    Bölüm sırasında uygulanabilecek takip eylemleri yerine getirildi.    Eğitmen gözlem kontrol listesi: Dördüncü pratik: Tekerlekli sandalye kullanıcı değerlendirmesi, reçete(seçim), ürün(tekerlekli sandalye) hazırlığı, uygunluk ve kullanıcı eğitimi. Eğitmenin adı: __________________________________________ Uygulama tarihi: ________________________________________________ Bölüm süresini yakından izle İyi ve kötü uygulama örneklerini geri bildirim için yaz: Gelişme kaydetmek için uygulama yapılması gereken örnekleri geri bildirim için yaz: Dakika1  Değerlendirme 30  Reçete (seçim) 20  Ürün(tekerlekli sandalye) hazırlığı 60  Uygunluk 30  Kullanıcı eğitimi 45  Geri bildirim 30  Grubun gösterim yaptığı ve gözlemlediğiniz aşağıdaki becerileri kontrol et. Grup geri bildirimi için sahip olduğunuz geri bildirimi yaz. Grup: Bir İki Üç Katılımcının adı: Tekerlekli sandalye kullanıcısının adı:  Yorum  Yorum  Yorum General gözlemler: Tekerlekli sandalye kullanıcısı ve ailesi ile iyi iletişim becerileri var    Tekerlekli sandalye kullanıcısı her bir adıma ve kararlara dâhil oldu    Uygulama zamanında tamamlandı    Değerlendirme: 1 Dikkat edin; Eğitmenlerin her adımı kontrol etmeleri ve herhangi bir problemin çözümü için ek olarak 20 dakika müsaade edilir. Görüşme sırasında anahtar noktalarla ilgili bilgi elde edildi.    Kullanıcının değerlendirme sedyesine transferinin güvenli bir şekilde sağlanması izleniyor    Şu anda olan, riski olan ya da geçmişte olan basınç yaraları tanımlandı    İtme metodu doğru bir şekilde tanımlandı    Ölçüler doğru şekilde alındı    Tekerlekli sandalye değerlendirme formu doğru bir şekilde dolduruldu.    Reçete (seçim): En uygun tekerlekli sandalye ve minder (boyut ve cins olarak) seçildi    Küçük modifikasyonlar / problem çözme ihtiyacı belirlendi    Tekerlekli sandalye reçete (seçim ) formu doğru bir şekilde tamamlandı    Ürün(tekerlekli sandalye) hazırlığı: Tekerlekli sandalyenin kurulumu reçete (seçim) formundakine uygun olarak yapıldı.    Tekerlekli sandalye güvenli ve kontrol listesi doğru bir şekilde dolduruldu.    Uygunluk: Uygunluk sürecinin her adımı güvenli bir şekilde (örn. transferler) ve doğru bir şekilde uygunluk kontrol listesi takip edilerek tamamlandı.    Uygunlukla ilgili problemler tanımlandı ve belirtildi.    Tekerlekli sandalyeyi doğru uygunluğa getirmek için grubun problemi çözmesi ve sandalyeyi ayarlaması.    Kullanıcı eğitimi: Grup kullanıcı eğitim kontrol listesini bir rehber olarak kullanarak, kullanıcıya ve ailesine öğretilecek en uygun tekerlekli sandalye becerilerini seçti.    Beceriler öğretilirken iyi öğretme teknikleri gösterildi.(örn. uygulama, gösterim, açıklama).    Eğitim güvenli bir şekilde yürütüldü (örn. tekerlekli sandalye hareketlilik becerileri öğretilirken arkada yardımcı bulundu, transfer güvenli bir şekilde öğretildi).   

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Tekerlekli Sandalye Hizmet Eğitim Paketi Temel düzey Katılımcı El Kitabı Tekerlekli Sandalye Hizmet Eğitim Paketi Temel düzey Katılımcı El Kitabı Published by the World Health Organization in 2012 under the title Wheelchair Service Training Package: Basic Level (Dünya Sağlık Örgütü Tarafından 2012 yılında Tekerlekli Sandalye Hizmet Eğitim Paketi-Temel Seviye başlığı altında yayınmalmıştır) © World Health Organization (Dünya Sağlık Örgütü) 2012 Her hakkı saklıdır. Dünya Sağlık Örgütü yayınları şu bağlantılar yoluyla elde edilebilir: WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264; faks: +41 22 791 4857; e-mail: bookorders@who.int). Dünya Sağlık Örgütü yayınlarını çoğaltmak veya tercüme etmek için olan talepler – satışı veya ticari olmayan dağıtımı – WHO Press, yukarıda geçen adrese (faks: +41 22 791 4806; e-mail: permissions@who.int) yönlendirilmelidir. Bu yayında geçen başlıklar ve sunulan içerik, hiç bir şekilde, herhangi bir ülkenin, bölgenin, şehrin ya da sahanın hukuki statüsü ya da bu yerlerin yetkilileri ya da sınırlarının ya da sinir bölgelerinin tahdit edildiği ile ilgili herhangi bir görüsün Dünya Sağlık Örgütü tarafından ifade edildiği anlamına gelmez. Yayında belli başlı şirketlerin ya da imalatçıların ürünlerinin isimlerinin geçmesi bunların, adi geçmeyen ayni nitelikle diğer ürünlerin aleyhine, Dünya Sağlık Örgütü tarafından onaylandığı ya da tavsiye edildiği anlamına gelmez. Hatalar ve eksikler dışında, müseccel markaların isimleri, büyük bas harfleri ile belirtilmiştir. Bu yayında yer alan bilgilerin doğruluğunun teminatı için Dünya Sağlık Örgütü tarafından tüm makul önlemler alınmıştır. Ancak, yayınlanan içerik, sarih ya da zımni, herhangi bir garanti olmadan dağıtılmaktadır. İçeriğin kullanımına ya da yorumlanmasına ilişkin sorumluluk okuyucuya aittir. Dünya Sağlık Örgütü, hiç bir şekilde, bu yayının kullanımından doğabilecek zararlardan sorumlu değildir. The Director General of the World Health Organization has granted translation and publication rights to an edition in Turkish to Latter-day Saint Charities, which is solely responsible for the Turkish edition. (Dünya Sağlık Örgütü Genel Direktörü, Türkçe çeviri ve yayınlama hakkını,Türkçe baskısının tek sorumlusu olarak Son Zaman Azizler Hayır İşleri’ ne vermiştir.) © Latter-day Saint Charities 2012 Wheelchair Service Training Package: Basic Level (Tekerlekli Sandalye Hizmet Eğitim Paketi: Temel düzey) 1. Tekerlekli sandalye - hizmet 2. Tekerlekli sandalye - tedarik ve dağıtım. 3. Tekerlekli sandalye - özellikler. 4. Engelli kişiler - rehabilitasyon. 5. Gelişmekte olan ülkeler. 6. Dünya Sağlık Örgütü Orijinal İngilizce versiyonuna katkıda bulunanlar: Editörler: Chapal Khasnabis ve Kylie Mines Yazarlar: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Değerlendirmeciler: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, ve Isabelle Urseau Çizimler: Melissa Puust Fotoğraf Jeneriği: Chapal Khasnabis and Jesse Moss Video Jeneriği: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Rehber eğitimciler: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri Maddi destek: ABD Uluslararası Kalkınma Ajansı ve Avustralya Uluslararası Kalkınma Ajansı Ortak Kuruluşlar: ASSERT Doğu Timor, Kenya Fiziksel Engelliler Derneği (APDK), Soloman Adaları Sağlık Bakanlığı ve Medikal Hizmetler’in Toplum Temelli Rahabilitasyon Ünitesi, Eğitim Gelişim Merkezi (EDC), Handicap İnternasyonal, Uluslararası Kızıl Haç Komitesi (ICRC), Uluslararsı Protetik Ortetik Derneği (ISPO), Kilimanjaro Omurilik Felçliler Derneği (KASI), Mobility India, Motivasyon Australia, Motivasyon Hayır Vakfı (Motivasyon), Motivasyon Romanya ve Tanzania Ortopedi Teknoloji Uzmanları Merkezi (TATCOT) Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 3. İçindekiler Amaç .............................................................................................. ............................................ 5 A.4: Dik Oturuş .................................................................................... ........................................ 5 A.6: Uygun Tekerlekli Sandalye .................................................................................................. 7 A.7: Minderler ..................................................................................... ......................................... 9 A.8: Transferler ................................................................................... ...................................... 10 B.3: Değerlendirme Görüşmesi ................................................................................................. 11 B.4: Fiziksel Değerlendirme ...................................................................................................... 16 B.5: Reçete (seçim) – tekerlekli sandalye verileri ...................................................................... 21 B.5: Reçete (seçim) – uygun tekerlekli sandalye boutunun seçimi............................................. 21 B.7: Ürün (tekerlekli sandalye) hazırlığı ..................................................................................... 23 B.8: Minder yapımı ................................................................................. ................................... 24 B.11: Kullanıcı eğitimi ............................................................................ .................................... 26 B.12: Bakım ve onarım .............................................................................................................. 27 B.13: Takip ........................................................................................ ........................................ 29 B.14: Sonuç ........................................................................................ ...................................... 34 İsim: _________________ Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 4. Amaç: Temel seviye eğitim paketi, hareketlilik noksanlığı çeken ama aynı zamanda ilave duruş desteği olmadan kendi başına oturabilen gençler ve yetişkinlere uygun manüel tekerlekli sandalyeler ve minderler sağlamak amacıyla personel ve gönüllülere eğitim vermek için hazırlanmış bir programdır. Katılımcı El Kitabının amacı, tekerlekli sandalye hizmet dağıtımı ile ilgili personelin bilgi ve becerilerini geliştirmektir. Katılımcı El kitabı, katılımcıların bilgi ve becerilerini test edip geliştirmelerine yardımcı olacak alıştırmaları içermektedir. Katılımcı El Kitabı; konferans materyalleri, slayt sunumları ve başvuru kitabını içermektedir; burada amaçlanan katılımcıların ileride ihtiyaç duyduklarında başvurabilecekleri kendi nüshalarının olmasıdır. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 5. A.4: Dik Oturuş o Her bir örnekteki farklı duruşlara yakından bakınız. o Dik oturuştan farkı nedir yazınız. o Dik oturuşun önden ve yandan ne özellikleri olduğunu düşünün. 1. Bu kişinin duruşunun “dik oturuş” dan ne farkı olduğunu anlatınız. 2. Bu kişinin duruşunun “dik oturuş” dan ne farkı olduğunu anlatınız. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 6. 3. Bu kişinin duruşunun “dik oturuş” dan ne farkı olduğunu anlatınız. Dik oturmamaktan kaynaklanan problemler nelerdir? 1. 2. 3. 4. 5. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 7. A.6: Uygun Tekerlekli Sandalye o Bütün kullanıcıların hikâyelerini okuyun. o Kullanıcıların ihtiyaçlarını karşılayacak, mevcut olan en iyi tekerlekli sandalye hangisi olduğu konusunu görüşün. o Katılımcıların, tekerlekli sandalye kullanıcısına bu tekerlekli sandalyeyi önermeleri için en az üç sebebi sıralayın. o Tekerlekli sandalye kullanıcısının fiziksel, çevresel ve hayat tarzı ile ilgili ihtiyaçlarını – ve bir tekerlekli sandalyede hangi özelliklere ihtiyacı olduğunu göz önünde bulundurun. o Cevaplarınızı yazın. Bao Mevcut tekerlekli sandalyelerden hangisi Bao’nun ihtiyaçlarını en iyi karşılar? Neden? Bao kırsal bir bölgede yaşamaktadır. Çift taraflı diz altı ampütasyonu vardır. Kaza geçirmeden önce köy yolundaki bir bakkal dükkânını işletiyordu. Dükkâna giden yol uzun, (yaklaşık 1 km) engebeli ve genellikle de çamurlu olduğu için şimdi işine ancak yardım alarak gidebiliyor. Bu durum hem o hem de ailesi için dükkânın işlemeye devam etmesini zorlaştırıyor. Uzun zaman önce Bao’nun bağış olarak verilmiş ortopedik cins bir tekerlekli sandalyesi oldu. Bu sandalye paslanmış ve döşemesi de parçalanmıştı. Ön tekerlekleri çok küçük ve arka tekerlek lastikleri çok ince ve yıpranmıştı. Tekerlekli sandalyeyi kulübesinden köye giden yol boyunca itemiyordu çünkü tekerlekler yola batıyordu. Karısına ya da ona yardım eden diğer kişilere bağımlı kalmadan kendi dükkânına kendi başına gidebilmek istiyordu. Amanthi Mevcut tekerlekli sandalyelerden hangisi Amanthi’nin ihtiyaçlarını en iyi karşılar? Neden? Amanthi 24 yaşında bir kızdır ve ailesi ile birlikte küçük bir kasabada yaşamaktadır. 18 yaşındayken bir kaza geçirmiştir ve paraplejik olmuştur (belden aşağısı tutmamaktadır). Amanthi’nin kısa bir süre önce basınç ülseri (yarası) olmuştur ve iyileşmesi altı ay sürmüştür. Amanthi’nin ortopedik bir tekerlekli sandalyesi vardır ancak sandalye ona iyi bir destek sağlamamakta ve o sandalyedeyken çok yorulmaktadır. Sandalyesinin minderi yoktur ve o, basınç yarası geliştirmesinin sebebinin bu durumdan kaynaklandığını düşünmektedir. Amanthi bir sekreterlik kursuna kayıt olması için davet almıştır kendisi de bunu istemektedir. Ancak şu anda sahip olduğu tekerlekli sandalyede bütün gün oturamayacağından korkmaktadır. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 8. Phillip Mevcut tekerlekli sandalyelerden hangisi Philip’in ihtiyaçlarını en iyi karşılar? Neden? Philip 62 yaşındadır ve küçük bir adada yaşamaktadır. Altı ay önce felç geçirmiştir. Evine dönmeden önce hastanede bir ay geçirmiştir ve tekerlekli sandalyesi yoktur. Ya yatağında yatmakta ya da evinin verandasındaki sandalyesinde oturmaktadır. Philip sol kolunu ya da bacağını hareket ettirememektedir. Bununla beraber her geçen gün güçlenmektedir ve aileden birilerinin yardımı ile dik durabilmektedir. Sağ kolunu çalıştırmaktadır ve bir tekerlekli sandalyesi olmasını çok istemektedir ki bu yolla daha hareketli olabilir ailesine daha az bağımlı hale gelebilir. Tek kat olan küçük evinin etrafında dolaşabilmek ve etrafta bulunan komşularını gezebilmek istemektedir. Bölge oldukça kumlu bir yapıya sahiptir. Torunlarından birinin arabası vardır ve onun tekerlekli sandalyesi olduğu takdirde onu gezdireceğini söylemektedir. Sabina Mevcut tekerlekli sandalyelerden hangisi Sabrina’nın ihtiyaçlarını en iyi karşılar? Neden? Sabrina 56 yaşındadır ve küçük bir adada yaşamaktadır. Yıllar önce, dördüncü çocuğunun doğumunun ardından bacaklarının gücünün büyük bir kısmını kaybetmiştir. Biraz olsun ayakta durabilmektedir ama yürüyememektedir. Hiçbir zaman bir tekerlekli sandalyesi olmamıştır. Sabrina deniz kenarında küçük bir köyde yaşamaktadır – ve evinin etrafındaki yüzeyler engebeli ve kumludur. Zamanını torunlarının bakımına yardımcı olarak, yemek pişirerek ve örgü örerek geçirmektedir. Evinde tekerlekli sandalye için yeterli alan yoktur ama evinin aşağısında muhafaza edilebilir çünkü evi direkler üzerinde (sütunlar) yapılı bir evdir. Çevresel şartlarınıza mevcut olan tekerlekli sandalyelerden hangileri en iyi şekilde uyar ve neden? 1. 2. 3. 4. 5. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 9. A.7: Minderler o Gruptaki herkesle kalça kemiğinin altındaki (sol ve sağ) basınç kontrolünün uygulamasını yapın o Gruptaki herkesin testi yapma ve kendi üzerinde de yapılma imkânına sahip olduğuna emin olun. o Gruptaki her bir kişinin basınç düzeylerini aşağıdaki tabloya yazın. Bütün tekerlekli sandalye kullanıcılarının basınç yarası geliştirme riski olduğu için kalça kemiklerinin altındaki basıncın kontrol edin. Başlamadan önce tekerlekli sandalye kullanıcısına testi açıklayın. . B Tekerlekli sandalye kullanıcısına öne eğilmesini ya da kendisini yukarı doğru itmesini söyleyin. Parmak uçlarınızı tekerlekli sandalye kullanıcısının kalça kemiğinin altına koyun. C Tekerlekli sandalye kullanıcısından parmaklarınızın üzerine geri oturmasını isteyin. Dik bir şekilde ve elleri bacaklarının (uyluklarının) üzerine koyulmuş olarak oturduklarından emin olun. D Basıncın tanımlanması: Seviye bir = güvenli: Parmak uçları yukarı ve aşağı 5 mm ya da daha fazla kıpırdatılabiliyor. Seviye iki = uyarı: Parmak uçları kıpırdatılamıyor ama kolaylıkla dışa doğru kaydırılabiliyor. Seviye üç =tehlikeli: Parmak uçları sıkıca sıkışmış. Parmakları çekip çıkarmak oldukça zor E İkinci kalça kemiğinde de tekrarlayınız. Gruptaki her bir kişi için basınç seviyelerini aşağıdaki tabloya kaydedin. Sol kalça kemiği Sağ kalça kemiği Kişi 1 Seviye1: Seviye2: Seviye3: Seviye1: Seviye2: Seviye3: Kişi 2 Seviye1: Seviye2: Seviye3: Seviye1: Seviye2: Seviye3: Kişi 3 Seviye1: Seviye2: Seviye3: Seviye1: Seviye2: Seviye3: Kişi 4 Seviye1: Seviye2: Seviye3: Seviye1: Seviye2: Seviye3: Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 10. A.8: Transferler o Kullanıcının hikâyesini okuyun. o Her bir tekerlekli sandalye kullanıcısı ile onlar için en uygun olan transfer yolunu ve bunun nedenlerini görüşün. o Cevaplarınızı yazın. Faridah Fridah için en uygun transfer yolu ne olabilir? Neden? Fridah 60 yaşındadır. Mahallesindeki hastaneden tekerlekli sandalye servisine sevk edilmiştir. Yakın zamanda bir felç geçirmiştir ve yürüyemediğinden dolayı bir tekerlekli sandalyeye ihtiyacı vardır. Fridah biraz da olsun ayağa kalkabilmektedir ve kendi ağırlığını taşıyabilmektedir ancak ayakları üzerinde denge kuramamaktadır. Fridah kızı ve ailesiyle beraber yaşamaktadır. Kızı çalışmamaktadır ve annesine yardım edebilecek durumdadır. Dört tekerlekli ve yanlara dönebilen ayaklıkları olan bir tekerlekli sandalyesi vardır. Jose Jose için en uygun transfer yolu ne olabilir? Neden? Jose 45 yaşındadır ve 10 yıldır tekerlekli sandalye kullanmaktadır. Çift taraflı diz üstü alt- ekstremite ampütasyonu vardır ve mahalle pazarında bir radyo tamir atölyesinde çalışmaktadır. Jose tekerlekli sandalye servisine yeni bir sandalye almak için gelmiştir çünkü eski sandalyesi çok yıpranmış durumdadır. Tahir Tahir için en uygun transfer yolu ne olabilir? Neden? Tekerlekli sandalye kullanıcısı Tahir 14 yaşındadır ve kısa bir süre önce ağaçtan düşüp omurilik zedelenmesi sıkıntısı yaşamıştır ve tekerlekli sandalye için sevk edilmiştir. Tahir kollarını iyi bir şekilde kullanabilmektedir ama henüz çok güçlü değildir. Bacaklarını hiç kullanamamaktadır. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 11. B.3: Değerlendirme Görüşmesi o Gruptaki her bir kişi bir hikâyeyi okuyup tekerlekli sandalye kullanıcılarından biri gibi rol yapacak. Sizinle görüşme yapılırken, hikâyedeki bilgileri kullanın ve görüşme sorularını en iyi şekilde cevaplandırmaya çalışın. o Kullanıcının hikâyesini gruptaki diğer kişilerin duyacağı şekilde yüksek sesle okumayın ve başkalarının hikâyelerini okumayın. o Sırayla arka arkaya görüşme yaparak takip eden sayfalardaki değerlendirme formunu doldurun. Felicia şiddetli artrit (eklem iltihabı) sıkıntıları olan yaşlı bir kadındır. Kollarında, ellerinde ve bacaklarında ağrıları vardır. Birkaç adımdan daha fazla yürüyememektedir çünkü ağrıları vardır ve kendine bakmak çok zor gelmektedir. Felicia kızı ile değerlendirmeye katılmıştır. Küçük bir kasabada yaşamaktadır evinin girişinde üç basamaklı bir merdiven vardır. Artrit dışında başka bir sağlık problemi yoktur. Daha önce düzenli olarak kiliseye giderken artık bunu yapamamaktadır. Evinde alafranga tipi bir tuvaleti vardır. Ailesinin arabası yoktur ve toplu taşıma araçlarını kullanmaktadırlar. Değerlendirmeye gelmek için taksi tutmuşlardır. Ancak bu onlar için pahalı bir yoldur. Hali hazırda bir tekerlekli sandalyesi yoktur. Anton ‘un polyosu (çocuk felci) vardır. 26 yaşındadır ve küçük bir kasabada yaşamaktadır. Bilgisayar eğitimi almaktadır ve gelecekte kendi işini kurmayı çok istemektedir. Değerlendirmeye karısıyla birlikte gelmiştir. Çok uzun zaman önce Anton’a bağış olarak verilmiş ortopedik cins bir tekerlekli sandalyesi vardır. Tekerlekli sandalye paslanmıştır ve döşemesi parçalanmıştır. Ön tekerlekler küçük ve incedir. Arka tekerlekler ince ve yıpranmış durumdadır. Tekerlekli sandalye rahatsız ve itmesi zor bir sandalyedir. Anton ailesi ile aynı tuvaleti kullanmaktadır. Kasabalarındaki yollar engebelidir ve tekerlekli sandalye sıklıkla yere saplanmaktadır. Ancak Anton evinden mesleki eğitim merkezine kendi başına gitmek istemektedir. Gitmesi gereken mesafe 1½ km’dir. Şu an itibariyle onun küçük erkek kardeşinin yardımına ihtiyacı vardır ancak kardeşi oma her zaman yardımcı olamamaktadır. Chantou 13 yaşındadır. İki Bacağını da (dizinin üstünden) deprem sırasında kaybetmiştir. Ailesi ile beraber kasana yakınlarındaki bir apartman dairesinde yaşamaktadır. Değerlendirmeye annesi ve büyük kız kardeşi ile gelmiştir. Ona bağışlanmış bir tekerlekli sandalyesi vardır. Bu sandalye erişkin boyutunda ortopedik cins bir tekerlekli sandalyedir. Tekerlekli sandalye Chantou’ya göre fazla büyüktür. İtme kasnaklarına ulaşmak için kolçakların üzerinden uzanması gerekmektedir. Bu onun için zor bir durumdur. Arkalık da fazla yüksektir ve minder yoktur. Chantou tekrar okula başlamak istemektedir fakat tekerlekli sandalyede fiziksel olarak rahatsız hissetmektedir. Kendi başına gezinemediği için utanmaktadır. Kendi başına itebileceği ve ona daha fazla destek sağlayacak bir tekerlekli sandalye istemektedir. Eğer tekerlekli sandalyesini de götürebilecekse okula okul servisiyle gidebileceğini söylemektedir. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 12. Grubunuzdaki tekerlekli sandalye kullanıcısı rolü yapan kişiyle görüşme yapın ve aşağıdaki değerlendirme formunu doldurun. Değerlendirme yapan kişinin adı: Değerlendirme tarihi: Tekerlekli sandalye kullanıcısı hakkında bilgi Adı: Numara: Yaşı: Bay  Bayan  Telefon: Adres: Hedefler: Fiziksel durum Beyin felci (serebral palsi) Çocuk felci (polyo)  Omurilik zedelenmesi  Felç (inme)  Zayıf, güçsüz  Spazmlar ya da kontrolsüz hareketler  Ampütasyon: Sağ diz üstü  Sağ diz altı  Sol diz üstü  Sol diz altı Mesane problemleri  Bağırsak problemleri  Eğer tekerlekli sandalye kullanıcısının mesane ya da bağırsak problemleri varsa ilgilenilmiş mi? Evet  Hayır  Diğerleri: _________________________________________________________________ Hayat tarzı ve çevresel durum Tekerlekli sandalye kullanıcısının bu sandalyeyi nerelerde kullanacağını tanımlayın: ______________________________________________________________________________ Günlük kat edilen yol: 1 km  ‘ye kadar. 1 – 5 km  5 km  ‘den fazla Günlük tekerlekli sandalye kullanımı nedir? 1  saatten az. 1-3  3-5  5-8  8 saatten fazla  Tekerlekli sandalye kullanıcısı sandalyede oturmuyor iken nerede oturuyor ya da uzanıyor ve nasıl bir yüzeyde oturuyor ve duruşu nasıl? ______________________________________________________________________________ Transfer: Kendi kendine  Yardım ile  Ayakta  Ayakta değil  Kaldırılarak  Diğer  Tuvalet cinsi (eğer tuvalete transfer yapılıyorsa ): Alaturka  Alafranga  Uyarlanmış  Tekerlekli sandalye kullanıcısı sıklıkla toplu / özel taşıma araçlarını kullanıyor mu? Evet  Hayır  Cevap evet ise, ne cins bir: Araba  Taksi  Otobüs  Diğer _________________________________________________________________________ Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 13. Mevcut tekerlekli sandalye (eğer şahsın zaten tekerlekli sandalyesi var ise) Tekerlekli sandalye kullanıcının ihtiyaçlarını karşılıyor mu? Evet  Hayır  Tekerlekli sandalye kullanıcının çevresel şartlarına uygun mu? Evet  Hayır  Tekerlekli sandalye kullanıcı için yerinde ve uygun mu ve duruşu için destek sağlıyor mu? Evet  Hayır  Tekerlekli sandalye sağlam ve güvenli mi? (Minder olup olmadığını göz önünde bulundurun) Evet  Hayır  Minder uygun basınç rahatlatması sağlıyor mu? (eğer şahıs basınç yarası riski taşıyorsa) Evet  Hayır  Yorumlar: _____________________________________________________________________ Soruların hepsinin cevabı evet ise kullanıcının yeni bir sandalyeye ihtiyacı olmayabilir. Eğer bu soruların cevabı hayır ise kullanıcının yeni bir sandalyeye ya da mindere ihtiyacı vardır; ya da mevcut sandalyenin ya da minderin tamire ya da modifikasyona ihtiyacı vardır. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 14. Grubunuzdaki tekerlekli sandalye kullanıcısı rolü yapan kişiyle görüşme yapın ve aşağıdaki değerlendirme formunu doldurun. Değerlendirme yapan kişinin adı: Değerlendirme tarihi: Tekerlekli sandalye kullanıcısı hakkında bilgi Adı: Numara: Yaşı: Bay  Bayan  Telefon: Adres: Hedefler: Fiziksel durum Beyin felci (serebral palsi) Çocuk felci (polyo)  Omurilik zedelenmesi  Felç (inme)  Zayıf, güçsüz  Spazmlar ya da kontrolsüz hareketler  Ampütasyon: Sağ diz üstü  Sağ diz altı  Sol diz üstü  Sol diz altı Mesane problemleri  Bağırsak problemleri  Eğer tekerlekli sandalye kullanıcısının mesane ya da bağırsak problemleri varsa ilgilenilmiş mi? Evet  Hayır  Diğerleri: _________________________________________________________________ Hayat tarzı ve çevresel durum Tekerlekli sandalye kullanıcısının bu sandalyeyi nerelerde kullanacağını tanımlayın: ______________________________________________________________________________ Günlük kat edilen yol: 1 km  ‘ye kadar. 1 – 5 km  5 km  ‘den fazla Günlük tekerlekli sandalye kullanımı nedir? 1  saatten az. 1-3  3-5  5-8  8 saatten fazla  Tekerlekli sandalye kullanıcısı sandalyede oturmuyor iken nerede oturuyor ya da uzanıyor ve nasıl bir yüzeyde oturuyor ve duruşu nasıl? ______________________________________________________________________________ Transfer: Kendi kendine  Yardım ile  Ayakta  Ayakta değil  Kaldırılarak  Diğer  Tuvalet cinsi (eğer tuvalete transfer yapılıyorsa ): Alaturka  Alafranga  Uyarlanmış  Tekerlekli sandalye kullanıcısı sıklıkla toplu / özel taşıma araçlarını kullanıyor mu? Evet  Hayır  Cevap evet ise, ne cins bir: Araba  Taksi  Otobüs  Diğer _________________________________________________________________________ Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 15. Mevcut tekerlekli sandalye (eğer şahsın zaten tekerlekli sandalyesi var ise) Tekerlekli sandalye kullanıcının ihtiyaçlarını karşılıyor mu? Evet  Hayır  Tekerlekli sandalye kullanıcının çevresel şartlarına uygun mu? Evet  Hayır  Tekerlekli sandalye kullanıcı için yerinde ve uygun mu ve duruşu için destek sağlıyor mu? Evet  Hayır  Tekerlekli sandalye sağlam ve güvenli mi? (Minder olup olmadığını göz önünde bulundurun) Evet  Hayır  Minder uygun basınç rahatlatması sağlıyor mu? (eğer şahıs basınç yarası riski taşıyorsa) Evet  Hayır  Yorumlar: _____________________________________________________________________ Soruların hepsinin cevabı evet ise kullanıcının yeni bir sandalyeye ihtiyacı olmayabilir. Eğer bu soruların cevabı hayır ise kullanıcının yeni bir sandalyeye ya da mindere ihtiyacı vardır; ya da mevcut sandalyenin ya da minderin tamire ya da modifikasyona ihtiyacı vardır. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 16. B.4: Fiziksel değerlendirme Grubunuzdaki her bir üye gruptaki diğerlerinin ölçümlerini yapmalıdır. Ölçümler aşağıya kayıt ediniz. Ölçümü yapan kişi de kendi ismini de tabloya yazmalıdır. 1. Tekerlekli sandalye kullanıcısının ismi: _______________________________________ Ölçüm yapan 1: Ölçüm yapan 2: Vücut ölçümü Ölçüm (mm) Ölçüm (mm) A Basen genişliği B Koltuk genişliği Sol Sağ C Baldır uzunluğu Sol Sağ D Göğüs kafesinin alt kısmı E Kürek kemiğinin alt kısmı 2. Tekerlekli sandalye kullanıcısının ismi: _______________________________________ Ölçüm yapan 1: Ölçüm yapan 2: Vücut ölçümü Ölçüm (mm) Ölçüm (mm) A Basen genişliği B Koltuk genişliği Sol Sağ C Baldır uzunluğu Sol Sağ D Göğüs kafesinin alt kısmı E Kürek kemiğinin alt kısmı 3. Tekerlekli sandalye kullanıcısının ismi: _______________________________________ Ölçüm yapan 1: Ölçüm yapan 2: Vücut ölçümü Ölçüm (mm) Ölçüm (mm) A Basen genişliği B Koltuk genişliği Sol Sağ C Baldır uzunluğu Sol Sağ D Göğüs kafesinin alt kısmı E Kürek kemiğinin alt kısmı Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 17. B.5: Reçete (seçim ) – tekerlekli sandalye verileri o Size eğitmen tarafından verilen tekerlekli sandalye için tekerlekli sandalye veri sayfasını doldurun. o Formu doldurmak için şunlara ihtiyacınız olacaktır: o tekerlekli sandalyeye dikkatlice bakın; o tekerlekli sandalye ile ilgili yazılı bilgilere bakın (eğer mümkünse); o ölçüleri alın (eğer yazılı bilgide yoksa ), ki bu ayarlanabilir özellikleri olan sandalyelerin minimum ve maksimum aralığında ayarlanmasını gerektirebilir. Tekerlekli sandalye adı: İmalatçı / tedarikçi: Mevcut olan boyutlar: Tam ağırlığı: Tanımlama: İskelet: Katlanabilir Sabit / Sert İskelet yüksekliği: Arkalık: Askı şeklinde/ Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Koltuk: Askı şeklinde / Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Minder: Minderi yok Yassı köpük Konturlu köpük (şekillendirilmiş) Ayaklıklar: Çıkartılabilir/dönebilen Sabit Diğer: Ön tekerlekler: Çap: Genişlik(en): Arka(büyük) tekerlekler: Hava basınçlı Çap: İtme kasnakları Dolgu Genişlik(en): Ayarlanabilir akslar İç lastikli Çıkartılabilir Frenler: Kısa kaldıraçlı Uzun kaldıraçlı Diğer: Kolçaklar: Sabit Çıkartılabilir/dönebilen Diğer: İtme tutamakları: İtme tutamakları Ekstra parçalar / seçenekler: Destek bandı Arka destek barları Tepsi Diğer: Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 18. Ölçümler, ayarlama seçenekleri ve ayarlanabilirlik aralığı (sınırları) : Ölçüm (Eğer tekerlekli sandalye değişik boyutlarda mevcutsa bütün boyutları hepsini listeleyin ) Bu ayarlanabilir mi? Ayarlanabilirlik aralığı, sınırları (bu sandalye için ayarlanabilirlik aralığı). Evet Hayır Koltuk genişliği(eni): Koltuk derinliği: Koltuk yüksekliği: Arkalık yüksekliği: Arkalık açısı: Ayaklık yüksekliği: Ayaklık açısı: İtme tutamakları yüksekliği: İskelet mesafesi (uzunluğu): Dingil mesafesi (uzunluğu): Tekerlekli sandalye verisini yerel olarak bulunabilen başka herhangi bir sandalye için doldurun. Tekerlekli sandalye adı: İmalatçı / tedarikçi: Mevcut olan boyutlar: Tam ağırlığı: Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 19. Tanımlama: İskelet: Katlanabilir Sabit / Sert İskelet yüksekliği: Arkalık: Askı şeklinde/ Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Koltuk: Askı şeklinde / Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Minder: Minderi yok Yassı köpük Konturlu köpük (şekillendirilmiş) Ayaklıklar: Çıkartılabilir/dönebilen Sabit Diğer: Ön tekerlekler: Çap: Genişlik(en): Arka(büyük) tekerlekler: Hava basınçlı Çap: İtme kasnakları Dolgu Genişlik(en): Ayarlanabilir akslar İç lastikli Çıkartılabilir Frenler: Kısa kaldıraçlı Uzun kaldıraçlı Diğer: Kolçaklar: Sabit Çıkartılabilir/dönebilen Diğer: İtme tutamakları: İtme tutamakları Ekstra parçalar / seçenekler: Destek bandı Arka destek barları Tepsi Diğer: Ölçümler, ayarlama seçenekleri ve ayarlanabilirlik aralığı (sınırları) : Ölçüm (Eğer tekerlekli sandalye değişik boyutlarda mevcutsa bütün boyutları hepsini listeleyin ) Bu ayarlanabilir mi? Ayarlanabilirlik aralığı, sınırları (bu sandalye için ayarlanabilirlik aralığı). Evet Hayır Koltuk genişliği(eni): Koltuk derinliği: Koltuk yüksekliği: Arkalık yüksekliği: Arkalık açısı: Ayaklık yüksekliği: Ayaklık açısı: İtme tutamakları yüksekliği: İskelet mesafesi (uzunluğu): Dingil mesafesi (uzunluğu): Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 20. Tekerlekli sandalye verisini yerel olarak bulunabilen başka herhangi bir sandalye için doldurun. Tekerlekli sandalye ismi: İmalatçı / tedarikçi: Mevcut olan boyutlar: Tam ağırlığı: Tanımlama: İskelet: Katlanabilir Sabit / Sert İskelet yüksekliği: Arkalık: Askı şeklinde/ Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Koltuk: Askı şeklinde / Kanvaz,(branda) Yekpare (içi dolu) Gerginliği ayarlanabilir Minder: Yastıksız Yassı köpük Konturlu köpük (şekillendirilmiş) Ayaklıklar: Çıkartılabilir/dönebilen Sabit Diğer: Ön tekerlekler: Çap: Genişlik(en): Arka(büyük) tekerlekler: Hava basınçlı Çap: İtme kasnakları Dolgu Genişlik(en): Ayarlanabilir akslar İç lastikli Çıkartılabilir Frenler: Kısa kaldıraçlı Uzun kaldıraçlı Diğer: Kolçaklar: Sabit Çıkartılabilir/dönebilen Diğer: İtme tutamakları: İtme tutamakları Ekstra parçalar / seçenekler: Destek bandı Arka destek barları Tepsi Diğer: Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 21. Ölçümler, ayarlama seçenekleri ve ayarlanabilirlik aralığı (sınırları) : Ölçüm (Eğer tekerlekli sandalye değişik boyutlarda mevcutsa bütün boyutları hepsini listeleyin ) Bu ayarlanabilir mi? Ayarlanabilirlik aralığı, sınırları (bu sandalye için ayarlanabilirlik aralığı). Evet Hayır Koltuk genişliği(eni): Koltuk derinliği: Koltuk yüksekliği: Arkalık yüksekliği: Arkalık açısı: Ayaklık yüksekliği: Ayaklık açısı: İtme tutamakları yüksekliği: İskelet mesafesi (uzunluğu): Dingil mesafesi (uzunluğu): B.5: Reçete (seçim) – doğru tekerlekli sandalye boyutunu seçme Aşağıdaki her bir örnek için: o ideal tekerlekli sandalye boyutuna karar vermeye çalışın ve o mevcut olan tekerlekli sandalyelerden kullanıcı ile eşleşen en iyi boyutu seçin. (Her iki durumda tekerlekli sandalye minderinin 50 mm yükseklikte olduğunu farz edin.) 1 Vücut Ölçümü Ölçüm (mm) Vücut ölçülerini ideal tekerlekli sandalye boyutuna çevir Tekerlekli sandalye ölçümleri A Basen genişliği 360mm Basen genişliği = koltuk genişliği 360mm B Koltuk derinliği Sol 400mm B, koltuk derinliği = 30 – 50 mm’ den daha küçük ise. (eğer uzunluk farklı ise daha kısa olanını kullanın) 370mm Sağ 400mm C Baldır uzunluğu Sol 380mm = koltuk minderinin üstünden* ayaklık yüksekliğine kadar Ya da = koltuk minderinin üstünden* yere kadar ayakla itmek için 330mm Sağ 380mm 330mm D Göğüs kafesinin alt kısmı 310mm = koltuk minderinin üstünden * arkalığın üstüne kadar ( D ya da E’ i ölçün – kullanıcının ihtiyaçlarına bağlı olarak ) 360mm E Kürek kemiğinin alt kısmı 420mm 470mm Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 22. Bu tekerlekli sandalye kullanıcısı ideal tekerlekli sandalye boyutu: Koltuk genişliği: Koltuk derinliği: Arkalık yüksekliği: Mevcut olan tekerlekli sandalyelerden hangi cins ve boyut kullanıcı için en uygun olanıdır? 2 Vücut Ölçümü Ölçüm (mm) Vücut ölçülerini ideal tekerlekli sandalye boyutuna çevir Tekerlekli sandalye ölçümleri A Basen genişliği 360mm Basen genişliği = koltuk genişliği 360mm B Koltuk derinliği Sol 400mm B, koltuk derinliği = 30 – 50 mm’ den daha küçük ise. (eğer uzunluk farklı ise daha kısa olanını kullanın) 370mm Sağ 400mm C Baldır uzunluğu Sol 380mm = koltuk minderinin üstünden* ayaklık yüksekliğine kadar Ya da = koltuk minderinin üstünden* yere kadar ayakla itmek için 330mm Sağ 380mm 330mm D Göğüs kafesinin alt kısmı 310mm = koltuk minderinin üstünden * arkalığın üstüne kadar ( D ya da E’ i ölçün – kullanıcının ihtiyaçlarına bağlı olarak ) 360mm E Kürek kemiğinin alt kısmı 420mm 470mm Bu tekerlekli sandalye kullanıcısı ideal tekerlekli sandalye boyutu: Koltuk genişliği: Koltuk derinliği: Arkalık yüksekliği: Mevcut olan tekerlekli sandalyelerden hangi cins ve boyut kullanıcı için en uygun olanıdır? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 23. B.7: Ürün (tekerlekli sandalye ) hazırlığı Kontrol Listesi: Tekerlekli Sandalye Güvenli ve Kullanıma Hazır mı? Tekerlekli sandalye servisinin adı: Tekerlekli sandalye kullanıcısın ismi: Tekerlekli sandalye cinsi: Tekerlekli sandalye seri numarası: Bütün tekerlekli sandalyeler Keskin kenarlar bulunmamaktadır.  Çizilmiş ve zarar görmüş parça bulunmamaktadır.  Tekerlekli sandalye düz bir hat üzerinde yol almaktadır.  Ön küçük tekerlekler Serbest dönmektedir.  Tekerlek tutma çatalına dokunmadan dönmektedir.  Cıvatalar sıkılmış durumdadır.  Ön küçük tekerleklerin oturduğu aksam (boru) Tekerlekleri tutan çatal serbestçe dönmektedir.  Arka büyük tekerlekler Serbestçe dönmektedir.  Aks cıvataları sıkılmış durumdadır.  Lastikler doğru bir şekilde şişirilmiştir (başparmakla basınç uygulandığında 5 mm den daha az bir içeri girme olabilir.)  İtme kasnakları güvenlidir.  Frenler Düzgün bir şekilde çalışmaktadır.  Ayaklıklar Ayaklıklar güvenli bir şekilde takılmıştır.  İskelet Katlanabilir tekerlekli sandalye için – tekerlekli sandalye kolaylıkla açılıp kapanmaktadır.  Arkalığı katlanabilir tekerlekli sandalye için – arkalık kolaylıkla katlanıp açılmaktadır.  Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 24. Minder Minder kılıfının içinde düzgün bir şekilde durmaktadır.  Minder tekerlekli sandalyenin üzerinde düzgün bir şekilde durmaktadır.  Minder kılıfının kuması gergin bir şekilde ama gereğinden fazla gergin değildir.  Tekerlekli sandalyenin yekpare bir koltuğu var ise: minder yekpare koltuğun tamamını kaplamaktadır.  Tekerlekli sandalyeyi kontrol eden kişinin ismi: İmza: Tarih: B.8: Minder yapımı Kalça kemiği çukuru boyutları Aşağı tablodaki tekerlekli sandalye kullanıcılarının doğru kalça kemiği çukuru boyutlarını hesaplayınız: Genişlik Derinlik Yükseklik o Erişkin tekerlekli sandalye kullanıcısı – 360 mm koltuk genişliği o Erişkin tekerlekli sandalye kullanıcısı – 460 mm koltuk genişliği o Çocuk tekerlekli sandalye kullanıcısı – 280 mm koltuk genişliği Minder yapımı o Bir partner ile çalışın. o Minder yapmak için aşağıdaki talimatları takip edin. Bir sorunuz varsa eğitmene sorun. 1. Kesim yapılacak yerleri planlayın o 400 mm x 400 mm x 50 mm boyutlarında katı bükülmez bir köpük kullanın. o Kalça kemiği çukuru merkezi minderin merkez hattında olmalıdır. o Bu ölçüdeki minder için kalça kemiği çukuru ölçüleri 200 mm x 200 mm x 35 mm olmalıdır. o Kesilecek hatları koyu renk bir keçeli kalemle, taban köpüğünün bütün yüzeylerinde (6 yüzeyinde) işaretleyin. Ölçüler mm’ dir Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 25. 2. Kalça kemikleri için çukuru kesip çıkartın: Bilenmiş bir demir testeresi ağzı ya da uzun bir bıçak kullanın. Keserken ve çoğunlukla da bıçağı çekerken kontrolü artırmak için yavaş ve uzun hareketlerde bulunun. o Öncelikle arka taraftan kalça kemiği çukuruna doğru kesin. o “Kalça kemiği çukuru” nu dışarı çıkartın. o Kalça kemiği çukurunun her iki tarafında kalan “kanat”ları yapıştırıcı ile tekrar yapıştırın. 3. Kalça kemiği çukurunun iç taraflarındaki köşeleri kesin. 4. Askı şeklinde koltuk minderleri için: tabanın (alt bölümünün) her iki tarafına da açılı (eğimli) kesim yapın. o Gösterildiği şekilde işaretleyin ve kesin. o Bu kesim minderin tabanının, askı kayışlı sandalye koltuğun şekli ile uyuşmasını sağlayacaktır. 5. Üst köpük katmanını minderin üstüne yerleştirin. o Üst ve alt yani her iki katman minder kılıfının içine beraber yerleştirilir. o Bu iki katmanın yapıştırılmasına gerek yoktur. o Eğer üst katman kirlenirse veya yıpranırsa yıkanıp, kurutulup tekrar yerine yerleştirilebilir. o Kılıfın içerisine pelvik çukurun yüksekliğini artırmak için bir yükselti eklenebilir (alt katmanın üstü ile rahatlatma tabakasının altı arasına). Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 26. B.11: Kullanıcı Eğitimi o Kullanıcı hikâyelerini okuyun. o Tekerlekli sandalye kullanıcısının yeni sandalyesiyle, tekerlekli sandalye hizmetlerinden ayrılmadan önce bilmesi gereken, tekerlekli sandalye kullanıcı eğitim kontrol listesinde olan en az üç beceriyi belirleyin. o Tekerlekli sandalye kullanıcısına bir beceriyi öğretme uygulaması yapın (sırayla tekerlekli sandalye personeli, eğitici ve aile üyesi olarak). Bölümde tartışılmış olan iyi öğretme yollarını hatırlayın. Moses Moses’ın hangi becerileri öğrenerek yarar sağlayabileceğini düşünüyorsunuz? Moses 23 yaşındadır. İki yıl önce bir kamyonun arkasından düşmüş ve paraplejik olmuştur. Bir yıl hastanede kaldıktan sonra köyüne bağışla edinilmiş eski bir tekerlekli sandalye ile gelmiştir. Tekerlekli sandalye çok çabuk bozulmuştur ve dolaşamamaktadır. İyileşmiş olan bir basınç yarası geliştirmiştir. Moses tekerlekli sandalye servisi aracılığı ile bir tekerlekli sandalye ve basınç rahatlatma minderi edinmiştir. Bu tekerlekli sandalye, engebeli zeminlerde kullanılması için yapılmıştır. Eve bu sandalyeyle gideceği için çok heyecanlanmıştır ve artık daha bağımsız hareket edebileceğini umut etmektedir. Sian Sian’ın hangi becerileri öğrenerek yarar sağlayabileceğini düşünüyorsunuz? Sian 40 yaşındadır ve çift taraflı diz üstü ampütasyonu vardır. 20 yıldır tekerlekli sandalye kullanmaktadır ve bu süre içerisinde beş tane tekerlekli sandalyesi olmuştur. Kullandığı tekerlekli sandalyelerin çabuk bozulduğu kararına varmıştır. Çok aktif bir kişidir ve yerel bir dükkânda çalışmaktadır. Evinden işine her gün; engebeli, tümsekli ve genellikle de çamurlu olan bir yoldan gitmektedir. Tekerlekli sandalye servis personeline arka tekerlekler üzerinde nasıl dengede durabildiğini göstermiştir. Ona daha şimdi yeni bir tekerlekli sandalye reçete edilmiştir. Yeni sandalyesinin, en son kullandığından daha uzun ömürlü olmasını umut etmektedir ki en son sandalyesi aldıktan altı ay sonra bozulmuştur. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 27. Zoe Zoe’nin hangi becerileri öğrenerek yarar sağlayabileceğini düşünüyorsunuz? Zoe 16 yaşındadır. Genç bir kızdır polyosu vardır ve yürüyememektir. Çok çekingendir ve hiç okula gitmemiştir. Annesi ona evde ders vermiştir ve çok iyi bir şekilde okuyup yazabilmektedir. Daha yeni bir tekerlekli sandalye almıştır ve tekerlekli sandalye personeline nasıl transfer yapabildiğini ve tekerlekli sandalyesine nasıl kolayca binip indiğini göstermiştir. Zoe yerel bir meslek okuluna gitmek istemektedir fakat okula gidip gelmeyi beceremeyeceğini düşünmektedir. Okul binasında birkaç basamak vardır. Aynı zamanda okulda tuvalete nasıl gideceği konusunda da endişeleri vardır. B.12: Bakım ve Onarım Bakım: Tekerlekli sandalye ve minder için evde neler yapılabileceğini tanımla 1. ______________________________________________________________________ _______________________________________________________________________ 2. _______________________________________________________________________ _______________________________________________________________________ 3._______________________________________________________________________ ________________________________________________________________________ 4._______________________________________________________________________ ________________________________________________________________________ 5._______________________________________________________________________ ________________________________________________________________________ 6. _______________________________________________________________________ _________________________________________________________________________ Onarım: o Mevcut olan her bir tekerlekli sandalyeye eğitim amaçlı olarak yakından bakın. o Tamirat gerektiren şeyleri tanımla (eğer varsa) ve bulunduğunuz yerde bu tamiratlar nasıl yapılabilir öneride bulun. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 28. Tekerlekli sandalye A Ne tamirine ihtiyaç var? Bulunduğunuz yerde bu tamir nasıl yapılabilir? Tekerlekli Sandalye B Ne tamirine ihtiyaç var? Bulunduğunuz yerde bu tamir nasıl yapılabilir? Tekerlekli Sandalye C Ne tamirine ihtiyaç var? Bulunduğunuz yerde bu tamir nasıl yapılabilir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 29. B.13: Takip o Her bir kullanıcının hikâyesini okuyun. o Alınacak önlemler ile ilgili görüşün. o Alınacak önlemleri de içeren takip formunu her kullanıcı için doldurun. Hala Hala yetişkin kızı ve ailesiyle beraber aynı evde yaşamaktadır. Altı ay önce tekerlekli sandalye hizmetleri aracılığı ile bir tekerlekli sandalye edinmiştir. Daha bir yıl önde felç geçirmiştir ve yürüyememektedir. Tekerlekli sandalyesi olduğunda, kızının yardımı ile dikilerek transfer yapmayı öğrenmiştir. Bir tekerlekli sandalye istediğini ve böylece evde daha çok yardımcı olabileceğini ve kiliseye gitmek istediğini söylüyordu. Bir takip ziyaretinde Hala evinden birkaç ay ayrılmadığını söylemişti. Evine gelen yolun oldukça engebeli olduğunu ve eve doğru bir merdiven olduğunu söyledi. Bununla beraber o tekerlekli sandalyesini evde kullanmaktadır ve evde kızının çocuklarına bakarak kızına yardım etmektedir. Tekerlekli sandalyede dik oturmaktadır ve sandalye iyi durumdadır. Tekerlekli sandalyesine ve sandalyeden başka yere kızının yardımı olmadan kendi transferini yapabilmektedir. Daarun Daarun’un omurilik zedelenmesi vardır. Yerel pazarda bir radyo tamir atölyesinde çalışmaktadır. Tekerlekli sandalyesini ve basınç rahatlatma minderini iki yıl önce almıştır. Takip ziyaretinde tekerlekli sandalyesini her gün işe gidip gelmek için kullandığını söylemiştir. Basınç yarası yoktur. Daarun’un iki patlak lastiği olmuştur ve kendisi tamir etmiştir. Tekerlekli sandalye kontrol edilirken servis çalışanı jant tellerinin gevşek olduğunu ve koltuk kaidesine ait iki cıvatanın kayıp olduğunu fark etmiştir. Minderindeki yumuşak köpük oldukça yassılmıştır. Tekerlekli sandalyesinde iyi bir şekilde oturmaktadır ve sandalyesinden çok memnun olduğunu söylemektedir. Talha Talha 10 yaşındadır. Hafif serebral palsisi vardır ve mahalle okuluna gitmektedir. Bir yıl önce kendisine dört tekerlekli ve ekstra duruş destek minderi olan bir tekerlekli sandalye reçete edilmiştir. Takip ziyaretinde Talha tekerlekli sandalyesini her gün okula gidip gelmek için kullandığını söylemiştir. Kendini itecek güce sahip olmadığından dolayı sandalyesini babası itmektedir. Tekerlekli sandalyesi iyi durumdadır. Babası tekerleği bir defa tamir ettiğini söylemiştir. Tekerlekli sandalye servis çalışanı fark etmiştir ki; Talha büyümüştür ve ayaklıklar onun için fazla yüksek olduğundan dolayı bacakları tekerlekli sandalye koltuğunda yeteri kadar desteklenmemektedir. Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 30. Tekerlekli Sandalye Takip Formu Bu form takip ziyaretinde elde edilen bilgileri kaydetmek içindir. 1. Tekerlekli sandalye kullanıcısı bilgileri Tekerlekli sandalye kullanıcısının adı: Hala Numara: Uygunluk tarihi: Takip tarihi: Takibi gerçekleştiren kişinin adı: Takibin uygulandığı yer: Tekerlekli sandalye kullanıcısının evi  Tekerlekli sandalye servis merkezi  Diğer: ________________________________________ 2. Görüşme Alınacak önlemleri kaydet: Tekerlekli sandalyenizi istediğiniz kadar çok kullanabiliyor musunuz? Evet  Hayır  Cevap hayır ise – neden? Tekerlekli sandalyenizi kullanırken hiç problem yaşıyor musunuz? Evet  Hayır  Cevap evet ise – bu problemler nelerdir? Tekerlekli sandalyenizin kullanımı ile ilgili sorularınız var mı? Evet  Hayır  Cevap evet ise – bu sorular nelerdir? Daha ileri düzey bir eğitime ihtiyaç var mı? Kullanıcının basınç yarası mevcut mu? Evet  Hayır  Eğer cevap ise - tanımlayınız (nerede ve ne düzeyde) Tekerlekli sandalyenizle ilgili memnuniyetinizi 1 ile 5 arasında değerlendirirseniz kaç verirsiniz? (1 çok memnun ve 5 hiç memnun değil) Değer: Yorum: 3. Tekerlekli sandalye ve minder kontrolü Tekerlekli sandalye iyi çalışır vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Minder kullanıma uygun vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Her biri için cevap hayır ise, problem nedir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 31. 4. Uygunluk kontrolü Tekerlekli sandalye doğru bir şekilde uyuyor mu? Evet  Hayır  Cevap hayır ise – problem nedir? Basınç testi düzeyi (1 = güvenli, 2 = uyarı, 3 = tehlikeli) (eğer kullanıcı basınç yarası geliştirme riski altındaysa) Sol: Sağ: Tekerlekli sandalye kullanıcısı hareketsizken, hareket ederken ve gün boyunca rahat ve dik oturabiliyor mu? Evet  Hayır  Eğer cevap hayır ise – problem nedir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 32. Tekerlekli Sandalye Takip Formu Bu form takip ziyaretinde elde edilen bilgileri kaydetmek içindir. 1. Tekerlekli sandalye kullanıcısı bilgileri Tekerlekli sandalye kullanıcısının adı: Daruun Numara: Uygunluk tarihi: Takip tarihi: Takibi gerçekleştiren kişinin adı: Takibin uygulandığı yer: Tekerlekli sandalye kullanıcısının evi  Tekerlekli sandalye servis merkezi  Diğer: ________________________________________ 2. Görüşme Alınacak önlemleri kaydet: Tekerlekli sandalyenizi istediğiniz kadar çok kullanabiliyor musunuz? Evet  Hayır  Cevap hayır ise – neden? Tekerlekli sandalyenizi kullanırken hiç problem yaşıyor musunuz? Evet  Hayır  Cevap evet ise – bu problemler nelerdir? Tekerlekli sandalyenizin kullanımı ile ilgili sorularınız var mı? Evet  Hayır  Cevap evet ise – bu sorular nelerdir? Daha ileri düzey bir eğitime ihtiyaç var mı? Kullanıcının basınç yarası mevcut mu? Evet  Hayır  Eğer cevap ise - tanımlayınız (nerede ve ne düzeyde) Tekerlekli sandalyenizle ilgili memnuniyetinizi 1 ile 5 arasında değerlendirirseniz kaç verirsiniz? (1 çok memnun ve 5 hiç memnun değil) Değer: Yorum: 3. Tekerlekli sandalye ve minder kontrolü Tekerlekli sandalye iyi çalışır vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Minder kullanıma uygun vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Her biri için cevap hayır ise, problem nedir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 33. 4. Uygunluk kontrolü Tekerlekli sandalye doğru bir şekilde uyuyor mu? Evet  Hayır  Cevap hayır ise – problem nedir? Basınç testi düzeyi (1 = güvenli, 2 = uyarı, 3 = tehlikeli) (eğer kullanıcı basınç yarası geliştirme riski altındaysa) Sol: Sağ: Tekerlekli sandalye kullanıcısı hareketsizken, hareket ederken ve gün boyunca rahat ve dik oturabiliyor mu? Evet  Hayır  Eğer cevap hayır ise – problem nedir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 34. Tekerlekli Sandalye Takip Formu Bu form takip ziyaretinde elde edilen bilgileri kaydetmek içindir. 1. Tekerlekli sandalye kullanıcısı bilgileri Tekerlekli sandalye kullanıcısının adı: Talha Numara: Uygunluk tarihi: Takip tarihi: Takibi gerçekleştiren kişinin adı: Takibin uygulandığı yer: Tekerlekli sandalye kullanıcısının evi  Tekerlekli sandalye servis merkezi  Diğer: ________________________________________ 2. Görüşme Alınacak önlemleri kaydet: Tekerlekli sandalyenizi istediğiniz kadar çok kullanabiliyor musunuz? Evet  Hayır  Cevap hayır ise – neden? Tekerlekli sandalyenizi kullanırken hiç problem yaşıyor musunuz? Evet  Hayır  Cevap evet ise – bu problemler nelerdir? Tekerlekli sandalyenizin kullanımı ile ilgili sorularınız var mı? Evet  Hayır  Cevap evet ise – bu sorular nelerdir? Daha ileri düzey bir eğitime ihtiyaç var mı? Kullanıcının basınç yarası mevcut mu? Evet  Hayır  Eğer cevap ise - tanımlayınız (nerede ve ne düzeyde) Tekerlekli sandalyenizle ilgili memnuniyetinizi 1 ile 5 arasında değerlendirirseniz kaç verirsiniz? (1 çok memnun ve 5 hiç memnun değil) Değer: Yorum: 3. Tekerlekli sandalye ve minder kontrolü Tekerlekli sandalye iyi çalışır vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Minder kullanıma uygun vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Her biri için cevap hayır ise, problem nedir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 35. 4. Uygunluk kontrolü Tekerlekli sandalye doğru bir şekilde uyuyor mu? Evet  Hayır  Cevap hayır ise – problem nedir? Basınç testi düzeyi (1 = güvenli, 2 = uyarı, 3 = tehlikeli) (eğer kullanıcı basınç yarası geliştirme riski altındaysa) Sol: Sağ: Tekerlekli sandalye kullanıcısı hareketsizken, hareket ederken ve gün boyunca rahat ve dik oturabiliyor mu? Evet  Hayır  Eğer cevap hayır ise – problem nedir? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 36. B.14: Sonuç Bütün grup için 10 dakikalık bir sunum hazırlayın. Sunum şunları içermelidir. 1. Değerlendirmeden elde edilen bilgiler: o tekerlekli sandalye kullanıcısının amaçları (kullanıcının neden bir tekerlekli sandalyeye ihtiyacı var); o kullanıcının fiziksel ihtiyaçları; o kullanıcının hayat tarzı ile ilgili ihtiyaçları; o kullanıcının hali hazırda tekerlekli sandalyesi olup olmadığı – ve bu sandalyenin kullanıcının ihtiyaçlarını karşılayıp karşılamadığı; o basınç yarası geçmişinin veya varlığının risk durumu; o itme metodu; o desteksiz olarak otururken duruşu; o pelvis ve kalça duruş taramasının (görüntülemesinin ) sonuçları; 2. Reçete edilmiş tekerlekli sandalye ve minder: o tekerlekli sandalye cinsi o minder cinsi o reçete edilmiş olan her türlü destek araçları. 3. Uygunluk: o uygunluk sırasında tanımlanmış ve çözülmesi gereken her türlü problem – ve eğer varsa nasıl çözümlenmiş. 4. Kullanıcı eğitimi: o grup ve tekerlekli sandalye kullanıcısı, kullanıcı eğitiminin kapsamı konusunda ne karar verdiler? 5. Tekerlekli sandalye kullanıcısı geri bildirimi: o kullanıcı tekerlekli sandalyeyi aldıktan sonra herhangi bir yorum yaptı mı / geri bildirim var mı? 6. Bakım ve onarım: o tekerlekli sandalye alındıktan sonra – hangi bakımlar ve ne sıklıkla yapılmalı? o tekerlekli sandalye veya minderin tamiri gerekiyorsa yapılacaklar nelerdir? 7. Takip planı: o takip için ne gibi ayarlamalar yapıldı? Wheelchair Service Training Package: Basic Level. Participant’s Workbook: Page 37. For more information of the English version, please contact: World Health Organization 20 Avenue Appia 1211 Geneva 27, Switzerland Tel: (+41 22) 791 2715 Fax: (+41 22) 791 4857 http://www.who.int/disabilities/en/ dar@who.int

Tekerlekli Sandalye Hizmet Eğitim Paketi Temel düzey Katılımcilar için referans kılavuzu Tekerlekli Sandalye Hizmet Eğitim Paketi Temel düzey Katılımcilar için referans kılavuzu Published by the World Health Organization in 2012 under the title Wheelchair Service Training Package: Basic Level (Dünya Sağlık Örgütü Tarafından 2012 yılında Tekerlekli Sandalye Hizmet Eğitim Paketi-Temel Seviye başlığı altında yayınmalmıştır) © World Health Organization (Dünya Sağlık Örgütü) 2012 Her hakkı saklıdır. Dünya Sağlık Örgütü yayınları şu bağlantılar yoluyla elde edilebilir: WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264; faks: +41 22 791 4857; e-mail: bookorders@who.int). Dünya Sağlık Örgütü yayınlarını çoğaltmak veya tercüme etmek için olan talepler – satışı veya ticari olmayan dağıtımı – WHO Press, yukarıda geçen adrese (faks: +41 22 791 4806; e-mail: permissions@who.int) yönlendirilmelidir. Bu yayında geçen başlıklar ve sunulan içerik, hiç bir şekilde, herhangi bir ülkenin, bölgenin, şehrin ya da sahanın hukuki statüsü ya da bu yerlerin yetkilileri ya da sınırlarının ya da sinir bölgelerinin tahdit edildiği ile ilgili herhangi bir görüsün Dünya Sağlık Örgütü tarafından ifade edildiği anlamına gelmez. Yayında belli başlı şirketlerin ya da imalatçıların ürünlerinin isimlerinin geçmesi bunların, adi geçmeyen ayni nitelikle diğer ürünlerin aleyhine, Dünya Sağlık Örgütü tarafından onaylandığı ya da tavsiye edildiği anlamına gelmez. Hatalar ve eksikler dışında, müseccel markaların isimleri, büyük bas harfleri ile belirtilmiştir. Bu yayında yer alan bilgilerin doğruluğunun teminatı için Dünya Sağlık Örgütü tarafından tüm makul önlemler alınmıştır. Ancak, yayınlanan içerik, sarih ya da zımni, herhangi bir garanti olmadan dağıtılmaktadır. İçeriğin kullanımına ya da yorumlanmasına ilişkin sorumluluk okuyucuya aittir. Dünya Sağlık Örgütü, hiç bir şekilde, bu yayının kullanımından doğabilecek zararlardan sorumlu değildir. The Director General of the World Health Organization has granted translation and publication rights to an edition in Turkish to Latter-day Saint Charities, which is solely responsible for the Turkish edition. (Dünya Sağlık Örgütü Genel Direktörü, Türkçe çeviri ve yayınlama hakkını,Türkçe baskısının tek sorumlusu olarak Son Zaman Azizler Hayır İşleri’ ne vermiştir.) © Latter-day Saint Charities 2012 Wheelchair Service Training Package: Basic Level (Tekerlekli Sandalye Hizmet Eğitim Paketi: Temel düzey) 1. Tekerlekli sandalye - hizmet 2. Tekerlekli sandalye - tedarik ve dağıtım. 3. Tekerlekli sandalye - özellikler. 4. Engelli kişiler - rehabilitasyon. 5. Gelişmekte olan ülkeler. 6. Dünya Sağlık Örgütü Orijinal İngilizce versiyonuna katkıda bulunanlar: Editörler: Chapal Khasnabis ve Kylie Mines Yazarlar: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler, and Rebecca Jackson Stoeckle Değerlendirmeciler: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Ghosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif, ve Isabelle Urseau Çizimler: Melissa Puust Fotoğraf Jeneriği: Chapal Khasnabis and Jesse Moss Video Jeneriği: Chapal Khasnabis, Amanda McBaine, and Jesse Moss Rehber eğitimciler: Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama Raju, and Elsie Taloafiri Maddi destek: ABD Uluslararası Kalkınma Ajansı ve Avustralya Uluslararası Kalkınma Ajansı Ortak Kuruluşlar: ASSERT Doğu Timor, Kenya Fiziksel Engelliler Derneği (APDK), Soloman Adaları Sağlık Bakanlığı ve Medikal Hizmetler’in Toplum Temelli Rahabilitasyon Ünitesi, Eğitim Gelişim Merkezi (EDC), Handicap İnternasyonal, Uluslararası Kızıl Haç Komitesi (ICRC), Uluslararsı Protetik Ortetik Derneği (ISPO), Kilimanjaro Omurilik Felçliler Derneği (KASI), Mobility India, Motivasyon Australia, Motivasyon Hayır Vakfı (Motivasyon), Motivasyon Romanya ve Tanzania Ortopedi Teknoloji Uzmanları Merkezi (TATCOT) Terminoloji Eğitim boyunca kullanılan terimler aşağıda tanımlanmıştır. Uygun tekerlekli sandalye Kullanıcının ihtiyaçlarını karşılayan ve çevresel koşullarına uygun; yerinde ve uygun duruş desteği sağlayan ve güvenli, sağlam; ülke içerisinde mevcut olan ve elde edilebilir; ülke içerisinde bakımı ve servis desteği olan ve yine ülke içinde en ekonomik ve karşılanabilir ücreti olan tekerlekli sandalye Manüel tekerlekli sandalye Kullanıcı tarafından veya başka bir kişinin yardımı ile itilerek ilerleyen tekerlekli sandalye. Tekerlekli sandalye Yürüme ya da etrafta dolaşma, hareket konusunda zorlukları olan kişiler için yapılmış, tekerlekleri aracılığı ile hareketlilik sağlayan ve oturma desteği olan araç. Tekerlekli sandalye provizyonu Tekerlekli sandalyenin tasarlanması, üretimi, tedariki, hizmet ve servis sağlanmasını içeren geniş kapsamlı bir terimdir. Tekerlekli sandalye hizmeti ( servisi) Tekerlekli sandalye provizyonunun, her bir kullanıcının uygun tekerlekli sandalye almasının sağlanmasıyla ilgili bölümüdür. Tekerlekli sandalye hizmet personeli Uygun tekerlekli sandalye provizyonu ile konusunda bilgili, yetkin, teknik bilgisi olan kişiler. Tekerlekli sandalye kullanıcısı Yürüme veya etrafta dolaşma, hareket etme konusunda zorlukları olan ve hareketlilik için tekerlekli sandalye kullanan kişi. İçindekiler Önsöz .................................................................................................... .......................... 7 Tekerlekli Sandalye Eğitim Hizmeti Hakkında: Temel Seviye .................................... 9 A. Temel Bilgi ................................................................... Hata! Yer işareti tanımlanmamış. A.1. Tekerlekli Sandalye Kullanıcıları ............................................................................... 9 Tekerlekli Sandalyenin yararları nelerdir? ......................................................... 10 ‘’Uygun Tekerlekli sandalye” ne demektir? ........................................................ 11 Birleşmiş Milletler Engelli Kişi Hakları Kongresi (The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) .................................................... 11 A.2. Tekerlekli Sandalye Hizmetleri ................................................................................ 12 A.3. Tekerlekli Sandalye Hareketliliği ............................................................................. 14 A.4. Dik Oturuş ............................................................ Hata! Yer işareti tanımlanmamış. A.5. Basınç Yaraları ....................................................................................................... 19 A.6. Uygun Tekerlekli Sandalye ..................................................................................... 24 Tekerlekli Sandalye Kullanıcısının İhtiyaçlarını Karşılama ................................ 24 Tekerlekli Sandalye Kullanıcısının Çevresini Tanıma ....................................... 29 Yerinde uygunluk ve duruş desteği sağlama .................................................... 30 A.7. Minderler ................................................................................................................. 32 A.8. Transferler ........................................................... Hata! Yer işareti tanımlanmamış. B. Tekerlekli Sandalye Hizmet Aşamaları ...................................................................... 41 Adım 1 : Sevk ve randevu ............................................................................................. 42 Adım 2 : Değerlendirme ................................................................................................. 44 Adım 3 : Reçete (seçim) ................................................................................................. 52 Adım 4: Finansman ve Sirapiş ...................................................................................... 54 Adım 5: Ürün (Tekerlekli Sandalye) hazırlığı .................................................................. 55 Adım 6: Uygunluk ........................................................................................................... 61 Adım 7: Kullanıcı eğitimi ................................................................................................. 72 Adım 8: Bakımı, onarım ve takip .................................................................................... 75 Önsöz Tekerlekli sandalye kişilerin hareket kabiliyeti sağlaması açısından en sık kullanılan araçlardan birisidir. Hareket sağlama kabiliyeti kişilerin, haklarını kullanmalarına, mağdur olmadan, toplumun üretken birer parçaları olmada büyük önem taşımaktadır. Birçok kişi için, ayarları doğru yapılmış, kişiye uygun bir tekerlekli sandalye, toplumda kendilerine bir yer yapmaları açısından önemli bir adımdır. Birleşmiş Milletler Engelli Kişiler için Fırsatların Eşitlenmesi Üzerine Standart Kuralları, Engelli Haklarına İlişkin Sözleşmesi ve Dünya Sağlık Asamblesi kararı (WHA58.23) engellilikle ilgili korunma, kontrol altına alma ve rehabilitasyon konularıyla ilgilenilmiştir ve hepsi tekerlekli sandalye ve diğer yardımcı araçların önemini vurgulamışlardır. Tekerlekli sandalyeye ihtiyacı olan kişilerin, özellikle de dar kaynaklı ülkelerde, bir tekerlekli sandalyeye sahip olabilmesi için çalışmaktadır. Dünya Sağlık Örgütü, A.B.D. Uluslararası Kalkınma Ajansı (USAID) ile Uluslararası Prostetik e Ortotik Topluluğu ile işbirliği içersinde az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler’i hazırlamıştır. İnsan kaynaklarını doğru eğitebilmek ve onlara iyi bir tekerlekli sandalye sağlayabilmek için Dünya Sağlık Örgütü, tekerlekli sandalye yönergelerini temel alarak bu Tekerlekli Sandalye Hizmet Eğitim Paketi – Temel Seviye’yi hazırlamıştır. Alana Officer Robert Horvath Koordinatör Demokrasi Bürosu, Anlaşmazlık ve Engelliler ve Rehabilitasyon İnsancıl Yardım Şiddet ve Zararı Engelleme ve Engelliler Bölümü A.B.D. Uluslararası Gelişim Ajansı Dünya Sağlık Örgütü Tekerlekli Sandalye Hizmet Eğitimi: Temel Seviye Hakkında Giriş Kaynakları az olan yerler için hazırlanan manüel tekerlekli sandalye provizyonu, yönergelerin 2008 yılında yayınlanmasından sonra, Dünya Sağlık Örgütü (WHO), Tekerlekli Sandalye Hizmet Eğitimi Paketi– Temel Seviye’yi oluşturmuştur. Tekerlekli sandalye, kişilere hareket kabiliyeti kazandırabilmek açısından en sık kullanılan araçlardan biridir. Yürüme zorluğu çeken kişiler için, fiziksel durumlarına, hayat standartlarına uygun bir tekerlekli sandalye, onların sağlığını, sosyal ve ekonomik durumlarını geliştirmek için faydalıdır. Hareketlilik kazanma kabiliyeti, kullanıcılar için, okula gitme ve kültürel olayların bir parçası olmanın yanı sıra, sağlık kuruluşlarına gidebilmek gibi değişik hizmetlerden de yararlanmalarını sağlar. Hareket kabiliyetinin, önemi Birleşmiş Milletlerin Engelli Kişiler Hakları Sözleşmesinde belirtilmiştir. Sözleşme, engelli kişilere maksimum hareket kabiliyeti sağlanması için gerekli tüm şartları savunmaktadır. Kişilerin etkili bir biçimde hareket kabiliyetini sağlamaları için onlara, uygun biçimde ayarlanmış bir tekerlekli sandalye sağlanmalıdır ve kişilerin özel ihtiyaçlarına cevap veren bir bakış açısı edinilmelidir. Tekerlekli sandalye kullanıcılarının ihtiyaçlarını karşılamanın en faydalı şekli, bu hizmeti veren kuruluşlardan, tekerlekli sandalye provizyonu almaktır. Fakat yapılan istatistiklere göre, tekerlekli sandalye kullanıcılarından sadece %5’inden az bir kısmı kendilerine uygun ayarlanmış bir tekerlekli sandalye kullanabiliyorlardır. Buna ek olarak, bu hizmeti sağlayan yerlerden çok azında, tekerlekli sandalye hizmet eğitimi almış personel bulunmaktadır. Tekerlekli Sandalye Hizmet Eğitimi Paketi– Temel Seviye ile tekerlekli sandalye hizmeti veren yerlerdeki personelin temel anlamda doğru olarak eğitilmesi amaçlanmaktadır. (bkz Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeler, Tablo 4.2) Eğitim paketi teoride ve pratik anlamda tekerlekli sandalye kullanıcılarının sandalyede dik ve ek destek almadan oturmaları fikrini destekler. Eğitim paketi, kullanıcıların kişisel ihtiyaçlarının nasıl karşılanacağını, uygun tekerlekli sandalye seçimini, kullanıcıların ve onlara yardımcı olan kişilerin, sandalye kullanımı ve bakımı ile ilgili doğru eğitilmesini hedefler. Gerekirse daha sonrası için takibini de yapar. Bu eğitim paketinde yazılanlar 35-40 saatlik bir süreçte öğretilebilir ancak bu süre, kişisel ihtiyaçlar ve elde bulunan kaynaklarla orantılı bir şekilde değişkenlik gösterebilir. Eğitimden sonra, bağımsız olarak kullanma yeterliliğini geliştirmek için bir danışman ile pratiklerin devam ettirilmesi tavsiye edilir. Dünya Sağlık Örgütü, bu eğitim paketinin, kısa eğitim programlarında ve bu konu ile alakalı çalışan kuruluşların halihazırda bulunan programlarına entegre etmelerini hedeflemektedir. Hedef Kitle Bu eğitim paketi, tekerlekli sandalye hizmeti vermek isteyen tüm personel ve gönüllüler içindir. Bu kişiler, sağlık ve rehabilitasyon personeli veya teknik personel, kamu sağlık kurumu çalışanları, sağlık ocağı çalışanları, meslek terapisti, fizyoterapist, prostetist, ortotist, teknisyenler ve tekerlekli sandalye kullanıcıları olabilirler. Amaç Temel seviye eğitim paketi, destek almadan kendi başlarına tekerlekli sandalyede dik oturabilen engelli kişilerin, uygun tekerlekli sandalyeye ve mindere oturtulmalarına ilişkin eğitim alan personel ve gönüllüler için hazırlanmıştır. Esas amaç tekerlekli sandalye hizmeti veren yerlerdeki personelin bilgi ve yetenek kazanmasıdır. Bu eğitimin sağlayacağı yararlar: o İhtiyaçlarını karşılayan bir tekerlekli sandalyede oturan insanların sayısını arttırmak; o Eğitimli ve sağlıklı tekerlekli sandalye kullanıcılarının sayısını arttırmak; o Tekerlekli sandalye eğitimi bilen personel sayısını arttırmak; o Tekerlekli sandalye sağlayan personellerin yeterliliklerini arttırmak; o Tekerlekli sandalye sağlayan kurumların kalitesini arttırmak ve o Tekerlekli sandalye sağlayan kurumlar ve rehabilitasyon merkezleri arasında bütünlük sağlamak. Kapsam Eğitim paketinin kapsamları: o Dünya Sağlık Örgütü tarafından belirlenen sekiz aşamalı tekerlekli sandalye hizmeti verme (Tablo 1); o Tekerlekli sandalye kullanıcıları ile beraber çalışma onların hareketliliğini arttırmak için çözümler bulma; o Uygun manüel tekerlekli sandalye ile uygun minderi sağlama; o Kullanıcıya tam uygunluğunu sağlayabilmek için sandalyeye basit modifikasyonlar yapabilme; o Tekerlekli sandalye bakım ve onarımı; o Kullanıcıları eğitme, tekerlekli sandalyelerinden tam randıman almalarını sağlama ve o Köpük minderin üretimi. Tekerlekli sandalyeye yapılabilecek modifikasyonlar özellikle burada önem taşıyor. Tekerlekli sandalyelere belli ölçülerde basit modifikasyonlar yapılarak, kullanıcıya uygun hale getirilebilir. Üç tekerlekli sandalyelerin provizyonu bu pakete dâhil edilmemiştir. Fakat uzun yol giden kullanıcılar için bunun önemi not alınmıştır. Tablo1. Tekerlekli sandalye hizmet sunumu için kilit adımlar: Adım 1 Sevk ve randevu Adım 2 Değerlendirme Adım 3 Reçete (seçim) Adım 4 Finansman ve sipariş Adım 5 Ürün ( tekerlekli sandalye ) hazırlığı Adım 6 Uygunluk Adım 7 Kullanıcı eğitimi Adım 8 Bakım, onarım ve takip Gerekli Bilgi ve Beceriler Daha öncesinden tekerlekli sandalye hizmeti sağlama deneyimi gerekmemektedir. Fakat eğitim programını alacak olan kişinin aşağıda belirtilen bilgi ve becerilere ihtiyacı vardır: o Katılımcıların eğitim programının öğretildiği dilde yazma ve okuma kabiliyetleri olmalıdır; o Katılımcıların temel düzeyde sık görülen sağlık koşullarını bilmelidirler veya o Tekerlekli sandalyeden fayda sağlayabilecek fiziksel bozuklukları bilmelidirler.(Ör: beyin felci, çocuk felci, omurilik zedelenmesi, ampütasyon ve felç). Katılımcılar yukarıda belirtilen konular ile ilgili bilgili değiller ise, eğitmenlerin bu konuları içeren ek bir eğitim vermesi gerekmektedir. Yapılandırma Tekerlekli Sandalye Hizmet Eğitimi Paketi – Temel Seviye, tekerlekli sandalye hizmeti verme konusunda eğitilmiş ve bu konu hakkında yeterliliği bulunan eğitimciler tarafından verilmektedir. Aşağıdaki maddeler kullanılan eğitim kaynaklarının bir listesidir: o Eğitmen kılavuzu ve aletleri; o Katılımcılar için referans kılavuzu (Bundan sonra referans kılavuzu olarak bahsedilecektir); o Katılımcı el kitabı; o Tekerlekli sandalye servis formları; o Tekerlekli sandalye kontrol listesi; o Görseller: PowerPoint slâytları, videolar, posterler. Gelişim Süreci Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeleri nin yayınlanmasından sonra, Dünya Sağlık Örgütü, Tekerlekli Sandalye Hizmeti Eğitim Paketini hazırlayacak bir grup oluşturmuştur. İlk grup 2008 yılının Ekim ayında bir araya gelerek, bu pakette olması gereken konu başlıklarını oluşturmuşlardır. Bu alanda uzman 20 kişiden alınan geri dönüşler ile birlikte paketi hazırlayıp, ilk deneme için hazır duruma getirmişlerdir. 2010 senesinde Temel Seviye eğitim paketi Hindistan’da, Solomon adalarında ve Kenya’da test edildi. Her bir test, Dünya Sağlık Örgütü Tekerlekli Sandalye Eğitim Paketi program üyeleri tarafından gözlemlendi. Nihai taslağın oluşmasında, eğitmelerin, öğrencilerin ve kullanıcıların geri dönüşleri büyük fayda sağladı. Bunlara ek olarak, nihai hale getirilen doküman, konusunda uzman olan kişiler ile de paylaşıldı ve onların değerli görüşleri de eklendi. Eğitim kılavuzunun yazımında yer alan tüm yazarlar, konu ile ilgili alakalarını bildiren ve konu ile ilgili zıt düşen düşünceleri olmadığını belirten bir antlaşma imzaladılar. Eğitim Paketi.......tarafından ......tarihinde onaylanmıştır. A. Temel Bilgi A.1: Tekerlekli Sandalye Kullanıcıları Tekerlekli sandalye kullanıcıları, hali hazırda tekerlekli sandalye kullanan kişiler veya yürüme kabiliyetleri kısıtlandığından tekerlekli sandalye kullanmaya başlayan kişilerdir. Tekerlekli Sandalye kullanıcıları: o Erkek veya kadın çocuklar, ergenler ve yaşlılar; o Değişik hayat stilleri, rolleri veya geçmişi olan kimseler; o Kırsal, kentsel veya yarı kentsel alanlarda yaşayan kimseler olabilirler. Tekerlekli sandalye kullanıcılarının ihtiyaçları kişiden kişiye değişebilir ancak hepsinin kendilerine uygun olmaları gerekmektedir. Tekerlekli Sandalyenin faydaları nelerdir? o Hareket kabiliyeti: Tekerlekli sandalye kişilerin özgür olmalarını ve yapmak istedikleri şeyleri yapmalarını sağlar. o Sağlık: Tekerlekli sandalye kişinin sağlığına çok yararlı olabilir. Uygun ölçülerde bir tekerlekli sandalye ve minder ile kişi oturma bozukluğu yaşamaz ve basınç yaraları oluşmaz. Uygun ve kolay hareket edebilen bir tekerlekli sandalye kişinin sağlığına katkıda bulunur. o Özgürlük: Tekerlekli sandalye kullanıcıları, daha bağımsız olurlar ve kendi hayatlarını kontrol altında tutarlar. o Özgüven: Tekerlekli sandalye kullanıcıları eğer kendilerine uygun bir sandalye kullanıyorlarsa, özgüvenleri artar. o Toplum hayatına erişim: Tekerlekli sandalye sayesinde, kullanıcılar toplum hayatında daha aktif bir rol oynarlar. Örneğin: okula gitmek, arkadaş ziyareti yapmak, ibadet yerlerine gitmek gibi. “Uygun tekerlekli sandalye” nedir?  Uygun tekerlekli sandalye: – Kullanıcının ihtiyaçlarını karşılayan; – Kullanıcının çevresine uyan; – Kullanıcıya uygun olan; – Kullanıcının sandalyede dik oturmasını sağlayabilen; – Tamiri ve bakımı yerel olarak yapılabilen. Birleşmiş Milletler Engelli Kişiler Hakları Sözleşmesi (The United Nations Convention on the Rights of Persons with Disabilities - UNCRPD) Birleşmiş Milletler Engelli Kişiler Hakları Sözleşmesi 3 Mayıs 2008 yılında yürürlüğe girmiştir. İnsan hakları herkese uygulanır. UNCRPD’in esas amacı bu hakların engelli kişilere de uygulanmasıdır. Bu sözleşmede 50 değişik madde bulunmaktadır. 20. madde, kişisel hareket kabiliyeti ile alakalıdır. Kişisel hareket kabiliyeti, kişinin kendi isteği doğrultusunda istediği zamanda hareket edebilme kabiliyetidir. Ayrıca 20.madde, engelli kişilere azami özgürlüğü tanımak için gereken her şeyi yapacaklarını belirtir. Tekerlekli sandalyeler ve tekerlekli sandalye hizmeti veren kurumlar, engelli kişilerin hareket kabiliyeti kazanmaları için çok önemlidir. Tekerlekli sandalye hizmeti veren personeller, UNCRPD’nin belirlediği 20. Maddeyi uygulamada yardımcı olabilirler: o Kurumlarını ziyarete gelenlere, uygun tekerlekli sandalye sağlayarak; o Tekerlekli sandalye kullanıcılarına sandalyeden kalkıp oturmayı öğreterek; o Tekerlekli sandalye kullanıcılarının sandalyelerini kendi kendilerine itmelerini öğrenmelerini sağlayarak; o Aile bireylerinin tekerlekli sandalye kullanıcılarının özgür olmaları için destekleyerek. Uygun bir tekerlekli sandalyede oturan kişiye uyan diğer maddeler: o Tek başlarına yaşamak ve toplumun bir parçası olmak (Madde 19); o Eğitim görme hakları (Madde 24); o Yaşayabilecekleri en sağlıklı biçimde yaşamak (Madde 25); o Çalışma hakları (Madde 27); o Politika ve kamu hayatında yer alabilme (Madde 29); o Kültürel hayat, spor ve sosyal hayatın bir parçası olma hakkı (Madde 30). UNCRPD (Madde 20 – Kişisel Hareketlilik): Engelli kişilere azami özgürlüğü tanımak için gereken her şeyi yapacaklarını belirtir. Buna dâhil olanlar: a) Tekerlekli sandalyeleri uygun bir fiyat ile satarak, kullanıcıların kişisel hareketliliklerini, istedikleri zamanda, istedikleri yere gitmelerini kolaylaştırmak; b) İyi kalitedeki yardımcı teknoloji araçlarını uygun fiyatlar ile engelli kişilere sunmak; c) Engelli kişilere ve bu konuda profesyonel anlamda çalışan uzmanlara eğitim olanakları sunmak; d) Yardımcı teknoloji ürünlerini üreten şirketleri, hareketliliğin her yönünü ele alacak ürünler yapmaları için teşvik etmek. Bunun anlamı:1 Ülkeler, engelli vatandaşlarına hareket kazandırabilmek için:  Kişilerin dışarı çıkmaları için asiste etme.  Kişilerin yüksek kaliteli ve uygun fiyatlı tekerlekli sandalye almasını sağlama.  Tekerlekli sandalye ile dolaşabilmeleri için eğitim verme.  Şirketlerin, engellilerin tüm ihtiyaçlarına cevap verecek ürünler üretmelerini sağlama. A.2: Tekerlekli Sandalye Hizmetleri Tekerlekli sandalye hizmetleri, tekerlekli sandalye kullanıcıları ile beraber çalışarak onlara en uygun sandalyeyi vermeyi hedefler. Dünya Sağlık Örgütü Tekerlekli Sandalye aşamaları, aşağıda belirtildiği 8 aşamada doğru ve uygun tekerlekli sandalyeyi sağlamayı gösterir. Aşağıda özetleri belirtilen bu aşamaların detaylı açıklamalarını B bölümünde görebilirsiniz. 1Uluslararası Engelli Kişi Hakları Antlaşması (Birleşmiş Milletler Engelli Kişi Hakları Sözleşmesinin kolay versiyonu), Birleşik Krallık İş e Emekl Maaşı Departmanı için ”Kolay Okuma” servisi tarafından hazırlanmıştır. @ Inspired Services.IS164/07. Newmarket, Inspired Services, 2007 (http://odi.dwp.gov.uk/docs/wor/uncon/un- agree.pdf, accessed 15 Aralık 2011). Aşama Özet 1. Sevk ve Randevu Tekerlekli sandalye kullanıcılarının sevk ediliş biçimleri değişkenlik gösterebilir. Kullanıcılar kendileri gidebilirler. Aynı zamanda devlet kuruluşu veya özel kuruluşlar tarafından da sevk edilebilirler. Bazı tekerlekli sandalye kullanıcılarının belli başlı sosyal sağlık hizmetleri, okullar ya da kamu kuruluşları tarafından sevk edilmeleri gerekir. 2. Değerlendirme Her bireyin hayat stilini, fiziksel durumunu, çevre ve işini göz önünde bulundurarak kişisel bir değerlendirmeye ihtiyaç vardır. 3. Reçete (seçim) Değerlendirmeden elde edilen bilgiler ışığında, kullanıcı ve yardımcıları ile beraber bir tekerlekli sandalye reçetesi yazılır. Seçilen sandalyenin tipi, şekli, boyutu, özel fonksiyonları ve modifikasyonları reçetede belirtir. Ayrıca reçete sandalyenin nasıl kullanacağına dair eğitimi ve bakım gereklerini de içerir. 4. Finans ve sipariş Finans kaynağı belirtilir, tekerlekli sandalye siparişi verilir. 5. Ürün (tekerlekli sandalye) hazırlığı Eğitimli personel, tekerlekli sandalyenin ilk ayarlarını yapar. Duruma göre bu servis, montaj veya üreticinin sağladığı başka ürünlerin modifikasyonu da olabilir. 6. Uygunluk Kullanıcı tekerlekli sandalyeyi dener ve son ayarlar yapılır. Eğer modifikasyon ve duruş desteği gerekli ise, ek ayarlar yapılır. 7. Kullanıcı Eğitimi Kullanıcı ve yardımcı kişiler tekerlekli sandalye kullanımına ve bakımına dair eğitilir. 8. Bakım, onarım ve takip Tekerlekli sandalye hizmeti, teknik anlamda bakım ve onarım ile ilgili olarak yardımcı olabilir. Kamu seviyesinde takip aktivitelerine katılmanın yanı sıra, sandalyenin düzenli olarak bakımının yaptırılması gerekmektedir. Zamanlama kullanıcının ihtiyaçları ile orantılıdır. Şayet tekerlekli sandalye artık uygun değilse gerekli değişim yapılmalı ve ilk adımdan başlayarak tüm adımlar takip edilmelidir. Kaynak: Dünya Sağlık Örgütü Az sayıdaki kaynak ayarlamaları ile manüel tekerlekli sandalye sağlanması konusunda yönergeleri, Tablo 3.2. Cenevre, 2008:76. A.3: Tekerlek Sandalye Hareketliliği Birçok tekerlekli sandalye kullanıcı, tekerlekli sandalye ile hareket etmesi zor olan yerlerde yaşamakta ve çalışmaktadır. Örneğin bu zorlu mekânlar, kumlu, engebeli, çamurlu olabilir veya etrafta kaldırımlar, merdivenler olabilir. Tekerlekli sandalye kullanıcılarına sağlanılan bu eğitim ile kişilerin ve onlara yardımcı olanların bu tip zorlu mekânlarda nispeten daha rahatça hareket edebilmeleri sağlanmaktadır. Aşağıda belli başlı tekerlekli sandalye hareket pozisyonları verilmiştir: Tekerlekli Sandalye Hareket Becerileri: İtm e o Doğru itme daha az çaba sarf edilerek yapılandır. o Tekerleği saat 10 yönünden saat 2 yönüne doğru itin. o Uzun ve düzgün bir hareket ile itin. D ön m e o İtme kasnaklarından birini öne ve diğerini arkaya doğru tutunuz. o Öndeki eli arkaya doğru itiniz ve arkadaki eli öne doğru aynı anda itiniz. E ği m Y uk ar ı o Öne doğru eğilin. Bu hareket tekerlekli sandalyenin devrilmesini engeller. o Bu hareketi denerken, yanınızda güvenlik açısından birinin olmasına dikkat edin. o Durmak veya dinlenmek için tekerlekli sandalyeyi yolda dik olarak park edin. E ği m A şa ğı o Geriye yaslanın. o İtme kasnaklarının hareket etmesi için yavaşça itin. o Deneyimli tekerlekli sandalye kullanıcıları, sandalyelerini arka tekerleklerinde dengeleyerek, yokuş aşağı gidebilirler. Bu çok etkili bir yöntemdir. T ar dı m cı il e M er di ve n Ç ık m ak o Geriye doğru çıkın. o Tekerlekli sandalyeyi arka tekerleklere doğru eğin ve ilk basamağa dayayın. o Yardımcı tekerlekli sandalyeyi yukarı doğru sürüklerken aynı zamanda geri ve yukarı doğru çeker. o Tekerlekli sandalye kullanıcısı itme kasnaklarını geriye doğru iterek yardımcı olabilir. o İkinci bir yardımcı tekerlekli sandalyenin önünde, sandalye kasasını tutarak yardımcı olabilir (ayaklıklardan değil) Y ra dı m cı il e M er di ve n A şa ğı İ nm ek o Öne doğru inin. o Tekerlekli sandalyeyi arka tekerleklere doğru eğin o Yardımcı, arka tekerlekleri bir seferde bir basamak inecek şekilde indirir. o Tekerlekli sandalye kullanıcısı itme kasnaklarını tutup kontrol ederek yardımcı olabilir. o İkinci bir yardımcı tekerlekli sandalyeyi önden sandalye kasasından tutup sabit kalmasını sağlamak suretiyle yardımcı olabilir (ayaklıklardan değil). A rk a T ek er le kl er Ü ze rin de K ıs m i D en ge de D ur m a o Arka tekerlekler üzerinde kısmi dengede durma hareketini yapabilmek bir tekerlekli sandalye kullanıcısı faydalı, kullanışlıdır. o Tekerlekli sandalye kullanıcısı ön tekerleklerini küçük kaldırımlardan, taşlardan ve tepeciklerden geçmek için kaldırabilir. o Tekerlekli sandalyeyi eller saat 10 pozisyonunda olana kadar arkaya doğru sürün ve hızlıca öne doğru itin. o Ön tekerlekler havaya kalkmalıdır. . o Küçük engelleri aşmak için ön tekerlekleri doğru zamanda kaldırmak pratik yaparak mümkün olacaktır. o Tekerlekli sandalye kullanıcısı bu beceri için uygulama yaparken her zaman arkasında birisi olduğundan emin olun. Tekerlekli Sandalye hareketlilik becerileri nasıl güvenli hale getirilebilir? Tekerlekli sandalyeden kalkarken ayaklıklara basmayınız. o Parmaklarınızın tekerlek çevresinde olmamasına dikkat edin. o Eğim yukarı veya eğim aşağı giderken HER ZAMAN yanınızda biri olmasına özen gösterin. o Tekerlekli sandalyeli birisini eğim aşağı veya yukarı iterken, bu işi yapabileceğinizden emin olun, değilseniz başkasından yardım alın. A.4: Dik oturuş Birçok tekerlekli sandalye kullanıcısı, çoğu zamanlarını oturarak geçirirler. Bu da, tekerlekli sandalyenin sadece bir hareket aracı değil aynı zamanda kullanıcıların dik oturmasını sağlayan bir destek olduğunu gösteriyor. Dik oturmak/Dengeli oturma duruşu Duruş nedir? Duruş, bir insan vücudunun nasıl durduğudur. Mümkün olduğunca, tekerlekli sandalyelerin kişiye uygun olması ve kullanıcının içinde dik oturabilmesi gerekir. Bazı zamanlar dik oturmak, dengeli oturma duruşu olarak da adlandırılabilir. Dik oturmak neden önemlidir? Tekerlekli sandalyede dik oturmak, kullanıcılar için birçok yönden faydalıdır. Bunlar: o sağlık: dik oturmak rahat nefes almaya, ve yenilenleri kolay hazmetmeye yardımcı olur; o denge: dik durmak dengeyi kolay sağlamanıza yarar; o ağırlığı eşit dağıtmak: dik oturmak vücut ağırlığını dengeli olarak dağıtmanızı sağlar. Bu sayede vücudunuzda basınç yaralarının oluşmasını engeller; o konfor: Ağırlığın eşit olarak dağıtılması kullanıcı için daha rahattır. o duruş ile ilgili problemleri engellemeye: Dik oturmak, ilerde oluşabilecek omurilik problemlerini engeller; o özgüven: dik oturmak, tekerlekli sandalye kullanıcılarının kendilerine olan güvenlerinin artmasını sağlar. Her ne kadar, dik oturmanın sağlığa faydaları olsa da, gerekli postural destek olmadan, bütün gün dik oturmak çok zordur. Bu sebepten dolayı, tekerlekli sandalye kullanıcıları, gün boyunca değişik oturma pozisyonları denerler. Tekerlekli sandalye kullanıcısının tüm gün rahat bir şekilde dik oturabilmesi için, sandalyenin yeterli desteği sağlıyor olması gerekir. Kişinin dik oturduğunu nasıl anlarsınız? Yan taraftan bakın ve kontrol edin:  Pelvis dik;  Gövde dik, sırttaki üç doğal kavis izlenir halde;  Kalça eklemi 90 dereceye yakın kıvrımlı;  Dizler ve bilekler 90 dereceye yakın kıvrımlı;  Topuklar hemen dizin arka tarafında veya çok az arkasında ya da önünde;  Ayaklar yerde veya ayaklık üzerinde düz. Ön taraftan bakın ve kontrol edin:  Pelvis dengede;  Omuzlar dengede, kollar serbest hareket edebilir;  Bacaklar hafif aralık (abdükte);  Baş dik ve vücut üzerinde dengede; Pelvis (leğen kemiği) oturuş şeklimizi nasıl etkiler? Pelvis dik oturmak için temel oluşturur. Güçlü ve dengeli olabilmek için binaların sağlam bir temele ihtiyacı vardır. Aynı mantık ile düşünülünce, sağlam oturabilmek için pelvisin güçlü ve sağlam olması gerekir. Tekerlekli sandalye kullanıcısı dik oturduğu zaman, pelvis: o Önden bakıldığında aynı hizada ve o Yandan bakıldığında ise dik ve hafif öne doğru olmalıdır. Pelvis önden Pelvis yandan Pelviste baş gösteren değişiklikler tüm vücudu etkiler. Eğer pelvis dik değilse, dik oturmak zor olur. Leğen kemiği değişik şekillerde hareket eder. Aşağıdaki tablo, leğen kemiğinin dört pozisyonunu ve bu pozisyonlarda vücudunuzun nasıl değiştiğini göstermektedir. Hareket Resim Vücuttaki değişimler Öne doğru eğilme: (pelvisin öne eğilmesi). Pelvisin yandan görünüşü o Omuzların geriye çekilmesiyle vücut dikleşir; o Pelvis üzerindeki omurga kavisinde bir yükselme olur. Arkaya doğru eğilme: (pelvisin arkaya eğilmesi). Pelvisin yandan görünüşü o Omuzlar ilerideyken vücut yuvarlanmış hale gelir. Yanlara doğru eğilme: (yanal eğilme ). Pelvisin arkadan görünüşü o Vücut yanlara eğilir. Rotasyon. Pelvisin yukarıdan görünüşü o Vücudun diğer kısmı da döner (rotasyon yapar) A.5: Basınç Yaraları Basınç yarası, ciltte ve dokuda oluşan yaralardır. Basınç yarası, birkaç saatte oluşabilir, ancak etkisi aylarca sürebilir, hatta ölüme bile sebebiyet verebilir. Basınç yaraları nasıl oluşur? Basınç yaralarına sebep olan üç neden vardır. Basınç: Basınç yaraları, aynı pozisyonda, hiç hareket etmeden aynı yere basınç olacak şekilde, uzun saatlerce oturmak ve yatmakla oluşur. Tekerlekli sandalye kullanıcıları, günün çoğu kısmını oturarak geçirdikleri için, özellikle risk altındadırlar. Eğer basınç rahatlatılmaz ise hızlı bir şekilde yaraya dönüşebilir. Sürtünme: Deriye sürekli olarak yapılan sürtünmeden oluşan yaralar. Örneğin, kolun sürekli olarak kolçaklara sürtünmesi, basınç yarası oluşmasına sebebiyet verir. Sıyrılma (kayma): Deri gevşemesi, genişlemesi, kemiklerin ve kasların hareket etmesi sonucu derinin sıkışması. Örneğin, kullanıcı sandalyede kaykılmış bir biçimde oturuyorsa, deri zedelenebilir. Gevşeyen deri, kalça ve leğen kemiklerinin öne arkaya hareketi ile ya da sırttaki kemiklerin arkalığa dayanması ile zarar görebilir. Basınç yarası risk faktörleri: Yukarıda belirtilen üç sebebin yanı sıra, basınç yarasına sebebiyet veren başka faktörler de vardır. Bunlara basınç yarası risk faktörleri denir. Aşağıda bu risk faktörlerinden bazılarını bulabilirsiniz. o Kişide his olmayışı (duyumun azalmış olması): Kalçasını hissedemeyen veya hissetmekte zorluk çeken kişilerde basınç yarası oluşma riski vardır. o Kişinin hareket edememesi: Kişi hareket edemediği zaman, basınç noktalarını rahatlatamaz. o Terden veya mesane probleminden oluşan nem: Nem, deriyi yumuşak ve zedelenmeye karşı hassas kılar. Eğer kişi mesane ya da bağırsak problemi yaşıyorsa, idrar ve dışkı deriyi yakar ve zarar verir. o Kötü duruş: Dik oturmamak, bir noktada basıncın artmasına sebep olur. o Önceden oluşan ve hali hazırda olan basınç yaraları. o Kötü beslenme ve yeterli miktarda su içmeme: İyi beslenme, yeterli miktarda su içme, sağlıklı bir deri yapısının olmasında ve yaraların iyileşmesinde önemli bir rol oynar. o Yaşlanma: Yaşlı kişilerin genelde incelmiş ve hassas derileri olduğundan derileri zarar görebilir. o Ağırlık (normalin altında veya üzerinde kilo): Fazla kilosu olan kişilerde kan akışı yavaş olur ve yaralar zor iyileşir. Zayıf olan kişilerde ise, kemiklerini koruyacak deri ve doku katmanı ince olduğundan basınç yarası olma olasılığı artar. Basınca hassas olan noktalar: Yandan görünüm Arkadan görünüm Basınç Yaralarının Dört Aşaması1 Neler yapılmalıdır? 1 Kişinin derisi üzerinde oluşan kırmızı veya koyu renk iz. Basınç noktası rahatlatıldıktan 30 dakika sonra, iz halen durmaktadır. o O bölgeden basıncı derhal kaldırın. o Deri tamamen iyileşene kadar basınçtan arındırın. Bu yatak istirahatı olabilir. o Sebebini bulun, bu konuya eğilin. o Tekerlekli sandalye kullanıcısına, basınç noktalarının nasıl oluştuğunu anlatın ve rahatlatma yöntemlerini öğretin. 2 Yüzeyesel bir yara. İlk katman deri soyulur veya su toplar. o 1. Bölümdeki aşamaları gerçekleştirin. o Bir sağlık uzmanından tedavi için yardım alın. o Açık basınç yaraları, enfeksiyon kapmaması için iyi bir bakım ve yakından takip gerektirir. o 4. Aşama yaralar genelde cerrahi müdahale ile tedavi edilir. 3 Derin bir yara; bütün deri katmanı soyulur ve yok olur. 4 Çok derin bir yara, neredeyse kasın ve kemiğin görünmesine yol açar. 1 Spinal Injury Network. Basınç Yaraları Adımları (http://www.spinal-injury.net/pressure-sore-stages-sci.htm, accessed 13 Aralık 2011). Basınç yaraları nasıl önlenir? Basınç rahatlatma minderi kullanın: Basınç rahatlatan minderler basıncı en aza indirgemeye yarar. Basınç yarası oluşma riski olan herkesin bu minderleri kullanması gerekir. Dik oturun: Dik oturmak, ağırlığın eşit yayılmasına sebep olur. Eşit yayılan ağırlık, basınç noktalarını azaltır. Dik oturmak aynı zamanda derinin incelmesini ve sıyrılmasını da engeller. Tekerlekli sandalye hizmeti veren kişiler, sandalyelerin kullanıcılara uygun ayarlanmış olduğunu kontrol ederek dik oturmalarını sağlayabilirler. Aynı zamanda kullanıcılara dik oturmanın ne kadar faydalı olduğunu da anlatmalıdırlar. Basınç rahatlatma yöntemleri: Düzenli olarak, basınç rahatlatma yöntemleri kullanarak, basınç noktalarınızı rahatlatabilirsiniz. Aşağıda bu konu ile ilgili daha fazla bilgi bulabilirsiniz. Düzenli beslenin ve bol bol su için: Taze sebzeler, meyveler ve proteinden oluşan dengeli beslenme, basınç yaralarını engellemeye yarar. Bol su içmek, deriyi daha sağlıklı kılar ve basınç yaraları olmasını engeller. Tekerlekli sandalye kullanıcısı olarak dengeli beslenme hakkında bilgi almak isterseniz, bu konuda bir profesyonelden yardım alabilirsiniz. Sürtünmeyi engelleme: Tekerlekli sandalyenin kişiye uygun olduğundan, pürüzlü kenarları olmadığından emin olun. Hissi olmayan tekerlekli sandalye kullanıcılarına, vücutlarının herhangi bir yerinin sandalyeye sürtünüp sürtünmediğini kontrol etmelerini öğretin. Ayrıca kullanıcılara, sandalyeden nasıl kalkıp, tekrar oturmaları gerektiğini öğretin. Nemden uzak durun: Tekerlekli sandalye kullanıcılarının, ıslak veya kirlenmiş kıyafetlerini hemen değiştirmeleri önerilir. Minderleri da ıslanmış ise hemen değiştirilmelidir. Mesane ya da bağırsak problemi yaşayan kişilerin tedavi görmesi, nem oluşmasını önler. Bu tip rahatsızlığı olan kişileri tedavi almaları için yönlendirin. Deriyi her gün kontrol edin: Basınç yaraları çok hızlı oluşur. Bu sebeple, oluştuğu fark edildiği an bir önlem alınması gerekir. Risk faktörü yüksek olan tekerlekli sandalye kullanıcılarının, derilerini bir ayna kullanarak kontrol etmeleri veya bir yakınlarına kontrol ettirmeleri için teşvik verilmelidir. Eğer kırmızı veya koyu renk bir iz görürlerse (1. Evre basınç yarası) o yarayı hemen tedavi etmek gerekir. Yatarken veya otururken pozisyonunuzu sık sık değiştirin: Pozisyon değiştirmek, basınç yarası oluşumunu engeller. Yatarken veya otururken pozisyonunuzu değiştirin. Bu konu, özellikle basınç yarası riski taşıyan veya yeni kapanmış yarası bulunan kişiler için önemlidir. Pozisyonunu tek başına değiştiremeyen kişiler özellikle risk altındadırlar. Basıncı rahatlatma teknikleri: Tekerlekli sandalye kullanıcıları, oturma pozisyonundayken basınç noktalarını rahatlatabilirler. Bunu nasıl yapacakları, ne kadar güçleri olduğu ve nasıl denge sağlayabildikleri ile bağlantılıdır. Tekerlekli sandalye hizmeti veren personel, basınç yarası oluşma riski yüksek kullanıcılara, basınçlarını nasıl rahatlatacaklarına dair en az bir yöntem öğretilmelidir. Öne eğilmek: Birçok tekerlekli sandalye kullanıcısı için uygun bir yöntem. Bağımsız: Dengesi ve gücü yerinde olan kişiler için. Yardım ile: Dengesi bozuk ve gücü az olan kişiler için. Yanlara eğilme: Limitli dengesi ve az gücü olan tekerlekli sandalye kullanıcıları için. Bazı tekerlekli sandalye kullanıcıları kollarını itme tutamaklarına takarak destek alabilirler. A.6: Uygun tekerlekli sandalye Tekerlekli sandalyenin parçaları Arkalık Kolçak Minder Koltuk Ayaklık Ön tekerlekler Fren İtme tutamakları Arka tekerlekler İtme kasnakları Bacak emniyet bantları Koltuk tırabzanları Ayaklık askısı “Uygun tekerlekli sandalyenin” tanımı Lütfen A.1 bölümüne bakın. Tekerlekli sandalye kullanıcısının ihtiyaçlarını karşılama Uygun bir tekerlekli sandalye, kullanıcının yapmaya ihtiyaç duydukları şeyleri kolayca yapmalarını sağlar. Kullanıcılar, günlük aktivitelerini yerine getirebilmek için, sandalyeye rahatça oturup, sandalyeden rahatça kalkabilmeli, sandalyeyi itebilmeli ve katlayabilmelidirler. Uygun bir tekerlekli sandalye, kullanıcının bütün bunları yapmasını sağlar. Aşağıda aktivite örneklerini görebilirsiniz. Transferler Sandalyeden kalkıp, oturmak Kişisel becerilerine bağlı olarak, tekerlekli sandalye kullanıcıları, sandalyeden kalkıp oturmakta farklı yöntemler izlerler. Sandalyenin değişik bölümleri transferleri kişiler için kolaylaştırabilir. Transferleri kolaylaştıran bölümler, kolçaklar, ayaklıklar ve frendir. Yerinden çıkan kolçaklar veya arka tekerlek ile aynı şekilde olan kolçaklar, kişilerin kalkıp oturmasını kolaylaştırır. Sandalyeden kalkabilen ve ayakta durabilen kişiler kolçaklardan destek alıp kalkabilirler. Katlanabilen ayaklıklar, kullanıcıların sandalyeden kalkıp oturabilmelerine yardımcı olur. Yere oturmak isteyen kişiler içinse, ayaklıkları katlanabilir sandalye tercih etmelidirler. Frenler, tekerlekli sandalye kullanıcıları için çok önemlidir. Kullanıcılar sandalyeden kalkıp, otururken, sandalyeyi sabitlemek için gereklidir. Tekerlekli Sandalyeyi İtmek Tekerlekli sandalye kullanıcıları, sandalyelerini değişik yöntemler kullanarak yürütürler. Birçok kullanıcı kollarını kullanarak, bir kısmı ise her iki ayağını kullanarak ya da bir ayak ve bir elle yürütürler. Bazı kullanıcılar ise her zaman onları itecek birisine ihtiyaç duyarlar. Kolçaklar ve ayaklıklar doğru yükseklikte olduğunda tekerlekli sandalyeyi elle itmek kolaylaşır. Arkalık çok yüksek. Tekerlekli sandalye kullanıcısı kollarını ve omuzlarını rahatça hareket ettiremez. Kolçaklar çok yüksek. Tekerlekli sandalye kullanıcısı, sandalyeyi yürütmek için tekerleklere ulaşamaz. Arkalık daha alçak olduğunda, tekerlekli sandalye kullanıcısı, hareket etmek için omuzlarını kullanabilir. Denge sağlayabilen ve dik oturabilen bir kullanıcı için resimdeki arkalık uygun bir yüksekliktedir. İtme kasnaklarına ulaşabilen bir kullanıcı, tekerlekli sandalyesini rahatça yürütebilir. Tekerleğin pozisyonu öyle olmalıdır ki, tekerlekli sandalye kullanıcısı itme kasnaklarını tuttuğu zaman dirsekleri 90 derece açıda olmalıdır. Bu iyi bir pozisyondur. Eğer tekerlek daha arkada olursa, yürütmek kullanıcı için yorucu hale gelir. Bazı tekerlekli sandalyelerde, ayarlanabilir arka tekerlekler bulunur. Arka tekerleklerin pozisyonu, arka tekerlekler üzerinde nasıl denge sağlayabileceğinizi etkiler. Arka tekerlekler üzerinde dengede durmak, pürüzlü yüzeylerde, kaldırımlardan inerken, çıkarken, ve yokuş aşağı inerken yararlı olur. Eğer arka tekerlekler ileriye doğru gidiyorsa, arka tekerlekler üzerinde dengede durmak daha kolaydır. Eğer, arka tekerlekler geriye doğru gidiyorsa, sandalye daha dengeli olur ancak yürütmek ve arka tekerlek üzerinde dengede durmak daha zorlaşır. Eğer tekerlekli sandalye kullanıcısının yeterli gücü varsa, sandalyenin arka tarafından destek alarak leğen kemiği sayesinde ayağı ile itmek daha kolay hale gelir. Ayağı ile yürüten, tekerlekli sandalye kullanıcısı için koltuk ve minder büyük önem taşır. Yan taraflara açılan ayaklıklar gereklidir. Ayakları ile yürüten kullanıcıların öne doğru eğilmeleri için kolçaklara ihtiyaçları vardır. Ağır tekerlekli sandalyeler, gerek ayakla ve kolla gerekse de yardımcı tarafından yürütülse de çok enerji harcar. Ancak tekerlekli sandalye, iyi tasarlanmış ve dengeli ise, ağırlık problem olmayabilir. Tekerlekli sandalyenin ağırlığı çocuklar için problem teşkil edebilir. Eğer tekerlekli sandalye ağır ise çocuk kullanıcılar yürütmede zorlanabilirler. Tekerlekli sandalyeyi katlama Tekerlekli sandalyeyi saklamak ve nakliyesinde yardımcı olmak için, sandalyenin katlanabilir olması gerekir. Çapraz katlama iskeleti olan tekerlekli sandalyeler, katlanınca, iki kenarı birleşir. Bazen tekerleklerini çıkartmak da mümkün olabilir. Çapraz katlanan tekerlekli sandalyeler dar yerlerden geçebilme özelliği olduğu için yararlıdır. Nakliye gerektiği zamanlarda bazı kullanıcılar, çapraz katlanan tekerlekli sandalyeleri tercih ederler. Bu tip sandalyelerde tek dezavantaj ise devamlı açma ve katlama, tekerleğin mekanizmasının gevşemesine sebep olur ve yürütmek zorlaşır. Bazı tip tekerlekli sandalyelerde ise arkalık öne doğru katlanır ve tekerlekler çıkar. Bu tip tekerlekli sandalyelerin avantajı ise daha az hareketli parça olduğu için sandalyeler daha sağlam olur. Faaliyetlerin Yürütülmesi Günlük aktivitelerin kolaylıkla yerine getirilmesi, tekerlekli sandalyenin bazı özelliklerinden ileri gelmektedir. Mesela, kullanıcının sandalyeyi yürütmesine yardımcı olacak özelliklerden iki örneği aşağıda görebilirsiniz. Tekerlekli sandalye iskelet uzunluğu: Tekerlekli sandalyenin uzunluğu, küçük mekânlarda ne kadar kolaylıkla veya zorlukla hareket edilip edilemeyeceğini etkiler. İç mekânlarda çok vakit geçiren birisi için daha kısa çerçeveli bir tekerlekli sandalye en iyi seçim olur. Tekerlekli sandalyenin uzunluğu, en arka kısmından en ön kısmına kadar olan mesafenin ölçülmesi ile bulunur. Kolçaklar: Yüksek kolçaklar, kullanıcıların, masalara yaklaşmasına engel olur. Hatırlatma: Uygun bir tekerlekli sandalye, kullanıcısının ihtiyaçlarını karşılamalıdır. Buna kullanıcıların yapmak istediklerini kolayca yapabilmeleri de dâhildir. Tekerlekli sandalye kullanıcısının çevresel ihtiyaçlarının karşılanması Değişik tekerlekli sandalyeler, değişik çevreler için uygundur. Buna etken olan özelliklerden en temelleri: o Ön ve arka tekerlekler arasındaki mesafe (Aks mesafesi); o Tekerleklerin boyutu ve genişliği. Ön ve arka tekerlek arasındaki mesafe (Aks mesafesi). Ön ve arka tekerlekler arasındaki mesafe önemlidir. Tekerlekler birbirinden uzak olduğu zaman, buna “uzun aks mesafesi” denir. Tekerlekler birbirine yakın olduğu zaman, buna “kısa aks mesafesi” denir. Uzun aks mesafeli olan sandalyeler, daha stabil olup, öne doğru düşme tehlikeleri daha azdır. Çoğu zamanını dış mekanlarda geçiren, engebeli yüzeylerde hareket eden kullanıcılar için daha iyi bir seçimdir. Üç tekerlekli ve dört tekerlekli olmak üzere iki çeşit uzun aks mesafeli olan sandalyeler vardır. Üç tekerlekli uzun aks mesafeli sandalyeler, genelde daha dengeli olup, dış mekanlar ve engebeli yüzeyler için uygundur. Dört tekerlekli, uzun aks mesafeli olan sandalyelerde ön tekerlekler, ayaklıkların arkasında olacağına altında bulunur. Böyle olunca sandalyede uzun aks mesafesi oluşur. Kısa aks mesafesi olan tekerlekli sandalyeler, düz yerlerde ve çevrelenmiş iç mekânlarda kullanışlı olur. Örneğin kısa aks mesafeli olan sandalyeler, yokuş aşağı giderken, bir engebeye çarpma durumunda, öne düşme ihtimalleri fazladır. Kısa aks mesafeli olan ortopedik stil tekerlekli sandalyeye örnektir. Bu sandalye engebeli yüzeylerde yürütmesi zordur. Tekerlekli sandalye kullanma becerisi fazla olan kullanıcılar, dış mekanlarda kısa aks mesafeli olan sandalyeler kullanabilirler ve arka tekerlekle üzerinde dengede durarak, yokuş aşağı inip, engebeli yüzeylerde ilerleyebilirler. Tekerlekli sandalye boyutu ve genişliği Tekerlek ne kadar büyük olursa, engebeli yüzeylerde yürütmek o kadar kolay olur. Büyük boyutlu arka tekerlekler ve hareketli ön tekerlekler her ne kadar büyük olursa, engebeli yüzeylerde yürütmek de o denli kolay olur. Bu tip tekerlekler, sandalyenin çamurlu veya kumlu yüzeylerde batmasını engeller. Hatırlatma: Uygun bir tekerlekli sandalyenin, kişinin en çok zaman harcadığı ortamlara uyması gerekir. Yerinde uygunluk ve duruş desteği sağlanması Bütün tekerlekli sandalye kullanıcıları farklı boyutlardadır. Tekerlekli sandalye, kullanıcısına uygun olmalı ve gerekli desteği vermelidir. Tekerlekli sandalyelerin değişik boyutları, çeşitleri ve ayarları bulunduğu için kişiye uygun tekerlekli sandalye bulmak kolaylaşır. Tek boy bir tekerlekli sandalye olmasındansa ayarlanabilir sandalyelerin mevcudiyeti işleri nispeten kolaylaştırmaktadır. Aşağıda belirtilen tekerlekli sandalyenin bölümleri, tekerlekli sandalye kullanıcısına uygun olmalı ve dik oturmasına destek olmalıdır. Koltuklar Koltuklar: Tekerlekli sandalye koltukları yekpare veya askı şeklinde olabilir. Solda gördüğünüz sandalye yekpare koltuğu olan bir tekerlekli sandalye. Sert koltuklar tahtadan veya plastikten yapılabilir, üzerlerinde her zaman bir minder konularak kullanılmalıdır. Askı şeklindeki koltuklar genellikle kanvas malzemesinden yapılır ve kumaş her iki taraftan çerçeveye bağlıdır. Kalitesi düşük askı şeklindeki koltuklar, zamanla esneme yapar ve sarkar. Bu esneme ve sarkma, tekerlekli sandalye kullanıcısına yeterli desteği veremez, dolayısı ile kişinin dik oturması zorlaşır. Arkalık: Arkalıklar, yekpare veya askı şeklinde olabilir. Yekpare olan arkalıklar için minder kullanılmalıdır. Tekerlekli sandalyelerin farklı yüksekliklerde arkalıkları olur. Bazı sandalyelerin arkalıkları ayarlanabilir, bu sebeple de yükseklik kişiye göre ayarlanmalıdır. Kolçaklar: Kolçaklar destek sağlamak açısından yararlıdırlar. Bazı kolçakların yüksekliği ayarlanabilir şekilde üretilir. Eğer kendinden ayarı yoksa modifiye edilerekten kişiye gerekli desteği verebilir. Minder: Minder konfor sağlaması açısından önemlidir. Basıncı rahatlatır, destek verir ve kişinin yanlara kaymasını engeller. Ayaklıklar: Ayaklıklar kullanıcısının desteklenmesini sağlar. Ayaklıkların doğru ayarlanması çok önemlidir bu yüzden genellikle ayaklık yüksekliği ayarlanabilir şekilde yapılmıştır. Bazı ayaklıklar, açısı ve tekerleğe olan mesafesi durumuna göre de ayarlanabilir yapılmıştır. Hatırlatma: Kişiye uygun bir tekerlekli sandalye, kullanıcısına gerekli desteği verir. A.7: Minderler Minderlere neden ihtiyaç duyulur? Minder, bir tekerlekli sandalyenin en önemli bölümlerinden biridir. Minderlerin sağladığı: o Konfor; o Duruş desteği (kişilerin dik oturmasına yardımcı olur); o Basınç rahatlatma Bütün tekerlekli sandalye kullanıcıları, sandalyelerinde rahat olmalıdırlar. İyi bir minder, kullanıcıların rahat ve dik oturmasını sağlar. Bu sebeple her tekerlekli sandalye kullanıcısının bir minder ihtiyacı vardır, ancak bu minderin basınç rahatlatma minderi olması gerekmez. Farklı minder çeşitleri: Minderler bazı özelliklerine göre farklı kategorilerde olabilir: o Yapıldığı materyale göre (örneğin köpük, Hindistan cevizi lifi); o Dolgu maddelerine göre (örneğin hava, sıvı veya jel); o Fonksiyonuna göre (örneğin basınç rahatlatma, konfor, duruş desteği); o Şekline göre (örneğin düz veya konturlu); o Nasıl yapıldığına göre (örneğin köpükten kalıp minder veya köpük katmanlardan oluşabilir). En sık görülen ve en ekonomik olan minder türü köpük minderdir. Köpük minderler kullanımı kolay olduğundan kişiye uygun olarak ayarlanabilir. Kimlerin mindere ihtiyacı vardır? Her tekerlekli sandalye kullanıcısının minderi olmalıdır. Basınç yarası olma riski yüksek tekerlekli sandalye kullanıcıları basınç rahatlatma minderi kullanmalıdır. Basınç rahatlatma minderleri Basınç rahatlatma minderlerinin değişik cinsleri bulunur, bunlardan bazıları: o Konturlu köpük minderler; o Hava/sıvı/jel dolgulu minderler. Köpükten yapılmış basınç rahatlatma minderleri Köpükten yapılmış basınç rahatlatma minderleri ana özellikleri aşağıda belirtilmiştir: Sert ve sabit taban: Basınç rahatlatma minderlerinin tabanı sert olmalıdır. Bu sayede, minder kullanıcı için gerekli desteği sağlar ve kullanıcının her hareketinde yerinden oynamaz. Üst katman: Minderin tabanının üstünde, konforlu bir katman bulunmalıdır. Bu katman veya katmanlar daha yumuşak bir köpükten oluşmalıdır. En üst katman, otururken, kemiklerin gömüleceği kadar yumuşak olmalı, fakat en dibine kadar gömülerek sert tabana değecek kadar yumuşak olmamalıdır. Basınç rahatlatma minderleri, basıncı aşağıdakilerin yardımı ile azaltmaktadır: o Kişinin ağırlığını sandalyede mümkün olduğu kadar eşit dağıtması; o Yüksek basınç riski olan noktalardaki basıncı en aza indirgeyerek. (kalça kemikleri, kuyruk sokumu); o Tekerlekli sandalye kullanıcısının dik oturmasını sağlayarak, derisinin sıyrılmasını ve sarkmasını engelleyerek. Basınç rahatlatma minderi şekillenmesi Basınç rahatlatma minderleri değişkenlik gösterebilir. Bu tip minderlerde oluşan şekillerden bazıları: o Basıncı azaltmak için kalça kemiği altında çukur, boşluk; o Kalça kemikleri altına konulan destek ile ağırlığı eşit olarak yayma; o Kalça kemiğinin önüne konulan bir yükselti ile kalçayı daha dik tutma ve öne kaymasını engelleme; o Bacakların yerleşmesi için gerekli oyuklar. Hava/sıvı/jel dolgulu basınç rahatlatma minderleri o Minderlerin içi hava dolu olanı veya içi sıvı / jel dolgulu olanı bulunur. o Jel dolgulu minderlerin, tıpkı konturlu köpük yastıklar gibi sert köpükten tabanları olması gerekir. o Taban katmanının üzerinde jel / sıvı dolgulu bir tampon olmalıdır. o Jel tamponu otomatik olarak, tekerlekli sandalyenin ve kullanıcının vücut hatlarını alır. Böylelikle kullanıcının vücut ağırlığı eşit olarak yayılır. Hangi minderi kullanmalı? Köpük konturlu veya hava / sıvı / jel dolgulu minderlerin hem avantajları hem de dezavantajları vardır. Avantajlar Dezavantajlar Köpük konturlu minderler o Yerel olarak yapılabilir (yüksek kaliteli köpük olan yerlerde) o Değişik ihtiyaçlara uyarlamak için modifiye edilebilir. o “Ani çöküş” söz konusu değildir (havanın ya da jelin tahliyesine neden olan bir delinme minderin “ani çöküşüne” neden olur ve minderin basıncı rahatlatmasını engeller). o Katmanlı bir minderin en üst katmanı kolaylıkla değiştirilebilir ve az masraflıdır (bütün minderi yenilemekten daha kolaydır) o Köpük zamanla sıkışır (düz ve sert bir hale gelir). Bu nedenle köpük minderler düzenli olarak kontrol edilmeli ve her 1-2 yılda yenilenmelidir. o Kuruması zaman alabilir (idrar tutma problemi olanlar için bir problemdir). o Köpük ısı yalıtımı yapar ve doku sıcaklığında artışa sebep olabilir. Hava/sıvı/jel dolgulu minderler o Koltuk üzerinde basınç eşit olarak dağıtılır o Tekerlekli sandalye kullanıcısı hareket ettiğinde veya pozisyonunu değiştirdiğinde jel tampon otomatik olarak kullanıcının vücuduna adapte olur. o Hava/likit/jel minderler köpük minderlere oranla daha pahalıdırlar ve çok kolaylıkla hemen bulunmazlar. o Bazı tekerlekli sandalye kullanıcıları hava/likit/jel minderlerinin kendilerini dengesiz hissettirdiğini düşünürler. o “Ani çöküş” söz konusu olabilir. Tekerlekli sandalye kullanıcısının çabuk bir şekilde minder bulamayacağı şartlarda bu problem olabilir. Minder kılıfları Basınç rahatlatma minderlerinin, yıkanabilmesi için üzerinde bir kılıf olmalıdır ve bu kılıf su geçirmez olmalıdır. Kılıf, kalça kemiklerinin rahatça mindere gömülebilmesi için yeterince esnek olmalıdır. Eğer kılıf esnek değilse, ince bir kumaştan olmalıdır. İnce kumaşta oluşan kırışıklıklar, deriye daha az iz yapma olasılığı olduğundan, basınç yarası yapma ihtimali daha azdır. Kılıfın altında naylon bir katman var ise, o naylon da yeteri kadar gevşek olmalıdır ki kalça kemikleri köpük üzerimde rahat edebilsin. Tekerlekli sandalye minderleri ıslandığında hemen değiştirilmelidir. Kuruyana kadar da yerine yerleştirilmemelidir. Kullanıcıların bu konuda uyarılması gerekir. Mesane ya da bağırsak problem olan kullanıcılar ve basınç yarası oluşma riski yüksek olan kişilerin çift minder bulundurması ve dönüşümlü olarak kullanması gerekir. Su geçirmez kılıfınız yoksa ne yapılmalıdır? Mesane problem yaşayan kişilerin, mümkün olduğunca su geçirmez kılıf kullanmaları gerekir. Eğer su geçirmez kılıfınız yoksa: o Mesane problemi yaşayan kişiler için, bu durum ile ilgili farklı bir yardım alınmalıdır; o İkinci bir minder edinin – ıslandıkça dönüşümlü olarak kullanılabilir; o İnce bir naylon katman ile kılıfın içinden minderi koruyun. Eğer naylon kullanılıyorsa: o Naylonun kaygan olup, kullanıcının sandalyeden kaymasına sebebiyet vermemesi gerekir; o Basınç yarası oluşturacak şekilde, naylonda kırışıklıklar olmamasına özen gösterilmelidir; o Sıvıların naylonun üzerinde bir havuz oluşturmaması, basınç yarası oluşumunu engellemesi açısından tekerlekli sandalye kullanıcısı için önem taşır. o Tekerlekli sandalye kullanıcısının, kılıfın kuru olması, temizlenmesi ve gerektiğinde değiştirilmesi konusunda uyarılması gerekir. Basınç rahatlatmak için kullanılan minderler işe yarıyor mu? Basınç rahatlatma minderi salık verildiği zaman, aşağıda gösterilen basit testleri uygulayarak, minderin basıncı rahatlatıp rahatlatmadığını kontrol edebilirsiniz. Testi yapmak için, yardımcı personelin, ellerini tekerlekli sandalye kullanıcısının kalça kemiklerinin altına koyması gerekir. Personelin yapacağı her hareketi, yapmadan önce, kullanıcıya anlatmalı ve neden yaptığını açıklamalıdır. Bu testi her zaman kullanıcının mevcut olan tekerlekli sandalyesi ve minderi ile yapılmalıdır. Manüel Basınç Testi A Tekerlekli sandalye kullanıcısına basit bir şekilde ne yapacağınızı ve bunun neden önemli olduğunu açıklayın. B Tekerlekli sandalye kullanıcısına, parmak uçlarınızı onların sağ ya da sol kalçalarının altına koymanıza müsaade edecek şekilde öne eğilmesini ya da kendisini yukarı doğru itmesini söyleyin (el ayası yukarıda olacak). En iyi yapılış şekli tekerlekli sandalyenin arka tarafından döşemenin altından bir elle uzanmaktır. C Tekerlekli sandalye kullanıcısından parmaklarınızın üzerine geri oturmasını isteyin. O dik bir şekilde, yüz karşıya doğru ve elleri bacaklarının (uyluklarının) üzerine koyulmuş bir şekilde oturmalıdır. Bu siz her bir ayrı bölgeyi kontrol ederken onun aynı pozisyonda oturmasını sağlayacaktır. Eğer parmaklarınız kemiğin altındaki basıncı hissetmek için iyi bir pozisyonda değilse, kullanıcıya kendini tekrar yukarı çekmesini söyleyin ve parmaklarınızı tekrar yerleştirin. D Basıncın tanımlanması: Seviye bir = güvenli: Parmak uçları yukarı ve aşağı 5 mm ya da daha fazla kıpırdatılabiliyor. Seviye iki = uyarı: Parmak uçları kıpırdatılamıyor ama kolaylıkla dışa doğru kaydırılabiliyor. Seviye üç =tehlikeli: Parmak uçları sıkıca sıkışmış. Parmakları çekip çıkarmak oldukça zor E İkinci kalça kemiğinde de tekrarlayınız. ‘Uyarı’ ve ‘tehlikeli’ seviyesindeki basınçları nasıl azaltabilirsiniz? İkinci veya üçüncü seviyede basınç hissedildiği zaman, bu basıncın derhal rahatlatılması gerekir. En basit çözümlerden biri, fazladan bir kat sert köpük daha koymaktadır. Buna ‘kat (yükseltme)’ denir. Bu sert köpük yaklaşık olarak 20 mm ve kalça kemiği altında çukur olacak şekilde olmalıdır. Bu kat minderin altına, kılıfın içine konmalıdır. Bazen birden fazla kat gerekebilir. Test tekrar yapılmalı ve basınç halen ikinci ve üçüncü seviyede ise bir kat daha konulmalıdır. A.8 Transferler Tekerlekli sandalyeden kalkıp oturmak Yardım alarak veya bağımsız olarak tekerlekli sandalyeden kalkıp, oturabilme becerisi kullanıcının günlük hayatında çok ihtiyacı olan bir beceridir. Tekerlekli sandalyeden kalkıp, oturma işlevine “transfer etmek” denilebilir. Tekerlekli sandalye kullanıcıları neden transfer yapmayı öğrenmelidirler? Tekerlekli sandalye kullanıcılarının, günde birkaç kere sandalyeden kalkıp oturmaları gerekebilir. Becerileri ve fiziksel özelliklerine bağlı olarak, kendilerini güvende hissedebilecekleri, hızlı ve fazla enerji harcamalarını gerektirmeyen bir yöntem bulmalıdırlar. Tekerlekli sandalye kullanıcıları, farklı yöntemler denerler ve alıştırma yaparlar. Bazı tekerlekli sandalye kullanıcıları, yardım almadan sandalyeden kalkıp oturabilirler, bazıları ise yardıma ihtiyaç duyarlar. Kimisi ayağa kalkıp başka bir yere oturabilir, kimisi için ise bu mümkün değildir. Tekerlekli sandalyeden kalkıp oturmanın üç yolu Tekerlekli sandalye kullanıcısına, transferi için alıştırma yapmasını önermeden önce, bağımsız olarak sandalyeden kalkıp, oturabildiğini veya bu konuda yardıma ihtiyacı olup olmadığını bilmeniz gerekir. o Bağımsız transfer için, tekerlekli sandalye kullanıcısının, kollarını kullanarak kendi vücudunu kaldırıp kaldıramadığını kontrol edin. o Bağımsız transfer için, kullanıcının sandalyeden kalkıp, ayakta durabilmesi, kendi vücut ağırlığını bacakları üzerinde taşıyabilmesi gerekir. Eğer bunu yapamıyorsa, yardıma ihtiyacı vardır. Farklı transfer yöntemler aşağıda gösterilmiştir. Bağımsız transfer (Oturarak – sandalyeden yatağa) o Tekerlekli sandalyeyi yatağa doğru yaklaştırın ve frenleri çekin. o Ayaklarınızı ayaklıktan kaldırın ve ayaklıklarını yanlara itin. o Yatak tarafındaki kolçağı kaldırın. o Ellerinizle, vücudunuzu tekerlekli sandalyenin ön tarafına itin. o Bir eliniz yatakta, bir eliniz tekerlekli sandalyede, kendinizi kaldırın ve yatağa oturun. o Eğer kullanıcının denge problemi varsa veya kendini yukarı kaldıramıyorsa, bir transfer tahtası kullanabilir. o Eğer yatağa transfer yapılıyorsa bazı tekerlekli sandalye kullanıcıları transferden önce ayaklarını yatağa koymayı tercih ederler. Transfer tahtası ile yardım alarak yapılan transfer (Tekerlekli sandalyeden yatağa) o Tekerlekli sandalye pozisyonunu yatağa yakın ayarla ve frenleri çek. o Ayaklıkları çıkar ve ayaklıkları döndür ya da çıkart (uygulanabilen durumlarda). o Yatağa yakın olan kolçağı çıkart. o Kullanıcıya ileri hareket etmek için yardımcı ol. o Kalça altına, yatakla tekerlekli sandalye arasına boylu boyunca transfer tahtasını koy. o Kullanıcı tekerlekli sandalyede ve yatakta mümkün olduğunca kollarıyla yükselerek kendi ağırlığını alabilmeye yardımcı olmalıdır. o Yardımcı kullanıcının arkasında durur ve kullanıcının pelvisini yatağa doğru hareket ettirir. Yardım alarak transfer yapmak (Yataktan tekerlekli sandalyeye) o Tekerlekli sandalye pozisyonunu yatağa yakın ayarla ve frenleri çek o Ayaklıkları çıkar ve ayaklıkları döndür ya da çıkart (uygulanabilen durumlarda). o Yatağa yakın olan kolçağı çıkart. o Kullanıcının yatağın üzerinde ileriye doğru hareket etmesi için yardımcı ol ve ayaklarını yere koy. o Kullanıcının dizlerini kenarlardan destekle (ön taraftan dizin karşısından itme). o Kullanıcının vücudunu ileri ve yukarı doğru kürek kemiğinden destekleyerek getir. o Kullanıcıyı tekerlekli sandalyeye doğru nazikçe çevirin ve oturmasını sağlayın. Transfer tahtası nedir? Transfer tahtası, ince ve sağlam bir tahta parçası olup, transfer sırasında tekerlekli sandalye ve yatak arasında bir köprü oluşturmaya yarar. Transfer tahtası, bağımsız olarak transfer yapmayı öğrenenler için ve kollarında yeterince gücü olmayan kişiler için çok yararlıdır. Tekerlekli sandalye kullanıcıları, bir seferde kalkmak yerine, seriler halindeki minik kalkma hareketleri ile transfer edebilirler. Transfer tahtası, kullanıcıların, daha az yardıma gereksinim duymasını sağlar. Transfer tahtaları tahtadan veya kontrplaktan yapılabilir. İnce, sağlam ve pürüzsüz olmalıdır. Kenarları kalın olmamalıdır. Tavsiye edilen ölçüleri 300 mm x 600 mm’dir. Kalınlığı yapıldığı materyale göre değişkenlik gösterebilir. Genelde kalınlığı 20 veya 25 mm’dir. Bağımsız olarak tekerlekli sandalyeden yere transfer yapmak o Bu tip transfer, tekerlekli sandalye kullanıcısının güçlü kolları olmasını gerektirir. o Basınç yarası oluşma riski olan tekerlekli sandalye kullanıcılarının yerde otururken, basınç rahatlatma minderi kullanmaları gerekir. o Tekerlekli sandalye kullanıcıları, sandalyenin önünde oturun, dizlerinizi kendinize doğru çekin. o Aşağı doğru bakın ve sandalyeye oturana kadar bakmaya devam edin. o Bir elinizi yere, diğerini sandalyenin ön tarafına koyun. o Kollarınız ve omzunuzdan destek alarak, aşağı bastırın, kalçanızı kaldırın ve kendinizi tekerlekli sandalyeye yerleştirin. o Sandalyeye yerleştikten sonra eğilip minderi yerden alın. o Ağırlığınızı bir tarafa vererek, tekerlekli sandalye minderini yerine koyun. Tekerlekli sandalyeden yere oturma o Tekerlekli sandalyenin ön tarafına doğru oturun. o Ayaklarınızı, ayaklıklardan kaldırın, transfer edeceğiniz yöne doğru döndürün. o Minderi yere koyun. o Bir elinizi tekerlekli sandalye koltuğuna koyun, diğeri ile yerden destek alın. o Omuz ve kollarınızı kullanarak, kalçanızı kaldırın ve yere koyduğunuz mindere kontrollü bir şekilde kendinizi yerleştirin. Tekerlekli sandalyeye güvenli bir şekilde oturup kalkmak Tekerlekli sandalye kullanıcısı için: o Tekerlekli sandalyeden kalkar ve otururken her zaman frenlerin çekili olduğundan emin olun. o Nereye gittiğinizi kontrol edin – Yolda size engel bir şey olmadığına emin olun. o Her zaman kendinizi kaldırın, sürtünmeyin, sürtünmek derinize zarar verir ve basınç yarası oluşumuna yol açar. Yardımcı olan kişiler için: o Birisine yardımcı olmadan önce, onların vücut ağırlığını kaldırabileceğinizden emin olun. o Tekerlekli sandalye kullanıcısına ne yapacağınızı her zaman önceden anlatın. o Güvenli kalkma teknikleri kullanın. o Hamile iseniz veya beliniz ile ilgili bir rahatsızlığınız var ise yardımcı olmayın. B. Tekerlekli Sandalye Hizmet Adımları 1. Adım: Sevk ve Randevu Sevk Sevk demek: Kişiyi, yardım veya tedavi alması için doğru yere yönlendirmek veya göndermektir. Tekerlekli sandalye kullanıcılarının bir yere sevk edilmesi birkaç şekilde olabilir. Bunlara örnek: o Bu hizmeti veren yerleri duyarlar ve kendileri giderler; o Yerel bir hastane, sağlık ocağı, rehabilitasyon merkezi, engelliler derneği veya diğer tekerlekli sandalye kullanıcıları tarafından sevk edilebilir. Tekerlekli sandalye hizmeti veren merkezler, sevk edilen tekerlekli sandalye kullanıcılarının sayılarının artması için sevk kaynaklarını, var olduklarına dair bilinçlendirmeleri gerekir. Sevk kaynakları, kullanacağı basit içerikli bir sevk formu ile tekerlekli sandalye hizmeti veren merkezlerin, tekerlekli sandalye kullanıcısı hakkında bilgi edinmesini sağlar. Her merkezin, sevk formunu kullanışlı bulup bulmayacağı ve formun ne gibi bilgiler içermesi gerektiğine kendileri karar vermelidir. Örnek bir sevk formu bir sonraki sayfada verilmiştir. Randevu Tekerlekli sandalye kullanıcısı bir merkeze sevk edildiği zaman, personel ile görüşüp bir değerlendirme yapılması gerekir. Şayet sevk edildiği gün değerlendirme yapılamıyorsa, o zaman bir randevu verilmelidir. Randevu, tekerlekli sandalye kullanıcısının merkeze gelmesi veya merkez personelinin tekerlekli sandalye kullanıcısını evinde ziyaret etmesi ile gerçekleşebilir. Randevu sistemi, tekerlekli sandalye hizmeti veren merkezlerin, zamanlarını verimli bir şekilde kullanmalarına yararlı olur. Ayrıca tekerlekli sandalye kullanıcıları da boş yere bekleyerek vakitlerini harcamazlar. Tekerlekli sandalye kullanıcılarına nasıl randevu verildiği onlara gönderilecek iletinin en kolay nasıl ulaştırılabileceği ile alakalıdır. Randevu bilgileri posta, telefon veya sevk edildiği yer aracılığı ile iletilebilir. Bazen tekerlekli sandalye kullanıcıları, randevu almadan merkeze ziyarette bulunabilirler. Bu gibi durumlarda onlara geldikleri gün hizmet vermek gerekir. Özelliklede uzun yoldan gelmişler ise. Sevk etme ve randevu vermede izlenecek yollar o Her bir tekerlekli sandalye kullanıcısı için, bilgilerini içeren bir dosya hazırlayın. o Sevk kaynaklarını, tekerlekli sandalye hizmeti veren merkezler ve nasıl sevk edileceği hakkında eğitin. o Sevk kaynakları ile sevk formunuzu paylaşın. o Tekerlekli sandalye hizmeti veren merkezler, kullanıcılarından hangilerine önce bakacaklarını doğru bir sıraya koymalıdırlar. Örneğin çocukların ve basınç yarası olan kişilerin ihtiyaçlarının önce karşılanmasına özen gösterin. Tekerlekli Sandalye Sevk Formu Lütfen sevk formunu doldurun ve şu adrese postalayın: Tekerlekli Sandalye Hizmetlerinin Adı ve Adresi: Sevk eden kişinin adı: Çalıştığınız kurumun adı: Sevk eden kişinin irtibat detayları (sizinle irtibata geçmenin en uygun yolu): Tekerlekli sandalye kullanıcısının adı: Doğum tarihi: Ebeveyn / bakıcının adı: Adres: Tekerlekli sandalye kullanıcısı ile nasıl bağlantı kurulabilir? Posta Kendi Telefonu Arkadaş /Komşunun telefonu Eğer telefon ile bağlantı kurulacak ise telefon numarası: Tekerlekli sandalye kullanıcısının engeli nedir?(eğer biliniyor ise): Sevkin sebebi:  Tekerlekli sandalyesi yok  Bozulmuş tekerlekli sandalyesi var  İhtiyaçlarını karşılamayan bir tekerlekli sandalyesi var Tekerlekli sandalye kullanıcısı ile ilgili önemli olan ve tekerlekli sandalye hizmetinin bilmesi gerektiğini düşündüğünüz bilgi varsa lütfen ekleyiniz: Tekerlekli sandalye kullanıcısı ile tekerlekli sandalye hizmetine sevk edilme konusunda anlaşmaya varıldı mı? Evet Hayır Sevk eden kişinin imzası: Tarih: Sevk formunda tekerlekli sandalye hizmeti veren merkezin telefon ve adresi dahil olmak üzere bütün iletişim bilgileri açık olarak belirtilmelidir. Tekerlekli sandalye kullanıcısını sevk eden kişi, tekerlekli sandalye hizmeti veren merkezin ne gibi bir hizmet verdiğini kullanıcıya anlatmalı, kullanıcı da sevk edilmek ile ilgili hem fikir olması gerekir. Bu sevk formunda, merkez, tekerlekli sandalye merkezi, randevu vermek için kullanıcı ile iletişime geçer. Randevu vermek her zaman mümkün olmayabilir, bu durumda merkez randevusuz gelenleri de kabul etmek durumundadır. 2. Adım: Değerlendirme Kimlerin tekerlekli sandalyeye ihtiyacı vardır? Kişiler tekerlekli sandalye hizmeti veren merkezlere gittikleri zaman, o kişilerin gerçekten tekerlekli sandalyeye ihtiyaçları olup olmadığı değerlendirilmelidir. Genelde tekerlekli sandalyeye ihtiyaç duyan kişiler: o Yürüyemeyenler; o Zorlukla ve sadece kısa mesafeleri yürüyebilen kişiler. Neden bir değerlendirmeye ihtiyaç vardır? Tekerlekli sandalye değerlendirme formu, yardımcı olabilecek bilgileri toplamaya yarar: o Tekerlekli sandalye kullanıcısı için en uygun tekerlekli sandalyeyi seçmemizi sağlar; o Kullanıcıya en uygun tekerlekli sandalye parçalarını seçmeye yardımcı olur; o Tekerlekli sandalye kullanıcısının veya aile bireylerinin tekerlekli sandalyeden azami olarak nasıl faydalanabilecekleri konusunda almaları gereken eğitimin hangisi olduğunu anlamayı sağlar. Değerlendirme nerede yapılmalıdır? Değerlendirmeler her zaman temiz ve sessiz bir yerde yapılmalıdır. Burası, tekerlekli sandalye hizmeti veren bir merkez, sağlık ocağı veya kullanıcının kendi evi olabilir. Eğer kullanıcının basınç yarası olup olmadığı kontrol edilecekse, bu işlem özel bir yerde yapılmalıdır. Tekerlekli sandalye kullanıcısının, yaşına, cinsiyetine, dinine, sosyoekonomik statüsüne saygı duyun ve gerektiği şekilde davranın. Değerlendirmenin iki aşaması: o Değerlendirme görüşmesi; o Fiziksel değerlendirme. 1. Değerlendirme görüşmesi Tekerlekli sandalye kullanıcısı hakkında bilgi almanın en iyi yolu, soru sormaktır. Tekerlekli sandalye değerlendirme formu, doğru değerlendirme yapabilmek için, tekerlekli sandalye hizmeti veren personelin, kullanıcı hakkında bilmesi gereken en önemli soruları sormaktadır. Dört farklı soru başlıkları vardır. Bunlar: o Tekerlekli sandalye kullanıcısı hakkında bilgi; o Fiziksel durum; o Hayat tarzı ve çevresel durumu; o Mevcut olan tekerlekli sandalyesi. Tekerlekli sandalye kullanıcısı hakkında bilgi: Adı: Numarası: Yaşı: Erkek  Kadın  Telefon numarası: Adres: Hedefler: Yukarıda belirtilen sorular, ileriye dönük olarak tekerlekli sandalye kullanıcısı ile iletişim kurabilmek için önemlidir. Ayrıca bu sorular, tekerlekli sandalye hizmeti veren merkez için istatistikî bilgiler içermektedir. “Hedefler” bölümüne kişinin neden tekerlekli sandalyeye ihtiyaç duyduğunu ve tekerlekli sandalye sayesinde neler yapabileceğini yazın. Soru sorarken bunları unutmayın: o Tekerlekli sandalye kullanıcısına bu soruları sormanın önemini açıklayın; o Tekerlekli sandalye kullanıcısı, küçük bir çocuk, sorularınızı anlamayan veya cevaplayamayan birisi olmadığı müddetçe, her zaman kullanıcının kendisini (bakıcısı / aile bireyi değil) muhatap olarak alın; o İyi iletişim becerileri kullanın; o Size verilen bilgiler, formda yazıldığı sırada olmayabilir, o yüzden bilgileri doğru yere kaydedebilmek için formla iyice aşina olun. Fiziksel durum: Bu bölümdeki sorular çok önemlidir. Kişinin sağlık durumunu ne tip bir tekerlekli sandalye seçilmesi gerektiğini gösterir. Bazı örnekler aşağıda belirtilmiştir. Fiziksel durum Beyin felci (serebral palsi)  Çocuk felci (polyo)  Omurilik zedelenmesi  Felç (inme)  Zayıf, güçsüz  Spazmlar ya da kontrolsüz hareketler  Ampütasyon: Sağ diz üstü  Sağ diz altı  Sol diz üstü  Sol diz altı Mesane problemi  Bağırsak problemi  Eğer tekerlekli sandalye kullanıcısının mesane ya da bağırsak problemleri varsa ilgilenilmiş mi? Evet  Hayır  Diğerleri:______________________________________________________________ Değişik sağlık şartları ne tip bir tekerlekli sandalye kullanılması gerektiğini etkiler: Bilmeniz gerekenler Sakın unutmayın Beyin Felci Beyin felci kişileri değişik şekillerde etkiler. Beyin felci geçirmiş, fakat dik oturabilen kişiler için bilinmesi gereken en önemli nokta, uzun süre dik oturmak onları yorar ve bu durum yaptıkları şeyleri yapmalarını daha zor hale getirir. İyi bir destek sağlamak çok önemlidir. Beyin felci geçirmiş kişiler, tekerlekli sandalye üzerinde fazladan duruş desteğine ihtiyaç duyabilirler. Bunu etkili bir şekilde yerine getirebilmek için orta seviye eğitim gerekmektedir. Çocuk Felci Çocuk felci geçirmiş kişilerin vücudunda güçsüzlük olabilir. Çocuk felci, kolları, bacakları ve gövdeyi etkiler. Bunların içinde en sık etkilenen vücut kısmı, bacaklardır. Kaslar ve kemikler incelir, vücudun uzuvları yavaş büyüdüğünden normalden kısa kalır. Gövde etkilendiği zamanlar da ise gövde daha kısa görünür. Çocuk felci geçirmiş kişilerin hissetme duyularını kaybetmediklerinden, rahat etmek için yastığa ihtiyaç duyarlar. Yüksekçe bir yastık, daha rahat bir itme pozisyonu sağlamaya yardımcı olur. Omurilik zedelenmesi Omurilik zedelenmesi geçirmiş kişilerde, basınç yarası oluşma riski ihtimali daha fazladır. Bunun sebebi, omurilik zedelenmesi geçirmiş kişiler zedelenmenin olduğu seviyeden aşağısını hissedememeleridir. Her zaman basınç rahatlatma yastığı kullanmaları gerekmektedir. Felç (inme) Felç geçirmiş olan kişilerin genelde vücutlarının tek tarafı felçlidir. Bu da kişinin tekerlekli sandalyeden felçli taraflarına düşme riskini arttırır. Felçli kişilerin, felçli taraflarını hissetmemeleri normaldir. Felçli kişiler, tekerlekli sandalyelerinden kalkıp, oturma hareketini dikilerek yapabilirler. İyi destek çok önemlidir. Kişinin ne kadar hissedebildiğini kontrol edin, basınç rahatlatma yastığına ihtiyaç duyabilirler. Felçli kişilerin, ayaklıkları kenarlara katlanabilen bir tekerlekli sandalye tercih edebilirler. Bu sayede dikilerek transfer yapabilirler. Ampütasyon Çift bacağını da kaybetmiş kişilerde, bacak ağırlıkları olmadığından, tekerlekli sandalyeleri geriye doğru düşebilir. Ampütasyonu olan kişilerin, ilk defa tekerlekli sandalyeyi denediklerinde dikkatli olunmalıdır. Tekerlekli sandalyenin dengesini kontrol edin. Ekstra destek sağlaması açısından arka tekerleğin geriye doğru gidebilmesi gerekir. Zayıf, güçsüz Yaşlılar, farklı sebeplerden dolayı tekerlekli sandalyeye ihtiyaç duyarlar. Genelde yürüme zorluğu çektikleri için olur. Tekerlekli sandalye, onların hayatlarını kolaylaştırır, aileleri ile beraber olmalarını ve topluma karışmalarını sağlar. Yaşlılar ayağa kalkarak transfer yapabilir ve genelde yanlara katlanabilen ayaklıklı sandalyeleri tercih ederler. Yaşlılara her zaman iyi destekli ve konforlu bir tekerlekli sandalye verilmelidir. Bu sayede düzgün oturabilirler e dik duruşlarını muhafaza edebilirler. Yanlara açılıp katlanabilen ayaklıklar en iyi seçim olur. Spazmlar ve kontrolsüz hareketler Bazı insanlarda spazm veya kontrolsüz hareket problemleri olabilir. Bu tip kişiler, kendi vücut ağırlıklarını geriye doğru verebilir ve tekerlekli sandalyenin devrilmesine sebep olabilirler. Kontrolsüz hareketler, ayağın ayaklıklardan aniden kalkmasına sebebiyet verebilir, bu da sandalyenin yürütülmesi esnasında tehlikeli olabilir. Güvenli arka tekerlek pozisyonu ya da çok sağlam bir tekerlekli sandalye seçilmelidir. Ayağı yerinde tutmak için kemer kullanmak gerekebilir. Not: Eğer emniyet bandı kullanılacaksa, bunların yapışkan bantlı (cırt cırtlı) olmasına özen gösterin. Kullanıcının tekerlekli sandalyeden düşmesi durumunda, kişiyi rahat kurtarabilmek için gereklidir. Mesane ve bağırsak problemleri Bazı kişiler mesane e bağırsaklarını kontrol edemeyebilirler. Bu problem doğru malzemelerin kullanılması, ilaç tedavisi ve mesane / bağırsak eğitimi ile giderilebilir. Mesane ve bağırsak problemi olan kişilerin kirli veya ıslak bir yastığa oturmaması gerekir. Bu durum derinin parçalanmasına sebebiyet verir. Dışkıda bulunan bazı mikroplar, önceden oluşmuş basınç yaralarının hızla enfeksiyon kapmasına neden olur. Bölgenizde bulunan, bu konuda ihtisas yapmış doktor e hemşireleri bulun. İhtiyacınız olduğu durumlarında bu kişilerden yardım alabilirsiniz. Su geçirmez kılıfı olan bir yastık sağlayın. Tekerlekli sandalye kullanıcısına yastığı nasıl yıkayıp, kurutacağını öğretin. Yastık yıkandığında, kullanıcının günlük aktivitelerine devam edebilmesi için ikinci bir yastığa ihtiyaç vardır. Hayat tarzı ve çevresel durum: Burada sorulan sorular, tekerlekli sandalye kullanıcısının nerede yaşadığını, e sandalye üzerindeyken neler yaptığını öğrenebilirsiniz. Hayat tarzı ve çevresel durum Tekerlekli sandalye kullanıcısının bu sandalyeyi nerelerde kullanacağını tanımlayın: ______________________________________________________________________________ Günlük kat edilen yol: 1 km’ye kadar  1 – 5 km  5 km’den fazla  Günlük tekerlekli sandalye kullanımı nedir? 1 saatten az  1-3  3-5  5-8  8 saatten fazla  Tekerlekli sandalye kullanıcısı sandalyede oturmuyor iken nerede oturuyor ya da uzanıyor ve nasıl bir yüzeyde oturuyor ve duruşu nasıl? ______________________________________________________________________________ Transfer: Kendi kendine  Yardım ile  Ayakta  Ayakta değil  Kaldırılarak  Diğer  Tuvalet cinsi (eğer tuvalete transfer yapılıyorsa ): Alaturka  Alafranga  Uyarlanmış  Tekerlekli sandalye kullanıcısı sıklıkla toplu / özel taşıma araçlarını kullanıyor mu? Evet  Hayır  Cevap evet ise, ne cins bir: Araba  Taksi  Otobüs  Diğer___________________ Mevcut tekerlekli sandalye: Burada belirtilen sorular, kişinin mevcut tekerlekli sandalyesinin kendisine uygun olup olmadığını anlamaya yardımcı olur. Mevcut tekerlekli sandalye (eğer şahsın zaten tekerlekli sandalyesi var ise) Tekerlekli sandalye kullanıcının ihtiyaçlarını karşılıyor mu? Evet  Hayır  Tekerlekli sandalye kullanıcının çevresel şartlarına uygun mu? Evet  Hayır  Tekerlekli sandalye şahıs için yerinde ve uygun mu ve duruşu için destek sağlıyor mu? Evet  Hayır  Tekerlekli sandalye sağlam ve güvenli mi? (Minder olup olmadığını göz önünde bulundurun) Evet  Hayır  Minder uygun basınç rahatlatması sağlıyor mu? (eğer şahıs basınç yarası riski taşıyorsa) Evet  Hayır  Yorumlar: _____________________________________________________________________ Soruların hepsinin cevabı evet ise kullanıcının yeni bir sandalyeye ihtiyacı olmayabilir. Eğer bu sorulardan bazılarının cevabı hayır ise kullanıcının yeni bir sandalyeye ya da mindere ihtiyacı vardır; ya da mevcut sandalyenin ya da minderin tamire ya da modifikasyona ihtiyacı vardır. 2. Fiziksel Değerlendirme Üç farklı soru başlıkları vardır. Bunlar: o görünüş, basınç yarası tarihçesi ve oluşma riski; o itme metodu; o ölçü alma. Görünüş, basınç yarası tarihçesi ve oluşma riski /// = hissetmiyor O = önceki basınç yarası  = mevcut basınç yarası Normal hissedebiliyor mu? Evet  Hayır  Önceden basınç yarası var mıydı? Evet  Hayır  Halen basınç yarası var mı? Evet  Hayır  Evet ise, açık bir yara mı (evre 1 – 4)? Evet  Hayır  Süresi ve sebebi: _________________________ _________________________________________ Bu kişi basınç yarası riski* taşıyor mu? *Bir şahıs hissedemiyor ise ya da 3 ve daha fazla risk faktörü taşıyorsa risk altındadır. Risk faktörleri: hareket edilememesi, ıslaklık, kötü duruş, önceki / hali hazırdaki basınç yarası, kötü beslenme, yaşlanma, normal kilonun altında ya da üstünde olmak. Evet  Hayır  Vücut diyagramında işaretleyin: o Tekerlekli sandalye kullanıcısının hissedemediği kısımlara //// işaretini koyun. o Tekerlekli sandalye kullanıcısının daha önce basınç yarası oluşmuş yerlerine O işareti koyun. o Tekerlekli sandalye kullanıcısının mevcut yarası var ise  işareti koyun. Eğer tekerlekli sandalye kullanıcısı basınç yarası olduğunu söylerse mutlaka size göstermesini isteyin. Bu işlemi özel bir yerde yapmaya özen gösterin. Eğer tekerlekli sandalye kullanıcısının hissetme ile ilgili problemi varsa veya başka risk faktörleri taşıyorsa basınç yarası geliştirme riski vardır. Bu riskler: 2 Kişi hissedemez ise (his kaybı); 3 Kişi hareket edemiyorsa; 4 Terden, sudan ya da mesane problemlerinden dolayı oluşan nem; 5 Kötü duruş; 6 Önceden oluşmuş veya mevcut basınç yarası; 7 Kötü beslenme ve yeterli su içmeme; 8 Yaşlanma; 9 Kilo (kilonun normalin altında veya üstünde olması). Hatırlatma: Basınç yarası oluşma riski bulunan her tekerlekli sandalye kullanıcısının, basınç rahatlatma minderine ve basınç yarasının oluşmasını önleme eğitimine ihtiyacı vardır. İtme metodu İtme metodu Tekerlekli sandalye kullanıcısı sandalyesini nasıl itecek? İki kolla  Sol kolla  Sağ kolla  İki bacağıyla  Sol bacakla  Sağ bacakla  Bir yardımcı aracılığı ile  Yorum: _____________________________________________________________________ Tekerlekli sandalye kullanıcısının nasıl bir tekerlekli sandalyede oturması gerektiğini, e sandalyenin nasıl ayarlanması gerektiğini saptamak için, kullanıcının nasıl ittiğini bilmek gerekir. (Bkz. A.6. bölüm Uygun Tekerlekli Sandalye Seçimi, ``Tekerlekli sandalyeyi İtmek``). Ölçümler Tekerlekli sandalye kullanıcısına en uygun tekerlekli sandalyeyi bulabilmek için dört ölçü gereklidir. Her bir ölçü tekerlekli sandalye ile alakalıdır. Vücut Ölçümü Ölçümler (mm) Vücut ölçülerini ideal tekerlekli sandalye ölçülerine çevirin Tekerlekli sandalye ölçüleri A Basen genişliği Basen genişliği = koltuk genişliği B Koltuk değişikliği Sol B koltuk derinliği 30–50 mm’den daha küçük ise. (Eğer uzunluk farklı ise daha kısa olanını kullanın) Sağ C Baldır uzunluğu Sol = koltuk minderinin üstünden * ayaklık yüksekliğine kadar Ya da = koltuk minderinin üstünden * yere kadar ayakla itmek için Sağ D Göğüs kafesinin alt kısmı = koltuk minderinin üstünden * arkalığın üstüne kadar (D ya da E’yi ölçün – kullanıcının ihtiyaçlarına bağlı olarak) E Kürek kemiğinin alt kısmı *Kullanıcının kullanacağı minderin yüksekliğini ölçün. Ölçüm Aletleri o Sağdaki resimdeki gibi bir metal şerit metre. o Kıskaçlı dosyalar/kitaplar, ölçü almakta yardımcı olabilir. (bkz. nasıl ölçü alınır). o Ölçmek için uzun bir kumpas da kullanılabilir. o Belli ölçülerde tahta bloklar, tekerlekli sandalye kullanıcısının ayağına destek sağlamak için kullanılabilir. Vücut ölçüleri nasıl alınır? Tekerlekli sandalye kullanıcısından oturabildiği kadar dik oturmasını isteyin. Tekerlekli sandalye kullanıcısının ayaklarını yere basmasını isteyin, yere değmiyorsa, tahta bir blok ile ayakların altına destek koyup, kullanıcının basmasını sağlayın. Bütün ölçümleri yaparken, çelik metre düz tutulmalı, tekerlekli sandalye kullanıcısı ise dik oturmalıdır. Tekerlekli sandalye kullanıcısının her iki yanına, bir dosya/kitap koymak, doğru ölçü almanıza yardımcı olur. Gerekirse eğilip, doğru açı ile şerit metreyi gördüğünüzden emin olun. A o Ölçü almadan önce, tekerlekli sandalye kullanıcısının ceplerinin boş olduğundan emin olun. o Kalçaları ve baldırların en geniş kısmını ölçün. o Tekerlekli sandalye kuklacısının her iki yanına dosya/kitap koyarak hatasız ölçü alabilirsiniz. B o Tekerlekli sandalye kullanıcısının sırt tarafına dosya/kitap koyarak hatasız ölçü alabilirsiniz. o Kalçanın arka kısmından, diz arkasına kadar düz olarak ölçün. o Her zaman her iki bacağı da ölçün. Bacak uzunlukları arasında fark varsa, tekerlekli sandalye kullanıcısının, kalçası düz olarak oturduğundan emin olun. Eğer halen bir fark varsa, tekerlekli sandalyeyi kısa bacağa göre ayarlayın. C o Diz arkasından, ayak topuğuna kadar olan mesafeyi ölçün. o Tekerlekli sandalye kullanıcısının mümkünse dizlerinin 90 derece durduğuna emin olun. o Her zaman her iki bacağı da ölçün. o Eğer varsa tekerlekli sandalye kullanıcısı her gün kullandığı ayakkabıyı giymelidir. D o Koltuğu göğüs kafesinin altına kadar ölçün. o Göğüs kafesinin alt kısmını bulmak için, elleri kalçanın her iki yanına koyun. Yavaşça elleri içeri doğru sıkıştırın ve elleri yukarı doğru kaydırın. Göğüs kafesinin alt kısmı, belin hemen üstünde kalan kısımdır. E o Koltuktan, kürek kemiğinin altına kadar olan kısmı dik bir çizgi halinde ölçün. o Kürek kemiğinin altını bulabilmek için kullanıcıya, omuzlarını yukarı kaldırmasını isteyin. Daha fazla bilgi için, tekerlekli sandalye için doğru ayarlar, 6. adım Uygunluk kısmına bakınız. -A- 3. Adım: Reçete (seçim) Reçete (seçim) nedir? Reçete (seçim), tekerlekli sandalye kullanıcısının ihtiyaçları ile uygun tekerlekli sandalyeyi eşleştirmek anlamına gelir. Reçete (seçim) her zaman tekerlekli sandalye kullanıcısı ve uygun olan durumlarda aile bireyi veya bakıcı ile karar verilmelidir. Reçete (seçim) aşağıdakileri kapsar:  Doğru tekerlekli sandalyeyi, minderi ve sandalye parçalarını seçmek;  Doğru tekerlekli sandalye ve minder boyunu seçme;  Tekerlekli sandalye kullanıcısı ile beraber tekerlekli sandalyesinin ve minderin bakımını nasıl yapacağının ve hangi eğitimi alacağının kararlaştırmalıdır. Yerel olarak bulunabilen tekerlekli sandalyeler ve minderler Doğru boyutta tekerlekli sandalye seçmek çok önemlidir. Doğru boyuttaki tekerlekli sandalye, daha rahattır, dik oturmak için gerekli desteği sağlar, kullanıcı için kullanımı kolaydır. Daha fazla bilgi için, tekerlekli sandalye için doğru ayarlar, 6. adım Uygunluk kısmına bakınız. o İskelet; örneğin, tekerlek aks mesafesi kısa ya da uzun olabilir; iskelet uzunluğu, katlanabilir veya sabit sandalye. o Özellikleri; koltuk tipi, ayaklıklar, kolçaklar, ön tekerlekler, arka tekerlekler. o Tekerlekli sandalye boyutu: Tekerlekli sandalyenin boyutu, koltuğun eni ya da boyu ile ölçülür. Koltuğun yerden olan mesafesini önceden bilmek de bu ölçümde yardımcı olur. o Ayar seçenekleri: Tekerlekli sandalyenin hangi kısımları ayarlanabilir, ayarlanabilme aralığı nedir? Genelde ayarlar bir ya da iki aşamalı olabilir. Mesela birçok tekerlekli sandalyenin ayaklıkları değişik yüksekliklerde ayarlanabilir. Ayarlar en düşükten en büyüğüne kadar yapılabilir. o Yastık: Ne tip bir yastık kullanılmıştır: Tekerlekli sandalye ile beraber mi gelmiştir yoksa ayrı olarak mı alınmıştır? Bazı tekerlekli sandalye hizmeti veren yerler, aynı zamanda aşağıdakileri de sağlarlar: a. Ürünün özelliklerini anlatan broşür b. Tekerlekli sandalyenin teknik bilgileri Tekerlekli sandalye ölçüleri, özellikleri ve varsa ek parçaları, liste olarak sunulmaktadır. Reçete ettiğiniz tekerlekli sandalyenin her zaman yukarıda belirtilen bilgilerinin size verildiğine emin olun. Bu bilgileri okuyun ve tekerlekli sandalye hakkında bilgilenin. Eğer bu bilgiler size verilmemiş ise mutlaka üreticiden isteyin. Reçete (seçim) yazılması Reçete her zaman yazılarak verilmelidir. Aşağıda tekerlekli sandalye reçete formunun bir örneği ardır. Bu forma, elinizde bulunan tekerlekli sandalye ve yastık cinslerini, boyutlarını ekleyerek kendinize göre adapte edin. Tekerlekli Sandalye Reçete Formu 1. Tekerlekli Sandalye kullanıcı bilgileri Tekerlekli sandalye kullanıcısının adı: Numara: Değerlendirmenin yapıldığı tarih: Uygunluk ölçümünün yapıldığı tarih: Değerlendirmeyi yapan kişinin adı: 2. Tekerlekli sandalyenin cinsi ve boyutunun seçimi Tekerlekli sandalyenin cinsinin ve boyutunun seçilmesi: o Tekerlekli sandalye kullanıcısıyla görüşünüz, tartışınız; o Tekerlekli sandalye kullanıcısının en önemli ihtiyaçlarının düşününüz; o Kontrol edilecek hususlar: tekerlekli sandalye iskeleti, ön e arka tekerlekler, ayaklıklar, kolçaklar, koltuk arkalığının yüksekliği, (ya da ayarlanabilirliği), arka tekerleklerin pozisyonu, destek ve rahatlık. Minderin cinsi Boyut      3. Minderin cinsinin seçimi Minderin cinsi Boyut Örn. Köpük basınç rahatlatma minderi  Örn. Yassı köpük minderi   4. Anlaşma sağlandı Kullanıcının imzası: Değerlendirmeyi yapan kişinin imzası: Yöneticinin imzası: Hizmetinizde ne tip tekerlekli sandalyeler olduğunu yazın. Hizmetinizde bulunan değişik tekerlekli sandalyeleri yazın. Hizmetinizde bulunan minder tipleri ve boyutlarını yazın. 4. Adım: Finansman ve sipariş verme Finansman Tekerlekli sandalye kullanılması önerildiğinde, tavsiye edilen tekerlekli sandalyenin ortalama ücreti tahmin edilmelidir. Tekerlekli sandalyenin kimin finanse edeceği öğrenilmelidir. Sandalye, kendi ceplerinden, özel bir kuruluştan, devlete ait bir kurumdan, sigortadan yapılan bir ödeme ya da bir hayır kurumumu tarafından finanse edilebilir. Gelişmekte olan dünyamızda, tekerlekli sandalyeye ihtiyacı olan fakat almakta zorlanan oldukça çok kişi olabilir. Tekerlekli sandalyeye ihtiyacı olan herkesin, her şeye rağmen maddi güçleri olsa da veya olmasa da tekerlekli sandalyesi olmalıdır. Finansal yardıma ihtiyacı olan kişilerin, tekerlekli sandalye almaları için bir kaynağa ihtiyacı vardır. Tekerlekli sandalye sevisi veren kurumların, tekerlekli sandalye siparişi vermeden önce, gerekli finansman kaynağını tanımlaması gerekir. Bu sorumluluk, klinik ve teknik personelden ziyade idari personel ya da program yöneticileri tarafından yerine getirilmelidir. Sipariş verme Tekerlekli sandalye kullanıcısı için en uygun tekerlekli sandalye seçildikten sonra, tekerlekli sandalye sipariş formu doldurulur, sandalye temin edilir veya stokta hazır yoksa sipariş edilir. Eğer tekerlekli sandalye hizmeti veren kurum, stokta tekerlekli sandalye bulunduruyor ise, tekerlekli sandalye reçete formunun kurumun yöneticisi tarafından onaylanması gerekir. Daha sonrasında, tekerlekli sandalye, sorumlu personel tarafından hazırlanmaya başlanır. Eğer tekerlekli sandalye hizmeti veren kurum, stokta tekerlekli sandalye bulundurmuyorsa, dışarıdan bir tedarikçiden sipariş verilir. Tekerlekli sandalye sipariş verme sistemi kurumdan kuruma değişkenlik gösterebilir. Aşağıdaki bölüme tekerlekli sandalye siparişi verirken hatırlamanız gereken noktaları yazın. Nasıl tekerlekli sandalye siparişi vereceğim: Sipariş verirken izlenecek yollar o Stokta tekerlekli sandalye bulundurmak, kullanıcıların fazla beklememesini sağlar. o Gecikmeleri önlemek için, tekerlekli sandalye siparişleri mümkün olduğunca çabuk verilmelidir. o Tekerlekli sandalye kullanıcısının, sandalyesine ne zaman sahip olacağı ile ilgili bilgi verilmelidir. 5.Adım: Ürün (tekerlekli sandalye) hazırlığı Ürün (tekerlekli sandalye) hazırlığı ne demektir? Ürün (tekerlekli sandalye) hazırlığına dâhil olanlar: o Tekerlekli sandalyeyi kullanıcının reçetesine (seçimine) uygun olarak hazırlamak; o Tekerlekli sandalyenin güvenli olduğuna ve bütün bölümlerinin düzgün çalıştığına emin olmak. Tekerlekli sandalyeyi hazırlamak Tekerlekli sandalyeyi aşağıdaki adımlara uygun şekilde hazırlayın: 1. Tekerlekli sandalyenin minder en ve boy ölçülerinin reçeteye (seçim) uygun olduğundan emin olun. 2. Minderin derinliğinin ve eninin koltuğa uyduğuna emin olun. 3. Gereken yerlere ayar yapın:  Arkalık yüksekliği ve açısı;  Kolçak yüksekliği;  Arka tekerlek pozisyonu;  Fren pozisyonları;  Ayaklık yükseklikleri;  İtme tutamakları yüksekliği;  Diğer ayarlar. 4. Tekerlekli sandalyenin güvenli ve hazır olduğunu kontrol edin. Ürün hazırlamada izlenecek yollar o Hazırlanan her tekerlekli sandalyeye kullanıcının ismi yazan bir etiket yapıştırın. o Tekerlekli sandalyeye yapılan her tür ayarın, konu ile ilgili eğitim almış birisi tarafından yapılması gerekir. Ayarlar tekerlekli sandalyenin dayanıklılığını ve fonksiyonunu etkiler. o Tekerlekli sandalyenin, kullanıcıya verilmeden önce güvenli olduğuna, bütün parçalarının düzgün çalıştığına emin olun. (Bkz. Bir sonraki sayfa) Tekerlekli sandalye uygunluk kontrol listesi Tekerlekli sandalyeyi aşağıdaki kontrol listesini uygulayarak, güvenli olduğuna ve bütün parçalarının çalıştığına emin olun. Kullanıcı sandalyeyi denemeden önce listeyi tamamlayın. Kontrol listesi: Tekerlekli sandalye güvenli ve kullanıma hazır mı? Tekerlekli sandalye Nasıl kontrol edeceksiniz? Keskin kenarlar yok  Tekerlekli sandalyeyi bütün olarak elleriniz ve gözleriniz ile kontrol edin. Parçalar çizilmemiş, zarar görmemiş  Tekerlekli sandalye düz bir hat üzerinde yol alabiliyor  Tekerlekli sandalyeyi ileriye itin, ön tekerleklerin sürülebilir pozisyonda olduğuna emin olun. Ön tekerlekler Serbestçe dönebiliyor.  Tekerlekli sandalyeyi arka tekerleklerin üstüne eğin, ön döner tekerlekleri çevirin. Tekerlek tutma çatalına değmeden dönüyor  Cıvatalar sıkıştırılmış.  Kontrol edin. Sıkışmış ama fazla sıkı olmamalı. Ön tekerlekler Tekerlek tutma çatalı rahatça dönüyor.  Tekerlekli sandalyeyi bir yanına eğin, ön tekerlek yuvasının rahatça döndüğüne emin olun. Arka tekerlekler Rahatça dönebilir  Tekerlekli sandalyeyi bir yanına eğin, arka tekerleğini çevirin. Diğer tarafına da uygulayın. Aks cıvataları sıkıştırılmış.  Kontrol edin. Sıkışmış ama fazla sıkı olmamalı. Tekerlekler (eğer basınçlı hava ile çalışıyorsa) doğru şişirilmiş.  Tekerleklere parmağınız ile bastırın, tekerlek maksimum 5mm kadar inmeli. İtme kasnakları sağlam.  Kontrol edin. Frenler Düzgün çalışıyor  Frenleri kapatın. Tekerlekli sandalyenin hareket etmediğine emin olun. Ayaklıklar Ayaklıklar güvenli bir şekilde takılmış  Kontrol edin. İskelet Katlanabilir tekerlekli sandalye kolayca açılıp kapanabiliyor.  Tekerlekli sandalyeyi katlayın ve katlama mekanizmalarının düzgün çalıştığına emin olun. Katlanabilir arkalık – arkalık kolayca katlanıp açılıyor.  Minder Minder kılıfın için doğru şekilde.  Genelde minder kılıfının fermuarlı kısmı, minderin arka altında bulunuyor. Minder tekerlekli sandalye üzerinde doğru duruyor.  Eğer minder konturlu ise, kalça kemikleri çukuru koltuğun arkasında olmalıdır. Minder kılıfı sıkı, fakat çok sıkı olmamalıdır.  Minder kılıfı konturların üzerinden gergin olmamalıdır. Minder koltuğu tamamen kaplamalıdır.  Minderin altında koltuğun herhangi bir kısmının görünmediğine emin olun. Bu özellikle yekpare koltuklarda önemlidir. Minder yapımı Eğer köpüğünüz varsa, tekerlekli sandalye hizmeti veren personel, birkaç basit alet ile köpük basınç rahatlatma minderi yapabilir. Personelin, ne tip bir köpük kullanması gerektiğini ve birkaç önemli ölçüyü bilmesi gerekir. Eğitmenleriniz ile bulabileceğiniz köpük tiplerini, basınç rahatlatma minderi yapmak için hangisinin en uygun olduğunu tartışın. Aşağıdaki talimatlar, köpükten çift konturlu basit bir basınç rahatlatma minderi yapımını gösterir. Konturlar, kalça kemiği altındaki boşluk, ve önündeki yükseltidir. Minderin özellikleri ve ölçüleri Köpükten yapılan basit bir minderin temel özellikleri: Taban katman, sert bir köpükten yapılmalıdır Kalça kemiği çukuru o Kalça kemiği ve kuyruk sokumu altındaki basıncı rahatlatır. o Kalçanın yukarı doğru ve minderin arkasında kalmasını sağlar. Askı şeklinde koltuk tabanı o Askı şeklinde tekerlekli sandalyede koltuğunda kullanılan minderlerin tabanının her iki yanında eğimli bir kesim olmalı. o Bu kesim sayesinde minder, askı şeklindeki tekerlekli sandalyenin koltuğunun şeklini alır. Minderin üst kısmı sabit kalır. Üst katman, yumuşak, konforlu bir köpükten yapılmalıdır Konfor üst katman: o Sert tabanın üstünde konforu sağlar. Basınç rahatlatma minder tabanı nasıl yapılır? Aşağıdaki talimatlar 400 mm en x 400 mm derinlik x 50 mm yükseklik ölçülerinde bir minder yapmayı gösterir. Kalça kemiği oyuğu, 200 mm en x 200 mm derinlik x 35 mm yükseklikte olmalı. Bu minder, koltuk genişliği 400 mm olan bir kullanıcı için uygun olur. Ölçüleri, aşağıda belirtildiği gibi tekerlekli sandalyenin kullanıcısına göre adapte edin. 1. Sert köpüğün kesilecek kısımlarını işaretleyin. o 400 mm x 400 mm x 50 mm ölçülerinde bir köpük ile kesin. o Kalça kemiği çukurunun ortası, minderin orta çizgisine denk gelmelidir. o Bu ölçüde minder için, kalça kemiği ölçüleri 200 mm x 200 mm x 35 mm olmalıdır. o Taban köpüğünün kesilecek kısımlarını koyu renk bir kalem ile çizin. ölçüler mm’dir Kalça kemiği çukuru ölçüleri Tekerlekli sandalye kullanıcısına uydurmak için, minderin ölçülerini ve kalça kemiği oyuğunu, kullanıcının ölçülerine göre ayarlayın: o Kalça kemiği çukuru genişliği = Tekerlekli sandalye kullanıcısının koltuk genişliğinin yarısı ya da 200 mm (hangisi daha az ise) [a]; o Kalça kemiği çukuru derinliği (önden arkaya) = Tekerlekli sandalye kullanıcısının koltuk derinliğinin yarısı ya da 200 mm (hangisi daha az ise) [b]; o Kalça kemiği çukuru yüksekliği = Yetişkinler için 35 mm ve çocuklar için 20– 25 mm [c]. 2. Kalça kemiği çukurunu kesin: El testeresi ya da uzun bir bıçak kullanın. Uzun ve yavaş hamleler ile kesmeye başlayın. o Önce arkasını, kalça kemiği çukurunun derinliğinde kesin. o Kalça kemiği çukurunu kesin. o Çukurun her iki yanını tekrar alt katmana yapıştırın. Yapışkan iyice kurumadan, iki köpük katmanını birbirine bastırın. 3. Kalça kemiği çukurunun her iki yanını eğimli olarak kesin. c b a 4. Askı şeklinde koltuk için: Köpük tabanının her iki yanını eğimli olarak kesin. o Resimdeki gibi işaretleyin ve kesin. o Bu kesim tipi, minderin tabanının, askı şeklinde koltuğu olan tekerlekli sandalyeye uymasını sağlar. 5. Köpük katmanı, minderin üzerine yerleştirin o Üst ve alt katmanların her ikisi de minder kılıfına konulur. o İki katmanın birbirine yapıştırılması gerekmez. o Eğer üst katman, kirlenir veya eskir ise yıkanıp, kurulanır ya da yenilenebilir. o Kalça kemiği oyuğunu yükseltmek için, kılıfın içine bir katman daha konulabilir. Köpük basınç rahatlatma minderleri hakkında sıkça sorulan sorular: Minder kılıfı kumaşını nasıl seçersiniz? o Esneyebilen bir kumaş seçin. Eğer bulabiliyorsanız, su geçirmez olması çok iyi olur. Su geçirmez kumaş bulabiliyorsanız, çok kalın olmamasına dikkat edin. Aksi takdirde kırışıklıkları deride basınç yarası açılmasına sebebiyet verir. o Bazen seçenekler limitli olabilir. Nasıl bir kumaş seçeceğiniz elinizdeki seçeneklere bağlıdır. o Eğer kumaş seçiminden emin değilseniz, tekerlekli sandalye kullanıcısının birkaç çeşit denemesini önerin. o Tekerlekli sandalye hizmeti veren personel, değişik kumaşlar denendikçe, deneyimleri artacaktır. Bu minder, tüm tekerlekli sandalye kullanıcıları için uygun mudur? o Hayır; bu tip minder her tekerlekli sandalye kullanıcısı için uygun değildir. o Fakat bu minderin en önemli avantajlarından biri kolayca, adapte olabilmesidir. Minder ısıtıyor mu ya da terlemeye yol açıyor mu? o Köpük minderler ısınıp, terlemeye yol açabilir. o Diğer yandan, ısınmaya yol açmasına razı olunur ise, köpük çok kullanışlı bir materyaldir. Tekerlekli sandalye kullanıcılarının tümüne basınç rahatlatma minderi gerekli midir? o Hayır; her tekerlekli sandalye kullanıcısının basınç rahatlatma minderine ihtiyacı yoktur. o Eğitim sırasında öğrendiklerinizi temel alarak, basınç yarası oluşma risklerini dikkate alın. o Basınç rahatlatma amacı ile kullanılmasa bile, minder kullanıcının dik ve rahat oturabilmesi için kullanışlıdır. Minder ters kullanılırsa ne olur? o Minder bir işe yaramaz hatta basınç yarası oluşmasına da sebep olur. o Tekerlekli sandalye kullanıcısı ve aile bireyleri, minderin kullanımı ve bakımı ile ilgili olarak bilinçlendirilmelidirler. o Minderin yönlerini belirlemek için "ön" ve "arka" ya da "üst" ve "alt" yazılabilir. 15 mm 15 mm Minder çocuklar için de kullanılabilir mi? o Evet, minder çocuklar içinde kullanılabilir. Ancak minderdeki kalça kemiği çukuru daha küçük olmalıdır. Çocuk minderi için, yukarıdaki ölçülere bakabilirsiniz. o Tekerlekli sandalye kullanan birçok çocuk fazladan duruş desteğine ihtiyaç duyabilir. Minder yeterli desteği sağlayamayabilir. Yastık uygunluğu Kalça kemiklerinin her zaman, kalça kemiği çukuru içine oturduğunu kontrol edin. Basınç rahatlatma minderinin uygunluğunu aşağıda belirtilen kriterlere göre her zaman kontrol ediniz: o Kalça kemiği altındaki basınç “güvenli” (Bkz. “Basınç Rahatlatma Minderi Uygunluk testi); ve o Kalça kemikleri çukurun içinde oturuyor ve kenarlara taşmamış veya çukurun dışında değil. 6.Adım: Uygunluk Uygunluk neleri kapsar? Uygunluk sırasında, tekerlekli sandalye kullanıcısı ve personel beraber aşağıdaki hususları kontrol ederler: o Tekerlekli sandalyenin boyutları doğru, gerekli bütün ayarları yapılmış, en elverişli uygunluk sağlanmış; o Tekerlekli sandalye ve minder, kullanıcının dik oturması için destek sağlıyor; o Eğer basınç rahatlatma minderi kullanılmış ise, gerçekten amacına hizmet ettiğine emin olma. Uygunlukta izlenecek yollar o Mümkünse değerlendirmeyi yapan personel ile uygunluğunu yapan personel aynı kişi olmalı. o Uygunluğu, hem tekerlekli sandalye sabit dururken, hem de kullanıcı ya da bir başkası yürütürken kontrol edilmelidir. o Uygunluğu aşağıdaki sıra ile yerine getirin: o Boyut ve ayarları kontrol edin; o Duruşu kontrol edin; o Basıncı kontrol edin; o Tekerlekli sandalye hareket halindeyken uygunluğu kontrol edin. o Her adımı hatırlamak için uygunluk kontrol listesini kullanın. Boyut ve ayarları kontrol edin Koltuk genişliği Doğru Ayar: Ayarı tam olmalıdır Nasıl kontrol edilir o Parmaklarınızı, tekerlekli sandalye kullanıcının kalçaları ile sandalyenin yan tarafları arasına sokun. Parmaklarınız sıkışmadan rahatça sığmalıdır. Tekerlekli sandalyenin yanlarının, kullanıcının kalçasına baskı yapmadığından emin olun. Bu husus, özellikle his kaybı olan, kalçalarına yapılan baskıyı hissedemeyen kullanıcılar için önemlidir. Yanlardan yapılan baskı basınç yarası oluşumuna sebebiyet verebilir. Koltuk derinliği Doğru Ayar: Diz arkası ve minder arasında iki parmak boşluk (30 mm) Nasıl kontrol edilir o Tekerlekli sandalye kullanıcısı dik oturuyor. o Elinizi minder ve dizin arkası arasına sokun. Her ikisi arasında 2 parmak kalınlığında (30 mm) boşluk olmalıdır. Uzun bacaklı kullanıcılar için daha geniş bir boşluk olabilir. 60 mm’ye kadar genişlik uygundur. o Baldırın arkasına elinizi sokun. Koltuğa ya da mindere değmediğinden emin olun. o Her zaman her iki tarafı da kontrol edin. Doğru ayar, kalçaya gerekli destek verir. Bu sayede kalça kemikleri altındaki basınç azalır, yara olma ihtimali düşer. Eğer koltuk uzunluğu fazla ise, kullanıcı dik oturamaz. Sağ ve sol bacak arasında fark var ise, kısa olan bacak ölçüleri kullanılarak ayar yapılmalıdır. Ayaklık yüksekliği Doğru Ayar: Kalçalar minderin üzerinde ara olmadan desteklenmiş. Ayaklar, ayaklıkların üzerinde boşluk olmadan duruyor. Nasıl kontrol edilir o Elinizi kalça ile minder arasına sokun. Kalça boyunca, boşluk olmadan, eşit bir baskı olmalı. o Ayaklıklar üzerinde ayaklara bakın. Ayak, önden ve arkadan boşluksuz şekilde desteklenmelidir. Eğer kalça altında boşluk varsa, ayaklıklar yüksek demektir. Eğer ayakaltında boşluk varsa, ayaklıklar çok alçakta demektir. Arkalık yüksekliği Doğru Ayar: Doğru arkalık yüksekliği, tekerlekli sandalye kullanıcısına, omuzlarını kullanarak hareket etme özgürlüğünü tanır. Nasıl kontrol edilir o Tekerlekli sandalye kullanıcısına arkalığının rahat olup olmadığını sorun. o Gövdenin, kalçalar üzerinde dengede durup durmadığını gözlemleyin. o Tekerlekli sandalye kullanıcısı, arkalık onu engellemeden, sandalyeyi hareket ettirebiliyor mu? Arkalığın yüksekliği, kullanıcının ihtiyaçlarına bağlıdır. Kendi kendini itebilen tekerlekli sandalye kullanıcıların, omuzlarını rahatça kullanabilmeleri gerekir. Dik oturmakta zorlanan tekerlekli sandalye kullanıcılarının, omuriliklerine daha çok destek verebilmek için daha yüksek bir arkalığa ihtiyacı olabilir. Tekerlekli sandalye değerlendirme formunda iki adet arkalık yükseklik ölçüsü verilmiştir. (bkz. 2.Adım: Değerlendirme bölümünde ”Ölçü Alma”). Değerlendirme sırasında, bazen tekerlekli sandalye kullanıcısının hangi ölçü ile rahat edeceği bilinemediğinden, her iki ölçüyü de alın. Tekerlekli sandalye kullanıcısının göğüs kafesinin altına kadar destek veren arkalık, ancak kullanıcı aşağıdaki şartlara uyuyorsa uygun desteği sağlar: o Kullanıcı zinde ve aktif ise; o Dengeli bir şekilde dik oturabiliyorsa; o Kendi kendini hareket edebilecek durumda ve bu özgürlüğe ihtiyaç duyuyorsa. Arkalık yüksekliği D (göğüs kafesinin altı) Tekerlekli sandalye kullanıcısının kürek kemiklerinin altına kadar destek veren arkalık, ancak kullanıcı aşağıdaki şartlara uyuyorsa uygun desteği sağlar: o Çabuk yoruluyorsa, örn. yaşlı, ya da ilerleyen bir hastalığı var ise; o Dik oturmakta zorlanıyorsa. Bu yükseklikteki bir arkalık, omuzlar çevresinde bir miktar hareket kabiliyetine izin verir, dolayısı ile kullanıcı kollarını kullanarak sandalyeyi hareket ettirebilir. Arkalık yüksekliği E (kürek kemiklerinin altı) Arka tekerlek pozisyonu – elle ile itebilmek için Doğru Ayar: Eller itme kasnaklarını tuttuğu zaman, kullanıcının dirsekleri dik açı olmalı. Nasıl kontrol edilir o Tekerlekli sandalye kullanıcısının, itme kasnaklarını tepeden tutmasını isteyin. Dirsekler 90 derece açı ile bükülmüş olmalıdır. o Kullanıcı ile arka tekerleklerin doğru dengede durduğunu kontrol edin. (aktif için ileri, güvenli için geri). Eğer tekerlekli sandalye kullanıcısı, arka tekerleklerin güvenli (arkaya doğru) pozisyonda durmasını istiyorsa, kollar iyice geride demektir, bu da hareket için idealdir. Bu durumu tekerlekli sandalye kullanıcısı ile paylaşın. Eğer arka tekerleklere herhangi bir ayar yapılmış ise, frenler de ayarlanmalı ve tekrar kontrol edilmelidir. Koltuk yüksekliği – ayakla itmek için Doğru Ayar: o Tekerlekli sandalye kullanıcısının dik oturması ve leğen kemiğinin arkalıktan destek alması ile ayaklar yerde düz olarak durabilmelidir. Nasıl kontrol edilir Tekerlekli sandalye kullanıcısından, leğen kemiği, arkalığa iyice dayanmış şekilde oturmasını ve ayakları ile yere düz basmasını isteyin. Ayakları yere düz olarak basabiliyor mu diye kontrol edin. Eğer koltuk fazla yüksek ise, tekerlekli sandalye hizmet personeli aşağıdakileri deneyebilir: o Minderin yüksekliğini azaltmak; o Orijinal koltuktan daha alçak, yekpare bir koltuk koymak (Bu konuda teknik personelden destek alın). Tek ayağı ayaklık üzerinde ve diğer ayağı ile sandalyeyi hareket ettirebilen bir kullanıcının, ayaklık üzerindeki tarafında, kalça kemiğinin üzerine yapılan baskıyı kontrol edin. (bkz. Bölüm A. 7: Minderler, section “Basınç yarasını rahatlatmak için kullanılan minderler işe yarıyor mu”). Duruşu kontrol edin Tekerlekli sandalye kullanıcısının, sandalyede nasıl oturduğunu yandan ve önden kontrol edin. Kullanıcı dik oturuyor mu? Bazı tekerlekli sandalye kullanıcıları, ayaklarını sandalyenin altına sokmaktan hoşlanırlar. Bazı tekerlekli sandalyeler bunu yapmaya uygundur. Eğer kullanıcı bu şekilde rahatsa ve dengesini sağlayabiliyorsa, problem teşkil etmez. Basıncı kontrol edin Basınç yarası geliştirme riski olan her tekerlekli sandalye kullanıcısının, kalça kemikleri altındaki basıncın güvenli olduğuna emin olun. Tekerlekli sandalye hareket halindeyken uygunluğunu kontrol edin Tekerlekli sandalyenin uygunluğunun son kontrole ise, sandalye hareket halindeyken yapılmalıdır. Eğer tekerlekli sandalye kullanıcısı, sandalyeyi rahatlıkla kendi yürütemiyorsa, bir aile bireyinden ya da bakıcısından yardım isteyin. Nelere bakılmalıdır: o Arkalık, tekerlekli sandalye kullanıcısının omuzlarından destek alarak sandalyeyi yürütmesine engel oluyor mu? o Tekerlekli sandalye kullanıcısının ayakları ayaklıkların üzerinde duruyor mu? o Arka tekerleklerin pozisyonu kullanıcı için uygun mu? Tekerlekli sandalye uygunluk kontrol listesi 1. Tekerlekli sandalye hazır mı? Tekerlekli sandalyenin bütün parçalarının güvenli bir kullanıma hazır olduğuna dair kontroller yapıldı mı?  2. Boyut ve ayarların kontrolü Koltuk genişliği (eni) : Oldukça uygun olmalı.  Koltuk derinliği: Koltuk/minder ile dizin arkası arasında iki parmaklık bir mesafe olmalı.  Ayaklık yüksekliği: Uyluklar minderin üzerine tam destekli ve altında boşluk olmadan durmalı. Ayaklar, ayaklığın üzerinde arada boşluk olmadan tam destekli bir şekilde durmalı.  Arkalık yüksekliği: Tekerlekli sandalye kullanıcısının omuzlarının desteklenmeye ve itmek için hareket serbestliğine ihtiyacı vardır (eğer tekerlekli sandalyesinin ilerlemesini kendisi sağlıyorsa).  Arka (büyük) tekerleklerin pozisyonu (el ile itmek için): Tekerlekli sandalye kullanıcısı kolunu sarkıttığı zaman, arka büyük tekerlek ekseni ile aynı hatta olmalıdır. Eller itmek için tekerleklerin itme kasnaklarına konulduğunda kullanıcının dirseği doğru bir açıda olmalıdır.  Frenler: Frenler çalışıyor mu?  Koltuk yüksekliği (ayak ile itmek için): Tekerlekli sandalye kullanıcısı dik bir şekilde oturuyor iken sırtı koltuk arkalığı tarafından rahat bir şekilde destekleniyor ve ayak yere düz bir şekilde dayanıyor olmalı.  3. Oturma pozisyonu kontrolü Tekerlekli sandalye kullanıcısı dik bir pozisyonda rahat oturabiliyor mu?  Oturuş pozisyonunu yandan kontrol ediniz.  Oturuş pozisyonunu önden/arkadan kontrol ediniz.  4. Basınç kontrol Bütün tekerlekli sandalye kullanıcılarının basınç yarası geliştirme riski olduğu için kalça kemiklerinin altındaki basıncı kontrol edin. Tekerlekli sandalye kullanıcısına testi açıklayın. B Tekerlekli sandalye kullanıcısına öne eğilmesini ya da kendisini yukarı doğru itmesini söyleyin. Parmak uçlarınızı tekerlekli sandalye kullanıcısının kalça kemiğinin altına koyun. C Tekerlekli sandalye kullanıcısından parmaklarınızın üzerine geri oturmasını isteyin. Dik bir şekilde ve elleri bacaklarının (uyluklarının) üzerine koyulmuş olarak oturduklarından emin olun. D Basıncın tanımlanması: Seviye bir = güvenli: Parmak uçları yukarı ve aşağı 5 mm ya da daha fazla kıpırdatılabiliyor. Seviye iki = uyarı: Parmak uçları kıpırdatılamıyor ama kolaylıkla dışa doğru kaydırılabiliyor. Seviye üç =tehlikeli: Parmak uçları sıkıca sıkışmış. Parmakları çekip çıkarmak oldukça zor E İkinci kalça kemiğinde de tekrarlayınız. 5. Uygunluğun tekerlekli sandalye hareket halinde iken kontrolü Arkalıklar, tekerlekli sandalye kullanıcısına omuzlarını itebilmek için gerekli hareket imkânını sağlıyor mu?  Arkalıklar, tekerlekli sandalye kullanıcısına yeterli desteği sağlıyor mu?  Tekerlekli sandalye kullanıcılarının ayakları ayaklıkların üzerinde mi duruyor?  Arka büyük tekerleklerin pozisyonu kullanıcı için doğru pozisyon mu?  6. Eylem? Gerekli olan daha ileri düzey bir eylem var mı? Tekerlekli sandalye kullanıcısının dosyasında her ne eylem var ise yazınız.  Hatırlatma: Uygunluktan bir sonraki aşama kullanıcı talimatıdır. Problem çözme Bazı durumlarda, var olan tekerlekli sandalyeyi kullanıcıya uygun hale getirmekte problemler yaşanabilir. Bu problemlerin sebepleri: o Yeterli miktarda değişik boyutlarda tekerlekli sandalye olmaması; o Tekerlekli sandalye kullanıcısının dik oturabilmek için fazladan desteğe ihtiyacı vardır. Aşağıda bazı basit problemlerin çözümlerini bulabilirsiniz. Ayar yapmak ve fazladan duruş desteği verme konuları daha detaylı olarak orta seviye eğitim programında öğretilmektedir. Bütün bu çözümler, elinizde kullanıcıya en uygun boyutlu tekerlekli sandalyenin olduğu varsayılarak önerilmiştir. Tekerlekli sandalyeye ayar yapmadan önce bunu kontrol edin. Problem: Koltuk derinliği kısa Eğer koltuk derinliği (önden arkaya), yetişkinler için tekerlekli sandalye koltuğunun derinliği 100mm’den az ise bu bir problem teşkil eder. Tekerlekli sandalye kullanıcısının yeterli desteği olmaz ve rahat oturamaz. Basıncı rahatlatma mümkün olmayacağından, koltuk derinliğinin uzatılması gerekir. Çözüm: Aşağıda üç değişik çözüm belirtilmiştir: Çözüm Uyarı 1. Tekerlekli sandalye koltuğunu, koltuk tırabzanları genişleterek ve döşemeyi değiştirerek uzatın. o Eğer tekerlekli sandalye katlanabilir ise, koltuk tırabzanları tekerlekli sandalyenin bir parçası olup olmadığından emin olun. o Bu durumda, koltuk tırabzanlarına ek yaparak ve yeni döşeme takarak, doğru uzunluğa getirilebilir. 2. Döşemeyi değiştirerek tekerlekli sandalye koltuğunun derinliğini uzatın. o Eğer tekerlekli sandalye katlanmaz ve döşemesi olan bir model ise, koltuk tırabzanlarının koltuktan daha uzun olup olmadığına bakın. o Bu durumda, eski döşemeyi, doğru ölçülerde yapılmış yeni döşeme ile değiştirin. 3. Tekerlekli sandalye koltuğunu minderli sert bir tahta koyarak uzatın. o Tahta, plastik veya başka sert, kolayca esnemeyen ve kırılmayan bir materyalden sert bir koltuk yapılabilir. o Koltuk, tırabzanların üstüne sabitlenebilir. o Koltuğun yeni ölçülerinde bir minder yerleştirin. o Yeni koltuğun, kullanıcının ağırlığını taşıyacak güçte olduğuna emin olun. Koltuğun esnemediğine, çatlamadığına emin olun. o Her tekerlekli sandalye kullanıcısı için, yekpare koltuğa bir minder temin edildiğinden emin olun. o Uygunluk sırasında, arkalığın ve ayaklığın doğru yükseklikte olduğuna emin olun. Sert koltuk ve minder kullanıcıyı yükseltebilir. Problem: Koltuk derinliği fazla uzun. Eğer mümkün olan en kısa koltuk, uzun kalırsa, tekerlekli sandalye kullanıcısının dik oturması zorlaşır. Koltuk derinliğinin kısaltılması gerekir. Çözüm: Aşağıda bir çözüm belirtilmiştir. Çözüm Uyarı 1. Koltuk derinliği fazla uzun. o İstenilen koltuk derinliğini elinizdeki koltuk üzerinde işaretleyin. o Eğer koltuk döşemesi varsa: döşemeyi çıkartın, kısaltın (endüstriyel bir dikiş makinesi kullanarak) ve tekrar yerleştirin o Eğer koltuk yekpare ise: koltuğu çıkartın, kısaltın ve yeniden yerleştirin. o Minderi de koltuğa uyacak şekilde kısaltın. o Yekpare koltuğu keserken – kenarların pürüzsüz ve kıymıksız olmasına dikkat edin. o Minderi keserken – basınç rahatlatma çukurunun aynı kalması için her zaman ön tarafından kesin. Problem: Ayaklıklar çok düşük (alçak). Eğer ayaklıkların yüksekliği düşük ise, tekerlekli sandalye kullanıcısı, ayaklarını rahat bir şekilde ayaklıklara koyamaz. Böyle bir durumda kullanıcı sandalyeden öne doğru kayabilir ve dengesini kaybedebilir. Dik oturması rahat olmayabilir. Ayaklıkların yükseltilmesi gerekir. Çözüm: Aşağıda iki çözüm belirtilmiştir. Çözüm Uyarı 1. Ayaklık asma yerini kısaltarak ayaklıkları yükseltin. o Çoğu dört tekerleği olan tekerlekli sandalyelerde ayaklık asma yerleri kısaltılabilir. Ayar mekanizmalarının her zaman çalıştığına emin olun. 2. Ayaklıkların üzerine bir katman koyarak yükseltebilirsiniz. o Ayaklıkların üzerine tahta ya da başka sert bir materyal koyarak yükseltebilirsiniz. Ayaklıkları daha yukarıdan takarak katlanmalarına engel olmayın. Ayaklıkların yükseltilmesi (yan taraftaki resimde, kısalan bacağı rahat ettirmek için ayaklıklardan bir tanesi yükseltilmiştir). Problem: Ayaklıklar çok yüksek. Eğer ayaklıklar çok yüksek ise, tekerlekli sandalye kullanıcısının kalçası koltuğun üzerine değmez. Yüksek ayaklıklar, kalça kemikleri üzerindeki baskıyı arttırır. Ayaklıkların yüksekliğinin indirilmesi gerekir. Çözüm: Aşağıda iki çözüm belirtilmiştir. Çözüm Uyarı 1. İç uzatma borusunu uzatarak, ayaklıkları alçaltın. o İç uzatma borusu, daha uzun bir boru ile değiştirilebilir mi diye kontrol edin. o Eğer değiştirilebiliyorsa, aynı çapta ve sertlikte uzun bir boru ile değiştirin. Ayaklıkların yere değecek kadar alçalmadığına emin olun. Eğer bu olursa, 2.seçeneği deneyin. Eğer 2. seçenekte çalışmazsa, bu tekerlekli sandalye kullanıcısı için uygun değildir. 2. Minderin yüksekliğini arttırın. o Minderin yüksekliğini arttırın ya da minderin altına sert bir yükseltici koyun. Minderi yükseltmek için yumuşak köpük kullanmayın. Yumuşak köpük, kompres yapar ve kullanıcının dengesini kaybetmesini sebep olabilir. Uygunluk sırasında, arkalığın doğru yükseklikte olduğuna emin olun. Minder yükselince, kullanıcının daha yüksekte oturmasına sebep olur. Minderi yükseltmekte fonksiyonel bir problem olmadığını kontrol edin. Örneğin tekerlekli sandalye kullanıcısı, masaların altına sığmayabilir. Problem: Bacaklar içeriye ya da dışarıya doğru yuvarlanma eğiliminde. Bazen tekerlekli sandalye kullanıcılarının bacakları içeriye ya da dışarıya doğru yuvarlanır. Buna sebep, o şekilde oturmaya alışık oldukları için ya da fiziksel bir problemleri (örneğin kas gevşekliği) olabilir. Tekerlekli sandalyeye ya da mindere yapılan basit ayarlar ile bu problem çözülebilir. Çözüm: Aşağıda üç çözüm belirtilmiştir. Çözüm 1. Ayaklık yüksekliklerini iki kere kontrol edin. Ayaklık yüksekliğinin, tekerlekli sandalye kullanıcısına doğru destek verdiğine emin olun. (Ayakların ve kalçanın altında eşit basınç hissedilmelidir) 2. Koltuğun iyice gerdirildiğini kontrol edin. o Eğer tekerlekli sandalyenin döşemeli bir koltuğu varsa – koltuğun sıkıca gerildiğine emin olun. o Eğer koltuk gevşek ise, kullanıcının bacaklarının içeriye doğru yuvarlanmasına sebep olur. 3. Mindere eklemeler yaparak, kalçaların denge pozisyonunda olmasını sağlayın (DVD ve resimde olduğu gibi) ya da konturlu bir yastık temin edin, gerekli durumlarda minderi modifiye de edebilirsiniz. o Bazı konturlu basınç rahatlatma minderlerinde kalça ortasından bacakları rahat ve ayrı tutması için bir yükseklik vardır. Bu yükseklik, gerekirse fazladan destek vermek için yükseltilebilir. o Bazı konturlu basınç rahatlatma minderlerinde bacakların yaslanması için oyuklar vardır. Bu oyuklar, bacakların dışarıya doğru kıvrılmasını engellemek için yükseltilebilir. Minderin ön ortasına bir yükseklik eklenerek, tekerlekli sandalye kullanıcısının bacaklarını hafifçe aralamaya yardımcı olur. Minderin her iki kenarına eklenen yükseltiler, tekerlekli sandalye kullanıcısının bacaklarının dışarıya yuvarlanmasını engeller. Problem: Ayaklar, ayaklıktan kayma eğiliminde Bazen tekerlekli sandalye kullanıcısının ayakları, ayaklıktan kayar. Bunun sebebi çoğu zaman fiziksel olabilir (Örneğin kas gevşemesi ya da kas spazmları). Çözüm: Aşağıda üç çözüm belirtilmiştir. Çözüm Uyarı 1. Ayaklıkların yüksekliğini iki kere kontrol edin o Ayaklıkların, tekerlekli sandalye kullanıcısını doğru şekilde desteklediğinden emin olun. (Ayakların ve kalçaların altında eşit basınç olduğuna emin olun). 2. Ayaklık açısını ayarlayın (eğer mümkünse). o Ayaklıkların açısının ayarlanabileceğini kontrol edin. o Ayarlanabiliyorsa – ayaklıkların açısını yükseltin. Bu sayede, kullanıcının ayaklarının yerinde kalmasını sağlayabilir. Ayakların altında eşit basınç olduğunu kontrol edin. 3. Kemer takın. o Ayaklık asma yerine, ayak bilekleri hizasında bir bant takın. o Eğer ayağın arkaya doğru kayma durumu söz konusu ise bant bacağın arkasında olmalıdır. o Eğer ayağın öne doğru kayma durumu söz konusu ise bant bacağın önünde olmalıdır. Tekerlekli sandalye kullanıcısının sandalyeden kolayca kalkıp oturabilmesi için bandın kolaylıkla çıkabilen cinsten olduğuna emin olun. Kullanıcısının banda ulaşabileceğini ve kediliğinden açıp kapatabildiğine emin olun. Baldır kemeri, tekerlekli sandalye kullanıcısının bacaklarının yerinde kalmasını sağlar. Ayaklıkların arkasında bulunan kemerler, ayaklara daha çok destek verir, ayakların ayaklıktan geriye doğru kaymasını engeller. Problem: Tekerlekli sandalye çok geniş. Bazen elinizde bulunan en dar tekerlekli sandalye bile kullanıcı için geniş olabilir. Eğer tekerlekli sandalye kullanıcısı için geniş ise, kullanıcı sandalyede dik oturamaz ve yana kayar. Basit köpükten bir destek ile kullanıcının dik oturması sağlanabilir. Çözüm: Aşağıda bir çözüm belirtilmiştir. Çözüm Uyarı 1. Kalçanın her iki yanına köpükten destekler koyun. o Tekerlekli sandalye kullanıcısı ile her iki kolçak arasındaki mesafeyi ölçün. (Ölçerken kullanıcıyı sandalyenin ortasında sırtı arkalığa dayanarak oturtun). o Aralardaki boşlukları doldurmak için köpük parçalar kesin ve sandalyenin her iki yanındaki boşluklara koyun. o Uygunluğu kontrol edin. o Köpük parçalara kumaş geçirin ve sandalyeye yerleştirin. Eğer kolçaklar sabit ise, köpük parçalar kolçaklara eklenebilir. Ayrıca istenirse minderin üstüne de eklenebilir. Köpük takozlar, kullanıcının gövdesine kadar uzanacak şekilde öne gelmelidir. Minderin genişliği koltuğun genişliğine uymalı. Eğer tekerlekli sandalye çok geniş ise, tekerlekli sandalye kullanıcısı itme kasnaklarına erişmekte zorluk çeker. Kendini zorlaması, omuz zedelenmesine yol açabilir. Tekerlekli sandalyeyi seçmeden önce kullanıcı için güvenli olduğuna emin olun. Köpük takozlar, sandalyenin iç genişliğini azaltabilir. 7.Adım: Kullanıcı Eğitimi Tekerlekli sandalye hakkında bilgilendirme ve eğitim, kullanıcının tekerlekli sandalyesinden fayda sağlamasına yardımcı olur. Bu adım olmadan, tekerlekli sandalye, kullanıcısına yeteri kadar yardımcı olamayabilir. Tekerlekli sandalye kullanıcısının edinmesi gereken yardımcı beceriler nedir? Öğretilmesi gereken en önemli 6 madde: o Tekerlekli sandalyeyi nasıl kullanacağı,idare edeceği; o Basınç yaralarını önleme ve oluşması halinde ne yapması gerektiği; o Tekerlekli sandalyeden kalkma ve oturma (transfer); o Tekerlekli sandalye hareketliliği – kullanıcının ihtiyaçlarını karşılaması; o Evde tekerlekli sandalye ve minder bakımı; o Problem olduğunda ne yapması gerektiği. Bir sonraki sayfadaki liste, tekerlekli sandalye kullanıcısının öğrenmesi gereken becerileri listeler. Bazı tekerlekli sandalye kullanıcıları bu bilgileri önceden biliyor olabilir. Bu becerilerin hepsini bilmeleri, her tekerlekli sandalye kullanıcısı için gerekli değildir. Personel, kontrol listesini kullanarak, kullanıcının bilmesi gereken becerileri seçer. Bu tekerlekli sandalye kullanıcısı ile konuşarak ve bir değerlendirme yaparak kararlaştırılır. Bazı hizmetler, bu kontrol listesini, tekerlekli sandalye kullanıcısının dosyasında saklamak üzere bir form halinde kullanabilirler. Bu durumda, kontrol listesi, verilen eğitimin bir kaydı olarak ta kullanılabilir. Her zaman, tekerlekli sandalye kullanıcısına, kendilerine verilen eğitimin bakıcılarına da öğretilmesini isteyip istemediklerini sorun. Birçok tekerlekli sandalye kullanıcısı, bir aile bireyi ya da bakıcı tarafından destek alırlar, bu durumda ilişkili kişilerin tekerlekli sandalye kullanımı ve bakımı hakkında eğitim alması yararlı olur. Tekerlekli sandalye kullanıcısının eğitimi nasıl başarılı hale getirilir? o Tekerlekli sandalye kullanıcısının önceden neler bildiğini öğrenin. o Kullanıcının anlatmasına, göstermesine ve uygulama yapmasına izin verin. o Herkesin anlayabileceği bir dil kullanın. o Tekerlekli sandalye kullanıcısının başka kullanıcılara öğretmesini sağlayın. o İyi iletişim becerileri kullanın. o Teşvik edici olun. Tekerlekli sandalye eğitim kontrol listesi Öğretme Becerileri Öğrenme Becerileri Tekerlekli sandalye kullanımı Tekerlekli sandalyeyi katlama Tekerlekli sandalyeyi kaldırma Çıkarılabilir tekerleklerin kullanımı Frenlerin kullanımı Minderin doğru yerleştirme de dâhil kullanımı Transferler Kendi kendine transfer Yardımla transfer Diğer Tekerlekli sandalye hareket kabiliyeti Uygun bir şekilde itme Yukarı aşağı eğimler Yukarı aşağı basamaklar Engebeli yüzeyler Sadece büyük tekerleklerin üzerinde kısmi olarak dengede durabilme Basınç yaralarını önleme Basınç yaralarının kontrolü Basınç rahatlatma için yükselme İyi beslenmek ve bol su içmek Basınç yarası gelişirse nelerin yapılacağı Tekerlekli sandalyenin evde bakımı Tekerlekli sandalyeyi ve minderi temizleyin Hareketli parçaları yağlayın Tekerlekleri şişirin Somunları ve cıvataları sıkılayın (eğer gevşekse) Tekerlek jant tellerini sıkılayın (eğer gevşekse) Kaplamaları kontrol edin Paslanmayı kontrol edin Minderi kontrol edin Problem var ise yapılacaklar Tekerlekli sandalyenin tamire ihtiyacı var Tekerlekli sandalye uygun değil ya da rahat değil 8.Adım: Bakım, onarım ve takip Tekerlekli sandalyeye ve mindere belli aralıklarla yapılan bakımlar sayesinde, onarım masraflarını azaltır, tekerlekli sandalyenin ömrünü uzatır, kullanıcının vücuduna uzun vadeli zararlar vermesini önleyebilirsiniz. Bakımı düzenli olarak yapılmış bir tekerlekli sandalye, daha rahat, enerji tasarrufu yaptıran ve kullanımı daha kolay olan bir hale gelir. Bakımı yapılan bir minder ise, basınç rahatlatmaya ve destek vermeye devam eder. Tekerlekli sandalye hizmet personeli, kullanıcıya, sandalyelerinin ve minderlerinin bakımını nasıl yapacaklarına dair gerekli bilgiyi vermekle sorumludurlar. Önleyici onarımlar: Evde bakım Tekerlekli sandalye kullanıcılarının, sandalye ve minderlerinin bakımı için yapabileceği altı şey vardır. Kullanıcılara, sandalye ve minderlerinin bakımını evde nasıl yapacaklarına dair bilgi verin ve önemini anlatın. Bir sonraki sayfada, nasıl yapılacağını ve önemini anlatmaktadır. Tekerlekli sandalye onarımı için yerel kaynaklar Çevrenizde nerelerin tekerlekli sandalyenizi tamir edebileceğini araştırın. Bunlardan bazıları: o Bisiklet tamircileri; o Motosiklet ya da araba tamircileri; o Atölyeler– kaynak ustası, tesisatçı (metal parçalar için), marangoz, mobilya yapan ustalar (tahta parçalar için); o Tekerlekli sandalye kullanıcısı, aile bireyi, akrabası, komşusu; o Döşemeyi tamir etmek için terzi; o Tekerlekli sandalye servisi. Evde tekerlekli sandalye bakımı nasıl yapılır? Neden önemlidir? Nasıl yapılır 1. Tekerlekli sandalye ve minderi temizleyin Metal kısımların paslanmasını önler. Tahta kısımların ve döşemenin çürümesini önler. Hareketli kısımların, kirden zarar görmesini önler. Ilık su ve biraz sabun kullanın. Durulayın ve kurutun. Hareketli kısımlara ve döşemenin çerçeve ile birleşen kısmına dikkat edin. Minderi kılıfından çıkartın ve ayrı yıkayın. Minderi her zaman doğrudan güneş ışığında değil, gölgede kurutun. 2. Hareketli kısımlarını yağlayın Parçaların pürüzsüzce hareketini sağlar. Paslanmayı önler. Tekerlekli sandalyeyi önce temizleyip, kurulayın. Yağlayın. Bütün hareketli kısımlara uygulayın. 3. Lastikleri şişirin (hava basınçlı ise) Tekerlekler uzun ömürlü olur. Daha az enerji sağlayarak tekerleği rahatça hareket ettirebilir. Frenler doğru çalışır. Parmak ile bastırarak basıncı kontrol edin. Tekerleğin biraz inmesi mümkün olabilir. (Ortalama 5mm) Basınç her lastikte aynı olmalı. Bisiklet pompası ya da benzeri bir alet kullanın. Basıncı supaptan hava çıkartarak indirin. 4. Somun ve cıvataları sıkın (eğer gevşekse) Gevşek cıvatalar istenmeyen hareketlere yol açar. Bu durum rahatsızlık verebilir ve parçaların kaybolmasına yol açabilir. Tekerlekli sandalyeyi gevşek somun ve cıvatalar var mı diye kontrol edin, varsa cıvata anahtarı ile sıkılaştırın. Çok fazla sıkı olmamasına dikkat edin. Neden önemlidir? Nasıl yapılır 5. Jant tellerini sıkılaştırın (eğer gevşek ise) Gevşek jant telleri, lastiklerin bükülüp inmesine sebep olabilir. Tekerleğin çevresinden, iki jant tellini sıkıştırın. Siz çektikçe jant teli uzuyorsa, gevşek demektir, teller sıkılaştırın. Jant telleri fazla sıkı olmuş ise biraz gevşetmeniz gerekir. 6. Düzenli olarak kontroller yapın Pas ve döşemeleri kontrol edin. Pas materyalin gücünü azaltır. Bu da parçaların kırılmasına e kullanıcının zarar görmesine sebep olur. Döşemenin, iyi durumda ve rahat olması, kullanıcıya destek vermesi gerekir. . Eğer döşeme aniden yırtılırsa, kullanıcı zarar görebilir. Boyanmış metal kısımları, pas ve korozyon için kontrol edin. Eğer paslanmış ise, zımpara kâğıdı veya çelik fırça kullanarak pası çıkartın. Tiner ile temizleyin ve tekrar boyayın. Yırtık, kir, pas, ucu dışarı çıkmış metal parçalar var mı diye kontrol edin. Koltuğun ve arkalığın gerginliğini kontrol edin. Eğer döşeme yırtılmış ise, ya da gerginliğini kaybetmiş ise, onarım gerekmektedir. Minderi kontrol edin Minderler deriyi koruması açısından temiz ve kuru olmalıdır. Minderler, tekerlekli sandalyeler kadar uzun dayanmamaktadır. Düzenli kontroller sayesinde minderinizi değiştirmeniz gereken zamanı takip edebilirsiniz. Kılıfı çıkartın. Kılıfta ve köpük üzerinde, delik, kir ya da leke var mı diye kontrol edin. Eğer minder yırtılmış ise, tekerlekli sandalye personeli tarafından kontrolü yapılmalıdır. Değiştirilmesi gerekebilir. Sık görülen minder ve tekerlekli sandalye onarımları Tekerlekli sandalyeler ve minderlerin zaman içinde onarıma ihtiyacı vardır. Tekerlekli sandalye personeli, onarımları yapabilmeli ya da kullanıcıyı, nerede onarım yapılabileceğine dair bilgilendirebilmelidir. Bazı tekerlekli sandalye kullanıcıları onarımları kendileri halledebilir, bazıları ise yardıma ihtiyaç duyabilir. Tekerlekli sandalyelerini ve minderlerini nerede tamir ettireceklerine dair bilgi, tüm tekerlekli sandalye kullanıcıları için faydalıdır. Takip nedir ve nasıl yapılır? Takip, tekerlekli sandalye kullanıcısı, sandalyesini alıp bir süre kullandıktan sonra yapılır. Takip için yapılan randevularda: o Tekerlekli sandalye kullanıcısından bilgi toplayın; o Tekerlekli sandalyenin kullanılabilir halde olduğunu kontrol edin; o Tekerlekli sandalyenin uygunluğunu kontrol edin. Bütün tekerlekli sandalye kullanıcıları, yapılan takip ziyaretlerinden faydalanabilir. Fakat takip özellikle aşağıdaki kişiler için önemlidir: o Çocuklar; o Basınç yarası geliştirme riski olan kullanıcılar; o İlerleyen bir hastalığı olan kullanıcılar; o Eğitim sırasında kendilerine verilen bilgileri anlamakta zorlanan kullanıcılar. Takibin ne zaman yapılması gerektiği ile ilgili kesin kurallar yoktur, ancak tekerlekli sandalye kullanılmaya başladıktan altı hafta sonrası için ayarlanan bir takip görüşmesinin yararlı olduğu görülmüştür. Bu süreç kullanıcıya bağlıdır. Fakat çocuklarda takibin her altı ayda bir yapılması idealdir. Bunun sebebi, çocuklar büyüdükçe ihtiyaçları da bu yönde değişecektir. Takip, eve yapılan bir ziyaret şeklinde, kullanıcının tekerlekli sandalye merkezine yapacağı bir ziyaret sırasında ya da kullanıcıya ve personele uyan başka bir yerde gerçekleşebilir. Tüm bunlar, kullanıcının merkeze gidebilmesi ya da personelin kullanıcının evine gelebilmesi ile bağlantılı olarak değişkenlik gösterebilir. Sık görülen takip eylemleri  Tekerlekli sandalyenin iyi durumda olduğunu kontrol edin;  Ek eğitim temin edin ve püf noktaları paylaşın;  Eğer gerekirse, – Tekerlekli sandalyenin ayarını tekrar yapın; – Küçük çaplı onarımları, ya da evde bakımını gerçekleştirin; – Büyük çaplı onarımların organizasyonunu yapın, ya da tekerlekli sandalye kullanıcısına bu konuda destek olun. Bir sonraki sayfadaki form, takip sırasında yol gösterir. Personel, takip ziyaretinden sonra yapılan tüm eylemleri not almalıdır. Takip randevularını yönetmenin yolları o Tekerlekli sandalye kullanıcıları, sandalyelerini aldıkları sırada onlara, takip için randevu verin. o Takip için tekerlekli sandalye kullanıcılarını mümkün olan durumlarda evlerinde ziyaret edin. o Takip ziyaretlerini, takip konusunda eğitilmiş toplu temelli rehabilitasyon merkezi personeli ile beraber halka yaptığınız ziyaretin bir parçası haline getirin. o Ulaşımı zor olan tekerlekli sandalye kullanıcıları için, eğer telefon kullanabiliyorlar ise, telefon ile takip yapın. Tekerlekli Sandalye Takip Formu Bu form takip ziyaretinde elde edilen bilgileri kaydetmek içindir. 1. Tekerlekli sandalye kullanıcısı bilgileri Tekerlekli sandalye kullanıcısının adı: Numara: Uygunluk tarihi: Takip tarihi: Takibi gerçekleştiren kişinin adı: Takibin uygulandığı yer: Tekerlekli sandalye kullanıcısının evi  Tekerlekli sandalye servis merkezi  Diğer: ________________________________________ 2. Görüşme Alınacak önlemleri kaydet: Tekerlekli sandalyenizi istediğiniz kadar çok kullanabiliyor musunuz? Evet  Hayır  Cevap hayır ise – neden? Tekerlekli sandalyenizi kullanırken hiç problem yaşıyor musunuz? Evet  Hayır  Cevap evet ise – bu problemler nelerdir? Tekerlekli sandalyenizin kullanımı ile ilgili sorularınız var mı? Evet  Hayır  Cevap evet ise – bu sorular nelerdir? Daha ileri düzey bir eğitime ihtiyaç var mı? Kullanıcının basınç yarası mevcut mu? Evet  Hayır  Eğer cevap ise - tanımlayınız (nerede ve ne düzeyde) Tekerlekli sandalyenizle ilgili memnuniyetinizi 1 ile 5 arasında değerlendirirseniz kaç verirsiniz? (1 çok memnun ve 5 hiç memnun değil) Değer: Yorum: 3. Tekerlekli sandalye ve minder kontrolü Tekerlekli sandalye iyi çalışır vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Minder kullanımı uygun vaziyette mi ve kullanımı güvenli mi? Evet  Hayır  Her biri için cevap hayır ise, problem nedir? 4. Uygunluk kontrolü Tekerlekli sandalye doğru bir şekilde uyuyor mu? Evet  Hayır  Cevap hayır ise – problem nedir? Basınç testi düzeyi (1 = güvenli, 2 = uyarı, 3 = tehlikeli) (eğer kullanıcı basınç yarası geliştirme riski altındaysa) Sol: Sağ: Tekerlekli sandalye kullanıcısı hareketsizken, hareket ederken ve gün boyunca rahat ve dik oturabiliyor mu? Evet  Hayır  Eğer cevap hayır ise – problem nedir? For more information of the English version, please contact: World Health Organization 20 Avenue Appia 1211 Geneva 27, Switzerland Tel: (+41 22) 791 2715 Fax: (+41 22) 791 4857 http://www.who.int/disabilities/en/ dar@who.int

Apostila do Participante NÍVEL BÁSICO NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Apostila do Participante NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Apostila do Participante Informações sobre a edição em inglês: Editores: Chapal Khasnabis e Kylie Mines Autores: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler e Rebecca Jackson Stoeckle Revisores: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Gosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif e Isabelle Urseau Ilustração: Melissa Puust Crédito das fotos: Chapal Khasnabis e Jesse Moss Créditos de vídeo: Chapal Khasnabis, Amanda McBaine, e Jesse Moss Instrutores dos cursos Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama piloto: Raju, e Elsie Taloafiri Apoio financeiro: Agência dos Estados Unidos da América para o Desenvolvimento Internacional e Agência Australiana para o Desenvolvimento Internacional Organizações parceiras: ASSERT Timor Leste, Associação para os Deficientes Físicos do Quênia (APDK), Unidade de Reabilitação Baseada na Comunidade do Ministério de Serviços Médicos e de Saúde das Ilhas Salomão, Centro de Desenvolvimento da Educação (EDC), Handicap International, Comitê Internacional da Cruz Vermelha (CICV), Sociedade Internacional para Protéticos e Ortóticos (ISPO), Associação de Pessoas com Lesão Medular do Kilimanjaro (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania e Centro de Treinamento para Tecnólogos Ortopédicos da Tanzânia (TATCOT) Publicado pela Organização Mundial da Saúde em 2012 sob o título Wheelchair Service Training Package: Basic Level © Organização Mundial da Saúde 2012 © Secretaria de Estado dos Direitos da Pessoa com Deficiência de São Paulo 2014 O Diretor Geral da Organização Mundial da Saúde concedeu os direitos de tradução e publicação da edição em Língua Portuguesa à Secretaria de Estado dos Direitos da Pessoa com Deficiência de São Paulo, a qual é a única responsável pela exatidão da edição em Língua Portuguesa. Pacote de Treinamento em Serviços para Cadeiras de Rodas Conteúdo: Manual do Instrutor, nível básico – Manual de Referência para os Participantes, nível básico – Apostila do Participante, nível básico – Pôsteres e slides, nível básico. Manual do instrutor e slides disponíveis apenas em DVD. 1. Cadeiras de rodas – padrões; 2. Pessoas com deficiência – reabilitação; 3. Materiais de ensino. SU M Á R IO ObjetivoA.4: Sentar-se ereto A.6: Cadeira de rodas apropriada A.7: Almofadas A.8: Transferências B.3: Entrevista de avaliação B.4: Avaliação física B.5: Prescrição (seleção) – resumos das cadeiras de rodas B.5: Prescrição (seleção) – escolhendo o tamanho certo da cadeira de rodas B.7: Preparação do produto (cadeira de rodas) B.8: Fabricação das almofadas B.11: Treinamento de usuários B.12: Manutenção e reparos B.13: Acompanhamento B.14: Juntando tudo Nome: 1 2 4 6 7 8 13 14 18 20 21 23 24 26 30 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1 Objetivo O pacote de treinamento de Nível Básico é desenvolvido para dar suporte ao treinamento da equipe de atendimento ou dos voluntários para fornecer uma cadeira de rodas manual e almofadas apropriados para meninas, meninos, mulheres e homens que possuem mobilidade reduzida, mas que podem sentar eretos sem suporte adicional para a postura. O objetivo da Apostila do Participante é desenvolver as habilidades e conhecimentos das pessoas envolvidas na prestação de serviços para cadeira de rodas. A Apostila do Participante contém exercícios que ajudarão a testar e desenvolver o conhecimento e as habilidades do participante. A Apostila do Participante contém material das palestras, apresentações de slides e do manual de referência. O participante deve manter sua cópia da apostila consigo para consultas futuras, se necessário. 2A.4: Sentar-se ereto • Preste atenção em cada exemplo de diferentes posturas. • Anote de que forma a postura é diferente em relação a sentar-se ereto. • Pense sobre os aspectos de sentar-se ereto de frente e de lado. 1. Descreva em quê a postura dessa pessoa é diferente de “sentar-se ereto”. 2. Descreva em quê a postura dessa pessoa é diferente de “sentar-se ereto”. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3 3. Descreva em quê a postura dessa pessoa é diferente de “sentar-se ereto”. 4. Quais problemas podem ser causados por não sentar-se ereto? 1. 2. 3. 4. 5. 4A.6: Cadeira de Rodas Apropriada • Leia todas as histórias dos usuários. • Discuta qual das cadeiras de rodas disponíveis se encaixa melhor às necessidades de cada usuário. • Liste pelo menos três razões pelas quais os participantes recomendariam essa cadeira de rodas para o usuário. • Considere as necessidades físicas, ambientais e cotidianas do usuário – e as características que eles precisam na cadeira de rodas. • Anote suas respostas. Bao Qual das cadeiras de rodas disponíveis se ajustaria melhor às necessidades de Bao. Por quê? Bao vive numa zona rural. Teve as duas pernas amputadas acima do joelho. Antes do acidente, tinha um pequeno mercado na estrada que passa por sua cidade. Agora só consegue chegar à loja com ajuda porque a distância da cidade até a estrada é longa (quase 1 km), acidentada e em geral lamacenta. Isso torna difícil para ele e sua família cuidarem da loja. Muito tempo atrás ele ganhou uma cadeira de rodas de estilo ortopédico. A cadeira está enferrujada e o estofamento do assento rasgou. As rodas dianteiras são pequenas e as traseiras são finas e estão gastas. Ele não consegue impulsionar a cadeira de sua casa até a cidade porque as rodas atolam no caminho. Ele gostaria de poder chegar sozinho até a loja, para não ter que depender da esposa ou de terceiros para ajudá-lo. Amanthi Qual das cadeiras de rodas dis- poníveis se ajustaria melhor às necessidades da Amanthi. Por quê? Amanthi tem 24 anos e mora com sua família em uma cidadezinha. Sofreu um acidente automobilístico quando tinha 18 anos e ficou paraplégica. Recentemente ela teve uma úlcera/ferida de pressão que levou seis meses para cicatrizar. Ela tem uma cadeira de rodas ortopédica que não lhe dá boa sustentação e ela fica muito cansada nela. Não tem almofada. Amanthi acredita que foi por isso que ela desenvolveu a úlcera/ferida de pressão. Amanthi foi convidada para participar de um curso de secretariado e quer ir. No entanto, não tem certeza se conseguirá ficar sentada o dia todo em sua cadeira de rodas atual. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 5 Phillip Qual das cadeiras de rodas dis- poníveis se ajustaria melhor às necessidades de Phillip. Por quê? Phillip tem 62 anos e mora em uma comunidade em uma pequena ilha. Seis meses atrás teve um AVC/trombose cerebral. Voltou para casa depois de um mês internado e sem cadeira de rodas. Fica deitado na cama ou sentado em uma cadeira na varanda de sua casa. Phillip não consegue mover o braço e a perna esquerdos. No entanto, está ficando mais forte a cada dia e agora consegue ficar de pé com a ajuda de um familiar. Está exercitando o braço direito e quer muito ter uma cadeira de rodas para ter mais mobilidade e ser menos dependente da família. Quer poder circular por sua casa, que é térrea, e pela comunidade local. O terreno é muito arenoso. Um de seus netos tem um carro e disse que vai levá-lo para passear quando ele tiver uma cadeira de rodas. Sabina Qual das cadeiras de rodas dis- poníveis se ajustaria melhor às necessidades da Sabina. Por quê? Sabina tem 56 anos e mora em uma pequena ilha. Após o nascimento de seu quarto filho, muitos anos atrás, ela perdeu quase todos os movimentos das pernas. Consegue ficar um pouco em pé, mas não consegue andar. Nunca teve uma cadeira de rodas. Sabina mora perto do mar – e a superfície em torno de sua casa é acidentada e arenosa. Ela se dedica a cuidar dos netos, cozinhar e tecer. Não há espaço interno para uma cadeira de rodas, mas ela pode ser armazenada sob a casa construída sobre colunas. Qual das cadeiras de rodas disponíveis se ajustaria melhor ao seu ambiente? Por quê? 1. 2. 3. 4. 5. 6A.7: Almofada • Pratique verificando a pressão embaixo de cada lado do osso do ísquio (direito e esquerdo) de cada pessoa no grupo. • Certifique-se de que todos no grupo testaram e foram testados. • Anote o nível de pressão para cada pessoa do grupo na tabela abaixo. Verifique a pressão embaixo do osso do ísquio de cada usuário em risco de desenvolver úlceras/feridas de pressão. A Antes de começar, explique o teste ao usuário. B Peça ao usuário que se incline para frente ou erga o corpo para permitir que você coloque a ponta dos dedos debaixo do osso do ísquio do lado esquerdo ou direito (palma pra cima). C Peça ao usuário que se sente novamente em seus dedos. Ele/ela deve sentar-se normalmente, olhando para frente e colocando as mãos sobre as coxas. D Identifique a pressão: Nível 1 = seguro: A ponta dos dedos pode mover-se 5 mm ou mais para cima e para baixo. Nível 2 = atenção: A ponta dos dedos não pode se mover, mas pode deslizar para fora. Nível 3 = inseguro: A ponta dos dedos fica comprimida firmemente. É difícil deslizar os dedos. E Repita debaixo do segundo osso do ísquio. Anote o nível de pressão para cada pessoa do grupo na tabela abaixo. Osso ísquio esquerdo Osso ísquio direito Pessoa 1 Nível 1:  Nível 2:  Nível 3:  Nível 1:  Nível 2:  Nível 3:  Pessoa 2 Nível 1:  Nível 2:  Nível 3:  Nível 1:  Nível 2:  Nível 3:  Pessoa 3 Nível 1:  Nível 2:  Nível 3:  Nível 1:  Nível 2:  Nível 3:  Pessoa 4 Nível 1:  Nível 2:  Nível 3:  Nível 1:  Nível 2:  Nível 3:  CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 7 A.8: Transferências • Leia as histórias dos usuários. • Discuta qual método de transferência se encaixa melhor para cada usuário e por quê. • Anote suas respostas. Faridah Qual método de transferência seria mais apropriado para Faridah? Por quê? Faridah tem 60 anos. Foi encaminhada ao serviço para cadeira de rodas pelo hospital local. Recentemente teve um AVC/trombose cerebral e precisa de cadeira de rodas porque não consegue andar. Ela consegue ficar em pé um pouco e sustentar seu peso. No entanto fica muito instável quando em pé. Faridah mora com sua filha e sua família. A filha não trabalha e pode ajudar a mãe em casa. Ela tem uma cadeira de quatro rodas com apoios para os pés dobráveis. José Qual método de transferência seria mais apropriado para José? Por quê? José tem 45 anos e é usuário de cadeira de rodas há dez anos. Ele amputou as duas pernas acima do joelho e trabalha em uma oficina de conserto de rádios no mercado local. José veio ao serviço para cadeira de rodas para obter uma cadeira nova porque a dele é velha e gasta. Tahir Qual método de transferência seria mais apropriado para Tahir? Por quê? Tahir tem 14 anos e foi encaminhado recentemente para o serviço para cadeira de rodas após cair de uma árvore e sofrer uma lesão medular. Tahir usa muito bem seus braços, mas não é muito forte. Não consegue usar as pernas de modo algum. 8B.3: Entrevista de Avaliação • Cada pessoa no grupo escolhe uma história para ler – e interpretar o papel do usuário da história. Quando você for entrevistado use a informação da história para responder as perguntas da entrevista da melhor forma possível. • Não leia a história do usuário em voz alta para o resto do grupo e não leia a história dos outros. • Faça a entrevista em turnos e complete os formulários de avaliação nas páginas seguintes. Felicia é uma senhora idosa com artrite severa. Tem dor nos braços, mãos e pernas. Não consegue andar mais do que alguns passos devido à dor e porque acha difícil cuidar de si própria. Felicia foi à avaliação com a filha que também a ajuda em casa. Ela mora em uma cidadezinha e sua casa tem três degraus na entrada da frente. Ela não tem outros problemas de saúde além da artrite. Costumava ir à igreja regularmente, mas já não consegue ir. Sua família não tem carro e depende do transporte público. Para ir à avaliação, a família contratou um taxi. No entanto isso é caro para eles. Atualmente ela não tem cadeira de rodas. Anton tem pólio. Tem 26 anos e mora em uma cidadezinha. Está estudando computação e quer muito ter seu próprio negócio no futuro. Foi à avaliação com sua mulher. Muito tempo atrás ele ganhou uma cadeira de rodas estilo ortopédico. A cadeira está enferrujada e o estofamento do assento rasgou. As rodas dianteiras são pequenas e finas. As rodas traseiras são muito finas e estão gastas. A cadeira de rodas é desconfortável e difícil de impulsionar. As ruas da cidade são muito acidentadas e sua cadeira de rodas vive atolando. No entanto, ele gostaria de poder ir de casa ao centro de treinamento profissional sozinho. A distância é de cerca de ½ km. Atualmente, ele precisa da ajuda de seu irmão mais novo – que nem sempre pode levá-lo no horário. Chantou tem 13 anos. Ela perdeu as duas pernas (acima do joelho) durante um terremoto. Mora com sua família em um apartamento em uma cidade vizinha. Vai à avaliação com sua mãe e a irmã mais velha. Tem uma cadeira de rodas que ganhou. É uma cadeira de tamanho adulto e ortopédica. É grande demais para Chantou. Ela tem que passar o braço por cima do apoio para os braços para alcançar o aro de impulsão. Isso é difícil para ela. O encosto também é muito alto e não há almofada. Chantou gostaria de voltar para a escola, mas não se sente confortável na cadeira de rodas. Tam- bém tem vergonha de não conseguir se locomover sozinha. Gostaria de uma cadeira de rodas que ela pudesse impulsionar e que desse melhor sustentação. Ela diz que poderia usar o ônibus escolar se a cadeira de rodas pudesse ir com ela. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 9 Entreviste a pessoa do seu grupo que está interpretando o usuário e complete o formulário de avaliação abaixo. Nome do avaliador: Data da avaliação: Informação sobre o usuário Nome: Número: Idade: Masculino  Feminino  Telefone: Endereço: Metas: Condição Física Paralisia cerebral  Pólio  Lesão medular  AVC/trombose cerebral  Fragilidade  Espasmos ou movimentos involuntários  Amputação: D acima do joelho  D abaixo do joelho  E acima do joelho  E abaixo do joelho  Problemas de bexiga  Problemas de intestino  Se o usuário tem problema de bexiga ou de intestino, eles estão sendo gerenciados? Sim  Não  Outros: Estilo de vida e ambiente Descreva onde o usuário utilizará a cadeira de rodas: Distância percorrida por dia: Até 1 km  1–5 km  Mais de 5 km  Horas de uso da cadeira de rodas por dia Menos de 1  1–3  3–5  5–8  Mais de 8 horas  10 Quando está fora da cadeira de rodas, onde o usuário se senta ou deita e como (postura e superfície): Transferência: independente  assistida  fica em pé  não fica em pé  erguido  outro  Tipo de banheiro (se transferido ao banheiro): latrina  vaso sanitário/sanita  adaptado  O usuário utiliza usar transporte público/privado, com regularidade? Sim  Não  Se sim, que tipo: Carro  Taxi  Ônibus  Outro Cadeira de rodas atual (quando a pessoa já possui cadeira de rodas) A cadeira de rodas atende às necessidades do usuário? Sim  Não  A cadeira de rodas atende às condições do ambiente do usuário? Sim  Não  A cadeira de rodas oferece adequação correta e suporte postural? Sim  Não  A cadeira de rodas é segura e durável? (verifique se há almofada) Sim  Não  A almofada alivia adequadamente a pressão? (se o usuário corre risco de úlcera/ferida por pressão) Sim  Não  Comentários: Se sim para todas as perguntas, o usuário pode não precisar de uma cadeira de rodas nova. Se não para qualquer uma das perguntas, o usuário precisa de uma cadeira de rodas ou almofada diferente; ou a cadeira de rodas ou a almofada atuais precisam de reparo ou modificação. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 11 Entreviste a pessoa do seu grupo que está interpretando o usuário e complete o formulário de avaliação abaixo. Nome do avaliador: Data da avaliação: Informação sobre o usuário Nome: Número: Idade: Masculino  Feminino  Telefone: Endereço: Metas: Condição Física Paralisia cerebral  Pólio  Lesão medular  AVC / Trombose cerebral  Fragilidade  Espasmos ou movimentos involuntários  Amputação: D acima do joelho  D abaixo do joelho  E acima do joelho  E abaixo do joelho  Problemas de bexiga  Problemas de intestino  Se o usuário tem problema de bexiga ou de intestino, eles são gerenciados? Sim  Não  Outros: Estilo de vida e ambiente Descreva onde o usuário utilizará a cadeira de rodas: Distância percorrida por dia: Até 1 km  1–5 km  Mais de 5 km  Horas de uso da cadeira de rodas por dia Menos de 1  1–3  3–5  5–8  Mais de 8 horas  12 Quando está fora da cadeira de rodas, onde o usuário senta ou deita e como (postura e superfície): Transferência: independente  assistida  fica em pé  não fica em pé  erguido  outro  Tipo de banheiro (se transferido ao banheiro): latrina  vaso sanitário/sanita  adaptado  O usuário costuma usar transporte público/privado? Sim  Não  Se sim, que tipo: Carro  Taxi  Ônibus  Outro Cadeira de rodas atual (quando a pessoa já possui cadeira de rodas) A cadeira de rodas atende às necessidades do usuário? Sim  Não  A cadeira de rodas atende às condições do ambiente do usuário? Sim  Não  A cadeira de rodas oferece adequação correta e suporte postural? Sim  Não  A cadeira de rodas é segura e durável? (verifique se há almofada) Sim  Não  A almofada oferece alívio adequado da pressão? (se o usuário corre risco de úlcera/ferida por pressão) Sim  Não  Comentários: Se sim para todas as perguntas, o usuário pode não precisar de uma cadeira de rodas nova. Se não para qualquer uma das perguntas, o usuário precisa de uma cadeira de rodas ou almofada diferente; ou a cadeira de rodas ou a almofada atuais precisam de reparo ou modificação. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 13 B.4: Avaliação física Cada membro do seu grupo deve medir os outros do grupo. Anote as medições abaixo. Escreva também na tabela o nome da pessoa que mediu. 1. Nome do usuário: Avaliador 1: Avaliador 2: Medida do Corpo Medida (mm) Medida (mm) A Largura do quadril B Profundidade do assento D E C Comprimento da perna D E D Altura da última costela E Altura do ângulo inferior da escápula 2. Nome do usuário: Avaliador 1: Avaliador 2: Medida do Corpo Medida (mm) Medida (mm) A Largura do quadril B Profundidade do assento D E C Comprimento da perna D E D Altura da última costela E Altura do ângulo inferior da escápula 3. Nome do usuário: Avaliador 1: Avaliador 2: Medida do Corpo Medida (mm) Medida (mm) A Largura do quadril B Profundidade do assento D E C Comprimento da perna D E D Altura da última costela E Altura do ângulo inferior da escápula 14 B.5: Prescrição (seleção) – resumo das cadeiras de rodas • Preencha a folha de resumo das cadeiras de rodas para as cadeiras de rodas designadas para você pelo instrutor. • Para preencher o formulário você vai precisar: - olhar com cuidado para a cadeira de rodas; - olhar qualquer informação escrita sobre a cadeira (se disponível); - tirar as medidas (se não estiverem disponíveis nas informações escritas), o que pode exigir o ajuste da cadeira de rodas para extensão máxima e mínima de alguns itens ajustáveis. Preencha o resumo da cadeira de rodas para qualquer outra cadeira de rodas disponível no local. Nome da cadeira de rodas: Fabricante/Distribuidor: Tamanhos disponíveis: Peso total: Descrição: Estrutura: Dobrável  Fixa/Rígida  Comprimento da estrutura(mm) Encosto: Flexível/lona  Rigida  Tensão ajustável  Assento: Flexível/lona  Rigida  Tensão ajustável  Almofada: Sem almofada  Espuma plana  Espuma moldada  Apoio para os pés: Móvel/Removível  Fixo  Outro : Rodas dianteiras Diâmetro: Largura: Rodas traseiras: Pneumática  Diâmetro: Aros de impulsão  Sólida  Largura: Eixo ajustável  Tubo interior sólido  Removível  Freios Alavanca curta  Alavanca longa  Outro: Apoio para os braços: Fixo  Removível/móvel  Outro: Manoplas: Manoplas  Partes extras/ opcionais: Faixa de Panturrilha  Dispositivo anti-queda  Mesa  Outro: CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 15 Medidas, opções e abrangência do ajuste: Medidas (se a cadeira de rodas está disponível em diferentes tamanhos liste todos os tamanhos) É ajustável? Abrangência do ajuste (o quanto é possível ajustar a cadeira)Sim Não Largura do assento:   Profundidade do assento:   Altura do assento:   Altura do encosto:   Ângulo do encosto:   Altura do apoio para os pés:   Ângulo do apoio para os pés:   Altura das manoplas:   Comprimento da estrutura:   Distância entre eixos:   Preencha o resumo da cadeira de rodas para qualquer outra cadeira de rodas disponível no local. Nome da cadeira de rodas: Fabricante/Distribuidor: Tamanhos disponíveis: Peso total: 16 Descrição: Estrutura: Dobrável  Fixa/Rígida  Comprimento da estrutura(mm) Encosto: Flexível/lona  Rígido  Tensão ajustável  Assento: Flexível/lona  Rígido  Tensão ajustável  Almofada: Sem almofada  Espuma plana  Espuma moldada  Apoio para os pés: Móvel/Removível  Fixo  Outro : Rodas dianteiras Diâmetro: Largura: Rodas traseiras: Pneumática  Diâmetro: Aros de impulsão  Sólida  Largura: Eixo ajustável  Tubo interior sólido  Removível  Freios Alavanca curta  Alavanca longa  Outro: Apoio para os braços: Fixo  Removível/ Móvel  Outro: Manoplas: Manoplas  Partes extras/ opcionais: Faixa de Panturrilha  Dispositivo anti-queda  Mesa  Outro: Medidas, opções e abrangência do ajuste: Medidas (se a cadeira de rodas está disponível em diferentes tamanhos liste todos os tamanhos) É ajustável? Abrangência do ajuste (o quanto é possível ajustar a cadeira) Sim Não Largura do assento:   Profundidade do assento:   Altura do assento:   Altura do encosto:   Ângulo do encosto:   Altura do apoio para os pés:   Ângulo do apoio para os pés:   Altura das manoplas:   Comprimento da estrutura:   Distância entre eixos   CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 17 Preencha o resumo da cadeira de rodas para qualquer outra cadeira de rodas disponível no local. Nome da cadeira de rodas: Fabricante/Distribuidor: Tamanhos disponíveis: Peso total: Descrição: Estrutura: Dobrável  Fixa/Rígida  Comprimento da estrutura(mm) Encosto: Flexível/lona  Rígido  Tensão ajustável  Assento: Flexível/lona  Rígido  Tensão ajustável  Almofada: Sem almofada  Espuma plana  Espuma moldada  Apoio para os pés: Móvel/Removível  Fixo  Outro : Rodas dianteiras: Diâmetro: Largura: Rodas traseiras: Pneumática  Diâmetro: Aros de impulsão  Sólida  Largura: Eixo ajustável  Tubo interior sólido  Removível  Freios Alavanca curta  Alavanca longa  Outro: Apoio para os braço: Fixo  Removível/ Móvel  Outro: Manoplas: Manoplas  Partes extras/ opcionais: Faixa de Panturrilha  Dispositivo anti-queda  Mesa  Outro: 18 Medidas, opções e abrangência do ajuste: Medidas (se a cadeira de rodas está disponível em diferentes tamanhos liste todos os tamanhos) É ajustável? Abrangência do ajuste (o quanto é possível ajustar a cadeira)Sim Não Largura do assento:   Profundidade do assento:   Altura do assento:   Altura do encosto:   Ângulo do encosto:   Altura do apoio para os pés:   Ângulo do apoio para os pés:   Altura das manoplas:   Comprimento da estrutura:   Distância entre eixos:   B.5: Prescrição (seleção) – selecionando o tamanho certo da cadeira de rodas Para cada um dos exemplos abaixo: • teste o tamanho ideal da cadeira de rodas e • selecione entre as cadeiras de rodas disponíveis o melhor tamanho para o usuário. (assuma que a almofada que o usuário utilizará nos dois casos é de 20 mm de altura) 1 Medida do corpo Medida (mm) Transforme a medida do corpo no tamanho ideal de cadeira de rodas Medida da cadeira de rodas A Largura do quadril 380 mm Largura do quadril = largura do assento B Profundidade do assento E 400 mm B menos 30–60 mm = profundidade do assento (se os comprimentos forem diferentes usem o menor) D 400 mm C Comprimento da perna E 420 mm = topo da almofada do assento até a altura do apoio para os pés ou = topo da almofada do assento até o chão para impulso com o pé D 420 mm CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 19 D Altura da última costela = topo da almofada do assento até o topo do encosto (medir D ou E – dependendo da necessidade do usuário) E Altura do ângulo inferior da escápula 380 mm Tamanho ideal da cadeira de rodas para esse usuário: Largura do assento: Profundidade do assento: Altura do encosto: Das cadeiras de roda disponíveis, qual cadeira e qual tamanho são melhores para o usuário? 2 Medida do corpo Medida (mm) Transforme a medida do corpo no tamanho ideal de cadeira de rodas Medida da cadeira de rodas A Largura do quadril 420 mm Largura do quadril = largura do assento B Profundidade do assento E 460 mm B menos 30–60 mm = profundidade do assento (se os comprimentos forem diferentes usem o menor) D 460 mm C Comprimento da perna E 360 mm = topo da almofada do assento até a altura do apoio para os pé ou = topo da almofada do assento até o chão para impulso com o pé D 360 mm D Altura da última costela 260 mm = topo da almofada do assento até o topo do encosto (medir D ou E – dependendo da necessidade do usuário E Altura do ângulo inferior da escápula Tamanho ideal da cadeira de rodas para esse usuário: Largura do assento: Profundidade do assento: Altura do encosto: Das cadeiras de roda disponíveis, qual cadeira e qual tamanho são melhores para o usuário? 20 B.7: Preparação do Produto (cadeira de rodas) Lista de verificação: A cadeira de rodas é segura e está pronta para uso? Nome do Serviço para cadeira de rodas: Nome do usuário: Tipo de cadeira de rodas: Nº de série da cadeira de rodas: Cadeira de rodas inteira Não há arestas pontiagudas  Nenhuma parte está danificada ou arranhada  A cadeira de rodas anda em linha reta  Rodas dianteiras Giram livremente  Giram sem tocar no garfo  Os parafusos estão apertados  Encaixe das rodas dianteiras O garfo gira livremente  Rodas traseiras Giram livremente  Os parafusos do eixo estão apertados  Pneus calibrados corretamente (com a pressão do polegar, a roda pode ser comprimida em menos de 5 mm)  Os aros de impulsão estão seguros  Freios Funcionam apropriadamente  Apoio para os pés Os apoios para os pés estão presos com segurança  Estrutura Para cadeira de rodas dobrável – a cadeira abre e fecha com facilidade  Para cadeira de rodas com encosto dobrável – o encosto abre e fecha com facilidade  Almofada A almofada está corretamente na capa  A almofada está colocada corretamente na cadeira de rodas  A capa do assento está justa, mas não muito apertada  Se a cadeira de rodas tem um assento rígido a almofada cobre completamente o assento  Nome da pessoa que verificou a cadeira de rodas: Assinatura: Data: CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 21 B.8: Fabricação da almofada Dimensões corretas da caixa de acomodação para o osso do ísquio Calcule as dimensões corretas da caixa de acomodação para o osso do ísquio para cada usuário na tabela abaixo: Largura Profundidade Altura Usuário adulto – largura do assento de 360 mm Usuário adulto – largura do assento de 460 mm Usuário criança – largura do assento de 280 mm Fabricação da almofada • Trabalhe em dupla. • Siga as instruções abaixo para fazer uma almofada. Se tiver alguma dúvida pergunte aos instrutores. 1. Marque as linhas de corte • Use um pedaço de espuma firme de 400 mm x 400 mm x 50 mm • O centro da caixa de acomodação do osso do ísquio deve estar na linha central do assento • Para uma almofada desse tamanho, a caixa de acomodação do osso do ísquio deve medir 200 mm x 200 mm x 35 mm • Desenhe as linhas de corte com marcador colorido escuro em todos os seis lados da base da espuma 22 2. Corte o buraco para a caixa de acomodação do osso do ísquio: Use uma lâmina denteada afiada ou uma faca comprida. Use movimentos longos e lentos, cortando principalmente quando estiver puxando para melhorar o controle. • Primeiro corte através da parte de trás da almofada para o fundo da caixa de acomodação do osso do ísquio. • Depois tire a “caixa de acomodação do osso do ísquio”. • Cole de volta as duas “abas” nas laterais da caixa de acomodação do osso do ísquio. 3. Corte as bordas internas da caixa de acomodação do osso do ísquio. 4. Para uma almofada flexível: faça um corte angular (chanfro) dos dois lados da base (lado inferior) • Marque como foi mostrado, e corte. • Esse corte ajuda a encaixar a base da almofada no formato do assento flexível da cadeira de rodas. 5. Coloque a camada superior de espuma na parte de cima da almofada • Tanto a camada de base como a do topo são colocadas juntas na capa da almofada. • Não há necessidade de colar as duas camadas. • Se a camada de cima ficar suja ou gasta, ela pode ser lavada e enxugada ou trocada. • Pode ser colocada uma camada de elevação junto com a capa (no topo da camada da base e embaixo da camada de conforto) para aumentar a profundidade da caixa de acomodação do osso do ísquio. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 23 B.11: Treinamento dos usuários • Leia as histórias dos usuários. • Identifique pelo menos três habilidades da lista de verificação de treinamento do usuário que serão muito importantes para o usuário saber antes de ir embora do Serviço para Cadeira de Rodas com a nova cadeira de rodas. • Pratique a instrução de uma habilidade para o usuário (faça isso em turnos, interpretando o papel do atendente do Serviço para Cadeira de Rodas, do instrutor e do membro da família). Lembre-se de usar os bons métodos de ensino discutidos na sessão. Moses De quais habilidades você acha que Moses se beneficiaria com o aprendizado? Moses tem 23 anos. Há dois anos, ele caiu de um caminhão e ficou paraplégico. Passou um ano no hospital, e depois voltou para sua cidadezinha natal com uma cadeira de rodas usada, que alguém havia doado. A cadeira de rodas quebrou logo em seguida e ele não conseguia se locomover. Ele desenvolveu uma úlcera/ferida de pressão que já sarou. Moses acabou de ganhar uma cadeira de rodas nova, com uma almofada para alívio de pressão, através do serviço de cadeira de rodas. Essa cadeira de rodas foi projetada para andar em terreno muito acidentado. Moses está muito entusiasmado com essa cadeira de rodas, e espera tornar-se mais independente. Sian De quais habilidades você acha que Sian se beneficiaria com o aprendizado? Sian tem 40 anos e teve as duas pernas amputadas acima do joelho. É usuário há 20 anos e já teve cinco cadeiras de rodas ao longo desse tempo. Ele acha que as cadeiras de rodas quebram muito rápido. Ele é muito ativo e trabalha numa loja nas redondezas. Todos os dias, ele vai e volta da loja e passa por caminhos esburacados e frequentemente cheios de lama. Ele já demonstrou à equipe de atendimento como consegue empinar a cadeira Em breve, ele vai receber uma cadeira de rodas nova. Sua esperança é que essa cadeira de rodas dure mais tempo que a anterior, que só durou seis meses. 24 Zoe De quais habilidades você acha que Zoe se beneficiaria com o aprendizado? Zoe tem 16 anos. Teve poliomielite quando criança e agora não consegue andar. Ela é muito tímida e não tem ido à escola. Sua mãe tem dado algumas aulas para ela em casa e ela sabe ler e escrever bem. Zoe acabou de ganhar uma cadeira de rodas e já demonstrou à equipe de atendimento que consegue transferir-se da cadeira de rodas com bastante facilidade. Zoe gostaria de se matricular na escola técnica local. Mas ela acha que não vai conseguir entrar e sair da escola. O prédio tem vários degraus na entrada. Ela também se preocupa com o fato de ir ao banheiro enquanto ela estiver na escola. B.12: Manutenção e reparos Manutenção: • Identifique o que pode ser feito para cuidar da cadeira de rodas e da almofada em casa 1. 2. 3. 4. 5. 6. Reparos: • Olhe bem cada cadeira de rodas disponível para a realização do treinamento. • Identifique quais precisam de reparos (se alguma precisar) e sugira como os reparos podem ser feitos na sua região ou local de trabalho. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 25 Cadeira de rodas A O que precisa de reparo? Como os reparos podem ser feitos na sua região ou local de trabalho? Cadeira de rodas B O que precisa de reparo? Como os reparos podem ser feitos na sua região ou local de trabalho? Cadeira de rodas C O que precisa de reparo? Como os reparos podem ser feitos na sua região ou local de trabalho? 26 B.13: Acompanhamento • Leia a história de cada usuário. • Discuta quais ações deveriam ser tomadas. • Preencha um formulário de acompanhamento para cada usuário, incluindo observações de ações que devam ser tomadas. Hala Hala mora em casa com sua filha, que já é adulta, e sua família. Ela recebeu sua cadeira de rodas há seis meses. Ela teve um AVC/trombose cerebral há pouco mais de um ano e não consegue andar. Quando sua cadeira de rodas chegou, Hala aprendeu como fazer a transferência, ficando em pé com a ajuda da filha. Ela havia dito que queria ter uma cadeira de rodas para poder ajudar mais em casa e conseguir ir para a igreja. Durante a visita de acompanhamento, Hala disse que há alguns meses não saía de casa. O caminho até sua casa é acidentado e tem um degrau na entrada da casa. Mas ela está usando a cadeira de rodas em casa, e tem conseguido tomar conta dos netos para ajudar a filha. Ela senta de forma ereta na cadeira de rodas e a cadeira de rodas está bem cuidada. Ela já consegue fazer a transferência sozinha. Daarun Daarun tem uma lesão medular. Ele trabalha em uma oficina de conserto de rádios no mercado local. Há dois anos ele recebeu a cadeira de rodas e a almofada para alívio de pressão. Durante a visita de acompanhamento, ele disse que usa sua cadeira de rodas todos os dias para ir de casa ao trabalho e voltar. Ele não tem úlceras/feridas de pressão. Daarun já consertou dois pneus furados da sua cadeira de rodas. Durante a visita, a equipe notou que os raios estavam soltos e que faltavam dois parafusos da base do assento. A espuma de baixa densidade da almofada estava achatada. Ele consegue sentar confortavelmente na cadeira de rodas e diz que está muito satisfeito com ela. Talha Talha tem 10 anos. Ele tem uma forma leve de paralisia cerebral, mas consegue ir para a escola. Há um ano, ele recebeu uma cadeira de rodas com uma almofada para suporte postural. Durante a visita de acompanhamento, Talha disse que usa sua cadeira de rodas todos os dias para ir à escola. Seu pai empurra a cadeira, pois Talha não tem força suficiente para impulsioná-la A cadeira de rodas está em bom estado. Seu pai disse que havia consertado o pneu apenas uma vez. A equipe de atendimento do serviço de cadeira de rodas notou que Talha cresceu, e suas pernas não estão sendo apoiadas corretamente pelo assento da cadeira de rodas pois o apoio para os pés está muito alto para ele. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 27 Formulário de acompanhamento da cadeira de rodas Este formulário é para registrar informações da visita de acompanhamento 1. Informação do usuário Nome do usuário: Número: Data da adequação: Data do acompanhamento: Nome da pessoa que fez o acompanhamento: Acompanhamento foi feito na: Casa do usuário  Centro de Serviços de cadeira de rodas  Outro  2. Entrevista Anote a ação a ser tomada: Você está usando sua cadeira de rodas tanto quanto gostaria? Sim  Não  Se não, por quê? Você tem algum problema para usar a cadeira de rodas? Sim  Não  Se sim – quais são os problemas? Você tem alguma dúvida sobre o uso da cadeira de rodas? Sim  Não  Se sim – quais dúvidas? É necessário algum outro treinamento? O usuário possui alguma úlcera/ferida de pressão? Sim  Não  Se sim – Descreva (local e estágio) Como você qualificaria sua satisfação com a sua cadeira de rodas de 1 – 5? ( 1 é insatisfeito e 5 muito satisfeito) Nota: Comentário: 3. Verificação da cadeira de rodas e da almofada A cadeira de rodas está funcionando bem e é segura? Sim  Não  A almofada está em boas condições e é segura? Sim  Não  Caso tenha respondido não para alguma pergunta, qual é o problema? 4. Verificação da adequação A cadeira de rodas se ajusta corretamente ao corpo do usuário? Sim  Não  Se não, qual o problema? Teste de nível de pressão (1 = seguro, 2 = atenção, 3 = inseguro) (se o usuário corre risco de desenvolver úlcera/ferida de pressão) Esquerda: Direita: O usuário senta ereto confortavelmente quando parado, se movendo e no decorrer do dia? Sim  Não  Se não, qual o problema? 28 Formulário de acompanhamento da cadeira de rodas Este formulário é para registrar informações da visita de acompanhamento 1. Informação do usuário Nome do usuário: Número: Data da adequação: Data do acompanhamento: Nome da pessoa que fez o acompanhamento: Acompanhamento foi feito na: Casa do usuário  Centro de serviços de cadeira de rodas  Outro  2. Entrevista Anote a ação a ser tomada: Você está usando sua cadeira de rodas tanto quanto gostaria? Sim  Não  Se não, por quê? Você tem algum problema para usar a cadeira de rodas? Sim  Não  Se sim – quais são os problemas? Você tem alguma dúvida sobre o uso da cadeira de rodas? Sim  Não  Se sim – quais dúvidas? É necessário algum outro treinamento? O usuário possui alguma úlcera/ferida de pressão? Sim  Não  Se sim – Descreva (local e estágio) Como você qualificaria sua satisfação com a sua cadeira de rodas de 1 – 5? ( 1 é insatisfeito e 5 muito satisfeito) Nota: Comentário: 3. Verificação da cadeira de rodas e da almofada A cadeira de rodas está funcionando bem e é segura? Sim  Não  A almofada está em boas condições e é segura? Sim  Não  Caso tenha respondido não para alguma pergunta, qual é o problema? 4. Verificação da adequação A cadeira de rodas se ajusta corretamente ao corpo do usuário? Sim  Não  Se não, qual o problema? Teste de nível de pressão (1 = seguro, 2 = atenção, 3 = inseguro) (se o usuário corre risco de desenvolver úlcera/ferida de pressão) Esquerda: Direita: O usuário senta ereto confortavelmente quando parado, se movendo e no decorrer do dia? Sim  Não  Se não, qual o problema? CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 29 Formulário de acompanhamento da cadeira de rodas Este formulário é para registrar informações da visita de acompanhamento 1. Informação do usuário Nome do usuário: Número: Data da adequação: Data do acompanhamento: Nome da pessoa que fez o acompanhamento: Acompanhamento foi feito na: Casa do usuário  Centro de serviços de cadeira de rodas  Outro  2. Entrevista Anote a ação a ser tomada: Você está usando sua cadeira de rodas tanto quanto gostaria? Sim  Não  Se não, por quê? Você tem algum problema para usar a cadeira de rodas? Sim  Não  Se sim – quais são os problemas? Você tem alguma dúvida sobre o uso da cadeira de rodas? Sim  Não  Se sim – quais dúvidas? É necessário algum outro treinamento? O usuário possui alguma úlcera/ferida de pressão? Sim  Não  Se sim – Descreva (local e estágio) Como você qualificaria sua satisfação com a sua cadeira de rodas de 1 – 5? ( 1 é insatisfeito e 5 muito satisfeito) Nota: Comentário: 3. Verificação da cadeira de rodas e da almofada A cadeira de rodas está funcionando bem e é segura? Sim  Não  A almofada está em boas condições e é segura? Sim  Não  Caso tenha respondido não para alguma pergunta, qual é o problema? 4. Verificação da adequação A cadeira de rodas se ajusta corretamente ao corpo do usuário? Sim  Não  Se não, qual o problema? Teste de nível de pressão (1 = seguro, 2 = atenção, 3 = inseguro) (se o usuário corre risco de desenvolver úlcera/ferida de pressão) Esquerda: Direita: O usuário senta ereto confortavelmente quando parado, se movendo e no decorrer do dia? Sim  Não  Se não, qual o problema? 30 B.14: Juntando tudo Prepare uma apresentação de 10 minutos para o grupo todo. A apresentação deve incluir o seguinte. 1. Informação adquirida na avaliação: • as metas do usuário (por que ele quer uma cadeira de rodas); • suas necessidades físicas; • as suas necessidades de estilo de vida; • se já possui uma cadeira de rodas – e se essa cadeira de rodas atende suas necessidades; • presença, risco ou histórico de úlcera/ferida de pressão; • método de impulso; • postura sentada sem suporte; • resultados do exame de postura da pelve e quadril; 2. Cadeira de rodas e almofada prescritas: • tipo de cadeira de rodas • tipo de almofada • qualquer dispositivo de suporte postural descrito. 3. Adequação: • qualquer problema que foi identificado na adequação e precisava ser resolvido – e se houve, como foi resolvido. 4. Treinamento de usuários: • o que o usuário e o grupo decidiram que deveria estar no treinamento? 5. Feedback do usuário: • depois de receber a cadeira de rodas – o usuário fez algum comentário/feedback? 6. Manutenção e reparos: • depois de receber a cadeira de rodas – qual tipo de manutenção deve ser feita e com que frequência? • o que fazer quando a cadeira de rodas ou a almofada precisam de reparos? 7. Plano de acompanhamento: • o que foi planejado para o acompanhamento?

NÍVEL BÁSICO Manual de Referência para os Participantes CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Informações sobre a edição em inglês: Editores: Chapal Khasnabis e Kylie Mines Autores: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler e Rebecca Jackson Stoeckle Revisores: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Gosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif e Isabelle Urseau Ilustração: Melissa Puust Crédito das fotos: Chapal Khasnabis e Jesse Moss Créditos de vídeo: Chapal Khasnabis, Amanda McBaine, e Jesse Moss Instrutores dos cursos Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama piloto: Raju, e Elsie Taloafiri Apoio financeiro: Agência dos Estados Unidos da América para o Desenvolvimento Internacional e Agência Australiana para o Desenvolvimento Internacional Organizações parceiras: ASSERT Timor Leste, Associação para os Deficientes Físicos do Quênia (APDK), Unidade de Reabilitação Baseada na Comunidade do Ministério de Serviços Médicos e de Saúde das Ilhas Salomão, Centro de Desenvolvimento da Educação (EDC), Handicap International, Comitê Internacional da Cruz Vermelha (CICV), Sociedade Internacional para Protéticos e Ortóticos (ISPO), Associação de Pessoas com Lesão Medular do Kilimanjaro (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania e Centro de Treinamento para Tecnólogos Ortopédicos da Tanzânia (TATCOT) Publicado pela Organização Mundial da Saúde em 2012 sob o título Wheelchair Service Training Package: Basic Level © Organização Mundial da Saúde 2012 © Secretaria de Estado dos Direitos da Pessoa com Deficiência de São Paulo 2014 O Diretor Geral da Organização Mundial da Saúde concedeu os direitos de tradução e publicação da edição em Língua Portuguesa à Secretaria de Estado dos Direitos da Pessoa com Deficiência de São Paulo, a qual é a única responsável pela exatidão da edição em Língua Portuguesa. Pacote de Treinamento em Serviços para Cadeiras de Rodas Conteúdo: Manual do Instrutor, nível básico – Manual de Referência para os Participantes, nível básico – Apostila do Participante, nível básico – Pôsteres e slides, nível básico. Manual do instrutor e slides disponíveis apenas em DVD. 1. Cadeiras de rodas – padrões; 2. Pessoas com deficiência – reabilitação; 3. Materiais de ensino. Terminologia Os termos usados neste pacote de treinamento estão definidos abaixo. Cadeira de rodas apropriada Cadeira de rodas que atende às necessidades do usuário e leva em consideração as condições ambientais; oferece conforto adequado e suporte postural; é segura e durável; está disponível no país; pode ser obtida e mantida com serviços oferecidos no país por um valor econômico e acessível. Cadeira de rodas manual Cadeira de rodas impulsionado pelo próprio usuário ou empurrada por uma outra pessoa. Cadeira de rodas Equipamento que proporciona mobilidade sobre rodas e suporte para o assento de uma pessoa com dificuldade para andar ou se movimentar. Fornecimento de cadeira de rodas Abrange o projeto, a produção, o fornecimento e a prestação de serviços para cadeira de rodas. Serviços de cadeira de rodas A parte de fornecimento de cadeira de rodas que assegura a provisão de cadeiras de rodas apropriadas aos usuários. Equipe de serviços de cadeira de rodas Pessoas capacitadas no fornecimento de cadeira de rodas apropriadas. Usuário de cadeira de rodas Pessoa com dificuldade para andar ou se movimentar que requer o uso da cadeira de rodas para sua mobilidade. SU M Á R IO PrefácioSobre o Pacote de Treinamento em Serviço para Cadeira de Rodas: Nível básico A. Conceitos fundamentais A.1: Usuários de cadeiras de rodas Quais são os benefícios de uma cadeira de rodas? O que é uma “cadeira de rodas apropriada”? A Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência A.2: Serviços para cadeira de rodas A.3: Mobilidade em cadeira de rodas A.4: Sentar-se ereto A.5: Úlceras/feridas de pressão A.6: Cadeira de rodas apropriada Atender às necessidades do usuário Atendem as necessidades do ambiente do usuário Proporcionar adequação e suporte postural apropriados A.7: Almofadas A.8 Transferências B. Etapas do serviço para cadeira de rodas Etapa 1: Encaminhamento e agendamento Etapa 2: Avaliação Etapa 3: Prescrição (seleção) Etapa 4: Financiamento e aquisição Etapa 5: Preparação do produto (cadeira de rodas) Etapa 6: Adequação Etapa 7: Treinamento de usuários Etapa 8: Manutenção, reparos e acompanhamento V 1 6 7 7 8 8 9 11 14 17 22 22 27 28 30 35 39 40 42 51 53 55 63 75 77 Prefácio A cadeira de rodas é um dos dispositivos assistivos mais comumente usados para melhorar a mobilidade pessoal, o que é uma precondição para desfrutar os direitos humanos e viver com dignidade, e ajuda pessoas com deficiência a se tornarem membros mais produtivos de sua comunidade. Para muitas pessoas, uma cadeira de rodas apropriada, bem projetada e adequada pode ser o primeiro passo para a inclusão e participação na sociedade. As Regras Padrão das Nações Unidas sobre a Equalização de Oportunidades para Pessoas com Deficiência, a Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência e a resolução WHA58.23 da Assembleia Mundial da Saúde, que trata da deficiência incluindo prevenção, tratamento e reabilitação, enfatizam a importância de cadeiras de rodas e outros dispositivos assistivos. Para garantir que as pessoas com deficiência possam ter acesso a uma cadeira de rodas apropriada, principalmente em partes do mundo com poucos recursos, a OMS desenvolveu as Diretrizes para fornecimento de cadeiras de rodas manuais em locais com poucos recursos, em parceria com a Agência dos Estados Unidos para Desenvolvimento Internacional (USAID) e a Sociedade Internacional de Próteses e Órteses (ISPO). Para capacitar recursos humanos adequadamente e oferecer um bom sistema de serviços de cadeiras de rodas baseado nas diretrizes para cadeiras de rodas, a OMS desenvolveu este Pacote de Treinamento em Serviços para Cadeira de Rodas – Nível básico. Alana Officer Robert G. Horvath Coordenadora Gerente Equipe de Deficiência e Reabilitação Programas para Populações Vulneráveis Departamento de Prevenção da Centro de Excelência sobre Democracia, Violência e Lesões e Deficiência Direitos Humanos e Governança Organização Mundial da Saúde Agência dos EUA para o Desenvolvimento Internacional 2CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Sobre o Pacote de Treinamento em Serviços para Cadeira de Rodas: Nível básico Introdução Depois da publicação em 2008 das Diretrizes para fornecimento de cadeira de rodas manuais em locais com poucos recursos11, a Organização Mundial da Saúde desenvolveu o Pacote de Treinamento em Serviços para Cadeira de Rodas: Nível Básico. A cadeira de rodas é um dos dispositivos assistivos mais comumente usados para melhorar a mobilidade pessoal. Para pessoas com dificuldades para andar, uma cadeira de rodas que seja adequada para suas necessidades físicas, de estilo de vida e de ambiente é uma ferramenta essencial, permitindo-lhes desfrutar de uma grande melhora em sua saúde e seu bem-estar social e econômico. A mobilidade abre oportunidades para os usuários estudarem, trabalharem, participarem de atividades culturais e acessarem serviços como atendimento de saúde. A importância da mobilidade é refletida na Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência (UNCRPD), que defende “medidas efetivas para garantir a mobilidade pessoal com a maior independência possível para pessoas com deficiência”. A fim de garantir a mobilidade pessoal efetiva, os usuários precisam de uma cadeira de rodas que se ajuste corretamente a eles e atenda suas necessidades específicas. Isso exige uma abordagem que seja sensível às necessidades individuais. Uma maneira efetiva de atender às necessidades individuais dos usuários é o fornecimento de cadeiras de rodas por meio de serviços de cadeiras de rodas. No entanto, as estatísticas mostram que menos de 5% daqueles que precisam de uma cadeira de rodas têm de fato acesso a uma adequadamente ajustada. Além disso, as oportunidades de treinamento para que as pessoas envolvidas no serviço obtenham as habilidades necessárias para prescrever uma cadeira de rodas de maneira eficaz são limitadas. O Pacote de Treinamento em Serviços para Cadeira de Rodas: Nível Básico tem o objetivo de apoiar as pessoas que trabalham em funções clínicas e técnicas em um serviço de cadeiras de rodas (ver Diretrizes para fornecimento de cadeiras de rodas manuais em locais com poucos recursos, Tabela 4.2) no nível básico. O pacote de treinamento proporciona a teoria e prática necessárias para começar a trabalhar com usuários que sejam capazes de se sentar eretos, sem suporte postural adicional. O pacote de treinamento inclui: como avaliar necessidades individuais, ajudar na seleção e montagem da cadeira de rodas mais apropriada entre as disponíveis, treinar usuários e cuidadores sobre como usar e manter a cadeira de rodas, e fazer o acompanhamento. 1 World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings. Genebra, 2008 (http://www.who.int/disabilities/publications/technology/wheelchairguidelines/en/index.html, acessado em 15 de dezembro de 2011). 3O pacote de treinamento pode ser aplicado em 35–40 horas, embora esse período possa ser estendido ou encurtado, dependendo das necessidades específicas e recursos disponíveis em cada contexto. Incentiva-se que o exercício prático prossiga com um orientador para melhorar as competências e a capacidade de trabalho independente. A OMS espera que o Pacote de Treinamento em Serviços para Cadeira de Rodas possa ser usado como um programa curto de treinamento independente para pessoas que já trabalham na área, e que também seja incluído no currículo de programas de treinamento para pessoas que trabalham com reabilitação. Público alvo Este pacote de treinamento é para todas as pessoas ou voluntários que precisam prestar serviços de cadeira de rodas em seu local de trabalho. Isto pode incluir profissionais de saúde, reabilitação ou técnicos, agentes de saúde comunitários, agentes de reabilitação comunitários, terapeutas ocupacionais, fisioterapeutas, profissionais de próteses e órteses, fabricantes locais, técnicos e usuários de cadeiras de rodas. Objetivo O pacote de treinamento de Nível Básico foi desenvolvido para apoiar o treinamento da equipe de serviços e voluntários para fornecer uma cadeira de rodas manual e almofadas apropriadas para meninas, meninos, mulheres e homens que tenham dificuldades de mobilidade, mas possam sentar-se eretos sem suporte postural adicional. O principal objetivo do pacote de treinamento é desenvolver as habilidades e o conhecimento das pessoas envolvidas no serviço de cadeiras de rodas. O uso deste pacote de treinamento ajudará a: • aumentar o número de usuários que recebem uma cadeira de rodas que atende suas necessidades; • aumentar o número de usuários que recebem treinamento no uso e manutenção de cadeiras de rodas e como permanecer saudáveis em uma cadeira de rodas; • aumentar o número de profissionais treinados em serviços básicos para cadeira de rodas; • melhorar as competências dos profissionais de serviços para cadeiras de rodas; • aumentar a qualidade dos serviços de cadeiras de rodas; e • conseguir maior integração do serviço de cadeiras de rodas dentro dos serviços de reabilitação. Escopo O pacote de treinamento cobre: • uma visão geral das oito etapas do serviço de cadeiras de rodas descritas nas Diretrizes para fornecimento de cadeiras de rodas manuais em locais com poucos recursos da OMS (Tabela 1); 4CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO • o trabalho com usuários para avaliar suas necessidades de mobilidade e identificar a melhor solução de mobilidade possível; • o fornecimento de uma cadeira de rodas manual apropriada com uma almofada adequada; • solução de problemas para encontrar modificações simples na cadeira de rodas que possam ajudar a garantir a melhor adequação para o usuário; • reparos e manutenção da cadeira de rodas; • treinamento de usuários para fazer o melhor uso de sua cadeira de rodas; e • fabricação de uma almofada de espuma moldada. A inclusão de modificações simples na cadeira de rodas é particularmente relevante em contextos onde existem limitações na variedade e tamanhos disponíveis de cadeiras de rodas manuais. Muitas vezes é necessário fazer modificações simples para assegurar que a cadeira de rodas se ajuste corretamente. O fornecimento de triciclos não é abordado em detalhes neste pacote de treinamento, embora seu valor para usuários que precisem se locomover por longas distâncias seja reconhecido. Tabela 1. Principais etapas da prestação de serviços para cadeira de rodas Etapa 1 Encaminhamento e agendamento Etapa 2 Avaliação Etapa 3 Prescrição (seleção) Etapa 4 Financiamento e aquisição Etapa 5 Preparação do produto (cadeira de rodas) Etapa 6 Adequação Etapa 7 Treinamento de usuários Etapa 8 Manutenção, reparos e acompanhamento Conhecimentos e habilidades necessários Não é necessária experiência anterior em prestação de serviços de cadeiras de rodas. No entanto, o programa de treinamento foi desenvolvido pressupondo que os participantes tenham os seguintes conhecimentos e habilidades: • os participantes devem ser capazes de ler e escrever no idioma do programa de treinamento; • os participantes devem ter conhecimento básico das condições de saúde comuns ou deficiências físicas que podem afetar as pessoas que se beneficiam com o uso de cadeiras de rodas, incluindo paralisia cerebral, amputação de membro inferior, poliomielite (pólio), lesão na coluna vertebral e AVC/trombose cerebral. 5Quando os participantes ainda não tiverem informações sobre essas condições de saúde ou deficiências físicas, os instrutores devem incluir uma sessão adicional com essas informações. Estrutura O Pacote de Treinamento em Serviços para Cadeira de Rodas: Nível Básico é projetado para ser usado por instrutores que tenham habilidades básicas com cadeiras de rodas e possam demonstrar com segurança as competências ensinadas neste programa de treinamento. Há uma variedade de recursos pedagógicos, como: • Manual do Instrutor e ferramentas para o instrutor; • Manual de Referência para os Participantes (doravante chamado de Manual de Referência); • Apostila do Participante; • Formulários de serviços de cadeira de rodas; • Listas de verificação de serviços de cadeira de rodas; • Auxílios visuais, incluindo apresentações em PowerPoint, vídeos e pôsteres. Processo de desenvolvimento Depois do lançamento das Diretrizes para fornecimento de cadeiras de rodas manuais em locais com poucos recursos, a OMS formou um grupo de trabalho para desenvolver o Pacote de Treinamento em Serviços para Cadeira de Rodas. A primeira reunião do grupo de trabalho foi convocada pela OMS em outubro de 2008 para determinar o escopo e conteúdo do Pacote de Treinamento. Depois da circulação do documento e recebimento de feedback de mais de 20 especialistas na área sobre o conteúdo proposto para o Pacote de Treinamento, um grupo menor de colaboradores trabalhou para preparar cada pacote para testes piloto. Em 2010, o pacote de treinamento de nível básico foi testado na Índia, Ilhas Salomão e Quênia. Cada experiência piloto foi observada por membros do grupo de trabalho do Pacote de Treinamento em Serviços para Cadeira de Rodas da OMS. O feedback de instrutores, participantes e usuários que fizeram parte das sessões práticas foi incorporado nas versões finais. Além dos pilotos, o pacote de treinamento de nível básico passou por revisão de pares, obtendo valioso feedback de vários especialistas da área. Todos os autores envolvidos no desenvolvimento do pacote de treinamento preencheram uma Declaração de Interesses (DOI) e nenhum declarou algum conflito de interesse relacionado ao tema. 6CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A. Conceitos fundamentais 7A.1: Usuários de cadeira de rodas Usuários são pessoas que já têm uma cadeira de rodas ou que podem se beneficiar com o uso de uma cadeira de rodas porque sua capacidade de andar é limitada. Usuários podem ser: • crianças, adultos e idosos; homens, mulheres, meninas e meninos; • pessoas com diferentes dificuldades de mobilidade, estilos de vida, ocupações e históricos; • pessoas que vivem e trabalham em diferentes ambientes, incluindo rural, semiurbano e urbano. As necessidades de cada usuário variam. No entanto, todos eles precisam de uma cadeira de rodas apropriada. Quais são os benefícios de uma cadeira de rodas? • Mobilidade: Cadeiras de rodas ajudam as pessoas a se movimentar com a maior independência possível e fazer as coisas que querem fazer. • Saúde: Uma cadeira de rodas pode melhorar a saúde do usuário de várias maneiras. Uma cadeira de rodas bem ajustada, com uma almofada, pode reduzir problemas comuns como úlceras/feridas de pressão ou má postura. Uma cadeira de rodas que funcione bem, seja adequada e possa ser impulsionada com facilidade pode aumentar a atividade física do usuário e, assim, melhorar sua saúde. • Independência: Usuários podem ser mais independentes e ter maior controle da própria vida. • Autoestima e autoconfiança: Usuários podem adquirir mais autoconfiança e ter mais autoestima quando têm uma cadeira de rodas que se ajuste a eles e que eles possam usar bem. • Acesso à vida comunitária: Com uma cadeira de rodas, os usuários podem participar mais da vida comunitária. Por exemplo, ela possibilita que o usuário vá ao trabalho ou à escola, visite amigos, frequente locais de culto ou participe de outras atividades comunitárias. 8CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO O que é uma “cadeira de rodas apropriada”? Uma “cadeira de rodas apropriada” é aquela que: • atende às necessidades do usuário; • está de acordo com o ambiente do usuário; • é a opção correta para o usuário; • garante suporte postural (ajuda o usuário a sentar-se ereto); • pode ter manutenção e consertos no próprio local. A Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência A Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência (UNCRPD) entrou em vigor em 3 de maio de 2008. Há direitos humanos que se aplicam a todos. A UNCRPD é focada em assegurar que todos reconheçam que esses direitos também se aplicam a pessoas com deficiência. Há 50 artigos diferentes na Convenção. Um dos artigos, o artigo 20, refere-se à “mobilidade pessoal”. Mobilidade pessoal significa a capacidade de se mover como e quando a pessoa quiser. O artigo 20 diz: “os Estados devem adotar medidas efetivas para garantir a mobilidade pessoal com a maior independência possível para pessoas com deficiência”. Cadeiras de rodas e serviços de cadeiras de rodas são muito importantes para ajudar a maioria das pessoas com dificuldades de mobilidade a obter mobilidade pessoal. Os profissionais de serviços de cadeiras de rodas podem ajudar a implementar o artigo 20 da UNCRPD: • fornecendo uma cadeira de rodas apropriada para usuários que visitem seu serviço; • ajudando os usuários a aprender como transferir-se da cadeira de rodas sozinhos; • ajudando os usuários a aprender como impulsionar a cadeira sozinhos; • incentivando os familiares para que apoiem o usuário a ser o mais independente possível. Há outros direitos humanos que pessoas com dificuldades de mobilidade podem desfrutar mais facilmente se tiverem uma cadeira de rodas apropriada: • viver independentemente e ser incluído na comunidade (artigo 19); • direito à educação (artigo 24); • direito a desfrutar o melhor padrão possível de saúde (artigo 25); • direito a trabalho e emprego (artigo 27); • direito de participar da vida política e pública (artigo 29); • direito de participar da vida cultural, recreação, lazer e esporte (artigo 30). 9A UNCRPD (artigo 20 – Mobilidade pessoal): Os Estados devem adotar medidas efetivas para garantir a mobilidade pessoal com a maior independência possível para pessoas com deficiência: a) Facilitando a mobilidade pessoal de pessoas com deficiência como e quando elas preferirem e a um custo acessível; b) Facilitando o acesso de pessoas com deficiência a aparelhos e dispositivos de mobilidade, tecnologias assistivas e formas de assistência direta ou por intermediários de qualidade, o que inclui tornar esses recursos disponíveis a um custo acessível; c) Proporcionando treinamento em técnicas de mobilidade para pessoas com deficiência e profissionais que trabalham com pessoas com deficiência; d) Incentivando fabricantes de dispositivos de mobilidade e tecnologias assistivas a levar em conta todos os aspectos da mobilidade para pessoas com deficiência. O que significa:2 Os países devem garantir que pessoas com deficiência possam se movimentar tão independentemente quanto possível. Devem: • ajudar as pessoas a se locomover. • ajudar as pessoas a obter uma cadeira de rodas de qualidade a um custo acessível. • Dar treinamento sobre como se locomover. • Fazer as instituições/empresas que fabricam dispositivos de auxílio pensarem nas diferentes necessidades de pessoas com deficiência. A.2: Serviços para cadeira de rodas Os serviços de cadeira de rodas trabalham com os usuários para encontrar a cadeira de rodas mais adequada entre as disponíveis para eles. As Diretrizes para Cadeiras de Rodas da OMS descrevem oito etapas que os profissionais devem seguir para fornecer uma cadeira de rodas. Essas etapas são resumidas abaixo. Cada etapa é comentada com mais detalhes na seção B deste manual. 2 Acordo internacional sobre os direitos de pessoas com deficiência (versão para leitura fácil da CRPD), preparado para o Departamento de Trabalho e Aposentadorias do Reino Unido pelo ”easy read” service @ Inspired Services.IS164/07. Newmarket, Inspired Services, 2007 http://odi.dwp.gov.uk/docs/wor/uncon/un- agree.pdf (acessado em 15 de dezembro de 2011). 10 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Etapa Resumo 1. Encami- nhamento e agendamento O modo de encaminhamento de usuários varia. Eles podem chegar ao serviço por conta própria ou ser encaminhados por profissionais ou voluntários que trabalham nas redes de saúde e reabilitação governamentais ou não governamentais da região, distrito ou comunidade. Alguns serviços de cadeiras de rodas podem ter que identificar usuários potenciais ativamente se ainda não estiverem recebendo nenhum serviço social ou de saúde ou participando de atividades em escolas, trabalho ou comunidade. 2. Avaliação Cada usuário precisa de uma avaliação individual que leve em conta o estilo de vida, trabalho, ambiente e condição física. 3. Prescrição (seleção) Usando as informações da avaliação, é feita uma prescrição de cadeira de rodas junto com o usuário, familiares ou cuidadores. A prescrição (seleção) detalha o tipo e tamanho da cadeira de rodas escolhida, características especiais e modificações. Também descreve o treinamento que o usuário precisa para usar e manter a cadeira de rodas adequadamente. 4. Finan- ciamento e aquisição Uma fonte de financiamento é identificada e a cadeira de rodas é requisitada do estoque mantido pelo serviço ou pelo fornecedor. 5. Preparação do produto (cadeira de rodas) O pessoal capacitado prepara a cadeira de rodas para a adequação inicial. Dependendo do produto e instalações disponíveis, isso pode incluir montagem e possíveis modificações de produtos fornecidos por fabricantes na oficina do serviço. continua... 11 Continuação Etapa Resumo 6. Adequação O usuário experimenta a cadeira de rodas. Ajustes finais são feitos para garantir que a cadeira de rodas esteja adequadamente montada e preparada. Se forem necessárias modificações ou componentes de suporte postural, pode ser preciso fazer novos ajustes. 7. Treina- mento de usuário O usuário e os cuidadores são treinados sobre como usar e manter a cadeira de rodas com segurança e eficácia. 8. Manuten- ção, reparos e acompanha- mento O serviço de cadeira de rodas oferece manutenção e consertos para problemas técnicos que não possam ser resolvidos na comunidade. É apropriado realizar as atividades de acompanhamento na comunidade tanto quanto possível. Agendamentos de acompanhamento são uma oportunidade para verificar a adequação da cadeira de rodas e dar mais treinamento e suporte. O momento para isso depende das necessidades do usuário e de outros serviços que estejam disponíveis para ele. Se for verificado que a cadeira de rodas não é mais apropriada, uma nova cadeira precisa ser fornecida, começando da etapa um. Fonte: Organização Mundial de Saúde. Diretrizes para fornecimento de cadeira de rodas manual em locais com poucos recursos, Tabela 3.2. Genebra, 2008, p. 76. A.3: Mobilidade em cadeira de rodas Muitos usuários vivem e trabalham em lugares em que têm dificuldade para se locomover, por exemplo, áreas em que o chão é irregular, arenoso ou lamacento, ou onde há degraus, guias ou pequenos espaços apertados. O treinamento em técnicas de mobilidade com a cadeira de rodas pode ajudar os usuários a lidar com alguns desses obstáculos, de forma independente ou com assistência. Várias técnicas de mobilidade em cadeira de rodas são descritas abaixo. 12 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Técnicas de mobilidade em cadeira de rodas: Im p u ls io n ar • Impulsionar corretamente requer menos esforço. • Impulsionar da posição "10 horas" para a posição "2 horas". • Use movimentos longos e suaves para impulsionar. G ir ar • Segure um aro de impulsão na frente e o outro atrás. • Puxe a mão à frente pra trás e a mão atrás para frente ao mesmo tempo. S u b ir r am p as • Incline-se para frente – isso ajuda a evitar que a cadeira de rodas caia. • Quando estiver treinando, tenha um assistente atrás por segurança. • Para parar ou descansar – pare a cadeira de rodas de lado. D e sc e r ra m p as • Incline-se para trás. • Deixe o aro de impulsão deslizar lentamente entre as mãos. • Usuários experientes que consigam empinar a cadeira (isto é, equilibrá-la apenas sobre as rodas traseiras) podem descer uma rampa com as rodas traseiras. Isso é muito eficiente. S u b ir d e g ra u s co m aj u d a • Suba de costas. • Incline a cadeira de rodas sobre as rodas traseiras, posicionadas junto ao primeiro degrau. • O assistente puxa para trás e para cima – rolando a cadeira de rodas para cima. • O usuário pode ajudar puxando o aro de impulsão para trás. • Um segundo assistente pode ajudar segurando a cadeira de rodas pela frente (não pelo apoio para os pés). 13 D e sc e r d e g ra u s co m aj u d a • Desça de frente. • Incline a cadeira de rodas sobre as rodas traseiras. • O assistente faz as rodas traseiras descerem devagar, um degrau por vez. • O usuário pode ajudar controlando a cadeira de rodas com os aros de impulsão. • Um segundo assistente pode ajudar firmando a cadeira pela frente, segurando na estrutura da cadeira (não no apoio dos pés). E m p in ar p ar ci al m e n te • Ser capaz de empinar a cadeira parcialmente é muito útil para o usuário. • O usuário pode levantar as rodas da frente para passar por guias baixas, pequenas pedras e elevações no terreno. • Role a cadeira de rodas para trás até que as mãos estejam na posição de "10 horas". Depois empurre rapidamente para frente. • As rodas dianteiras devem levantar. • Com prática, é possível levantar as rodas dianteiras na hora certa para superar obstáculos pequenos. • Sempre se assegure de que haja um assistente de pé atrás do usuário quando ele começar a praticar esta técnica. Como treinar técnicas de mobilidade em cadeira de rodas com segurança • Não suba no apoio para os pés quando sentar-se ou levantar-se da cadeira de rodas. • Cuidado para não machucar os dedos nos raios e freios das rodas. • Ao aprender como subir rampas, ou empinar parcialmente a cadeira de rodas, SEMPRE tenha um assistente atrás da cadeira. • Não ajude um usuário a subir e descer escadas a não ser que esteja muito seguro de que pode controlar a cadeira de rodas com segurança; Se não tiver certeza, procure ajuda. 14 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.4: Sentar-se ereto Em sua maioria, os usuários ficam sentados durante muitas horas. Isso significa que sua cadeira de rodas não é apenas um auxílio para a mobilidade. Ela também ajuda a mantê-los na posição ereta com conforto. Sentar-se ereto/postura sentada neutra O que é postura? Postura é o modo como as partes do corpo de uma pessoa se posicionam. Sempre que possível, uma cadeira de rodas bem ajustada deve proporcionar suporte aos usuários para que se sentem com uma postura ereta. Às vezes, o “sentar-se ereto” é descrito como postura sentada neutra. Por que é importante sentar-se ereto? Sentar-se ereto ajuda os usuários de muitas maneiras. Sentar-se ereto é bom para: • Saúde: uma postura ereta ajuda a digestão e a respiração; • Estabilidade: uma postura ereta é mais estável; • Distribuição do peso: quando se senta com postura ereta, o peso do corpo é proporcionalmente distribuído – isso ajuda a reduzir o risco de úceras/feridas; • Conforto: quando o peso do corpo é distribuído proporcionalmente, a posição é mais confortável para o usuário; • Prevenção de problemas posturais: sentar-se ereto ajudará a reduzir a chance de desenvolver deformidades da coluna vertebral no futuro; • Autoestima e autoconfiança: sentar-se ereto pode ajudar os usuários a se sentirem melhor quanto a si mesmos. Embora sentar-se ereto tenha muitos benefícios, sem suporte postural pode ser difícil ficar nessa postura o dia inteiro. É por isso que pessoas sem deficiência usam diferentes posturas ao longo do dia. Para um usuário que fica sentado na cadeira o dia todo, a cadeira de rodas precisa proporcionar suporte suficiente para ajudá-lo a sentar-se ereto com conforto. 15 Como saber se uma pessoa está sentada ereta Olhe de lado e verifique: 9 Pelve ereta; 9 Tronco ereto, costas seguindo as três curvas naturais; 9 Quadris flexionados em torno de 90 graus; 9 Joelhos e tornozelos flexionados em torno de 90 graus; 9 Calcanhares diretamente sob os joelhos ou pouco para frente ou para trás; 9 Pés totalmente apoiados no chão ou em apoios para os pés. Olhe de frente e verifique: 9 Pelve nivelada; 9 Ombros nivelados, relaxados e braços livres para se moverem; 9 Pernas ligeiramente afastadas (em abdução); 9 Cabeça ereta e equilibrada sobre o corpo. Como a pelve afeta o modo de nos sentarmos A pelve é a base para sentar-se ereto. Para ser forte e estável, um prédio precisa de fundações sólidas. Da mesma maneira, para sermos estáveis ao sentar, a pelve precisa ser forte e estável. Quando o usuário está sentado ereto, a pelve está: • nivelada (vista de frente); e • ereta ou ligeiramente inclinada para a frente (vista de lado). Qualquer alteração na pelve causará uma alteração nas outras partes do corpo. Se a pelve não estiver ereta, é difícil sentar-se ereto. Vista frontal da Pelve Vista lateral da Pelve 16 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A pelve se move de diferentes modos. A tabela abaixo mostra quatro movimentos pélvicos e como o corpo muda quando cada movimento é feito. Movimento Ilustração Mudanças no corpo Girar para frente: (inclinação da pelve para frente). Vista lateral da pelve • O corpo se endireita com os ombros indo para trás. • Há um aumento na curvatura da coluna sobre a pelve. Girar para trás: (inclinação da pelve para trás). Vista lateral da pelve • O corpo fica arredondado, com os ombros para frente. Inclinar para o lado: (inclinação lateral). Vista de trás da pelve • O corpo se inclina para o lado. Rotação. Vista de cima • O resto do corpo também sofre rotação. 17 A.5: Úlceras/feridas de pressão Uma úlcera/ferida de pressão, é uma área machucada de pele e de tecidos profundos. Uma úlcera/ferida pode se desenvolver em poucas horas, mas os resultados podem durar muitos meses e até causar a morte. O que causa úlceras/feridas de pressão? As três causas principais de úlceras/feridas são as seguintes. Pressão: Úlceras/feridas de pressão podem ser causadas por pressão na pele por ficar sentado ou deitado na mesma posição por muito tempo sem se mover. Usuários de cadeira de rodas estão particularmente em risco, porque às vezes passam todos os dias sentados em suas cadeiras de rodas por um longo tempo. Se a pressão não for aliviada, uma úlcera pode se desenvolver rapidamente. Fricção/Atrito: Fricção é o roçar constante da pele. Por exemplo, um braço roçando a roda/apoio para os braços enquanto a cadeira de rodas é movida pode causar uma úlcera/ferida Cisalhamento: Cisalhamento é quando a pele permanece imóvel e é estirada ou pinçada com o movimento de músculos ou ossos. Por exemplo, quando um usuário senta-se “caído” na cadeira de rodas, a pele pode ser danificada por cisalhamento pelo osso do ísquio quando a pelve gira para trás, ou pelos ossos das costas comprimindo a pele contra o encosto da cadeira. Fatores de risco para úlceras/feridas Além das três principais causas de úlceras/feridas de pressão, há várias coisas que aumentam a probabilidade de alguém ter úlceras/feridas. Todas elas são chamadas de fatores de risco para úlceras/feridas. Os fatores de risco para úlceras/feridas incluem os seguintes. 18 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO • A pessoa não pode sentir (sensibilidade reduzida): Qualquer pessoa que não possa sentir ou que tenha pouca sensibilidade nas nádegas (como acontece com a maioria dos paraplégicos ou tetraplégicos), sob o osso do ísquio ou pernas corre risco de desenvolver uma úlcera/ferida. • A pessoa não pode se mover: Quando uma pessoa não pode se mover, ela não pode aliviar a pressão. • Umidade de suor, água ou incontinência urinária: A umidade deixa a pele mais fina e mais sujeita a lesões. Se o usuário não puder controlar a função da bexiga ou dos intestinos, urina e fezes podem queimar e lesionar a pele. • Má postura: Não sentar-se ereto pode produzir um aumento da pressão sobre uma única área. • Úlcera/ferida prévia ou atual. • Dieta inadequada e não consumir água suficiente: Uma boa dieta, incluindo beber água suficiente, é importante para garantir que o sangue tenha fluidos e nutrientes para manter a pele saudável e curar feridas. • Envelhecimento: Pessoas idosas com frequência têm pele fina e frágil que pode ser facilmente lesionada. • Peso (acima ou abaixo do peso): Pessoas com excesso de peso podem ter um fluxo sanguíneo ruim na pele, que pode, então, ficar mais propensa a lesões e com mais dificuldade de cicatrização. Usuários abaixo do peso ideal estão em risco de desenvolver úlceras/feridas porque seus ossos não estão bem protegidos. A pele sobre ossos protuberantes pode se danificar facilmente. Áreas comumente sensíveis à pressão: Os quatro estágios de uma úlcera/ferida3 O que fazer 1 Uma marca vermelha ou escura na pele. A vermelhidão ou alteração de cor não desaparece dentro de 30 minutos após a remoção da pressão. • Remover a pressão da área imediatamente. • Manter sem pressão até a pele estar totalmente cicatrizada. Isso pode significar permanecer na cama. • Identificar a causa e tratá-la. • Ensinar ao usuário como úlceras/feridas são formadas e como evitá-las no futuro. continua... 3 Spinal Injury Network. Pressure sore stages (http://www.spinal-injury.net/pressure-sore-stages-sci.htm, acessado em 13 de dezembro de 2011). Vista lateral Vista traseira 19 Continuação Os quatro estágios de uma úlcera/ferida3 O que fazer 2 Uma ferida superficial. A camada superior da pele pode começar a descamar ou formar bolha. Seguir as ações para o estágio 1. Encaminhar a um profissional de saúde experiente para tratamento da úlcera/ferida. Úlceras/feridas abertas precisarão de limpeza, curativo e monitoração contínua para garantir que estejam cicatrizando e não infeccionem. Feridas em estágio 4 podem precisar de cirurgia. 3 Uma ferida profunda. Toda a camada de pele é perdida. 4 Uma ferida muito profunda, se estendendo até o músculo e talvez até o osso. Como úlceras/feridas podem ser evitadas? Usar uma almofada para alívio de pressão: Uma almofada para alívio de pressão ajudará a reduzir a pressão. Qualquer pessoa em risco de desenvolver úlceras/feridas deve ter uma almofada para alívio de pressão. Sentar-se ereto: Sentar-se ereto ajuda a distribuir o peso proporcionalmente. Isso reduz a pressão sobre as partes com ossos proeminentes e ajuda a reduzir úlceras/feridas causadas por pressão. Sentar-se ereto também ajuda a evitar úlceras/feridas causadas por cisalhamento. A equipe de serviço de cadeiras de rodas pode ajudar o usuário a sentar-se ereto garantindo que a cadeira se ajuste corretamente e explicando por que sentar-se ereto é importante. Usar técnicas para alívio da pressão: Aliviar regularmente a pressão pode ser eficaz para evitar úlceras/feridas. Ver abaixo mais informações sobre como aliviar a pressão. 20 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Alimentar-se adequadamente e beber boa quantidade de água: Uma dieta balanceada, com verduras frescas, frutas e carne pode ajudar a evitar úlceras/feridas. Beber bastante água ajuda a manter a pele saudável e evitar úlceras/feridas. Se estiver em dúvida quanto à dieta de um usuário, considere encaminhá-lo a um profissional que possa ajudar. Evitar fricção: Certifique-se de que a cadeira de rodas está corretamente ajustada e não possui arestas pontiagudas. Ensine usuários que não tenham sensibilidade a verificar se nenhuma parte de seu corpo sofre atrito com a cadeira de rodas. Ensine os usuários a ter cuidado ao transferir-se da cadeira de rodas. Evitar umidade: Usuários precisam saber que roupas molhadas ou sujas devem ser trocadas logo e que não devem usar uma almofada molhada. Um programa de controle da bexiga e intestinos pode ajudar a reduzir problemas com umidade. Encaminhe usuários que sofram de incontinência a um serviço que possa ajudá-los. Verificar a pele todos os dias: Úlceras/feridas podem se desenvolver rapidamente. É importante identificá-las logo e tomar as medidas necessárias. Incentive usuários em risco a verificarem a própria pele diariamente. Eles podem fazer isso com um espelho, ou pedir ajuda a um familiar. Se virem uma área vermelha ou escura na pele (estágio 1 de úlceras/feridas), devem tomar todas as medidas necessárias imediatamente para aliviar a pressão nesse local. 21 Quando deitado ou sentado, mudar de posição regularmente: Mudar de posição regularmente ajuda a aliviar a pressão. Por exemplo, mudar de sentado para deitado. Isso é particularmente importante para pessoas com vários fatores de risco para úlceras/feridas ou que tenham se curado recentemente de úlceras/feridas. Pessoas que não possam mudar sozinhas de posição estão em risco. Técnicas para alívio da pressão Usuários podem aliviar a pressão sob o osso do ísquio na cadeira de rodas. O modo de fazer isso varia dependendo da força e do equilíbrio que eles tiverem. A equipe de serviços de cadeiras de rodas deve ensinar a todos os usuários em risco de desenvolver úlceras/feridas pelo menos um modo de aliviar a pressão. Inclinar-se para frente: Um método adequado para a maioria dos usuários. Independente: para pessoas com bom equilíbrio e força. Com assistência: Para pessoas com pouco equilíbrio e força. Inclinar-se de um lado para outro: Método adequado para usuários com força e equilíbrio limitados. Alguns usuários podem prender a mão sob a manopla para apoio. 22 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.6: Cadeira de rodas apropriada Partes de uma cadeira de rodas Encosto Manopla Roda traseira Trilho do assento Freio Suporte do apoio para os pés Aro de impulsão Roda dianteira Apoio para os braços Almofada Assento Faixa de paturrilha Apoio para os pés Definição de uma “cadeira de rodas apropriada” Consulte a sessão A.1 Usuários de cadeira de rodas. Atender às necessidades do usuário Uma cadeira de rodas apropriada deve permitir que o usuário faça com mais facilidade o que precisa fazer. Os usuários precisam ser capazes de transferir-se da cadeira de rodas, impulsionar a cadeira de rodas, dobrar a cadeira para transporte e armazenagem e realizar suas atividades cotidianas. O tipo certo de cadeira de rodas pode facilitar todas essas coisas. Ver os exemplos abaixo. 23 Transferências Sentar-se e levantar-se da cadeira de rodas Os usuários transferem-se da cadeira de rodas de diferentes maneiras, dependendo de sua capacidade física. Diferentes características de cadeiras de rodas podem facilitar essas transferências. Três características que facilitam transferências são: apoios para os braços, apoios para os pés e freios. Com apoios para os braços removíveis, ou que sigam o contorno das rodas traseiras, é mais fácil transferir-se da cadeira de rodas pela lateral. Pessoas que ficam em pé para transferir-se da cadeira de rodas podem precisar dos apoios para os braços para ajudá- las a se levantar. Apoios para os pés que possam ser afastados são úteis para pessoas que conseguem se levantar para se transferir da cadeira de rodas. Pessoas que queiram se transferir para o chão podem preferir cadeiras de rodas com apoios para os pés removíveis. Freios são importantes para todos os usuários. Eles são essenciais para manter a cadeira de rodas parada enquanto a pessoa se transfere da cadeira. Impulsionando a cadeira de rodas Os usuários impulsionam sua cadeira de rodas de diferentes maneiras. Muitos usuários impulsionam a cadeira de rodas com os braços. Alguns usuários impulsionam com os pés, ou com um braço e um pé. Alguns usuários precisam que alguém empurre a cadeira de rodas para eles em algumas ocasiões ou todo o tempo. Impulsionar a cadeira de rodas com as mãos é mais fácil quando os apoios para os braços e o encosto são da altura certa. 24 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Encosto alto demais. O usuário não pode mover os braços e ombros com conforto para impulsionar a cadeira. Apoios para os braços altos demais. O usuário não pode alcançar as rodas com conforto para impulsionar a cadeira. Quando o encosto é mais baixo, o usuário tem liberdade de movimento dos ombros para impulsionar. Para um usuário que consegue sentar-se ereto e que tem bom equilíbrio, esta é uma boa altura do encosto. Impulsionar a cadeira de rodas é mais fácil quando o usuário consegue alcançar os aros de impulsão confortavelmente. A roda traseira deve ser posicionada de modo que, quando o usuário segurar o alto do aro de impulsão, seu cotovelo esteja dobrado em 90 graus. Esta é uma boa posição de impulsão. Se a roda estiver mais para trás, é mais cansativo para o usuário impulsioná-la. Algumas cadeiras de rodas permitem ajustar a posição da roda traseira. A posição da roda traseira afeta a facilidade para empinar a cadeira de rodas. Empinar a cadeira é útil para andar em solo irregular, subir e descer guias ou descer rampas. Se as rodas traseiras forem movidas para frente, fica mais fácil empinar a cadeira de rodas. Se as rodas traseiras forem movidas para trás, elas ficam mais estáveis, mas é mais difícil impulsionar ou empinar a cadeira de rodas. 25 Impulsionar a cadeira de rodas com os pés é mais fácil se o usuário tiver força suficiente em uma perna e puder sentar com a pelve apoiada no encosto da cadeira e os pés totalmente apoiados no chão. Para usuários que impulsionam a cadeira com os pés, a altura do assento até o chão (incluindo a almofada) é muito importante. Apoios para os pés que possam ser afastados também são essenciais. Alguns usuários que impulsionam com os pés podem gostar de ter uma mesa ou apoio para os braços para poderem se inclinar para frente enquanto impulsionam a cadeira. Uma cadeira de rodas pesada exige mais esforço para ser impulsionada, seja com as mãos, pés ou por um assistente. Mas se a cadeira de rodas for bem projetada e bem equilibrada, o peso pode não ser tão problemático. O peso da cadeira de rodas é particularmente importante para crianças. Se a cadeira for pesada, a criança pode ter dificuldade para controlá-la. Dobrar a cadeira de rodas Para transportar ou guardar a cadeira de rodas, ela precisa ser dobrada. Cadeiras de rodas dobram-se de duas maneiras principais. Cadeiras de rodas com estrutura dobrável dobram-se juntando os dois lados. Às vezes é possível remover as rodas também. Cadeiras de rodas dobráveis podem ser úteis para usuários que precisem se “esgueirar” por portas estreitas. Para transporte, algumas pessoas preferem uma cadeira de rodas dobrável. Por exemplo, ela pode caber melhor no corredor de um ônibus. Uma desvantagem de algumas cadeiras dobráveis é que o mecanismo para dobrar pode se desgastar, tornando a cadeira de rodas instável. Nessa situação, fica mais difícil impulsioná-la. 26 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Algumas cadeiras de rodas de estrutura rígida também se dobram. Só que, em vez de os dois lados se unirem, o encosto dobra para baixo e as rodas traseiras saem. Uma vantagem da estrutura rígida é que a cadeira de rodas pode ser mais durável, já que há menos partes móveis. Realizar atividades Há várias características de uma cadeira de rodas que afetam a facilidade com que o usuário pode realizar suas atividades cotidianas. Por exemplo, as características que ajudam um usuário a impulsionar a cadeira (descritas acima) determinarão a facilidade com que ele pode participar de atividades. Estes são mais alguns exemplos. Comprimento da estrutura da cadeira de rodas: O comprimento total da cadeira de rodas pode afetar a facilidade para usá-la em espaços pequenos. Para alguém que passe muito tempo em lugares fechados, uma cadeira de rodas de comprimento menor pode ser a melhor escolha. O comprimento da estrutura é medido do ponto mais traseiro até o ponto mais dianteiro da cadeira de rodas. Apoios para os braços: Apoios para os braços altos podem criar dificuldade para o usuário se aproximar de mesas. Lembre-se: uma cadeira de rodas apropriada ajuda a atender às necessidades do usuário. Isso inclui tornar mais fácil fazer as coisas que ele precisa ou quer fazer. Comprimento da estrutura 27 Atender as necessidades do ambiente do usuário Diferentes tipos de cadeiras de rodas são adequados para ambientes diferentes. As principais características que afetam o funcionamento de uma cadeira de rodas em vários ambientes são: • distância entre as rodas traseiras e dianteiras (distância entre os eixos); • tamanho e largura das rodas. Distância entre as rodas traseiras e dianteiras (distância entre os eixos). A distância entre as rodas dianteiras e traseiras é importante. Quando as rodas estão bem afastadas, fala-se em “distância longa entre os eixos”. Quando elas estão próximas, fala-se em “distância curta entre os eixos”. Cadeiras de rodas com distância longa entre os eixos são mais estáveis e têm menor risco de cair para frente. Podem ser uma boa escolha para uma pessoa que passará a maior parte do tempo ao ar livre, movendo-se por superfícies irregulares ou acidentadas. Há cadeiras de rodas com distância longa entre os eixos com três rodas e com quatro rodas. D istância entre os eixos Cadeiras de três rodas com distância longa entre os eixos costumam ser muito estáveis e adequadas para terrenos irregulares. D istância entre os eixos Cadeiras de quatro rodas com distância longa entre os eixos têm as rodas dianteiras sob o apoio para os pés e não atrás dele. Isso dá à cadeira de rodas uma distância maior entre os eixos. Cadeiras de rodas com distância menor entre os eixos são mais adequadas para uso em lugares onde o chão é plano ou o espaço é confinado – ambientes internos, por exemplo. Cadeiras de rodas com distância curta entre os eixos têm maior risco de cair para frente em descidas ou se as rodas dianteiras baterem em algum obstáculo. D istância entre os eixos 28 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Este é um exemplo de uma cadeira de rodas de estilo ortopédico com distância curta entre os eixos. Não seria fácil impulsionar esta cadeira em terreno acidentado. Usuários com boas habilidades de mobilidade podem usar uma cadeira de rodas de distância curta entre os eixos em ambientes externos, equilibrando-se nas rodas traseiras em declives ou terrenos acidentados. Tamanho e largura das rodas Quanto maior a roda, mais fácil é se mover em terrenos irregulares. Rodas traseiras largas e rodas dianteiras grandes e largas ajudam a evitar que a cadeira de rodas atole em terreno arenoso ou lamacento. Lembre-se: uma cadeira de rodas apropriada deve ser adequada para o ambiente do usuário, ou seja, a área em que ele passa a maior parte do tempo. Proporcionar adequação e suporte postural apropriados O tamanho dos usuários varia. A cadeira de rodas deve ajustar-se corretamente ao usuário para proporcionar adequação e suporte apropriados. Felizmente, muitas cadeiras de rodas têm tamanhos variados, ou ajustes de tamanho. É mais fácil ajustar a cadeira ao usuário desse modo do que se houvesse um único tamanho disponível. Os componentes ou características de cadeiras de rodas a seguir afetam sua adequação e o grau em que elas ajudam o usuário a sentar-se ereto. 29 Assentos Assentos: Os assentos de cadeira de rodas podem ser rígidos ou flexíveis. A figura à esquerda mostra um assento rígido. Os assentos rígidos podem ser feitos de madeira ou plástico e precisam sempre ter uma almofada. Assentos flexíveis costumam ser de lona. Assentos flexíveis são feitos de tecido preso aos dois lados da estrutura. Os assentos flexíveis de má qualidade podem às vezes ceder e não proporcionar bom suporte. O homem na figura à esquerda está sentado em uma cadeira de rodas com assento flexível que ficou frouxo e não lhe dá suporte. Isso faz com que seja difícil ele se sentar ereto. Encostos: Os encostos podem ser rígidos ou flexíveis. Os encostos rígidos devem ter algum revestimento/acolchoamento. As cadeiras de rodas têm diferentes alturas de encostos. Algumas têm alturas de encosto ajustáveis. A altura correta do encosto deve ser selecionada para cada usuário. Apoio para os braços: Os apoios para os braços também podem dar algum suporte ao usuário. Alguns apoios para os braços têm altura ajustável. Se não tiverem, podem às vezes ser modificados para proporcionar melhor suporte a um usuário que precise disso. Almofadas: A almofada proporciona conforto, ajuda a aliviar a pressão e também dá suporte e ajuda a impedir que o usuário escorregue. Apoio para os pés: Os apoios para os pés ajudam a dar suporte ao usuário. É muito importante que os apoios para os pés sejam ajustados corretamente. Por essa razão, sua altura geralmente é ajustável. Alguns apoios para os pés também permitem ajuste por ângulo e distância da cadeira de rodas. Lembre-se: Uma cadeira de rodas apropriada proporciona adequação e suporte apropriados ao usuário. Apoio para os pés Encosto Apoio para os braços Almofada 30 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.7: Almofadas Para que servem as almofadas? A almofada é uma parte muito importante de toda cadeira de rodas. Almofadas proporcionam: • conforto; • suporte postural (ajudam as pessoas a se sentarem mais eretas); • alívio de pressão. Todos os usuários de cadeira de rodas devem estar confortáveis em sua cadeira de rodas e uma boa almofada ajuda a se sentarem eretos com facilidade e conforto. É por isso que toda cadeira de rodas precisa ter uma almofada. Não é necessário que todos os usuários tenham uma almofada para alívio da pressão. Diferentes tipos de almofadas Almofadas podem ser descritas de várias maneiras, como: • o material de que são feitas (por exemplo, espuma, fibra); • o material de seu enchimento (por exemplo, ar, líquido ou gel); • sua função principal (por exemplo, alívio da pressão, conforto, suporte postural); • sua forma (por exemplo, plana ou moldada); • como elas são feitas (por exemplo, almofadas de espuma podem ser “esculpida” em uma só peça de espuma ou “em camadas” – feitas de várias camadas de espuma). A almofada mais comum é a de espuma. Almofadas de espuma também costumam ser mais baratas. São fáceis de fazer em locais onde há espuma disponível, e são fáceis de modificar para atender às necessidades individuais do usuário. Quem precisa de uma almofada? Todo usuário de cadeira de rodas deve ter uma almofada. Usuários em risco de desenvolver úlceras/feridas devem usar uma almofada para alívio da pressão. 31 Almofadas para alívio da pressão Há diferentes tipos de almofadas pra alívio da pressão, entre eles: • almofadas para alívio da pressão de espuma moldada; • almofadas com enchimento de ar/líquido/gel. Almofadas de espuma para alívio da pressão As principais características de uma almofada para alívio da pressão de espuma são as seguintes: Base firme e estável: A base de uma almofada para alívio da pressão deve ser firme. Isso garantirá que ela proporcione bom suporte para o usuário e não se mova quando o usuário se mover. Camada superior: Sobre a camada de base deve haver uma “camada de conforto”. Esta é uma camada (ou mais de uma camada) de espuma mais macia. A camada superior deve ser macia o suficiente para permitir que o osso do ísquio se afunde nela, mas não tão macia a ponto de que os ossos possam alcançar o fundo e se apoiar na base sólida ou no assento da cadeira de rodas. Almofadas para alívio da pressão ajudam a reduzir a pressão: • distribuindo o peso do usuário o mais igualmente possível pela superfície do assento; • reduzindo a pressão sob áreas de alto risco de pressão (osso do ísquio, ossos do quadril, cóccix); • reduzindo o cisalhamento por ajudar o usuário a sentar-se ereto. Formas em uma almofada para alívio da pressão Almofadas para alívio da pressão variam. As formas que você pode ver em uma almofada para alívio da pressão incluem: • uma caixa de acomodação sob o osso do ísquio para reduzir a pressão; • apoio sob os ossos do quadril para ajudar a distribuir o peso; • uma plataforma na frente do osso do ísquio para manter a pelve mais ereta e evitar deslizamento para a frente; • entalhes ou calhas para as pernas. 32 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Almofadas para alívio da pressão com enchimento de ar/líquido/gel • Almofadas de flutuação incluem as de ar e as de bolsas de líquido ou gel. • Almofadas de gel devem ter uma base de espuma firme muito semelhante à da almofada de espuma moldada. • Sobre a camada de base, vem a bolsa de gel/líquido. • A bolsa de gel ajusta-se automaticamente à forma do corpo do usuário. Isso ajuda a distribuir o peso do usuário adequadamente e reduz a pressão sob as áreas de proeminência óssea. Que almofada usar? Há vantagens e desvantagens tanto em almofadas de espuma moldada como em almofadas de ar/líquido/gel. Vantagens Desvantagens Almofada de espuma moldada Pode ser feita localmente (onde houver espuma de alta qualidade). Pode ser modificada localmente para se adequar a diferentes necessidades. Não está sujeita a “colapso súbito” (um furo em almofadas de ar/líquido/gel pode causar vazamento do material e fazer com que a almofada não alivie mais a pressão, sofrendo um “colapso súbito”). A camada superior de uma almofada em camadas pode ser substituída com facilidade e com baixo custo (ao invés de trocar a almofada inteira). A espuma se comprime (fica mais fina e mais firme) com o tempo. Por essa razão, almofadas de espuma devem ser examinadas regularmente e substituídas a cada 1-2 anos. Pode demorar a secar (um problema para pessoas com incontinência urinária). A espuma é isolante e pode causar um aumento na temperatura da pele. Almofada de ar/ líquido/gel A pressão é distribuída igualmente pela superfície do assento. A bolsa de gel adapta-se automaticamente ao corpo quando o usuário se move ou muda de posição. Almofadas de ar/líquido/gel costumam ser mais caras e menos prontamente disponíveis do que almofadas de espuma. Alguns usuários acham que almofadas de ar/líquido/gel dão sensação de instabilidade. Sujeita a “colapso súbito”. Em qualquer contexto em que um usuário não tenha como conseguir uma substituição rápida para a almofada, isto pode ser um problema. 33 Capa da almofada Uma almofada para alívio da pressão precisa ter uma capa que possa ser removida para lavagem e seja resistente à água. O material usado para a capa de uma almofada para alívio da pressão deve ser elástico ou frouxo o bastante para permitir que o osso do ísquio afunde-se na espuma. Se o tecido não for elástico, é melhor usar um tecido fino. As dobras em um tecido fino têm menos chance de marcar a pele e causar úlceras/feridas. Se for usado plástico fino sob o revestimento de tecido, este também precisa ser frouxo o bastante para permitir que o osso do ísquio afunde-se na espuma. Sempre avise os usuários que, se a almofada ou a capa se molharem, é preciso secar e colocar de volta apenas quando estiverem secas. Para usuários que sejam incontinentes e com risco de desenvolver úlceras/feridas, forneça duas almofadas que possam ser revezadas. O que fazer se não houver uma capa para almofada resistente à água Sempre que possível, os usuários que sejam incontinentes precisam de uma capa impermeável para a almofada, que evite que o líquido fique em contato com sua pele. Se não houver revestimento impermeável: • verifique que assistência pode ser oferecida para reduzir a incontinência; • forneça uma segunda almofada – para que uma possa secar enquanto o usuário utiliza a outra; • proteja a almofada com um saco plástico bem fino dentro da capa. Se estiver usando um saco plástico: • verifique se o saco plástico não faz o usuário “escorregar” sobre a almofada; • certifique-se de que não haja dobras no saco plástico que possam causar uma úlcera/ferida; • o usuário não deve deixar que líquidos “se acumulem” sobre o plástico, pois isso aumenta o risco de uma úlcera/ferida; • o usuário deve esperar a capa secar, se molhar, e deve limpar ou substituir o saco plástico. Como testar se uma almofada para alívio de pressão está funcionando Sempre que prescrever uma almofada para alívio da pressão, faça este simples teste manual para verificar se a almofada está reduzindo a pressão sob o osso do ísquio do usuário. O teste requer que o profissional coloque a mão sob o osso do ísquio do usuário. Sempre explique ao usuário o que vai fazer e por que isso é importante. Sempre faça o teste com a mesma almofada e cadeira de rodas que foi fornecida ao usuário. 34 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A Explique ao usuário o que vai fazer e por que isso é importante. B Peça que o usuário erga o corpo ou se incline para frente, para que você possa pôr os dedos sob seu osso do ísquio esquerdo ou direito (palma para cima). Isso deve ser feito por trás da cadeira de rodas, colocando uma das mãos sob o encosto. C Peça que o usuário sente-se de novo sobre seus dedos. Ele deve se sentar normalmente, voltado para frente, com as mãos sobre as coxas. Isso garantirá que ele se sente sempre na mesma posição cada vez que você mover a mão para testar outro local. Se seus dedos não estiverem em uma boa posição para sentir a pressão sob o osso do ísquio, peça ao usuário que erga o corpo outra vez e reposicione os dedos. D Identifique a pressão sob o primeiro osso isquiático como nível 1, 2 ou 3: Nível 1 = seguro: As pontas dos dedos podem se mover para cima e para baixo 5 mm ou mais. Nível 2 = atenção: Pontas dos dedos não podem se mover, mas podem deslizar para fora facilmente. Nível 3 = inseguro: Pontas dos dedos estão firmemente pressionadas e é difícil tirar os dedos. E Repetir sob o segundo osso do ísquio. Como reduzir a pressão “em nível de atenção” ou “insegura”? Quando pressões nível 2 (atenção) ou nível 3 (inseguro) são encontradas sob o osso do ísquio, é preciso agir para reduzir a pressão. Uma solução simples é adicionar mais uma camada de espuma firme. Esta é chamada de “elevação”. A elevação deve ser de aproximadamente 20 mm de espessura e ter buracos cortados sob a área do osso do ísquio. A elevação é colocada sob a almofada e dentro da capa. Às vezes é necessário ter mais de uma camada. O profissional deve colocar uma camada e testar a pressão. Se a pressão ainda for nível 2 ou 3, acrescentar outra camada. 35 A.8 Transferências Sentar-se e levantar-se da cadeira de rodas A capacidade de transferir-se da cadeira de rodas com facilidade e segurança, com ou sem assistência, ajudará o usuário na vida cotidiana. Sentar-se e levantar-se da cadeira de rodas pode ser chamado de “transferência”. Por que usuários precisam aprender a fazer transferências? Usuários podem ter que transferir-se de sua cadeira de rodas várias vezes por dia. Eles precisam de um método que seja seguro, rápido e que não exija muito esforço. Os usuários praticam diferentes métodos, dependendo de suas habilidades. Alguns usuários conseguem transferir-se sozinhos da cadeira de rodas e outros precisam de ajuda. Alguns usuários podem ficar em pé para se transferir, enquanto para outros isso não é possível. Três maneiras de se transferir da cadeira de rodas Antes de recomendar ou praticar uma transferência com um usuário, é preciso saber se ele pode se transferir de forma independente ou se precisa de ajuda. • Para se transferir de forma independente e sentado, verifique se o usuário consegue erguer o corpo apoiado nos braços. Se não conseguir, ele precisa de ajuda para se transferir. • Para se transferir de forma independente ficando em pé, verifique se o usuário consegue se levantar e apoiar o próprio peso nas pernas. Se não conseguir, ele precisa de ajuda para se transferir. Algumas modalidades de transferência são mostradas abaixo. 36 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Transferência independente sentada (cadeira de rodas para cama) • Posicionar a cadeira de rodas perto da cama, acionar os freios. • Retirar os pés do apoio e afastar ou remover (quando aplicável) o apoio para os pés. • Remover o apoio para os braços mais próximo da cama. • Erguer o corpo apoiando-se nas mãos e mover-se para frente da cadeira de rodas. • Com uma das mãos na cama e outra na cadeira de rodas, erguer o corpo e transferir-se para a cama. • Se o usuário tiver pouco equilíbrio ou não conseguir se erguer o suficiente ou se mover o suficiente para o lado, ele pode usar uma tábua de transferência. Na transferência para uma cama, alguns usuários preferem colocar as pernas na cama antes de se transferir. Transferência assistida sentada com tábua de transferência (cadeira de rodas para cama) • Posicionar a cadeira de rodas perto da cama, acionar os freios. • Retirar os pés do apoio e afastar ou remover (quando aplicável) o apoio para os pés. • Remover o apoio para os braços mais próximo da cama. • Ajudar o usuário a se mover para frente. • Colocar uma tábua de transferência sob as nádegas entre a cadeira e a cama. • O usuário deve ajudar tanto quanto possível apoiando-se na cadeira e na cama para aliviar seu peso. • O assistente fica atrás do usuário e move as nádegas dele para a cama. 37 Transferência assistida em pé (cama para cadeira de rodas) • Posicionar a cadeira de rodas, acionar os freios. • Baixar os pés da cama e afastar ou remover (quando aplicável) os apoios para os pés. • Remover o apoio para os braços mais próximo da cama. • Ajudar o usuário a mover-se para frente na cama e pôr os pés no chão. • Apoiar os joelhos do usuário pela lateral (não empurrar os joelhos pela frente). • Trazer o corpo do usuário para frente e para cima apoiando-o pela escápula. • Virar o usuário em direção à cadeira de rodas e ajudá-lo a sentar-se suavemente. O que é uma tábua de transferência? Uma tábua de transferência é uma tábua fina e forte que pode ajudar a fazer uma ponte entre a cadeira de rodas e a superfície para onde o usuário está se transferindo. Tábuas de transferência são úteis para usuários que estejam aprendendo a se transferir independentemente, ou que tenham força limitada nos braços. O usuário pode fazer a transferência em uma série de pequenas elevações ao invés de usar uma única grande elevação do corpo. Uma tábua de transferência também pode reduzir a assistência que o usuário precisa. Tábuas de transferência podem ser feitas localmente, de madeira ou compensado. Devem ser finas, fortes e muito lisas. A espessura deve ser reduzida nas bordas. As dimensões sugeridas são 300 mm x 600 mm. A espessura da tábua depende da resistência do material, mas uma espessura típica é entre 20 e 25 mm. 38 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Transferência independente do chão para a cadeira de rodas • Esta transferência exige que o usuário tenha braços fortes e bom equilíbrio. • Usuários em risco de desenvolver úlceras/feridas devem sempre sentar-se sobre a almofada para alívio da pressão quando estiverem sentados no chão. • Sentado em frente à cadeira de rodas, puxar os joelhos para perto do corpo. • Olhar para baixo e continuar olhando para baixo durante toda a elevação. • Pôr uma mão no chão e a outra na frente do assento da cadeira de rodas. • Fazer força para baixo com os ombros e braços para levantar as nádegas até a frente do assento da cadeira de rodas. • Sentar para trás na cadeira e abaixar para pegar a almofada. • Deslocar o peso para um lado e colocar a almofada no lugar adequado na cadeira de rodas. Ao se transferir da cadeira de rodas para o chão • Sentar-se em frente à cadeira. • Retirar os pés do apoio e coloca-los à frente e ligeiramente para o lado oposto à direção para onde está se transferindo. • Colocar a almofada no chão. • Com uma das mãos no assento da cadeira de rodas; pôr a outra mão no chão. • Usando o ombro e os braços, mover as nádegas para baixo até a almofada que foi colocada no chão, em um movimento controlado. Como transferir-se da cadeira de rodas com segurança Para o usuário: • Sempre acione os freios da cadeira de rodas ao sentar-se e levantar-se dela. • Examine para onde está indo – certifique-se que não há nada no caminho. • Sempre erga o corpo. Não se arraste – isso poderia causar dano à pele e levar a uma úlcera/ferida. Para o assistente: • Antes de ajudar alguém, certifique-se de que pode suportar o peso dessa pessoa. • Explique ao usuário o que vai fazer. • Use técnicas seguras para levantar o usuário. • Não ajude se estiver grávida ou tiver problemas nas costas. 39 B. Etapas do serviço para cadeira de rodas 40 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Etapa 1: Encaminhamento e agendamento Encaminhamento Encaminhamento significa indicar a uma pessoa o lugar certo para buscar atendimento ou assistência. Os usuários podem ser encaminhados a um serviço de cadeira de rodas de diferentes maneiras. Por exemplo, eles podem: • ouvir sobre o serviço e procurá-lo pessoalmente; • ser encaminhados ao serviço pelo hospital, centro de atendimento comunitário, serviço de reabilitação comunitário, líderes comunitários/religiosos, organizações de pessoas com deficiência, outros usuários. O serviço de cadeira de rodas pode ajudar a aumentar o número de usuários encaminhados procurando ser conhecido por todas as fontes de referência possíveis. O fornecimento às fontes de referência de um formulário de encaminhamento pode ajudar a obter algumas informações iniciais simples sobre o usuário. Cada serviço de cadeiras de rodas precisa decidir se um formulário de encaminhamento pode ser útil, quais informações devem ser incluídas e como o formulário será usado (por exemplo, enviado por correio ao serviço ou entregue ao usuário para que ele o leve consigo). Um modelo de formulário de encaminhamento para serviços de cadeira de rodas é mostrado na próxima página. Agendamento Quando um usuário é encaminhado a um serviço de cadeiras de rodas, deve ser agendada uma avaliação, se ele não puder ser atendido no mesmo dia. Essa avaliação pode ser feita no serviço/centro de atendimento, ou pode ser na casa do usuário. Um sistema de agendamento ajuda a equipe de cadeiras de rodas a organizar seu tempo com eficiência. Também faz com que os usuários não tenham que esperar para ser atendidos. O modo como o agendamento é feito depende da facilidade para contatar o usuário. Por exemplo, mensagens podem ser enviadas por correio, telefone ou pela fonte de referência original. Às vezes, usuários podem chegar sem ter agendado a visita. Se possível, atenda-os no mesmo dia, especialmente se tiverem vindo de longe. 41 Boas práticas em encaminhamento e agendamento • Abra um registro para cada usuário quando ele procurar o serviço. • Informe as fontes de referência sobre o serviço e como acessá-lo. • Entregue às fontes de referência um suprimento de formulários de encaminhamento. • Quando houver muitos usuários, o serviço deve criar uma maneira de decidir quem será atendido primeiro. Considere em particular as necessidades de crianças e de pessoas com condições que representem ameaça à vida, como úlceras/feridas. Formulário de encaminhamento para serviços de cadeiras de rodas Preencha o formulário de encaminhamento e envie para: Nome e endereço do serviço de cadeiras de rodas: Nome da pessoa que fez o encaminhamento: Organização em que trabalha: Detalhes de contato da pessoa que fez o encaminhamento (a melhor maneira de contatá-la): Nome do usuário: Data de nascimento: Nome do responsável/cuidador: Endereço: Como entrar em contato com o usuário? Correio  Telefone particular  Telefone de amigo / vizinho  Se por telefone, qual o número do telefone: Deficiência do usuário, se conhecida: Motivo do encaminhamento: • Não possui cadeira de rodas  • Cadeira de rodas está quebrada  • Cadeira de rodas que não atende suas necessidades  Por favor, adicione qualquer outra informação sobre o usuário que você ache importante que o serviço de cadeira de rodas tenha conhecimento: O usuário concordou em ser encaminhado para o serviço de cadeiras de rodas? Sim  Não  Assinatura da pessoa que fez o encaminhamento: Data: O formulário de encaminhamento deve conter informações claras de contato com o serviço, incluindo nome, endereço e telefone. Neste formulário de encaminha- mento, o serviço vai contatar o usuá- rio para fazer um agendamento. Isso pode nem sempre ser possível. Nesse caso, o serviço pode aceitar encami- nhamentos sem agendamento. A pessoa que faz o encaminhamento deve explicar ao usuário o que o serviço faz. O usuário deve concordar com o encaminhamento. 42 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Etapa 2: Avaliação Quem precisa de uma cadeira de rodas? Quando alguém vai a um serviço de cadeira de rodas em busca de uma cadeira, é importante certificar-se que a pessoa, de fato, precisa de uma cadeira de rodas. Uma pessoa geralmente precisa de uma cadeira de rodas se: • não puder andar; • puder andar, mas com dificuldade ou apenas por curtas distâncias. Por que é necessária uma avaliação? Uma avaliação para cadeira de rodas é uma oportunidade de obter informações para: • ajudar a escolher a cadeira de rodas mais apropriada para o usuário entre as disponíveis; • ajudar a escolher os componentes de cadeira de rodas mais apropriados entre os disponíveis; • descobrir qual treinamento o usuário e/ou a família precisam fazer para o melhor uso da cadeira de rodas. Onde fazer uma avaliação As avaliações devem sempre ser feitas em um lugar limpo e tranquilo. Pode ser um espaço dentro do serviço, em outro centro de atendimento de saúde ou centro comunitário ou na casa do usuário. Se for necessário verificar se a pessoa tem uma úlcera/ferida, faça isso em um lugar privado. Respeite a dignidade e a privacidade do usuário qualquer que seja sua idade, gênero, religião ou situação socioeconômica. 43 Duas partes de uma avaliação: • entrevista de avaliação; • avaliação física. 1. Entrevista de avaliação A melhor maneira de coletar informações sobre um usuário é fazendo perguntas. A ficha de avaliação do usuário orienta a equipe de atendimento do serviço de cadeiras de rodas para que façam as perguntas mais importantes na avaliação. Há quatro grupos diferentes de perguntas, que são: • informações sobre o usuário; • condições físicas; • estilo de vida e ambiente; • cadeira de rodas atual. Informações sobre o usuário: Nome: Número: Idade: Masculino  Feminino  Telefone: Endereço: Metas: Estas perguntas são importantes para que o usuário possa ser contatado para o acompanhamento no futuro. Também fornecem informações estatísticas sobre os usuários atendidos pelo serviço. Em “metas”, escreva por que o usuário quer uma cadeira de rodas e o que ele quer ser capaz de fazer com ela. 44 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Ao fazer perguntas, lembre-se: • Sempre explique ao usuário por que essas informações são importantes; • Dirija-se sempre ao usuário (e não a seu assistente/parente), a menos que esteja lidando com uma criança pequena ou alguém incapaz de entender ou responder as perguntas; • lembre-se de usar bons métodos de comunicação; • as informações podem nem sempre surgir na mesma ordem em que estão no formulário. Familiarize-se com o formulário para poder registrar as informações no lugar certo. Condições físicas: Estas perguntas são importantes porque algumas das características de condições de saúde podem afetar a escolha da cadeira de rodas. Alguns exemplos são dados abaixo. Condições físicas Paralisia Cerebral  Pólio  Lesão medular  AVC/trombose cerebral  Fragilidade  Espasmos ou movimentos involuntários  Amputação: D acima do joelho  D abaixo do joelho  E acima do joelho  E abaixo do joelho  Problemas de bexiga  Problemas intestinais  Se o usuário possui problemas de bexiga ou intestinais, estão sendo gerenciados? Sim  Não  Outros: 45 Várias condições que afetam a prescrição (seleção) da cadeira de rodas: O que você precisa saber Lembre-se sempre Paralisia cerebral A paralisia cerebral afeta as pessoas de modos muito diferentes. Para uma pessoa com paralisia cerebral que consiga sentar-se ereta, é importante lembrar que elas podem ter dificuldade para manter a posição porque se cansam. Isso torna as atividades mais difíceis e cansativas. Um bom suporte é muito importante. Pessoas com paralisia cerebral podem precisar de suporte postural adicional na cadeira de rodas. Para fazer isso com segurança e eficácia, é necessário treinamento de nível intermediário. Poliomielite Pessoas com poliomielite podem ter fraqueza ou flacidez em partes do corpo. A poliomielite pode afetar pernas, braços ou o tronco, mas mais comumente afeta as pernas. Os músculos e ossos ficam mais frágeis e o membro não cresce tão rápido, por isso é mais curto. Quando o tronco é afetado, ele pode parecer mais curto. Embora pessoas com poliomielite tenham sensibilidade, uma almofada é importante para dar conforto. Uma almofada mais alta pode proporcionar uma posição mais confortável para impulsionar a cadeira. Lesão medular Pessoas com lesão medular têm grande probabilidade de desenvolver úlceras/feridas. Isso porque a maioria das pessoas com lesão medular não tem sensibilidade abaixo do nível da lesão. Sempre prescreva uma almofada para alívio da pressão. AVC/trombose cerebral Pessoas que tiveram um acidente vascular cerebral (AVC)/trombose cerebral geralmente têm um lado do corpo afetado. Isso significa que podem pender para um lado na cadeira de rodas. Pessoas que tiveram um AVC/ trombose cerebral podem não ter sensibilidade normal no lado afetado do corpo. Às vezes são capazes de transferir-se da cadeira de rodas ficando em pé. Bom suporte é importante. Verifique se a pessoa tem sensibilidade – ela pode precisar de uma almofada para alívio da pressão. Uma pessoa com AVC/ trombose cerebral pode preferir uma cadeira de rodas com apoio para os pés removível ou móvel para poder fazer transferências em pé. Continua... 46 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Continuação O que você precisa saber Lembre-se sempre Amputação de membro inferior Pessoas com amputação dupla não têm o peso das pernas para impedir a cadeira de rodas de cair para trás. Tenha sempre cuidado quando um amputado experimentar uma cadeira de rodas pela primeira vez. Verifique o equilíbrio da cadeira de rodas. Pode haver necessidade de mover a roda traseira para trás para dar mais estabilidade. Fragilidade Pessoas idosas podem precisar de uma cadeira de rodas por diferentes razões. Em geral, por terem dificuldade para andar. A cadeira de rodas facilitará sua participação na vida familiar e comunitária. Pessoas idosas podem ser capazes de se transferir em pé e preferirão uma cadeira de rodas com apoio para os pés removível ou móvel. Pessoas idosas devem sempre ter uma cadeira de rodas com bom suporte e conforto. Isso as ajudará a se sentar corretamente e evitar problemas causados por má postura. Apoio para os pés removível ou móvel pode ser a melhor escolha. Espasmos ou movimentos involuntários Algumas pessoas têm problemas com movimentos súbitos que elas não podem controlar (espasmos). Estes podem jogar o peso para trás, criando mais risco de derrubar a cadeira de rodas para trás. Os movimentos podem fazer os pés “pularem” de repente do apoio. Isso pode ser perigoso com a cadeira em movimento. Selecione uma posição segura da roda traseira ou uma cadeira de rodas muito estável. Faixas podem ajudar a controlar a posição dos pés. Nota: sempre que for usar faixas, é importante usar Velcro, para que ela possa se soltar se o usuário cair da cadeira de rodas. Problemas de bexiga ou intestinais Algumas pessoas não conseguem controlar a bexiga ou os intestinos. Esse problema muitas vezes pode ser resolvido com o equipamento certo (cateteres, por exemplo), medicação e um programa de treinamento da bexiga e dos intestinos. Pessoas com problemas de bexiga ou intestinos não devem se sentar em uma almofada molhada ou suja, pois isso pode lesionar rapidamente a pele. Além disso, as bactérias presentes nas fezes levam rapidamente a úlceras/feridas infeccionadas. Identifique quem em sua área (ex., médicos e enfermeiras especialistas) pode oferecer ajuda e treinamento para evitar essas complicações. Forneça uma almofada com revestimento impermeável. Ensine ao usuário como lavar e secar a almofada. Uma segunda almofada pode ajudar, por permitir que o usuário mantenha suas atividades cotidianas enquanto a almofada seca. 47 Estilo de vida e ambiente: Estas perguntas coletam informações sobre onde o usuário vive e as coisas que ele precisa fazer na cadeira de rodas. Estilo de vida e ambiente Descreva onde o usuário utilizará a cadeira de rodas: Distância percorrida por dia: Até 1 km  1–5 km  Mais de 5 km  Horas de uso da cadeira de rodas por dia: Menos de 1  1–3  3–5  5–8  Mais de 8 horas  Quando fora da cadeira de rodas, onde o usuário-se senta ou deita, e como (postura e superfície)? Transferência: Independente  Assistida  Fica em pé  Não fica em pé  Erguido  Outros  Tipo de banheiro (em caso de transferência): Latrina  Vaso Sanitário/sanita  Adaptado  O usuário usa transporte público/privado com regularidade? Sim  Não  Se sim, que tipo: Carro  Táxi  Ônibus/Autocarro  Outro Cadeira de rodas atual: Estas perguntas ajudam a descobrir se a cadeira de rodas atual do usuário está atendendo suas necessidades e, em caso negativo, por quê. Cadeira de rodas atual (quando a pessoa já possui uma cadeira de rodas) A cadeira de rodas atende às necessidades do usuário? Sim  Não A cadeira de rodas atende às condições do ambiente do usuário? Sim  Não A cadeira de rodas é adequada e oferece suporte postural? Sim  Não A cadeira de rodas é segura e durável? (verifique se há uma almofada) Sim  Não A almofada oferece alívio adequado da pressão (se o usuário corre risco de desenvolver úceras/feridas)? Sim  Não Comentários: Se a resposta for sim para todas as perguntas, o usuário talvez não precise de uma nova cadeira de rodas. Se for não para alguma dessas perguntas, o usuário precisa de uma cadeira de rodas ou almofada diferente ou a cadeira de rodas ou almofada existentes precisam de reparos ou modificações. 48 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 2. Avaliação física Há três grupos de perguntas diferentes, que são: • presença, risco ou histórico de úlceras/feridas; • método de impulsão; • medidas. Presença, risco ou histórico de úlceras/feridas /// = não sente O = úlcera/ferida prévia • = úlcera/ferida existente Tem sensibilidade normal? Sim  Não  Úlcera/ferida prévia? Sim  Não  Úlcera/ferida atual? Sim  Não  Se sim, é uma ferida instalada (estágio 1–4)? Sim  Não  Duração e causa: Essa pessoa corre risco* de desenvolver uma úlceras/feridas? *Uma pessoa sem sensibilidade ou com 3 ou mais fatores de risco está em risco. Fatores de risco: imobilidade, umidade, má postura, úlcera/ferida prévia/atual, dieta ruim, idade avançada, estar acima ou abaixo do peso. Sim  Não  Marque no diagrama corporal: • áreas em que o usuário não tem sensibilidade; assim /// • áreas em que o usuário teve uma úlcera/ferida no passado; assim: O • áreas em que o usuário tem uma úlcera/ferida atual; assim: • Se o usuário disser que tem uma úlcera/ferida, sempre peça para vê-la. Faça isso em uma área com privacidade. Um usuário corre risco de desenvolver uma úlcera/ferida se não tiver sensibilidade ou tiver outros fatores de risco. Os fatores de risco incluem: • a pessoa não pode sentir (sensibilidade diminuída); • a pessoa não pode se mover; • umidade de suor, água ou incontinência; • má postura; • úlcera/ferida prévia ou atual; • dieta ruim e ingestão insuficiente de água; • idade avançada; • peso (acima ou abaixo). Lembre-se: todo usuário em risco de desenvolver uma úlcera/ ferida precisa de uma almofada para alívio da pressão e instruções sobre como evitar. 49 Método de impulsão Como o usuário impulsionará a cadeira de rodas? Dois braços  Braço esquerdo  Braço direito  Membros inferiores  Membro inferior esquerdo  Membro inferior direito  Empurrado por auxiliar  Comentários: É importante saber como o usuário impulsionará a cadeira, pois isso pode afetar a escolha da cadeira de rodas e sua configuração (consulte A.6: Cadeira de rodas apropriada, seção “Impulsionando a cadeira de rodas”). Medidas Quatro medidas do usuário são necessárias para escolher o melhor tamanho de cadeira de rodas disponível para essa pessoa. Todas as medidas relacionam-se à cadeira de rodas. Medida do corpo Medida (mm) Transforme a medida do corpo no tamanho ideial de cadeira de rodas Medida da cadeira de rodas (mm) A Largura do quadril Largura do quadril = largura do assento B Profundidade do assento E B menos 30 –60 mm = profundidade do assento (se o comprimento for diferente, usar o menor)D C Compri- mento da perna E = topo da almofada* até apoio para os pés ou = topo da almofada* até o chão para impulso com os pésD D Altura da última costela = topo da almofada* até topo do encosto (medir D ou E, dependendo da necessidade do usuário)E Altura do ângulo inferior da escápula *Verificar a altura da almofada que o usuário vai usar. Instrumentos de medição • Use uma trena (mostrada à direita). • Pranchetas/livros podem ser usados para ajudar a medir com precisão (ver Como tirar medidas do corpo). • Paquímetros grandes são outro instrumento que pode ser muito útil. Eles podem ser feitos localmente de madeira. • Blocos de apoio para os pés podem ser usados para apoiar os pés do usuário na altura correta. 50 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Como tirar medidas do corpo Peça ao usuário para se sentar o mais ereto possível. Os pés do usuário devem ficar apoiados no chão ou em blocos de apoio para os pés se ele não puder alcançar o chão com conforto. Para todas as medições, certifique-se de que a trena esteja reta e que o usuário esteja sentado ereto. Segurar uma prancheta/livro em cada lado do usuário pode ajudar a obter uma medida correta. Incline-se para ter certeza de que está vendo a trena pelo ângulo certo. A • Verifique se não há nada nos bolsos do usuário antes de medir. • Meça quadris ou a parte mais larga das coxas. • Segure duas pranchetas/livros nas laterais do usuário para ajudar a obter as medidas corretas. B • Coloque uma prancheta/livro nas costas do usuário para ajudar a obter uma medida correta. • Meça da parte traseira da pelve até atrás do joelho em uma linha reta. • Sempre meça as duas pernas. Se houver uma diferença entre as pernas, verifique se o usuário está sentado ereto com a pelve nivelada. Se ainda houver diferença, faça a prescrição da cadeira de rodas segundo o lado mais curto. C • Meça da parte de trás do joelho até a base do calcanhar. • Assegure-se de que os tornozelos do usuário estejam em um ângulo de 90 graus (se possível). • Sempre meça as duas pernas. • O usuário deve estar com os sapatos que usa com maior frequência (se houver). D • Meça do assento até a última costela. • Para ajudar a encontrar a última costela, coloque as mãos de ambos os lados da pelve. Aperte ligeiramente as mãos para dentro e deslize-as para cima. A última costela é logo acima da cintura. E • Meça do assento até o ângulo inferior da escápula em uma linha vertical. • Para ajudar a encontrar o ângulo inferior da escápula, peça que o usuário encolha os ombros. Para mais informações sobre o ajuste correto de uma cadeira de rodas, ver a etapa 6, Adequação. 51 Etapa 3: Prescrição (seleção) O que é prescrição (seleção)? Prescrição (seleção) significa selecionar a melhor correspondência possível entre as cadeiras de rodas disponíveis e as necessidades do usuário. A prescrição (seleção) deve sempre ser decidida junto com o usuário, incluindo um familiar ou cuidador, se apropriado. A prescrição (seleção) inclui: • selecionar a cadeira de rodas, almofada e componentes certos; • selecionar o tamanho certo da cadeira de rodas e da almofada; • conversar com o usuário sobre qual treinamento será necessário para ajudá-lo a usar e cuidar da cadeira de rodas e da almofada. Cadeiras de rodas e almofadas disponíveis no local Selecionar uma cadeira de rodas do tamanho certo é muito importante. A cadeira de rodas do tamanho correto é mais confortável, ajuda o usuário a sentar-se ereto e é mais fácil de usar. Para mais informações sobre o ajuste correto de uma cadeira de rodas, ver a etapa 6: Adequação. • Estrutura – por exemplo, se a distância entre os eixos é longa ou curta; o comprimento da estrutura; se ela é dobrável ou rígida. • Características – inclui o tipo de assento, encosto, apoio para os pés, apoios para os braços, rodas dianteiras, rodas traseiras. • Tamanho da cadeira de rodas: É geralmente descrito pela largura do assento e, às vezes, também a profundidade. Também é útil saber a altura do assento até o chão. • Opções de ajustes: Quais componentes são ajustáveis e qual é a abrangência dos ajustes? Geralmente são possíveis ajustes para duas ou mais posições. Por exemplo, a maioria das cadeiras de rodas tem apoios para os pés que podem ser ajustados em diferentes alturas, proporcionalmente espaçadas. A “abrangência” de ajustes é da menor medida para a maior. • Almofada: Que tipo de almofada (se for o caso) é fornecido com a cadeira de rodas ou está disponível separadamente? Alguns fornecedores de cadeiras de rodas oferecem: a. manual ou resumo do produto; b. especificações do produto (cadeira de rodas). Em geral, as medidas, peso, características e, às vezes, partes opcionais da cadeira de rodas estão nessas informações. Sempre verifique se há informações disponíveis sobre a cadeira de rodas que está prescrevendo. Leia essas informações para se familiarizar com o produto. Se os fornecedores não derem essas informações, peça. 52 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Registro da prescrição (seleção) A prescrição (seleção) precisa ser registrada por escrito. Abaixo há um exemplo de um formulário de prescrição (seleção) de cadeira de rodas. Adapte essa ficha para o seu serviço listando os tipos de cadeiras de rodas e almofadas disponíveis e seus tamanhos. Formulário de prescrição (seleção) de cadeira de rodas 1. Informações sobre o usuário Nome do usuário: Número: Data da avaliação: Data da adequação: Nome do avaliador: 2. Tipo e tamanho da cadeira de rodas selecionada Para escolher o tipo de cadeira de rodas: • Converse com o usuário; • Pense nas principais necessidades do usuário; • Verifique: estrutura, rodas dianteiras e traseiras, apoios para os pés, apoios para os braços, altura do encosto (ou possibilidade de ajustes), posição das rodas traseiras, apoio e conforto. Tipo de cadeira de rodas Tamanho      3. Tipo de almofada selecionada Tipo de almofada Tamanho ex.: Almofada de espuma para alívio da pressão  ex.: Almofada de espuma plana   4. De acordo Assinatura do usuário: Assinatura do avaliador: Assinatura do gerente: Liste os tipos de cadeiras de rodas disponíveis em seu serviço. Liste os tipos e tamanhos de almofadas disponíveis em seu serviço. 53 Etapa 4: Financiamento e aquisição Financiamento Depois que a cadeira de rodas é prescrita, é possível calcular com precisão o custo do produto recomendado. É essencial saber quem financiará a cadeira de rodas – ela pode ser paga pelo usuário, com um subsídio governamental, por uma organização não governamental ou agência doadora, ou por uma companhia de seguros. No mundo em desenvolvimento, muitas pessoas que precisam de cadeira de rodas não têm dinheiro para comprá-la. No entanto, todos que precisam de uma cadeira de rodas têm o direito a uma, independente da sua capacidade de pagamento. Assim, é preciso haver financiamento disponível para usuários que precisem de assistência financeira. Para a maioria dos serviços, será essencial identificar a fonte de financiamento antes que a cadeira de rodas seja requerida. Com frequência, essa responsabilidade é da equipe administrativa ou dos gestores do programa e não da equipe clínica ou técnica. Aquisição Quando a melhor cadeira de rodas para o usuário tiver sido selecionada e o formulário de prescrição (seleção) estiver pronto, precisa ser realizada a requisição da cadeira de rodas caso não haja disponível no estoque. Se o serviço tiver cadeiras de rodas em estoque, talvez só seja preciso preencher uma requisição para ser autorizada pelo gestor. A cadeira de rodas pode, então, ser preparada pela equipe responsável. Se o serviço não tiver cadeiras de rodas em estoque, deverá fazer a requisição a um fornecedor externo. O sistema de requisições e aquisições de cadeiras de rodas varia de um serviço para outro. Anote abaixo as coisas de que você precisa lembrar para fazer a requisição ou aquisição das cadeiras de rodas em seu serviço local. 54 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Como fazer a requisição ou aquisição de cadeiras de rodas em meu serviço local: Boas práticas para a requisição • Manter cadeiras de rodas em estoque pode reduzir o tempo de espera para os usuários. • A requisição deve sempre ser feita o mais rápido possível para evitar atrasos. • Sempre avise ao usuário quando é provável que a cadeira de rodas esteja disponível. 55 Etapa 5: Preparação do produto (cadeira de rodas) O que é a preparação do produto (cadeira de rodas)? A preparação do produto (cadeira de rodas) inclui: • preparar a cadeira de rodas de acordo com a prescrição (seleção) feita para o usuário; • verificar a cadeira de rodas para ter certeza de que ela está segura e pronta para ser usada e de que todas as partes estão funcionando corretamente. Preparação da cadeira de rodas Prepare a cadeira de rodas na seguinte ordem: 1. Verifique se as medidas de largura e profundidade do assento da cadeira de rodas estão corretas, de acordo com a prescrição (seleção). 2. Verifique se a largura e a profundidade da almofada correspondem às medidas do assento. 3. Ajuste (quando possível): • Altura e ângulo do encosto; • Altura dos apoios para os braços; • Posição das rodas traseiras; • Posição dos freios; • Altura do apoio para os pés; • Altura das manoplas; • Outros ajustes necessários. 4. Faça a verificação da “cadeira de rodas segura e pronta para uso”. Boas práticas na preparação do produto • Identifique cada cadeira de rodas em preparação com o nome do usuário. • Qualquer modificação em uma cadeira de rodas deve sempre ser feita por alguém com o conhecimento e técnica apropriados. Modificações podem afetar a resistência e a funcionalidade de uma cadeira de rodas. • Sempre confira se a cadeira de rodas está segura e pronta para ser usada e se todas as partes estão funcionando bem antes que o usuário a experimente (ver abaixo). Lista de verificação para cadeira de rodas segura e pronta para uso Use a lista de verificação abaixo para se certificar de que a cadeira de rodas está segura e pronta para uso e que todas as partes estão funcionando. Sempre faça isso antes de o usuário experimentar a cadeira. 56 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Lista de verificação: A cadeira de rodas está segura e pronta para uso? Cadeira de rodas inteira Como verificar Não há arestas pontiagudas.  Examine toda a cadeira de rodas com os olhos e as mãos. Nenhuma parte está danificada ou arranhada.  A cadeira de rodas anda em linha reta.  Empurre a cadeira de rodas à sua frente, com as rodas dianteiras em posição neutra. Rodas dianteiras Giram livremente.  Incline a cadeira de rodas sobre as rodas traseiras. Gire as rodas dianteiras. Giram sem tocar o garfo.  Os parafusos estão apertados.  Confira. Eles devem estar firmes. Não aperte em excesso. Encaixe das rodas dianteiras O garfo gira livremente.  Incline a cadeira de rodas sobre as rodas traseiras. Gire o garfo das rodas dianteiras. Rodas traseiras Giram livremente.  Incline a cadeira de rodas de lado sobre uma roda traseira. Gire a outra roda. Troque de lado. Os parafusos do eixo estão apertados.  Confira. Devem estar firmes. Não aperte em excesso. Os pneus (se forem pneumáticos) estão calibrados corretamente.  Pressione os pneus com o polegar. Eles devem comprimir um pouco, mas não mais que 5 mm. Os aros de impulsão estão seguros.  Confira. Freios Funcionam apropriadamente.  Acione os freios. Confira se a cadeira de rodas não pode ser movida. Apoio para os pés O apoio para os pés está preso com segurança.  Confira. 57 Estrutura Cadeira de rodas dobrável: a cadeira abre e fecha com facilidade.  Dobre a cadeira de rodas para conferir se o mecanismo está funcionando corretamente.Encosto dobrável: o encosto abre e fecha com facilidade.  Almofada A almofada está corretamente na capa.  Geralmente a capa da almofada é fechada atrás e embaixo da almofada. A almofada está colocada corretamente na cadeira.  Se for uma almofada moldada, a “caixa de acomodação” para o osso do ísquios deve estar para trás. A capa da almofada está justa, mas não muito apertada.  A capa de almofada não deve estar excessivamente esticada nos contornos da almofada. A almofada cobre totalmente o assento.  Confira se nenhuma parte do assento é visível sob a almofada. Isto é particularmente importante para assentos rígidos. Fabricação da almofada Se houver espuma disponível, a equipe do serviço de cadeiras de rodas pode fazer uma almofada para alívio da pressão com o uso de poucas ferramentas. É preciso saber qual espuma usar e conhecer algumas dimensões importantes. Converse com seus instrutores sobre as espumas disponíveis no local para saber quais seriam adequadas para uma almofada para alívio da pressão. As instruções abaixo mostram como fazer uma almofada para alívio da pressão básica, com dois contornos essenciais. Estes são uma caixa de acomodação sob o osso do ísquio e uma plataforma na frente desse osso. Características e dimensões da almofada As principais características da almofada básica de espuma moldada são as seguintes. Uma camada de base feita de espuma firme (por exemplo, bloco de espuma) 58 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Caixa de acomodação para o osso do ísquio • Alivia a pressão sob o osso do ísquio e o cóccix. • Ajuda a manter a pelve ereta na parte traseira da almofada. Base do assento flexível • Almofadas usadas sobre um assento flexível têm um corte chanfrado de cada lado da base da almofada. • Isso permite que a almofada tome a forma do assento flexível, enquanto o alto da almofada permanece plano. Uma camada superior com uma espuma macia “para conforto” Camada superior confortável: • Oferece conforto sobre a camada de base firme. Como fazer uma base de almofada para alívio da pressão? As instruções a seguir produzem uma almofada de 400 mm de largura x 400 mm de profundidade x 50 mm de altura. A caixa de acomodação tem 200 mm de largura x 200 mm de profundidade x 35 mm de altura. Essa almofada seria adequada para um usuário com uma largura de assento de 400 mm. Adapte as dimensões de acordo com o tamanho do usuário, conforme descrito no quadro abaixo. 59 1. Marque as linhas de corte na espuma firme. • Comece com um pedaço de espuma firme de 400 mm x 400 mm x 50 mm. • O centro da caixa de acomodação para o osso do ísquio deve estar na linha central da almofada. • Para esse tamanho de almofada, a caixa de acomodação para o osso do ísquio deve medir 200 mm x 200 mm x 35 mm. • Desenhe as linhas de corte com uma caneta de cor escura nos seis lados da base de espuma. Dimensões da caixa de acomodação para o osso do ísquio Ajuste as dimensões da almofada e da caixa de acomodação para o osso do ísquio para se adequar a usuários individuais como se segue: • largura da caixa de acomodação para o osso do ísquio = ½ da largura do assento do usuário ou 200 mm (o que for menor) [a]; • profundidade da caixa de acomodação para o osso do ísquio (frente para trás) = ½ da largura do assento do usuário ou 200 mm (o que for menor) [b]; • altura da caixa de acomodação para o osso do ísquio = 35 mm para adultos e 20 –25 mm para crianças [c]. 60 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 2. Corte a caixa de acomodação para o osso do ísquio: Use uma lâmina dentilhada afiada ou faca longa. Faça movimentos longos e lentos, cortando enquanto puxa para ter melhor controle. • Primeiro, corte da parte de trás da almofada até a profundidade da caixa de acomodação para o osso do ísquio. • Em seguida, corte a caixa de acomodação. • Cole de volta as duas “abas” que ficaram de cada lado da caixa de acomodação. Deixe a cola repousar e espere ficar ligeiramente pegajosa ao toque, mas sem secar completamente. Então pressione a espuma para colar. 3. Corte (em chanfro) nas bordas anteriores da caixa de acomodação. 4. Para uma cadeira de assento flexível, faça um corte angulado (chanfrado) em ambos os lados da base (lado de baixo). • Marque como mostrado e corte. • Esse corte ajuda a base da almofada a se moldar à forma de um assento flexível da cadeira de rodas. 61 5. Coloque a camada superior de espuma sobre a almofada. • A base e a camada superior são colocadas dentro da capa da almofada juntas. • As duas camadas não precisam ser coladas. • Se a camada superior ficar suja ou gasta, ela pode ser lavada e seca, ou substituída. • Uma camada de elevação pode ser acrescentada dentro da capa para aumentar a profundidade da caixa de acomodação. Perguntas frequentes sobre almofadas para alívio da pressão: Como escolher o tecido para a capa da almofada? • Escolha um tecido elástico, se possível. Tecidos impermeáveis são muito bons, se disponíveis. Se o tecido for impermeável, não deve ser grosso demais, ou as dobras podem causar marcas na pele do usuário, o que pode levar a uma úlcera/ferida. • A escolha dependerá dos tecido disponíveis. Às vezes, a escolha é limitada. • Se houver opção e você não tiver certeza, peça que os usuários experimentem diferentes tipos. • A experiência da equipe do serviço de cadeiras de rodas irá aumentando conforme diferentes tecidos forem experimentados. Essa almofada serve para todos os usuários? • Não – essa almofada não serve para todos os usuários. • No entanto, uma vantagem dessa almofada é que ela pode ser facilmente adaptada. Essa almofada é quente ou provoca sudorese? • Almofadas de espuma podem ser quentes e podem provocar sudorese. • No entanto, a almofada funciona bem em muitos outros aspectos, o que compensa o incômodo do calor. Todos os usuários precisam de uma almofada para alívio da pressão? • Não – nem todos os usuários precisam de uma almofada para alívio da pressão. • Leve em conta os fatores de risco para úlceras/feridas ensinados neste programa de treinamento para decidir se um usuário está ou não em risco de desenvolver uma úlcera/ferida. • Embora essa almofada possa não ser necessária para alívio da pressão, ela também pode melhorar o conforto e a postura, mesmo para usuários que não estejam em risco de desenvolver úlceras/feridas. 62 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO O que acontece se a almofada for usada do lado errado (frente-trás, lado de cima-de baixo)? • Ela não funcionará corretamente e pode até aumentar o risco de desenvolver úlceras/ feridas. • Sempre certifique-se de que os usuários e familiares (quando relevante) aprenderam como usar e cuidar da almofada corretamente. • Marque a almofada com “frente” e “trás” ou “lado de cima” e “lado de baixo” se necessário. Essa almofada serve para crianças? • Sim, essa almofada serviria para crianças. No entanto, a caixa de acomodação para o osso do ísquio precisa ser menor. Ver acima como corrigir as dimensões para uma almofada de criança. • Muitas crianças que usam cadeira de rodas precisam de suporte postural adicional. Essa almofada pode não oferecer suporte postural suficiente. Ajuste da almofada Sempre confira se o osso do ísquio fica dentro da caixa de acomodação, e não nas bordas ou na parte alta da almofada. Ao ajustar uma almofada para alívio da pressão para um usuário, sempre confira se: • a pressão sob o osso do ísquio é “segura” (ver “Como testar se uma almofada para alívio da pressão está funcionando”, acima); e • o osso do ísquio está dentro da caixa de acomodação e não na borda ou na camada superior. 63 Etapa 6: Adequação O que o processo de adequação envolve? Durante a adequação, o usuário e a equipe de serviço examinam juntos se: • a cadeira de rodas é do tamanho correto e todas as modificações necessárias foram feitas para assegurar um ajuste perfeito; • a cadeira de rodas e a almofada dão suporte ao usuário para se sentar ereto; • a almofada para alívio da pressão realmente alivia a pressão, caso uma tenha sido prescrita. Boas práticas de adequação • Sempre que possível, a mesma pessoa que fez a avaliação deve fazer a adequação. • Sempre confira a adequação com a cadeira de rodas parada e, depois, enquanto o usuário impulsiona a cadeira ou é empurrado. • Faça a adequação nesta ordem: • confira tamanho e ajustes; • confira postura; • confira pressão; • confira a adequação enquanto o usuário se move. • Use a lista de verificação de adequação para se lembrar de cada passo. Verifique o tamanho e ajustes Largura do assento Ajuste correto: Deve se ajustar perfeitamente. Como verificar • Passe os dedos entre a parte externa das coxas do usuário e as laterais da cadeira de rodas. Os dedos devem caber confortavelmente, sem estar apertados. Confira se as laterais da cadeira de rodas não pressionam as pernas do usuário. Isto é particularmente importante para usuários que não possam sentir a pressão nas coxas (que não tenham sensibilidade normal). Uma pressão firme da lateral da cadeira de rodas nas coxas pode causar uma úlcera/ferida. Profundidade do assento Ajuste correto: Folga de dois dedos (30 mm) entre a parte de trás do joelho e a almofada. continua... 64 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Continuação Como verificar • Verifique se o usuário está sentado ereto. • Deslize a mão entre a almofada e a parte de trás do joelho. Deve haver folga suficiente para caber dois dedos (30 mm). Pode haver uma folga maior para usuários com pernas longas. Até 60 mm são aceitáveis. • Deslize a mão pela parte traseira da panturrilha e certifique-se de que ela não esteja tocando o assento ou a almofada. • Sempre confira os dois lados. O ajuste correto dá bom suporte para as coxas. Isso reduzirá a pressão sob o osso do ísquio e ajudará a evitar úlceras/feridas. Se o comprimento do assento for grande demais, o usuário não conseguirá sentar-se ereto. Se houver diferença entre os lados direito e esquerdo, use a medida da perna mais curta para fazer a prescrição. Altura do apoio para os pés Ajuste correto: As coxas estão totalmente apoiadas na almofada, sem folga. Os pés estão totalmente apoiados nos apoios, sem folga. Como verificar • Deslize a mão entre a coxa e a almofada. Deve haver uma pressão uniforme sob toda a coxa, sem folgas. • Examine cada pé sobre o apoio. O pé deve estar apoiado na frente e atrás, sem folgas. Se houver folga sob a coxa, o apoio para os pés pode estar alto demais. Se houver folga sob os pés, o apoio pode estar baixo demais. Altura do encosto Ajuste correto: O ajuste correto deve dar ao usuário o suporte de que ele precisa e permitir que uma pessoa ativa tenha liberdade para mover os ombros e impulsionar a cadeira. Como verificar • Pergunte ao usuário se o encosto está confortável. • Observe se o tronco está equilibrado sobre os quadris. • O usuário consegue impulsionar a cadeira de rodas sem que o encosto interfira? A altura do encosto depende das necessidades do usuário. Usuários que se impulsionam sozinhos precisam de um encosto que deixe seus ombros se moverem livremente. Usuários que tenham dificuldade para sentar-se eretos podem precisar de um encosto mais alto que lhes dê mais suporte para a coluna. Há duas medidas de altura do encosto no formulário de avaliação para cadeira de rodas (ver Etapa 2: Avaliação, na seção “Medidas”). Tire ambas as medidas, porque às vezes não está claro na avaliação qual altura de encosto será mais confortável para o usuário. Continua... 65 Continuação Um encosto que proporcione suporte até a última costela do usuário é uma boa altura se o usuário: • estiver fisicamente bem e for ativo; • puder sentar-se ereto com facilidade e bom equilíbrio; • puder impulsionar sozinho a cadeira, e precisar de liberdade de movimento. Altura do encosto D (última costela) Um encosto que proporcione suporte até o ângulo inferior da escápula do usuário é uma boa altura se o usuário: • cansar-se facilmente, por exemplo, idosos ou pessoas com doença progressiva; • tiver alguma dificuldade para se sentar ereto. Esta altura de encosto ainda permite alguma liberdade de movimento dos ombros para o usuário impulsionar Altura do encosto E (ângulo inferior da escápula) Posição das rodas traseiras – para impulso com as mãos Ajuste correto: Quando as mãos estão nos aros de impulsão, os cotovelos do usuário devem estar em ângulo reto. Como verificar • Peça que o usuário segure os aros de impulsão no alto das rodas. O cotovelo deve estar dobrado em 90 graus. • Verifique também com o usuário se as rodas traseiras estão posicionadas corretamente para dar equilíbrio (para frente para ativo; para trás para seguro). Se o usuário precisar que as rodas traseiras sejam posicionadas na posição “seguro” (mais para trás), isso pode significar que os braços ficam mais para trás e isso é ideal para impulsionar a cadeira. Explique isso para o usuário. Se for feito algum ajuste na posição das rodas traseiras, os freios também terão que ser ajustados e testados novamente. Altura do assento – para impulso com os pés Ajuste correto: • Com o usuário sentado ereto e a parte de trás da pelve confortavelmente apoiada no encosto, ele deve ser capaz de apoiar os pés inteiros no chão. Continua... 66 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Continuação Como verificar • Peça para o usuário sentar-se com a pelve apoiada no encosto e o pé que impulsiona totalmente apoiado no chão. Verifique se os pés podem se apoiar inteiramente no chão. Se o assento estiver alto demais, a equipe pode tentar: • reduzir a altura da almofada; • colocar um assento sólido mais baixo que o assento original (procurar auxílio ou suporte técnico para fazer isso). Para um usuário que esteja movendo a cadeira com um só pé e mantendo o outro no apoio, verifique a pressão sob o osso do ísquio do lado do pé que fica em repouso sobre o apoio para os pés (consulte A.7: Almofadas, seção “Como testar se uma almofada para alívio da pressão está funcionando”). Verifique a postura Observe de lado e de frente como o usuário está sentado na cadeira. Ele está sentado em postura ereta? Alguns usuários gostam de posicionar os pés sob o corpo. Alguns modelos de cadeiras de rodas permitem isso. Se o usuário estiver confortável e se sentir equilibrado, não há nenhum problema. Verifique a pressão Para todos os usuários em risco de desenvolver úlceras/feridas, verifique se a pressão sob o osso do ísquio é segura. 67 Verifique a adequação enquanto o usuário se move A última parte da adequação é verificar como a cadeira de rodas se ajusta quando o usuário está em movimento. Se o usuário não puder impulsionar a cadeira de rodas independentemente, peça que um parente/cuidador a empurre. O que olhar: • O encosto permite que o usuário tenha liberdade para mover os ombros e impulsionar a cadeira? • Os pés do usuário mantêm-se no apoio para os pés? • A posição das rodas traseiras está correta para o usuário? Lista de verificação para a adequação da cadeira de rodas 1. A cadeira de rodas está pronta? A cadeira de rodas foi verificada para garantir que está segura para uso e que todas as suas partes estão funcionando?  2. Verificação de tamanho e ajustes Largura do assento Deve se ajustar perfeitamente.  Profundidade do assento Espaço livre de dois dedos (30 mm) entre parte de trás do joelho e o assento/ almofada.  Altura do apoio para os pés: As coxas estão totalmente apoiadas na almofada sem espaços livres. Os pés estão totalmente apoiados nos apoios sem espaços livres.  Continua... 68 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Continuação Altura do encosto: O usuário tem o suporte necessário e liberdade para mover seus ombros e impulsionar a cadeira (se for capaz de impulsioná-la sozinho).  Posição das rodas traseiras (para impulso com as mãos): Quando pendentes ao lado do corpo, os membros superiores do usúario devem estar alinhados com o eixo traseiro. Quando as mãos estiverem colocadas no aro de impulsão, o cotovelo deve estar em ângulo reto.  Freios: os freios estão funcionando?  Altura do assento (para impulso com o pé): Com o usuário sentado ereto, as costas devem estar confortavelmente apoiadas no encosto e os pés apoiados inteiramente no chão.  3. Verificação de postura O usuário está apto a sentar-se ereto de forma confortável?  Verificação da postura pela lateral.  Verificação da postura de frente/costas.  4. Verificação da pressão Verifique a pressão sob o osso do ísquio em usuários em risco de desenvolver úlceras/feridas. Explique o teste para o usuário. B Peça que o usuário se incline para frente ou erga o corpo. Coloque a ponta dos dedos sob o osso do ísquio do usuário. Continua... 69 Continuação C Peça que o usuário sente-se novamente sobre seus dedos. Tenha certeza de que ele se sentou ereto, com as mãos sobre as coxas. D Identifique a pressão: Nível 1 = seguro: As pontas dos dedos podem se mover para cima e para baixo 5 mm ou mais. Nível 2 = atenção: As pontas dos dedos não podem se mover, mas podem deslizar para fora com facilidade. Nível 3 = inseguro: As pontas dos dedos estão firmemente presas. É difícil deslizar os dedos para fora. E Repita em ambos os lados do osso do ísquio. 5. Verificação da adequação enquanto a cadeira de rodas se move O encosto permite ao usuário movimentar os ombros livremente para impulsionar a cadeira?  O encosto dá suporte suficiente ao usuário?  Os pés do usuário mantêm-se no apoio para os pés?  A rodas traseiras estão na posição correta para o usuário?  6. Ação? É necessária mais alguma ação? Em caso afirmativo, anote no prontuário/processo clínico do usuário.  Lembre-se: O próximo passo depois da adequação é o treinamento do usuário. Solução de problemas Às vezes os profissionais encontrarão problemas para ajustar corretamente a cadeira de rodas disponível para o usuário. Um problema pode acontecer se: • houver uma variedade limitada de cadeiras de rodas e tamanhos disponíveis; • o usuário precisar de suporte extra para sentar-se ereto com conforto. Abaixo estão algumas sugestões simples para alguns problemas comuns. Fazer modificações e oferecer mais suporte postural são temas cobertos de modo muito mais detalhado no treinamento de nível intermediário. Todas estas soluções pressupõem que a cadeira de rodas do tamanho mais próximo para o usuário já tenha sido selecionada entre as disponíveis. Sempre confira isso antes de modificar uma cadeira de rodas. 70 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Problema: Profundidade do assento muito curta. Se a profundidade do assento (da frente até o fundo) for mais de 100 mm mais curta do que a profundidade ideal do assento do usuário (para um adulto), isso é um problema. O usuário não terá suporte suficiente do assento para poder se sentar com conforto. O alívio da pressão também é reduzido. A profundidade do assento precisa ser aumentada. Solução: Três soluções diferentes são descritas abaixo: Solução Cautela 1. Aumente a profundidade do assento da cadeira estendendo os trilhos do assento e substituindo o estofamento. • Se a cadeira de rodas for de estrutura dobrável, verifique se os trilhos do assento são “exclusivos”, isto é se eles não são também parte da estrutura da cadeira de rodas. • Nesse caso, pode ser feita uma extensão dos trilhos do assento e um novo estofamento no comprimento correto. 2. Aumente a profundidade do assento da cadeira substituindo o estofamento. Se a cadeira de rodas for de estrutura rígida com estofamento, verifique se os trilhos do assento se estendem além do assento. Nesse caso, pode ser possível trocar o estofamento do assento por um novo estofamento feito do tamanho correto. 3. Aumente a profundidade do assento da cadeira acrescentando uma tábua rígida com uma almofada. • Um assento rígido pode ser feito de madeira, plástico ou qualquer outro material rígido que não flexione ou quebre. • O assento pode ser fixado sobre os trilhos do assento. • Acrescente uma almofada que seja da mesma largura e profundidade do novo assento. • Certifique-se de que o novo assento seja forte o bastante para suportar o peso do usuário. Verifique se o assento não se flexiona ou quebra na parte além do assento original da cadeira de rodas. • Sempre forneça uma almofada junto com um assento rígido, para todos os usuários. • Confira durante a adequação se o encosto e os apoios para os pés são da altura certa. O assento rígido e a almofada elevarão o usuário na cadeira de rodas. Problema: Profundidade do assento muito longa. Se a menor profundidade de assento disponível for longa demais, será impossível para o usuário sentar-se ereto. A profundidade do assento precisa ser reduzida. 71 Solução: Uma solução é descrita abaixo. Solução Cautela 1. Reduza a profundidade do assento da cadeira. • Marque a profundidade correta no assento existente. • Se o assento for estofado, remova o estofamento, encurte-o (usando uma máquina de costura industrial) e substitua-o. • Se o assento for rígido, remova o assento, encurte-o e recoloque-o. • Encurte a almofada para adequar-se à nova profundidade. • Ao cortar um assento rígido, sempre se assegure de que todas as bordas estejam lisas e sem farpas. • Ao cortar uma almofada, sempre corte a parte da frente, para que os contornos de alívio da pressão atrás não sejam alterados. Problema: Apoio para os pés muito baixo. Se a altura do apoio para os pés estiver muito baixa, o usuário não poderá apoiar os pés com conforto. Isso pode fazê-lo escorregar para frente na cadeira de rodas, ou sentir-se instável. Não haverá suporte suficiente para sentar-se ereto com conforto. O apoio para os pés terá que ser levantado. Solução: Duas soluções são descritas abaixo. Solução Cautela 1. Aumente a altura do apoio para os pés encurtando o suporte do apoio para os pés. • Na maioria das cadeiras de rodas de quatro rodas, o suporte do apoio para os pés pode ser encurtado. Sempre confira se o mecanismo de ajuste do apoio para os pés continua funcionando. 2. Aumente a altura do apoio para os pés acrescentando um preenchimento. • Use madeira ou outro material resistente para acrescentar altura ao apoio para os pés. Verifique se o acréscimo não impede que o apoio para os pés seja movido para o lado em transferências. Apoio para os pés elevado por um preenchimento de altura (nesta ilustração, apenas um lado foi elevado para acomodar o encurtamento de uma perna). Problema: Apoio para os pés muito alto. Se a altura do apoio para os pés estiver muito alta, as coxas do usuário não repousarão com conforto no assento. Apoios para os pés altos demais podem aumentar a pressão no osso do ísquio. O apoio terá que ser baixado. 72 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Solução: Duas soluções possíveis são descritas abaixo. Solução Cautela 1. Baixe o apoio para os pés aumentando o tubo extensor interno. • Verifique se o tubo extensor interno pode ser substituído por um tubo mais longo. • Se puder, substitua-o por um tubo similar de mesmo diâmetro e resistência. Certifique-se de que os apoios não fiquem baixos demais a ponto de tocar o chão. Se isso acontecer, experimente a opção 2. Se não funcionar, a cadeira de rodas não é adequada para o usuário. 2. Aumente a altura da almofada. • Aumente a altura da almofada ou eleve a almofada acrescentando algo sólido sob ela. Não use espuma macia para aumentar a altura da almofada. Ela vai se comprimir e dar sensação de instabilidade. Verifique durante a adequação se o encosto está na altura correta. A almofada mais alta elevará o usuário na cadeira. Verifique se não há problemas funcionais com a elevação da almofada. Por exemplo, o usuário pode não caber mais sob mesas ou escrivaninhas. Problema: As pernas do usuário tendem a girar para dentro ou para fora. Às vezes as pernas do usuário escorregam para dentro ou para fora. Isso pode acontecer pelo modo como ele está acostumado a se sentar ou pode ter uma razão física (por exemplo, fraqueza muscular). Ajustes simples no assento ou na almofada da cadeira de rodas podem ajudar a minimizar esse problema. Solução: Três soluções possíveis são descritas abaixo. Solução 1. Confira a altura do apoio para os pés. Certifique-se de que a altura do apoio para os pés esteja dando bom suporte para o usuário (deve ser sentida uma pressão uniforme sob os pés e sob as coxas). 2. Verifique se o assento está com a tensão correta. • Se a cadeira de rodas tiver um assento estofado, certifique-se de que ele esteja firmemente tensionado. • Se o assento estiver frouxo, isso fará as pernas do usuário tenderem a girar para dentro. 3. Acrescente calços à almofada para apoiar as coxas em posição neutra (como no DVD e ilustração) ou forneça uma almofada com contornos. Modifique a almofada se necessário. • Algumas almofadas para alívio da pressão com contornos têm uma elevação entre as coxas, o que ajudará a manter as pernas confortavelmente separadas. A elevação pode ser aumentada para dar mais suporte, se necessário. • Algumas almofadas para alívio da pressão com contornos têm “calhas” para encaixar as pernas. As bordas da calha podem ser aumentadas para impedir as pernas de escorregar para fora. 73 Calço acrescentado à parte dianteira central de uma almofada para ajudar a manter as pernas do usuário ligeiramente afastadas. Calços acrescentados às laterais frontais de uma almofada para ajudar a evitar que as pernas do usuário desloquem-se para fora. Problema: Pés tendem a escorregar dos apoios Às vezes, os pés do usuário deslizam para fora do apoio para os pés. Isso, com frequência, tem uma razão física (por exemplo, fraqueza muscular ou espasmos musculares). Solução: Três soluções são descritas abaixo. Solução Cautela 1. Confira a altura do apoio para os pés. • Certifique-se de que a altura do apoio para os pés esteja dando bom suporte para o usuário (deve ser sentida uma pressão uniforme sob os pés e sob as coxas). Sempre confira se o mecanismo de ajuste do apoio para os pés continua funcionando. 2. Ajuste o ângulo do apoio para os pés (se possível). • Verifique se o ângulo do apoio para os pés pode ser ajustado. • Se puder, experimente aumentar o ângulo do apoio. Isso pode ajudar a manter os pés do usuário no lugar. Confira se ainda há uma pressão uniforme sob os pés. 3. Acrescente uma faixa. • Prenda uma faixa aos suportes do apoio para os pés, no nível dos tornozelos. • Se os pés tenderem a deslizar para trás, a faixa passa atrás das pernas. • Se os pés tenderem a deslizar para frente, a faixa passa na frente das pernas. Certifique-se de que a faixa seja fácil de remover, para que o usuário possa transferir-se da cadeira de rodas sem esforço. Verifique se o usuário alcança a faixa sem assistência e consegue colocá-la e retirá-la com facilidade. 74 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Uma faixa pode ajudar a manter as pernas do usuário no lugar. Faixas atrás dos pés podem dar mais suporte, ajudando a evitar que as pernas do usuário deslizem para trás do apoio para os pés. Problema: A cadeira de rodas é muito larga. Às vezes a menor cadeira de rodas disponível ainda é muito larga para o usuário. Se o assento da cadeira de rodas for muito largo, o usuário terá dificuldade para sentar-se ereto e pode cair para um lado. Algumas inserções simples de espuma podem ajudar a dar apoio para que o usuário sente-se ereto. Solução: Uma solução é descrita abaixo. Solução Cautela 1. Acrescente inserções de espuma dos dois lados da pelve. • Meça o espaço entre o usuário (sentado centralizado na cadeira de rodas com as costas apoiadas no encosto) e as laterais de cada apoio para os braços. • Corte e posicione pedaços de espuma para preencher o espaço entre cada lado da cadeira e o usuário. • Confira a adequação. • Encape e prenda os pedaços de espuma. Se os apoios para os braços forem sólidos, as inserções podem ser presas nos apoios. Elas também podem ser presas ao topo da almofada. As inserções precisam se estender apenas ao longo do tronco do usuário. Assegure-se de que a almofada corresponda à largura do assento. Se a cadeira for muito larga, o usuário também terá dificuldade para alcançar os aros de impulsão. Ter que se esticar demais para alcançar os aros pode causar lesão nos ombros. Analise atentamente se a cadeira de rodas é segura para o usuário antes de prescrevê-la (selecioná-la). Inserções de espuma podem reduzir a largura interna da cadeira de rodas. 75 Etapa 7: Treinamento de usuários Informações e treinamento para uso da cadeira de rodas podem ajudar muitos usuários a realmente se beneficiar com sua cadeira de rodas. Sem esta etapa, é possível que a cadeira não ajude o usuário tanto quanto poderia. Quais são as habilidades úteis para o usuário? As seis coisas mais importantes a ser ensinadas são: • como manusear a cadeira de rodas; • como transferir-se da cadeira de rodas; • mobilidade em cadeira de rodas – de acordo com as necessidades do usuário; • como evitar úlceras/feridas e o que fazer se surgir uma úlcera/ferida; • como cuidar da cadeira de rodas e da almofada em casa; • o que fazer se houver um problema. A lista de verificação na próxima página traz as habilidades específicas que um usuário pode ter que aprender. Alguns usuários já terão essas habilidades e nem todas as habilidades são importantes para todos os usuários. Os profissionais podem usar essa lista de verificação para selecionar o treinamento que o usuário precisa. Isso é decidido por meio de avaliação e de conversa com o usuário. Alguns serviços podem usar essa lista de verificação como um formulário mantido nos registros do usuário. Nesse caso, a lista de verificação também pode ser usada para registrar o treinamento oferecido. Sempre verifique com o usuário se ele gostaria que seu cuidador também aprendesse as habilidades que estão sendo ensinadas. Muitos usuários são ajudados por familiares ou um cuidador e é útil que todos os envolvidos aprendam como usar e cuidar da cadeira de rodas. Como fazer com que o treinamento do usuário tenha sucesso • Descubra o que o usuário já sabe. • Explique, demonstre e, depois, faça o usuário praticar. • Use uma linguagem que todos possam compreender. • Tenha usuários ensinando a outros usuários. • Use boas habilidades de comunicação. • Seja encorajador. 76 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Lista de verificação de treinamento de usuários Habilidades a ensinar Habilidades ensinadas Manuseio da cadeira de rodas Dobrar a cadeira de rodas Erguer a cadeira de rodas Usar rodas de remoção rápida Usar os freios Usar a almofada, incluindo posicioná-la corretamente Transferências Transferência independente Transferência assistida Outra Mobilidade na cadeira de rodas Impulsionar corretamente Subir e descer rampas Subir e descer escadas Impulsionar em terreno irregular Empinar parcialmente Prevenção de úlceras/feridas de pressão Verificar a existência de úlceras/feridas de pressão Elevação para alívio de pressão (push up) Comer adequadamente e tomar boa quantidade de água O que fazer se aparecerem úlceras/feridas de pressão Cuidados com a cadeira de rodas em casa Limpar a cadeira de rodas e a almofada Lubrificar as partes móveis Calibrar os pneus Apertar porcas e parafusos (se frouxos) Apertar os raios (se frouxos) Verificar estofado do encosto Verificar se há ferrugem Verificar a almofada O que fazer se houver problemas A cadeira de rodas precisa de reparos A cadeira de rodas não é adequada ou não é confortável 77 Etapa 8: Manutenção, reparos e acompanhamento Cuidados constantes com a cadeira de rodas e a almofada poupam custos de consertos, estendem a vida últil da cadeira de rodas e evitam lesões e danos de longo prazo no corpo do usuário. Uma cadeira de rodas bem cuidada será mais confortável e eficiente pois exigirá menos esforço e será mais fácil de usar. Uma almofada bem cuidada continuará a proporcionar alívio da pressão e suporte. A equipe do serviço de cadeiras de rodas tem a responsabilidade de informar aos usuários como cuidar de sua cadeira de rodas e almofada em casa. Para evitar reparos: manutenção em casa Há seis coisas que os usuários podem fazer em casa para cuidar de sua cadeira de rodas e almofada. Mostre aos usuários como cuidar da cadeira de rodas e da almofada em casa e explique por que isso é importante. A tabela na próxima página explica o que precisa ser feito, por que é importante e como fazer. Recursos locais para reparos de cadeiras de rodas Descubra quem pode ajudar a consertar cadeiras de rodas em sua área. Locais e profissionais possíveis são: • oficinas de bicicletas; • mecânicos de motocicletas ou carros; • oficinas de solda, encanadores (partes de metal), marceneiros, moveleiros (partes de madeira); • usuários, familiares, parentes ou vizinhos de usuários; • alfaiate e costureiras para consertar estofamento; • serviços de cadeiras de rodas. 78 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Como cuidar de uma cadeira de rodas em casa Por que isto é importante? Como fazer 1. Limpar a cadeira de rodas e a almofada Evita que as partes de metal enferrujem. Evita que as partes de madeira e estofadas apodreçam. Evita danos causados pelo atrito da sujeira em partes móveis. Use água morna com um pouco de sabão. Lave e seque. Preste atenção nas partes móveis e nos pontos onde o estofamento encontra a estrutura. Remova a almofada da capa e lave separadamente. Sempre seque a almofada à sombra e não sob sol direto. 2. Lubrificar as partes móveis Mantém o movimento adequado das partes. Ajuda a evitar ferrugem. Limpe e seque a cadeira de rodas primeiro. Use um óleo lubrificante, por exemplo, óleo de rolamento. Aplique em todas as partes móveis. 3. Calibrar pneus (se for pneumática) Os pneus durarão mais. Facilita a impulsão da cadeira de rodas, exigindo menos esforço. Os freios funcionarão corretamente. Pressione o pneu com o polegar para verificar a pressão. Deve ser possível comprimir o pneu só um pouco (cerca de 5 mm). A pressão deve ser a mesma em todos os pneus. Encha usando uma bomba de bicicleta ou similar. Reduza a pressão soltando ar pela válvula. 4. Apertar porcas e parafusos (se estiverem frouxos) Parafusos frouxos causam movimentos indesejados das partes. Isso pode ser desconfortável e causar desgaste ou perda de partes. Examine a cadeira de rodas para ver se há parafusos frouxos. Aperte os parafusos frouxos com uma chave inglesa. Não aperte em excesso. Continua... 79 Continuação Por que isto é importante? Como fazer 5. Apertar raios (se estiverem frouxos) Raios frouxos podem fazer com que as rodas entortem e quebrem. Aperte os raios de dois em dois em toda a volta da roda. Se um raio “ceder” quando você apertar suavemente, ele pode estar muito frouxo. Aperte com uma chave de raio. Os raios também podem estar muito apertados. Se um raio parecer muito rígido, é provável que esteja apertado demais e deve ser afrouxado. 6. Fazer inspeções regulares Verificar ferrugem e estofamento A ferrugem reduz a resistência dos materiais. Isso pode fazer as partes quebrarem e pode levar a lesões no usuário. O estofamento deve estar em boas condições para dar suporte e conforto ao usuário. Se o estofamento rasgar de repente, o usuário pode se ferir. Examine as superfícies de metal pintadas para ver se há ferrugem / corrosão. Se houver ferrugem, use uma lixa de papel ou metal para remover a ferrugem. Limpe com tíner e um pano e repinte. Procure fendas, desgastes, sujeira ou pontas de metal salientes. Verifique se a tensão do assento e encosto está certa. Se o estofamento estiver rasgado ou a tensão de um assento flexível estiver muito frouxa, pode ser necessário consertar. Examinar a almofada As almofadas devem estar limpas e secas para ajudar a proteger a pele. As almofadas não duram tanto quanto as cadeiras de rodas. Um exame regular ajudará os usuários a reconhecer quando a almofada precisa ser trocada. Remova a capa. Examine se há pontos gastos, sujeira e furos na capa e na espuma. Se a almofada estiver gasta, ela deve ser examinada por profissionais de cadeiras de rodas. Talvez precise ser substituída. Consertos comuns de cadeira de rodas e almofada Cadeiras de rodas e almofadas às vezes precisarão de conserto. A equipe do serviço de cadeiras de rodas deve ser capaz de fazer o conserto ou informar ao usuário onde ele pode obter ajuda. Alguns usuários serão muito bons em fazer seus próprios consertos. Outros usuários podem precisar de ajuda para isso. Todos os usuários se beneficiarão com informações sobre onde levar sua cadeira de rodas e almofada para conserto. 80 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO O que é o acompanhamento e como ele é feito? O acompanhamento acontece depois que o usuário recebeu a cadeira de rodas e está usando-a por algum tempo. Visitas de acompanhamento são uma oportunidade para: • coletar informações do usuário; • verificar se a cadeira de rodas está funcionando bem; • verificar a adequação da cadeira de rodas. Todos os usuários se beneficiarão com uma visita de acompanhamento. No entanto, o acompanhamento é mais importante para: • crianças; • usuários em risco de desenvolver úlceras/feridas; • usuários que tenham alguma doença progressiva; • usuários que tenham tido dificuldade com alguma parte do treinamento e das instruções. Não há regra para quando o acompanhamento deve acontecer, embora uma sessão de acompanhamento após seis semanas da data de entrega da cadeira de rodas com frequência se mostre útil. Isso dependerá das necessidades do usuário. No entanto, para crianças, é ideal que o acompanhamento aconteça a cada seis meses. Isso porque as necessidades das crianças mudam rapidamente conforme elas crescem. O acompanhamento pode ser feito em uma visita domiciliar, em um centro ou em qualquer outro lugar que seja adequado para o usuário e os profissionais. Isso depende se o usuário tem ou não possibilidade de se deslocar até um centro, e de a equipe do serviço de cadeiras de rodas poder ou não se deslocar até a casa do usuário. Ações comuns no acompanhamento • Examinar se a cadeira de rodas está em ordem; • Dar mais orientações ou treinamento; • Se necessário, - reajustar a cadeira de rodas; - fazer pequenos reparos ou manutenção doméstica; - organizar consertos maiores ou ajudar o usuário a planejar os consertos. O formulário a seguir pode ser usado para orientar o acompanhamento. Os profissionais devem tomar nota de qualquer ação que seja necessária depois da visita de acompanhamento. 81 Maneiras de lidar com o acompanhamento • Marcar uma visita de acompanhamento com o usuário quando ele receber a cadeira de rodas. • Visitar usuários em casa para o acompanhamento, quando possível. • Fazer com que as visitas de acompanhamento sejam parte das visitas de rotina de agentes comunitários de reabilitação que tenham sido treinados para fazer o acompanhamento. • Organizar um acompanhamento por telefone se o transporte for difícil e o usuário tiver acesso a um telefone. 82 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Formulário de acompanhamento de cadeira de rodas Este formulário deve ser usado para registrar informações de visita de acompanhamento. 1. Informações do usuário Nome: Número: Data da adequação: Data do acompanhamento: Nome da pessoa que fez o acompanhamento: Acompanhamento feito em: Casa do usuário  Centro de serviço de cadeira de rodas  Outro: 2. Entrevista Registrar ação a ser tomada Você usa sua cadeira de rodas tanto quanto gostaria? Sim  Não  Se não, por quê? Você tem algum problema para usar sua cadeira de rodas? Sim  Não  Se sim, quais são os problemas? Você tem alguma dúvida sobre o uso de sua cadeira de rodas? Sim  Não  Se sim, quais são as dúvidas? É necessário mais treinamento? O usuário possui alguma úlcera/ferida? Sim  Não  Se sim, descreva (localização e estágio) Como você descreveria sua satisfação com sua cadeira de rodas de 1-5? (1 é insatisfeito e 5 é muito satisfeito) Nota: Comentários: 3. Verificação da cadeira de rodas e almofada A cadeira de rodas está funcionando bem e é segura? Sim  Não  A almofada está funcionando bem e é segura? Sim  Não  Caso tenha respondido não para alguma das duas perguntas, qual é o problema? 83 4. Verificação da adequação A cadeira de rodas se ajusta adequadamente ao corpo do usuário Sim  Não  Se não, qual é o problema? Teste do nível de pressão (1 = seguro, 2 = atenção, 3 = inseguro) (se o usuário corre risco de desenvolver escara) Esquerda: Direita: O usuário está sentado ereto confortavelmente quando parado, em movimento e ao longo do dia? Sim  Não  Se não, qual é o problema? NÍVEL BÁSICO Manual de Referência para os Participantes CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS

NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Manual do Instrutor NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Manual do Instrutor NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Manual do Instrutor CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Informações sobre a edição em inglês: Editores: Chapal Khasnabis e Kylie Mines Autores: Sarah Frost, Kylie Mines, Jamie Noon, Elsje Scheffler e Rebecca Jackson Stoeckle Revisores: Natasha Altin, Jo Armstrong, William Armstrong, Johan Borg, Jocelyn Campbell, Nelja Essaafi, Rob Horvath, Lauren Houpapa, Mohamed El Khadiri, R. Lee Kirby, Penny Knudson, Mark Kruizak, Bigboy Madzivanzira, Rob Mattingly, Cindy Mosher, Ritu Gosh Moulick, Alana Officer, Andrew Rose, Allan Siekman, Sue Steel Smith, Michiel Steenbeek, Claude Tardif e Isabelle Urseau Ilustração: Melissa Puust Crédito das fotos: Chapal Khasnabis e Jesse Moss Créditos de vídeo: Chapal Khasnabis, Amanda McBaine, e Jesse Moss Instrutores dos cursos Lauren Houpapa, Charles Kanyi, Norah Keitany, Seraphine Ongogo, M. Vennila Palanivelu Sama piloto: Raju, e Elsie Taloafiri Apoio financeiro: Agência dos Estados Unidos da América para o Desenvolvimento Internacional e Agência Australiana para o Desenvolvimento Internacional Organizações parceiras: ASSERT Timor Leste, Associação para os Deficientes Físicos do Quênia (APDK), Unidade de Reabilitação Baseada na Comunidade do Ministério de Serviços Médicos e de Saúde das Ilhas Salomão, Centro de Desenvolvimento da Educação (EDC), Handicap International, Comitê Internacional da Cruz Vermelha (CICV), Sociedade Internacional para Protéticos e Ortóticos (ISPO), Associação de Pessoas com Lesão Medular do Kilimanjaro (KASI), Mobility India, Motivation Australia, Motivation Charitable Trust (Motivation), Motivation Romania e Centro de Treinamento para Tecnólogos Ortopédicos da Tanzânia (TATCOT) Publicado pela Organização Mundial da Saúde em 2012 sob o título Wheelchair Service Training Package: Basic Level © Organização Mundial da Saúde 2012 © Secretaria de Estado dos Direitos da Pessoa com Deficiência de São Paulo 2014 O Diretor Geral da Organização Mundial da Saúde concedeu os direitos de tradução e publicação da edição em Língua Portuguesa à Secretaria de Estado dos Direitos da Pessoa com Deficiência de São Paulo, a qual é a única responsável pela exatidão da edição em Língua Portuguesa. Pacote de Treinamento em Serviços para Cadeiras de Rodas Conteúdo: Manual do Instrutor, nível básico – Manual de Referência para os Participantes, nível básico – Apostila do Participante, nível básico – Pôsteres e slides, nível básico. Manual do instrutor e slides disponíveis apenas em DVD. 1. Cadeiras de rodas – padrões; 2. Pessoas com deficiência – reabilitação; 3. Materiais de ensino. Terminologia Os termos usados neste pacote de treinamento estão definidos abaixo. Cadeira de rodas apropriada Cadeira de rodas que atende às necessidades do usuário e leva em consideração as condições ambientais; oferece conforto adequado e suporte postural; é segura e durável; está disponível no país; pode ser obtida e mantida com serviços oferecidos no país por um valor econômico e acessível. Cadeira de rodas manual Cadeira de rodas impulsionado pelo próprio usuário ou empurrada por uma outra pessoa. Cadeira de rodas Equipamento que proporciona mobilidade sobre rodas e suporte para o assento de uma pessoa com dificuldade para andar ou se movimentar. Fornecimento de cadeira de rodas Abrange o projeto, a produção, o fornecimento e a prestação de serviços para cadeira de rodas. Serviços de cadeira de rodas A parte de fornecimento de cadeira de rodas que assegura a provisão de cadeiras de rodas apropriadas aos usuários. Equipe de serviços de cadeira de rodas Pessoas capacitadas no fornecimento de cadeira de rodas apropriadas. Usuário de cadeira de rodas Pessoa com dificuldade para andar ou se movimentar que requer o uso da cadeira de rodas para sua mobilidade. SU M Á R IO Sobre o Pacote de Treinamento de Serviços para Cadeira de Rodas: Nível Básico Introdução Público-alvo Objetivo Escopo Instrutores Como começar 1. Notas de orientação para instrutores 1.1 Visão geral do treinamento 1.2 Cronograma e duração do pacote de treinamento 1.3 Planos das sessões 1.4 Apresentações em PowerPoint 1.5 Como observar/monitorar o progresso dos participantes 1.6 Avaliação do programa de treinamento como um todo 1.7 Dicas de boas práticas de treinamento 2. Como se preparar para ministrar o pacote de treinamento 2.1 Conhecer a rede de serviços para cadeira de rodas dos participantes 2.2 Esclarecer a função dos participantes nos serviços para cadeira de rodas 2.3 Rever cada plano de sessão e ajustar se necessário 2.4 Identificar as cadeiras de rodas que serão usadas 2.5 Convidar usuários para as sessões práticas 1 1 1 2 2 3 4 5 5 6 6 7 7 8 8 10 10 10 10 11 11 13 13 14 19 20 23 24 30 37 44 54 67 87 99 108 109 113 118 131 144 156 159 162 169 2.6 Planejar grupos para as sessões práticas 2.7 Preparar as instalações 2.8 Preparar os recursos e materiais de treinamento 3. Planos detalhados das sessões Introdução A: Conceitos fundamentais A.1: Usuários de cadeiras de rodas A.2: Serviços para cadeira de rodas A.3: Mobilidade em cadeira de rodas A.4: Sentar-se ereto A.5: Úlceras/feridas de pressão A.6: Cadeira de rodas apropriada A.7: Almofadas A.8: Transferências B: Etapas do serviço para cadeira de rodas B.1: Encaminhamento e agendamento B.2: Avaliação B.3: Entrevista de avaliação B.4: Avaliação física B.5: Prescrição (seleção) B.6: Financiamento e Aquisição Prática 1: Avaliação e prescrição (seleção) B.7: Preparação do produto (cadeira de rodas) B.8: Fabricação da almofada B.9: Adequação B.10: Solução de problemas B.11: Treinamento de usuários B.12: Manutenção e reparos Prática 2: Adequação e treinamento de usuários B.13: Acompanhamento Prática 3: Acompanhamento Prática 4: Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação e treinamento de usuários. B.14: Juntando tudo Anexos Anexo 1: Cronograma do pacote de treinamento de serviços para cadeiras de rodas Anexo 2: Formulário de Encaminhamento para Serviços de Cadeira de Rodas Anexo 3: Formulário de Avaliação para Serviços de Cadeira de rodas Anexo 4: Formulário de Prescrição (seleção) de cadeira de rodas Anexo 5: Formulário de Resumo da Cadeira de rodas Anexo 6: Lista de Verificação da Cadeira de Rodas Segura e Pronta para Uso Anexo 7: Lista de Verificação da Adequação da cadeira de rodas Anexo 8: Lista de Verificação do Treinamento de usuário Anexo 9: Formulário de Acompanhamento de Serviços de Cadeira de Rodas Anexo 10: Lista de Verificação das Observações do Instrutor 169 178 195 201 207 212 217 220 224 228 228 230 231 234 235 236 237 239 240 242 1Sobre o Pacote de Treinamento em Serviços para Cadeira de Rodas: Nível Básico Introdução A OMS desenvolveu este Pacote de Treinamento em Serviços para Cadeira de Rodas – Nível Básico para garantir a melhor implementação das diretrizes sobre o fornecimento de cadeira de rodas em locais com poucos recursos. A necessidade de pessoal especializado em cadeira de rodas é universal. A cadeira de rodas é um dos equipamentos mais comumente usados para permitir mobilidade pessoal, mas existem pouquíssimas oportunidades de treinamento para os prestadores de serviço para garantir que os usuários de cadeira de rodas possam ter mobilidade pessoal com a maior independência possível, possam ser produtivos e ter alta qualidade de vida. Este pacote de treinamento de nível básico é a primeira parte de uma série de cursos de treinamento de serviços para cadeira de rodas. O Pacote de Treinamento de Serviços para Cadeira de Rodas – Nível Básico contém uma série de documentos e apresentações para ministrar o treinamento sobre cadeira de rodas. O mais importante deles é o Manual do Instrutor. Por razões práticas, o Manual do Instrutor só está disponível em formato eletrônico (não existe versão impressa). O disco contém o Manual do Instrutor e todos os outros materiais informativos necessários para ministrar um programa de treinamento de nível básico para serviços para cadeira de rodas. Público-alvo Este pacote de treinamento é destinado a todas as pessoas ou voluntários que devam prestar serviços para cadeira de rodas em seu local de trabalho. Podem ser profissionais da saúde, reabilitação ou técnicos, agentes de saúde, profissionais de reabilitação na comunidade (CBR), terapeutas ocupacionais, fisioterapeutas, técnicos de órteses e próteses, artesãos locais, técnicos e usuários. O programa de treinamento foi elaborado pressupondo que os participantes terão os seguintes conhecimentos e aptidões: • os participantes devem saber ler e escrever no idioma do programa de treinamento; • os participantes devem ter conhecimento básico das incapacidades físicas comuns que podem afetar os usuários, inclusive paralisia cerebral, amputação de membros inferiores, poliomielite (pólio), lesão medular e AVC/trombose cerebral. Quando os participantes não tiverem as informações sobre as incapacidades físicas comuns, os instrutores devem incluir essas informações como uma sessão extra de conhecimentos fundamentais. CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 2CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Objetivo O objetivo do Pacote de Treinamento de Nível Básico é dar suporte ao treinamento de profissionais ou de voluntários para que forneçam cadeiras de rodas manuais e almofadas adequadas para meninas, meninos, mulheres e homens que tenham problemas de mobilidade, mas que consigam sentar-se eretos sem suporte postural adicional. O principal objetivo deste Pacote de treinamento é desenvolver as aptidões e os conhecimentos do pessoal envolvido em serviços para cadeira de rodas. Este treinamento vai ajudar a: • Aumentar o número de usuários que recebem uma cadeira de rodas que atende às suas necessidades; • Aumentar o número de usuários que recebem treinamento no uso e manutenção da cadeira de rodas e sobre como permanecer saudável em uma cadeira de rodas; • Aumentar o número de pessoas treinadas em serviços para cadeira de rodas de nível básico; • Melhorar as competências dos prestadores de serviço para cadeira de rodas; • Melhorar a qualidade da prestação de serviços para cadeira de rodas; e • Conseguir melhor integração entre a prestação de serviços para cadeira de rodas e os serviços de reabilitação. Escopo O pacote de treinamento contém: • Conhecimentos fundamentais necessários para a prestação de serviços para cadeira de rodas; • Visão geral das principais etapas dos serviços para cadeira de rodas descritas nas Diretrizes da OMS para o fornecimento de cadeira de rodas manuais em locais com poucos recursos (Tabela 1); • Trabalho com os usuários para avaliar suas necessidades de mobilidade e identificar a melhor solução possível de mobilidade; • Fornecimento de cadeira de rodas adequada com almofada adequada; • Solução de problemas para encontrar modificações simples na cadeira de rodas que possam ajudar a garantir a melhor adequação ao usuário; • Reparo e manutenção de cadeira de rodas; • Treinamento dos usuários para fazer o melhor uso da cadeira de rodas; e • Fabricação de almofada de espuma moldada. A inclusão de modificações simples nas cadeiras de rodas é particularmente importante em contextos onde existem poucos modelos e tamanhos de cadeiras de rodas manuais. 3Em geral é preciso fazer modificações simples para garantir a adequação correta da cadeira de rodas. O fornecimento de triciclos não é abordado em detalhes neste pacote de treinamento, embora seja reconhecido o valor de triciclos para usuários que precisam percorrer longas distâncias. Tabela 1. Principais etapas da prestação de serviços para cadeira de rodas: Etapa 1 Encaminhamento e agendamento Etapa 2 Avaliação Etapa 3 Prescrição (seleção) Etapa 4 Financiamento e aquisição Etapa 5 Preparação do produto (cadeira de rodas) Etapa 6 Adequação Etapa 7 Treinamento de usuários Etapa 8 Manutenção, reparos e acompanhamento Instrutores Habilidades: Este pacote de treinamento se baseia na disponibilidade de instrutores aptos a prestar serviços para cadeira de rodas e que possam demonstrar com confiança as competências ensinadas neste programa de treinamento. Também é aconselhável ter experiência prévia como instrutor. Usuários de cadeiras de rodas: A inclusão de um usuário nesta equipe de treinamento é altamente recomendada. Os usuários sabem usar sua experiência para ensinar os outros. Os usuários também sabem demonstrar várias das técnicas ensinadas durante o programa de treinamento. Ser treinado por um usuário ajuda os participantes a dar valor à função fundamental dos usuários na escolha de sua própria cadeira de rodas. Número de instrutores: Recomenda-se que haja dois instrutores para cada 8-10 participantes. Essa relação é particularmente importante para as sessões práticas, para que os instrutores possam dar aos participantes um bom suporte e feedback e garantir que todos os envolvidos possam treinar com segurança. Ter um usuário experiente que conheça bem o assunto e o pacote de treinamento também pode ser um ponto positivo durante o programa de treinamento. 4CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Como começar Antes de ministrar o programa de treinamento, você precisa copiar o disco (dentro da pasta) em seu disco rígido. Você precisa de aproximadamente 8 Gb de memória e de um DVD player para usar esse disco de treinamento. A maneira mais simples de ministrar este programa de treinamento é: 1. Abrir o Manual do Instrutor na pasta do manual. 1.1 Ler as seções Sobre o Pacote de Treinamento de Serviços para Cadeira de Rodas e as Notas de Orientação para Instrutores; 1.2 Imprimir e encadernar uma cópia do Manual do Instrutor para cada instrutor; 1.3 Imprimir um cronograma e as listas de verificação das observações do instrutor; 1.4 Imprimir os formulários do programa, os formulários de avaliação do programa de treinamento e os formulários de serviços para cadeira de rodas, inclusive as listas de verificação. 2. Fazer todos os arranjos necessários, sugeridos na seção Como Se Preparar para Ministrar o Pacote de Treinamento. 3. Dar aos participantes um conjunto completo dos materiais de treinamento, inclusive: Manual de Referência (1 por participante), Apostila do Participante (1 por participante) e um conjunto de pôsteres (1 conjunto por participante). Se você não os tiver em estoque, eles podem ser impressos do disco. 4. Abrir o cronograma e clicar nos hyperlinks de cada sessão, que o levarão para a localização exata dos slides e do vídeo. A melhor forma de ministrar o treinamento é seguir as aulas na ordem sequencial respeitando o tempo alocado para cada sessão o máximo possível. 51. Notas de orientação para instrutores 1.1 Visão geral do treinamento minutos Boas-vindas, introdução e visão geral. Introdução 60 A: Conceitos fundamentais Sessões que dão aos participantes o conhecimento básico para participar das sessões sobre etapas de serviços para cadeira de rodas. A.1 Usuários de cadeiras de rodas 45 A.2 Serviços para cadeira de rodas 30 A.3 Mobilidade em cadeira de rodas 90 A.4 Sentar-se ereto 60 A.5 Úlceras/feridas de pressão 60 A.6 Cadeira de rodas apropriada 120 A.7 Almofadas 75 A.8 Transferências 120 B: Serviços para cadeira de Rodas Encaminhamento e agendamento B.1 Encaminhamento e agendamento 30 Avaliação B.2 Avaliação 30 B.3 Entrevista de avaliação 90 B.4 Avaliação física 90 Prescrição (seleção) B.5 Prescrição (seleção) 120 Financiamento e aquisição B.6 Financiamento e aquisição 15 Prática 1 Avaliação e prescrição (seleção) 90 Preparação do produto (cadeira de rodas) B.7 Preparação do produto (cadeira de rodas) 75 B.8 Fabricação de almofadas 120 Adequação B.9 Adequação 60 B.10 Solução de problemas 45 Treinamento de usuários B.11 Treinamento de usuários 60 Manutenção, reparos e acompanhamento B.12 Manutenção e reparos 120 Prática 2 Adequação e treinamento de usuários 120 Manutenção, reparos e acompanhamento B.13 Acompanhamento 45 Prática 3 Acompanhamento 90 Prática 4 Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas, adequação e treinamento de usuários) 240 B.14 Juntando tudo 105 6CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1.2 Cronograma e duração do pacote de treinamento Este pacote de treinamento deve ser ministrado em dias consecutivos ou em blocos durante um período de tempo. O tempo mínimo para ministrar todo o pacote de treinamento de nível básico é de 35-40 horas. O plano de sessões contém uma estimativa do tempo necessário para ministrar cada sessão. Nota – o tempo real necessário para cada sessão vai variar dependendo dos seguintes fatores: • Experiência e aptidão dos participantes; • Número total de participantes; • Número de cadeiras de rodas disponíveis no local; • Necessidade ou não de tradução durante as sessões; • Se existe ou não material extra. Dependendo desses fatores, será necessário mais ou menos tempo para completar o programa de treinamento. O Anexo 1 contém um exemplo de cronograma de cinco dias. O DVD também contém esse modelo e um cronograma em branco. Estimulamos os instrutores a adaptar e modificar o cronograma para atender ao contexto local e às necessidades dos participantes. Por exemplo: • As sessões do pacote de treinamento podem ser incorporadas a programas existentes de treinamento em saúde ou reabilitação; • Sempre que o pessoal de reabilitação já tiver sido treinado em alguns aspectos do programa de treinamento, as sessões correspondentes poderão ser desnecessárias; • Quando as cadeiras de rodas precisarem de tempo extra de preparação (por exemplo, montagem completa), poderá ser necessário reduzir o número de usuários nas sessões práticas ou aumentar o tempo alocado. 1.3 Planos das sessões Cada sessão tem um plano de sessão que orienta os instrutores sobre a apresentação das sessões. O início de cada sessão possui as seguintes informações: • Objetivos: o que o participante deve saber fazer ao final da sessão; • Recursos: os recursos necessários para a sessão; • Contexto: como será necessário adaptar a sessão para contextos ou situações diferentes; • Preparação: como se preparar para a sessão; • Descrição: apresentação das partes principais da sessão. 7O restante do plano da sessão é dividido em tópicos. Para cada tópico, o plano da sessão dá instruções sobre como comunicar as informações do tópico. Nota: • Palavras em negrito são ações dos instrutores (por exemplo: pergunte, demonstre, explique, exiba o DVD); • Caixas sombreadas dão as respostas às perguntas feitas pelos instrutores – mas estimule os participantes a pensar sozinhos nas respostas. Ao final de cada sessão há um resumo dos pontos principais. Ao invés de ler os pontos principais, os instrutores podem fazer perguntas aos participantes para que eles identifiquem os pontos principais por si. Seguindo meticulosamente os planos de sessão os instrutores conseguirão ministrar bem cada sessão, e dentro do horário. Os planos de sessão apresentam todos os pontos principais necessários e as aptidões práticas que devem ser cobertas. Estimulamos os instrutores a trazer seus próprios conhecimentos, aptidões e estilo para a sessão. No entanto, é importante não se afastar dos tópicos e métodos fornecidos pelo plano. 1.4 Apresentações em PowerPoint Existem apresentações em PowerPoint (PPT) para quase todas as sessões. Os instrutores devem observar que apenas os pontos principais estão escritos nos slides. Os instrutores devem dar as informações apresentadas no Manual do Instrutor, ao lado de cada slide, para garantir que todos os pontos foram abordados. Evite ler o slide. Ao invés disso, consulte o Manual do Instrutor. 1.5 Como observar/monitorar o progresso dos participantes Os instrutores devem observar atentamente o progresso de cada participante. A melhor oportunidade de observar o progresso é durante as sessões práticas. O CD contém uma lista de verificação das observações de cada sessão prática. Os instrutores devem usar essa lista de verificação para: • Ajudá-los a observar o progresso de cada grupo de participantes durante cada sessão prática. • Registrar exemplos de boas práticas e de práticas que precisam melhorar – para que sejam discutidas durante as sessões de feedback. A lista de verificação das observações do instrutor pode ser modificada e/ou ampliada pelos instrutores que queiram obter informações mais detalhadas sobre o progresso de cada participante. 8CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1.6 Avaliação do programa de treinamento como um todo É uma boa prática avaliar o programa de treinamento como um todo. Os instrutores obtêm feedback regular dos participantes durante todo o programa de treinamento, à medida que é ministrado. Os instrutores também podem registrar suas próprias impressões sobre o programa de treinamento ao longo das sessões. Essas informações podem ajudá-los a avaliar o programa de treinamento no final, inclusive a identificar pontos fortes e fracos. Isso vai ajudar os instrutores a melhorar tanto o pacote de treinamento em si quanto suas próprias aptidões para ministrar seu em seu contexto no futuro. O DVD tem um formulário de avaliação do programa de treinamento. Os instrutores poderão adaptar ou ampliar o formulário para atender às suas necessidades. 1.7 Dicas de boas práticas de treinamento Estar preparado • leia cada sessão cuidadosamente antes do início do treinamento; • tenha certeza de estar confiante quanto ao material que vai ministrar; • reúna os recursos de treinamento e prepare bem a sala. Ser exemplo de boas práticas nos serviços para cadeira de rodas • respeite os participantes e os usuários; • mostre carinho em seu trabalho; • esteja sempre atento à segurança da sala de treinamento; • seja pontual e conduza as sessões de acordo com o cronograma. Apresente as informações claramente • fale clara e calmamente; • verifique se todos na sala podem ouvir você; • faça perguntas para saber se foi entendido; • assegure-se de que o que está escrito no quadro pode ser lido por todos; • repita pontos importantes para reforçá-los. Administre o tempo da sessão • anote o tempo alocado para cada sessão e se esforce para respeitá-lo; • se for provável a necessidade de mais tempo, planeje isso no início; • sempre complete todas as sessões planejadas para o dia. Faça demonstrações claras e cuidadosas • assegure-se de que todos podem ver bem; • explique o que vai acontecer e descreva o que vai fazer; • demonstre devagar e repita se necessário. 9Explore as aptidões dos participantes • depois de cada demonstração, dê sempre oportunidade para os participantes praticarem; • lembre-se que novos alunos precisam de tempo para entender as novas informações. Fomente o sucesso nas atividades de pequenos grupos • observe atentamente as atividades do grupo e ajude se necessário; • circule entre os pequenos grupos e verifique o progresso de cada um. Lembre-se das diferenças de idiomas • se os participantes estão aprendendo em seu segundo idioma, verifique se entendem – fale mais devagar se necessário; • lembre-se das diferenças de idioma entre usuários e seus cuidadores; • use intérpretes se necessário. Estimule os participantes a serem ativos e envolvidos durante todo o programa • use os diferentes estilos e métodos apresentados nos planos de sessão; • evite falar demais – estimule os participantes a falar e discutir entre si; • faça perguntas para estimular os participantes a pensar nas respostas, ao invés de lhes dar a resposta; • estimule todos a falar, não deixe que um participante domine; • elogie o bom trabalho dos participantes e dê feedback positivo; • diga aos participantes que podem fazer perguntas a qualquer momento; • relacione o aprendizado a exemplos reais que os participantes vão reconhecer; • mantenha o treinamento divertido! Use atividades/ jogos rápidos de “aquecimento” • Use atividades breves de aquecimento (5–10 minutos) para ajudar a focar a atenção. Use atividades que sejam inclusivas para participantes com deficiências. A pasta de ferramentas do programa de treinamento contém uma série de jogos de aquecimento. Considere as necessidades de pessoas com habilidades diferentes • Pense nas necessidades de qualquer participante com dificuldades de visão, audição ou mobilidade. Talvez seja necessário adaptar algumas atividades e métodos de ensino. 10 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 2. Como se preparar para ministrar o pacote de treinamento 2.1 Conhecer a rede de serviços para cadeira de rodas dos participantes Os instrutores precisam conhecer o sistema de fornecimento de cadeira de rodas de seu local de trabalho. Isso inclui: • Tipos de cadeiras de rodas disponíveis localmente e quem as fornece; • Serviços de cadeira de rodas da área, inclusive o nível de serviço oferecido; • Redes de encaminhamento da área; • Pessoas disponíveis na área, inclusive usuários que possam ajudar no treinamento; • Outros serviços de reabilitação aos quais a equipe de serviços para cadeira de rodas possa encaminhar usuários conforme necessário. 2.2 Esclarecer a função dos participantes nos serviços para cadeira de rodas Descubra como os serviços para cadeira de rodas se encaixam nos deveres de seu local de trabalho. Por exemplo, os participantes vão trabalhar apenas na prestação de serviços para cadeira de rodas ou também terão outras funções? Defina a função dos participantes na prestação de serviços para cadeira de rodas. Por exemplo, alguns deverão assumir apenas os aspectos clínicos ou os aspectos técnicos cobertos no treinamento. Outros poderão ter as duas funções, clínica e técnica. A função esperada deverá ser esclarecida antes do início do treinamento. Os instrutores podem então relacionar o treinamento diretamente às funções esperadas dos participantes. Antes de ministrar o treinamento, os instrutores locais talvez precisem adaptar o treinamento para as funções que os participantes vão desempenhar nos serviços para cadeira de rodas. 2.3 Rever cada plano de sessão e ajustar se necessário Reveja cada plano de sessão e indique um instrutor líder para cada sessão. Algumas sessões de treinamento precisarão ser ajustadas para se adequar ao contexto local. No início de cada sessão, no título “contexto”, existem sugestões de ajustes da sessão para diferentes contextos. 11 2.4 Identificar as cadeiras de rodas que serão usadas Identifique os tipos de cadeiras de rodas que serão usados no treinamento. Devem ser cadeiras de rodas disponíveis no ambiente de trabalho dos participantes. Se houver muitos tipos de cadeiras de rodas, escolha os melhores exemplos de tipos diferentes e as mais comumente disponíveis. Não inclua cadeiras de rodas com recursos de nível “intermediário”, como dispositivos de suporte postural ajustável (por ex., fixador de ombro, suportes para a coluna). Tenha certeza de que conhece muito bem os recursos de todas as cadeiras de rodas. Preencha o formulário de resumo de cadeira de rodas (consulte o DVD: formulários de serviços para cadeira de rodas) para todas as cadeiras de rodas e obtenha informações do produto com o fornecedor. 2.5 Convidar usuários para as sessões práticas Para que os participantes ganhem prática nas aptidões ensinadas por este pacote de treinamento é necessário que treinem com usuários. Antes do programa de treinamento, os instrutores devem identificar e convidar usuários que estejam dispostos a participar das sessões práticas. Damos abaixo uma lista para ajudar a identificar usuários. Verificação de usuários para participar das sessões práticas: Concordam em participar do treinamento para ajudar nas sessões práticas  Conseguem sentar-se bem e não precisam de modificações ou suporte postural adicional, pois isso não é coberto neste programa de treinamento  Estão bem e saudáveis o suficiente para tolerar confortavelmente a participação no programa de treinamento  Não têm úlceras/feridas de pressão  Moram perto o suficiente para participar da sessão prática sem tem que ir muito longe  Têm tempo disponível para participar da sessão prática  Moram perto o suficiente para que a organização anfitriã possa acompanhá-los após o treinamento  Mesmo número de usuários homens e mulheres  Várias necessidades físicas diferentes representadas  Idades diferentes representadas  Para usuários participando da sessão de acompanhamento – ter usado uma cadeira de rodas por pelo menos três meses  12 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Quantos usuários são necessários? O número necessário de usuários para as sessões práticas depende do número de participantes. No entanto, são necessários no mínimo dois usuários para qualquer número de participantes. Em geral, os participantes trabalham em grupos de dois ou três com um usuário. É melhor não ter mais do que quatro usuários na sessão prática, porque seria difícil para os instrutores administrar, monitorar e observar. O que os usuários que participam de sessões práticas precisam saber? Os usuários que participam de sessões práticas precisam saber: • O que vai acontecer quando participarem da sessão; • Quando terão que participar e por quanto tempo; • Que são bem-vindos a comparecer com um familiar/assistente pessoal; • Se vão ou não receber uma cadeira de rodas durante sua participação no treinamento. Os instrutores e as organizações anfitriãs devem garantir que todos os usuários participando de sessões práticas recebam transporte ou ajuda de custo para cobrir os custos de transporte para a participação. Deve haver comida e bebida durante o programa de treinamento. Os instrutores e as organizações anfitriãs também devem pagar aos usuários uma quantia diária pelo tempo que passam participando do treinamento. A pasta de formulários do DVD do programa de treinamento contém um modelo de carta-convite e de formulário de consentimento para usuários. Eles devem ser adaptados para o contexto específico, traduzidos e enviados a todos os usuários (voluntários) para que possam fazer uma escolha informada sobre a participação no treinamento. Acompanhamento • Os instrutores e as organizações anfitriãs devem planejar o acompanhamento imediato de todos os usuários presentes ao treinamento porque é possível que nem tudo tenha sido completado ao final do programa de treinamento para todos os usuários. • Todo usuário que receber uma cadeira de rodas durante o treinamento deve ser acompanhado pela organização anfitriã/instrutores dentro de 6 – 8 semanas após receber a cadeira de rodas. 13 2.6 Planejar grupos para as sessões práticas Cada grupo não deve ter mais do que três participantes. É melhor ter dois grupos de dois do que um grupo de quatro. Isso garante que os participantes tenham uma boa oportunidade de aplicar seu aprendizado e de desenvolver suas habilidades. Os instrutores devem decidir quem está em qual grupo. Não deixe isso para os participantes decidirem. Dependendo das aptidões dos participantes e do contexto, os instrutores podem escolher os grupos assim: • Agrupe participantes mais confiantes com participantes menos confiantes. Os participantes mais confiantes podem ajudar a orientar os participantes menos confiantes. Monitore/observe atentamente os grupos para garantir que todos estejam participando. • Agrupe pessoas que trabalharão juntas no futuro para que possam desenvolver suas habilidades como uma equipe. Para as Práticas ‘1 e 2’, mantenha os participantes nos mesmos grupos. Para as Práticas ‘3 e 4’ os grupos devem mudar, dependendo de quão bem estejam trabalhando juntos. Para cada sessão prática, indique um “líder” do grupo. Certifique-se que todos os participantes tenham a oportunidade de ser líder. Peça ao líder para ser responsável por garantir que todas as etapas foram cumpridas. O líder deve ser a pessoa principal a se comunicar com o usuário e sua família/cuidador, se necessário. 2.7 Preparar as instalações Deve-se usar uma sala grande de treinamento (ou espaço) para ministrar o treinamento. O espaço precisa ser grande o suficiente para que os participantes e os usuários participantes das sessões práticas possam se mover com facilidade e se dividir em pequenos grupos. Também é preciso uma área externa para prática de habilidades de mobilidade com a cadeira de rodas; um espaço separado para almoço e lanche; e banheiros limpos. Todas as áreas, inclusive os banheiros, devem ser acessíveis a usuários de cadeiras de rodas. 14 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A lista de verificação a seguir pode ser usada para avaliar e preparar as instalações de treinamento. Verificação das Instalações: Sala de treinamento Área para as apresentações  Cadeiras para todos os participantes com apoio para escrever  Espaço para os participantes se dividirem em pequenos grupos de 2–3  Espaço para exibir e mover pelo menos três cadeiras de rodas  Biombos para dar privacidade aos usuários durante as sessões práticas  Mesas ou bancadas grandes para a sessão de fabricação de almofadas  Iluminação e ventilação adequada  Que possa ser trancada/segura  Área de treinamento de mobilidade em cadeira de rodas Superfícies planas e lisas  Um só degrau  Lances curtos de escada  Superfície áspera  Superfície inclinada  Área de almoço/descanso Área limpa para refeições  Mesas e cadeiras  Espaço próximo para lavar as mãos – toalhas limpas e sabonete  Banheiros Banheiros limpos com água, papel higiênico, pias e prateleiras  2.8 Preparar os recursos e materiais de treinamento Recursos impressos Recurso Quantid.  Comentários/instruções Manuais, apostila e pôsteres: Manual do Instrutor 1 por instrutor  Pedir a OMS ou imprimir e encadernar. Manual de Referência 1 por participante  Pedir a OMS ou imprimir e encadernar. Apostila do Participante 1 por participante  Pedir a OMS ou imprimir e encadernar. Conjunto de pôsteres 1 por participante  Pedir a OMS ou imprimir e encadernar. 15 Material complementar: Diretrizes da OMS para fornecimento de cadeira de rodas manuais em locais com poucos recursos Pelo menos 1 cópia por instrutor  Dê uma cópia eletrônica para os participantes se possível; para cópias em outros idiomas consulte http://www.who. int/ disabilities/en/ Convenção das Nações Unidas sobre os Direitos de Pessoas com Deficiência (UNCRPD) 1 cópia por participante  Para versões em diferentes idiomas: http:// www.un.org/disabilities/default. asp?id=150 http://uncrpdindia.org/about/text/ Formulários do programa de treinamento: Formulário de registro do participante 1 por programa  Use o formulário para registrar a presença dos participantes. Crachás 1 por participante & por instrutor  Cronograma 1 por participante  Modelo no DVD; ajuste para o contexto local. Formulário de consentimento para fotos 1 por participante e 1 por usuário (voluntário)  Adapte o formulário para o treinamento/ organização anfitriã; traduza para o idioma local; assegure-se de que todas as pessoas fotografadas assinaram o formulário. Carta-convite e declaração de consentimento para usuários 1 por usuário  Adapte o modelo fornecido de carta para convidar cada usuário para a sessão prática. Lista de usuários para as sessões práticas. 1 por instrutor  Use este formulário para planejar a participação dos usuários nas sessões práticas e para manter um registro de quem participou e quando. Certificado de participação 1 por participante  Prepare os certificados de participação ou adapte o modelo fornecido. Formulários de avaliação do programa de treinamento: Formulário de avaliação do programa para participantes 1 por participante  Exemplos de formulários de avaliação do programa de treinamento podem ser adaptados pelos instrutores conforme necessário. Formulário de avaliação das sessões do programa para instrutores 1 por sessão  Formulário de avaliação do programa para instrutores 1 por instrutor  16 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Listas de verificações das observações do instrutor para as sessões práticas: Prática 1 1 por instrutor  Imprimir. Prática 2  Prática 3  Prática 4  Formulários de serviços para cadeira de rodas: Formulário de encami- nhamento para serviços para cadeira de rodas 1 por participante  Adapte para atender ao contexto local ou use formulário local de encaminhamento se disponível. Formulário de avaliação para serviços de caderas de rodas 1 por usuário  Adapte para atender ao contexto local – ex.: inclua o nome do fornecedor local ou qualquer informação adicional pedida pelo serviço local. Formulário de prescrição de cadeira de rodas (seleção) 1 por usuário  Finalize dependendo das opções e tamanhos de cadeira de rodas. Formulário de resumo de cadeira de rodas 1 por usuário  Complete um para cada cadeira de rodas disponível antes de iniciar o programa de treinamento. Formulário de acompanhamento 1 por usuário  Adapte para atender ao contexto local – por exemplo, inclua o nome do fornecedor da cadeira ou informações adicionais solicitadas pelo fornecedor. Listas de verificação: Lista de verificação da adequação da cadeira de rodas 1 por participante  As listas podem ser encontradas no material impresso “Formulários para Serviços de Cadeira de Rodas”. Lista de verificação do treinamento de usuários  Lista de verificação da cadeira de rodas segura e pronta para uso  Pôsteres Etapas do serviço para cadeira de rodas 1  1 por participante. Habilidades de mobilidade em cadeira de rodas 1  Úlceras/feridas de pressão 1  Como cuidar da cadeira de rodas em casa 1  Formulário opcional (observe que este formulário não está incluído no pacote, use apenas se estiver disponível localmente: Formulário de requisição de cadeira de rodas 1 por participante  Usar apenas se localmente disponível. 17 Materiais Item Quantidade Canetas para quadro branco 3–4  Pedaços de espuma 4–5  Pedaços para demonstração (aproximadamente 100 x 110 x 50 mm). Faixas de tornozelo/ panturrilha 2–3 conjuntos  Se disponível. Equipamentos Item Quantidade Quadro branco grande 1  Projetor 1  Computador 1  Auto -falantes portáteis 1 conj.  Para assistir ao DVD com som. Câmera digital 1  Se disponível – para sessões diferentes. Cama de avaliação 1 por usuário para sessões práticas  Cama ou bancada de avaliação. A altura deve estar no nível da altura média do assento da cadeira. Evite superfícies duras se possível – se usar bancadas use uma camada fina de espuma e capa, ou tapete de ioga. Conjunto de apoios para os pés  Blocos de madeira para dar suporte aos pés do usuário enquanto estiver sentado na cama de avaliação. São necessárias algumas alturas diferentes. Prancha de transferência 1 para 3 participantes  Fita métrica 1 por participante  ½ esqueleto anatômico com coluna, pelve e fêmur 1  Se disponível. Cadeiras de rodas e almofadas para treinamento Pelo menos 1 de cada cadeira e almofada dispo- níveis localmente; idealmente 1 cadeira e almo- fada para dois participantes  Certifique-se que todas as cadeiras estejam funcionando bem; e que haja pelo menos um bom exemplo de almofada para alívio de pressão. 18 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Cadeiras de rodas e almofada para os usuários voluntários 1 por usuário participante das sessões práticas  Deve haver cadeiras e almofadas suficientes para os usuários para poder prescrever a cadeira e almofada mais adequadas para eles. Kit de manutenção em casa 1 para cada 3 participantes  Inclui: chave-inglesa ajustável, chaves Allen, chave de fenda, bomba de pneu, óleo lubrificante, balde, sabão, pano, lixa. Post-it ou bloco de notas 1 por participante  Fabricação de almofadas – materiais e ferramentas Item Quantidade Modelo de almofada moldada para alívio de pressão e capa 1  Modelo de camada de elevação 1  Kit de fabricação da almofada 1 kit para 2 participantes  Inclui: • 1 x serra afiada ou faca longa; • 1 x caneta marcadora preta; • cola para espuma/adesivo de contato e pedaços de papelão para espalhar a cola. Materiais da almofada 1 conjunto para 2 participantes  Inclui 1 de cada: • espuma firme (p.ex. blocos de espuma) – 50 x 400 x 400 mm; • espuma macia – 50 x 400 x 400 mm Amostras disponíveis de tecido para fazer a capa da almofada 1 de cada  Consulte a sessão de fabricação de almofada para mais informações sobre tecidos adequados. 19 3. Planos detalhados das sessões 20 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Introdução O BJ ET IV O S Ao final desta sessão os participantes:  saberão os objetivos do programa de treinamento;  saberão os nomes dos participantes e dos instrutores;  terão uma visão geral do cronograma do programa de treinamento;  saberão todas as regras importantes a lembrar durante o treinamento. RE CU RS O S Para a sessão:  Apresentações em PPT: Introdução;  Manual de Referência para todos os participantes;  Apostila do participante para todos os participantes;  DVD: Introdução  Cópia do cronograma para todos os participantes;  Crachás para todos os instrutores e participantes. CO N TE X TO Adapte esta sessão para se adequar ao contexto local onde o treinamento está sendo ministrado. Por exemplo:  inclua uma cerimônia de abertura adequada à cultura/contexto;  mude ou adapte a sessão “Apresentação dos instrutores e participantes” para se adequar a instrutores e participantes;  mude, adapte e/ou amplie a lista de avisos gerais e as expectativas dos participantes conforme necessário – a descrição do programa de treinamento contém exemplos;  mude o slide de visão geral do programa de treinamento se o treinamento tiver sido modificado (ex., objetivos incluídos ou excluídos). PR EP A RA ÇÃ O  Reunir os recursos, rever as apresentações em PPT, assistir ao DVD e ler todo o plano da sessão. D ES CR IÇ Ã O 1. Cerimônia de abertura (se houver) 2. Apresentação de instrutores e participantes 3. Cronograma do treinamento, Manual de Referência e Apostila dos Participantes 4. Visão geral do programa de treinamento 5. Avisos gerais e expectativas dos participantes 15 15 10 10 10 Tempo total da sessão 60 21 1. Cerimônia de abertura (duração estimada 15 minutos) 2. Apresentação de instrutores e participantes (15 minutos) Instrutor: apresente-se. Faça um breve resumo de seu histórico e experiência com fornecimento de cadeiras de rodas. Peça aos participantes que se apresentem, dizendo seu nome, a organização de onde vêm, e o que esperam aprender com o programa de treinamento. Distribua os crachás se já não foram distribuídos durante a inscrição. 3. Visão geral do programa de treinamento (10 minutos) Explique: O objetivo do programa de treinamento é ensinar a cada participante como prover uma cadeira de rodas e almofada adequadas para meninas, meninos, mulheres e homens que conseguem sentar-se bem. • O pacote de treinamento inclui: - avaliação de cadeira de rodas; - seleção, preparo e adequação; - instruções para usuários; - manutenção e reparos; - acompanhamento; - como fazer uma almofada de espuma para alívio de pressão. Apresente o DVD: Introdução – Este DVD vai falar brevemente sobre o programa de treinamento de cadeira de rodas, seu objetivo, metas e expectativas. Exiba o DVD. Pergunte se existem dúvidas VIDEO • Esse pacote de treinamento inclui: – Avaliação da cadeira de rodas; – Seleção, preparação e adequação; – Instruções para usuários; – Manutenção e reparos; – Acompanhamento; – Como fazer uma almofada de espuma para alívio de pressão. 1. Introdução: 2 22 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 4. Cronograma do programa de treinamento, Manual de Referência e Apostila dos Participantes (10 minutos) Distribua uma cópia do cronograma do programa de treinamento a cada participante. Explique: • O programa de treinamento vai começar com sessões teóricas/em classe. • Depois os participantes vão treinar com usuários voluntários algumas habilidades que aprenderam na sessões teóricas. Distribua uma cópia do Manual de Referência para cada participante. Peça aos participantes que escrevam seus nomes no manual. Explique que podem fazer anotações nesse manual. Distribua uma cópia da Apostila do Participante a cada participante. Peça que escrevam seu nome na apostila. Explique que usarão a Apostila durante todo o treinamento e que devem trazê-la para todas as sessões. 5. Avisos gerais e expectativas (10 minutos) Explique o seguinte, conforme necessário: • localização dos banheiros; • com quem falar sobre acomodação; • com quem falar sobre viagem de retorno de participantes individuais (não entre em detalhes); • o que fazer se houver uma emergência. Explique as expectativas do programa com relação aos participantes, conforme necessário: • todas as sessões começarão no horário – os participantes devem sempre chegar no horário no início de cada dia, e voltar para as sessões no horário após os intervalos; • Os participantes devem sempre fazer perguntas se tiverem dúvida sobre alguma coisa; • Tratem todos os usuários da mesma forma e respeitem sua dignidade; • Desliguem os celulares durante as sessões; • Divirtam-se! Explique: Ao longo do programa de treinamento os participantes vão utilizar e empurrar cadeiras de rodas. Sempre que usarem as cadeira de rodas lembrem-se das seguintes regras de segurança: • não pisar nos apoios para os pés quando sentarem-se e levantarem-se da cadeira de rodas; • manter os dedos longe dos raios da roda e dos freios; • ao subir ou descer rampas, ter um assistente atrás de você caso caia para trás. 23 A: Conceitos fundamentais 24 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.1: Usuários de cadeiras de rodas O BJ ET IV O S Ao final desta sessão os participantes saberão:  listar ao menos sete benefícios de uma cadeira de rodas apropriada para o usuário;  explicar como a equipe de serviços para cadeira de rodas pode apoiar o usuário a ter seu direito à mobilidade pessoal;  listar ao menos cinco formas pelas quais os usuários podem se envolver ativamente no fornecimento de cadeira de rodas. RE CU RS O S Para a sessão:  Apresentação em PPT A.1 Usuários de cadeiras de rodas;  Manual de Referência;  DVD: Benefícios de uma cadeira de rodas apropriada;  Cópias da Convenção das Nações Unidas sobre os Direitos de Pessoas com Deficiências (UNCRPD), se houver;  Material extra de referência (para instrutores): • Diretrizes da OMS para fornecimento de cadeiras de rodas manuais em locais com poucos recursos (pag. 23). CO N TE X TO Adapte esta sessão para o contexto de onde os participantes vêm. Por exemplo:  os participantes podem já conhecer a UNCRPD – neste caso, você pode perguntar o que já sabem sobre a UNCRPD;  saber se a UNCRPD foi assinada/ratificada no país dos participantes PR EP A RA ÇÃ O  Reunir os recursos, rever as apresentações em PPT, assistir ao DVD e ler todo o plano da sessão. D ES CR IÇ Ã O 1. Introdução 2. Quais são os benefícios de uma cadeira de rodas? 3. O que é uma “cadeira de rodas apropriada”? 4. Convenção das Nações Unidas sobre os Direitos de Pessoas com Deficiências 5. Usuários são parceiros iguais na prestação de serviços para cadeiras de rodas 6. Resumo dos pontos principais 2 10 5 5 20 3 Tempo Total da sessão 45 25 1. Introdução (2 minutos) Explique: nesta sessão falaremos sobre como os usuários se beneficiam de uma cadeira de rodas apropriada. Pense sobre como os participantes podem envolver ativamente os usuários no processo de fornecimento de cadeira de rodas e por que isso é importante. Também vamos ver brevemente a Convenção das Nações Unidas sobre os Direitos de Pessoas com Deficiências (CRPD) principalmente artigos 1, 3 e 20. 2. Quais são os benefícios de uma cadeira de rodas? (10 minutos) Leia a definição de cadeira de rodas apropriada Explique: • Esta definição vem das Diretrizes da OMS para o fornecimento de cadeiras de rodas manuais em locais com poucos recursos. Usaremos muito essas Diretrizes durante o programa. • A “cadeira de rodas apropriada” para cada usuário sempre depende de suas necessidades individuais e das condições ambientais (onde mora e trabalha). Apresente o DVD: Os Benefícios de uma cadeira de rodas apropriada – Este breve DVD vai mostrar vários usuários envolvidos em várias atividades. Assista atentamente e depois falaremos sobre como a cadeira de rodas beneficiou diferentes usuários. Exiba o DVD. Pergunte se ficou alguma dúvida VIDEO • Nesta sessão os participantes vão: – Discutir sobre como os usuários se beneficiam de uma cadeira de rodas apropriada; – Discutir sobre como os usuários podem se envolver ativamente no processo de fornecimento de cadeira de rodas e por que isso é importante; – Discutir sobre a Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência. A.1. Usuários de Cadeiras de Rodas: 2 • Uma cadeira de rodas apropriada: – Atende às necessidades do usuário e às condições do ambiente em que ele vive; – Oferece adequação correta e suporte postural; – É segura e durável; – Está disponível no país; e – Sua aquisição, manutenção e serviços relacionados estão disponíveis no país por um custo acessível. A.1. Usuários de Cadeiras de Rodas: 3 26 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Pergunte: quais são os benefícios da cadeira de rodas para os usuários mostrados no DVD? Estimule respostas e anote no quadro. Respostas: • mobilidade; • saúde; • ajuda a sentar-se ereto; • conforto; • autoestima e confiança; • dignidade; • ir à escola; • praticar esportes; • trabalhar; • fazer parte da família e da comunidade; • maior independência. Explique: • Como podemos ver na lista, a cadeira de rodas traz muitos benefícios. • Mais importante; lembrem-se que fornecimento de cadeira de rodas não diz respeito apenas à cadeira, que é apenas um produto. • Fornecer cadeira de rodas significa capacitar pessoas com deficiência a ganhar mobilidade, permanecer saudáveis e participar totalmente da vida da comunidade. • Cada usuário do vídeo é diferente. No entanto, todos têm uma cadeira de rodas “apropriada” para eles. 3. O que é uma cadeira de rodas apropriada? (5 minutos) • Uma “cadeira de rodas apropriada” é aquela que: - Atende às necessidades do usuários; - Atende ao ambiente do usuário; - É o modelo certo para o usuário; - Garante suporte postural (ajuda o usuário a sentar-se ereto); - A manutenção e reparos podem ser feitos localmente. 4. Convenção das Nações Unidas sobre os Direitos de Pessoas com Deficiências (5 minutos) Explique: • Todos sabemos que muitas pessoas que precisam de cadeira de rodas ainda não têm uma cadeira apropriada. No entanto, existe hoje um instrumento importante que podemos usar para defender os direitos de pessoas que precisam de cadeira de rodas. • A Convenção das Nações Unidas sobre os Direitos de Pessoas com Deficiências (UNCRPD) foi assinada em 2006. Em 2008, a UNCRPD se tornou uma lei internacional (se a UNCRPD foi assinada pelo país/países dos participantes, ressalte isso). 27 Pergunte: Alguém já ouviu falar dessa convenção? Elogie quem já ouviu. Explique: Existem direitos humanos que se aplicam a todos. O foco da UNCRPD é garantir que todos reconheçam que esses direitos também se aplicam a pessoas com deficiências. Explique: • A convenção tem 50 artigos. • O artigo 20 é sobre mobilidade pessoal. • Mobilidade pessoal significa: • Capacidade de se mover como e quando a pessoa quiser. Pergunte: como os participantes, ao exercer sua função nos serviços para cadeira de rodas, podem apoiar o direito do usuário à mobilidade pessoal? Estimule respostas e anote no quadro. Respostas mais importantes: • Envolver os usuários nas decisões sobre sua cadeira de rodas; • Entender as necessidades do usuário e ajudar a atendê-las; • Ajudar a fornecer uma cadeira de rodas apropriada; • Ajudar os usuários a aprender como transferir-se da cadeira sozinhos; • Ajudar os usuários a aprender a impulsionar a cadeira sozinhos; • Estimular os familiares a apoiar o usuário para ser mais independente; • Defender a maior disponibilidade de produtos de mobilidade de qualidade no país; • Defender um ambiente livre de barreiras no país. Pergunte: alguém consegue pensar em algum outro direito humano que alguém com problema de mobilidade pode acessar mais facilmente se tiver uma cadeira de rodas apropriada? Estimule respostas e anote no quadro (dê exemplos, se necessário) • A Convenção das Nações Unidas sobre os Direitos das Pessoas com Deficiência (CRPD) diz: – Todas as pessoas têm direito à mobilidade pessoal. • Mobilidade pessoal significa: – A capacidade de se locomover da maneira e na hora em que a pessoa escolher. A.1. Usuários de Cadeiras de Rodas: 5 28 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Respostas (não é necessário citar os artigos da convenção): • viver independentemente e ser incluído na comunidade (artigo 19); • direito à educação (artigo 24); • direito de gozar do mais alto padrão possível de saúde (artigo 25); • direito ao trabalho e ao emprego (artigo 27); • direito de participar da vida política e pública (artigo 29); • direito de participar da vida cultural, recreação, lazer e esportes (artigo 30). 5. Usuários são parceiros iguais na prestação de serviços cadeira de rodas (20 minutos) Explique: Os usuários costumam saber o que é uma “cadeira de rodas apropriada” para eles. Se já usaram cadeira de rodas, têm ideias sobre o que é bom para eles e o que gostariam de mudar. Usuários que nunca usaram cadeira de rodas precisarão de mais informações; A equipe de serviços para cadeiras de rodas deve trabalhar com os usuários como um participante igual. Atividade em pequenos grupos Grupos: 2–3 pessoas em cada grupo. Instruções: Peça a cada grupo que gaste 5 minutos criando uma dramatização de 2 minutos em que o usuário solicita uma cadeira de rodas. Um participante será o usuário, um será da equipe de serviços para cadeiras de rodas e o outro um familiar Peça para metade dos grupos representarem a equipe de serviços que NÃO RESPEITA o direito do usuário de ter uma cadeira apropriada e NÃO trata o usuário como participante ativo na prestação de serviços para cadeira de rodas. Peça para a outra metade dos grupos representar a equipe de serviços que RESPEITA o direito do usuário de ter uma cadeira apropriada e TRATA o usuário como participante ativo na prestação de serviços para cadeira de rodas. Monitore: Monitore/observe os grupos e ajude se necessário. Tempo: 5 minutos para preparar; 10 minutos para representar para os outros grupos e 5 minutos para feedback. 29 Feedback: Peça a pelo menos um grupo que representa a equipe de serviços que NÃO respeita os direitos do usuário e um grupo que RESPEITA que apresentem sua dramatização. Discussão de Feedback: • discuta as diferenças na forma como a equipe de serviços para cadeira de rodas se comunica com o usuário e sua família; • pergunte ao usuário de cada grupo como se sentiu; • se houver usuários presentes ao treinamento, pergunte se tiveram experiências positivas ou negativas semelhantes às da dramatização. Pergunte: Da atividade de dramatização, quais são algumas formas pelas quais a equipe de serviços para cadeira de rodas pode envolver ativamente os usuários no processo de fornecimento de uma cadeira de rodas? Estimule respostas Respostas mais importantes: • Falar diretamente com o usuário; • Pedir a opinião do usuário; • Dar opções ao usuário sempre que possível e respeitar sua opção; • Dar ao usuário informações para ajudá-lo a fazer uma opção; • Obter informações do usuário sobre sua vida, as coisas que quer fazer na cadeira de rodas e o ambiente onde vive e trabalha. 6. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se há alguma dúvida. • Os usuários de cadeiras de rodas são diferentes entre si e possuem necessidades diferentes. • Uma cadeira de rodas apropriada atende às necessidades do usuário e do ambiente em que ele vive, também oferece adequação e suporte apropriados. • As cadeiras de rodas oferecem às pessoas com deficiência motora muitos benefícios, que incluem: mobilidade, suporte postural, conforto, liberdade e dignidade. • Importante: a mobilidade pessoal é um direito, e para muitas pessoas com deficiência motora uma cadeira de rodas é a maneira pela qual elas podem ter mobilidade pessoal. A.1. Usuários de Cadeiras de Rodas: 6 30 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.2: Serviços para cadeira de rodas O BJ ET IV O S Ao final desta sessão, os participantes saberão:  explicar o que são serviços para cadeira de rodas;  identificar sua função em um serviço para cadeira de rodas de nível básico;  definir “serviço de nível básico” na prestação de serviços para cadeira de rodas. RE CU RS O S Para a sessão:  Apresentação em PPT: A.2: Serviços para cadeira de rodas;  Manual de Referência;  Pôster: Etapas do serviço para cadeira de rodas. Material extra de referência (para instrutores):  Diretrizes da OMS para o fornecimento de cadeira de rodas manuais em locais com poucos recursos (páginas 71–72, 76–77). CO N TE X TO Adapte esta sessão para se adequar ao contexto no qual os participantes vão trabalhar. Pense no seguinte:  As funções de cada participante na prestação de serviços para cadeira de rodas em seu local de trabalho. Por exemplo, cada participante será responsável pelas oito etapas de prestação de serviços para cadeira de rodas? Use esta sessão para explicar aos participantes as suas funções. PR EP A RA ÇÃ O  Reunir recursos, rever os slides, ler todo o plano da sessão.  Preparar informações sobre a função dos participantes em cada etapa do serviço. D ES CR IÇ Ã O 1. Introdução 2. Serviços para cadeira de rodas 3. Funções da equipe de serviços para cadeira de rodas. 4. O que significa “serviços de nível básico”? 5. Resumo dos pontos principais 2 10 10 5 3 Tempo Total da sessão 30 31 1. Introdução (2 minutos) Explique: nesta sessão vamos • Explicar o que são serviços para cadeira de rodas e a diferença entre serviços de “nível básico” e serviços de nível “intermediário”; • Falar sobre as principais etapas da prestação de serviços para cadeira de rodas • Discutir a função de cada participante na prestação de serviços para cadeira de rodas em um serviço para cadeira de rodas de nível básico. 2. Serviços para cadeira de rodas (10 minutos) Explique: os serviços para cadeira de rodas trabalham com os usuários para fornecer a cadeira de rodas mais apropriada (entre as disponíveis) para aquele usuário. Pergunte: o que a equipe de serviços para cadeira de rodas deve fazer para ajudar a fornecer a cadeira mais apropriada para cada usuário? Estimule respostas e anote no quadro. Respostas mais importantes: • Descobrir o quê o usuário precisa da cadeira de rodas (avaliar); • Ajudar a selecionar a melhor cadeira de rodas para o cadeirante (prescrever) • Fornecer uma cadeira de rodas (requisitar, possivelmente montar, adequar) Pergunte: o que a equipe de serviços para cadeira de rodas deve fazer para ajudar o usuário a se beneficiar o máximo possível de sua cadeira? Estimule respostas e anote no quadro. Respostas mais importantes: • Ensinar os usuários como usar e cuidar da cadeira de rodas (treinamento de usuários); • Ajudar os usuários a fazer reparos (manutenção em casa, reparos e acompanhamento) • Dar suporte e acompanhamento para garantir que a cadeira continue atendendo às necessidades do usuário; • Encaminhar os usuários para outros serviços que possam ajudá-los. • Nesta sessão os participantes vão: – Explicar o que são serviços para cadeiras de rodas e a diferença entre serviços de nível “básico” e de serviços de nível “intermediário”; – Discutir sobre as oito etapas dos serviços para cadeira de rodas; – Discutir a função que cada participante irá desempenhar ao fornecer uma cadeira de rodas em um serviço para cadeiras de rodas de nível básico. A.2. Serviços para Cadeira de Rodas: 2 32 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3. Funções da equipe de serviços para cadeira de rodas (10 minutos) Pregue o pôster das etapas de serviços para cadeira de rodas. Explique: A função da equipe de serviços para cadeira de rodas de nível básico é dar aos usuários que podem sentar-se eretos (sem suporte postural extra) a melhor cadeira de rodas disponível. Para tanto, a equipe trabalha com cada usuário e sua família seguindo as etapas principais dos serviços para cadeira de rodas. Explique as seguintes etapas. Encaminhamento e agendamento: • Encaminhamento é como o usuário chega ao serviço para cadeira de rodas • A forma de encaminhamento pode variar. • O usuário pode encaminhar-se por conta própria ou ser encaminhado através de redes governamentais ou não, compostas de trabalhadores ou voluntários de saúde e reabilitação trabalhando na comunidade, distrito ou região. • Todos os serviços precisam ter um sistema para administrar o agendamento. Avaliação: • Cada usuário precisa de avaliação individual. • Isso inclui coletar informações sobre o estilo de vida do usuário, o trabalho que faz, onde mora e condições físicas, e tirar suas medidas. 33 Prescrição (seleção): • Com as informações da avaliação, é feita uma prescrição (seleção) junto com o usuário, sua família ou seu cuidador. • A prescrição (seleção) detalha o tipo, tamanho, características especiais e modificações da cadeira de rodas. • A prescrição (seleção) também pode incluir uma lista do treinamento que o usuário precisa para usar e manter a cadeira em boas condições. Financiamento e aquisição: • Identifica-se uma fonte de financiamento e a cadeira de rodas é requisitada ao estoque mantido pelo serviço, ou ao fornecedor. Preparação do produto (cadeira de rodas): • A equipe de serviços prepara a cadeira de rodas. • Dependendo da cadeira escolhida e das instalações disponíveis, a preparação pode incluir: - Montagem da cadeira de rodas; - Produção completa da cadeira de rodas; - Pequenas modificações à cadeira de rodas 34 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Adequação: • O usuário experimenta a cadeira. • São feitos ajustes finais para garantir que a cadeira esteja montada corretamente. • Se forem necessárias modificações ou componentes de suporte postural, talvez seja preciso ajustar novamente. Treinamento de usuários: • A equipe de serviços para cadeira de rodas verifica o que o usuário e o cuidador já sabem sobre usar e manter a cadeira e descobre o que mais precisam saber. • A equipe de serviços dá as instruções necessárias. Alguns dos principais tópicos são: - Como manusear a cadeira de rodas; - Como transferir-se da cadeira de rodas; - Mobilidade em cadeira de rodas; - Como manter a cadeira de rodas; - Como prevenir úlceras/feridas de pressão; - O que fazer se houver um problema. • Alguns serviços também podem ajudar com conselhos sobre como modificar a casa do usuário para facilitar o acesso da cadeira de rodas. Isso não é abordado neste programa de treinamento. 35 Manutenção, reparos e acompanhamento: • Prestar serviços de manutenção e reparos de problemas técnicos que não podem ser resolvidos na comunidade. • Consultas de acompanhamento são uma etapa importante na prestação de serviços para cadeiras de rodas. • Durante o acompanhamento, a equipe de serviços verifica a adequação da cadeira e fornece mais treinamento e suporte. • Se a cadeira de rodas se tornar inadequada, é preciso fornecer uma nova cadeira, começando novamente da etapa 1. Explique: Neste programa de treinamento os participantes vão aprender como realizar cada etapa. No entanto, em alguns serviços, pessoas diferentes podem ser responsáveis por etapas diferentes. Por exemplo, agendar consultas pode ser responsabilidade de um administrador ou o treinamento de usuários pode ser feito por um usuário instrutor. Pergunte: alguém tem dúvidas sobre sua função no serviço para cadeira de rodas? 4. O que significa serviço de “nível básico”? (5 minutos) Explique • Usuários têm diferentes necessidades físicas. É preciso mais conhecimento e habilidades para fornecer uma cadeira de rodas a alguém que tem problemas com a maneira como se senta, ou que tem dificuldades de equilíbrio, do que se o usuário conseguir sentar-se e se equilibrar bem. • O serviço de nível básico pode atender às necessidades físicas dos usuários que conseguem sentar-se bem. Neste programa de nível básico, os participantes aprendem como fornecer uma cadeira de rodas para alguém que consegue sentar-se bem. • Em treinamentos mais avançados, os participantes aprendem como prover uma cadeira de rodas a alguém que não consegue sentar-se ereto e pode ter problemas posturais. • É muito importante receber mais treinamento antes de prover uma cadeira de rodas a alguém com problemas posturais. Isso porque é preciso entender mais sobre postura, as razões dos problemas posturais da pessoa, e como dar suporte seguro a um usuário com problemas posturais. 36 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: Clara mora no Timor Leste. Trabalha na loja da família que é em frente à sua casa. Clara tem pólio e precisa de uma cadeira de rodas para se mover em casa, trabalhar na loja e circular pela cidade. Ela consegue sentar-se ereta sem nenhum suporte e usa uma cadeira de rodas manual que foi ajustada para ela. Clara é um exemplo de alguém que pode receber uma cadeira de rodas através de serviços de nível básico. Explique: Ishade tem oito anos e mora no Sri Lanka. Ela tem paralisia cerebral. Para Ishade isso significa problemas para controlar os braços, pernas, cabeça e pescoço. Ela não consegue sentar ereta sem suporte. Ishade é um exemplo de alguém que precisa de suporte postural extra em sua cadeira de rodas. Isso não é ensinado neste programa de treinamento de serviços para cadeira de rodas de nível básico. Ishade deverá receber a cadeira de rodas através de serviços de nível intermediário ou avançado. 5. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 37 A.3: Mobilidade em cadeira de rodas O BJ ET IV O S Ao final desta sessão, os participantes saberão:  usar com segurança as habilidades básicas de mobilidade em cadeira de rodas, inclusive impulsionar, girar, subir e descer rampas com ajuda, e empinar parcialmente a cadeira de rodas. RE CU RS O S Para a sessão:  Apresentação em PPT A.3: Mobilidade em cadeira de rodas;  Manual de Referência;  DVD: Aprendendo a usar minha cadeira de rodas;  DVD: Habilidade de mobilidade em cadeira de rodas;  Pôster: Habilidades de mobilidade em cadeira de rodas;  Uma cadeira de rodas para cada dois participantes. CO N TE X TO Adapte esta sessão para o contexto no qual os participantes vão trabalhar.  Os instrutores só devem ensinar ao usuário como empinar parcialmente a cadeira de rodas como descrito nesta sessão se estiverem confiantes em fazê-lo e em supervisionar os participantes enquanto aprendem. PR EP A RA ÇÃ O  Reunir recursos, rever a apresentação em PPT e ler todo o plano da sessão.  Escolher um local adequado para o treinamento de mobilidade em cadeira de rodas – área plana, algumas áreas inclinadas, um ou dois degraus e um pouco de terreno acidentado.  Convide um usuário com boas habilidades de mobilidade na cadeira de rodas para auxiliar no ensino dessas habilidades.  Treine você mesmo a mobilidade na cadeira de rodas usando o DVD como referência, para garantir que consegue demonstrar as técnicas.  Assegure-se de que as cadeiras estejam todas funcionando bem e com os pneus cheios. D ES CR IÇ Ã O 1. Introdução 2. Por que as habilidades de mobilidade em cadeira de rodas são importantes? 3. Habilidades de mobilidade em cadeira de rodas - segurança 4. Aptidões de mobilidade em cadeira de rodas – demonstração e prática 5. Resumo dos pontos principais 2 15 5 65 3 Tempo Total da sessão 90 38 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Introdução (2 minutos) Explique: nesta sessão os participantes vão aprender as habilidades básicas de mobilidade na cadeira de rodas, o que vai ajudá-los a ensinar os usuários a ganhar o máximo possível de mobilidade em sua cadeira de rodas. 2. Por que as habilidades de mobilidade em cadeira de rodas são importantes? (15 minutos) Explique: Muitos usuários moram e trabalham em locais difíceis para eles se movimentarem. Pergunte: Quais são algumas características do ambiente local que dificultam o uso de uma cadeira de rodas? Estimule respostas e anote no quadro. Respostas mais importantes: • escadas; • terreno lamacento; • terreno arenoso; • ladeiras íngremes; • pequenos espaços (p. ex., dentro de casa); • terreno acidentando ou irregular; • calçadas quebradas ou irregulares; • carros ou outras barreiras na calçada. Explique: Ensinar as habilidades de mobilidade em cadeira de rodas pode ajudar os usuários a enfrentar alguns desses obstáculos/dificuldades, seja de forma independente ou pedindo ajuda. Apresente o DVD: Aprendendo a usar minha cadeira de rodas. Neste vídeo, uma menina chamada Sai fala sobre como aprender a usar a cadeira de rodas fez diferença em sua vida. Exiba o DVD. Pergunte se existe alguma dúvida VIDEO 39 Pergunte: Quais foram algumas das habilidades com a cadeira de rodas que Sai aprendeu? Respostas mais importantes: • transferir-se da cadeira de rodas; • vencer um desnível – para entrar e sair de casa; • subir e descer rampas; • Impulsionar. Pergunte: que diferença essas habilidades fizeram na vida de Sai? Respostas mais importantes: • é mais independente; • tem mais confiança; • pode sair, ir à escola, fazer amigos e brincar. 3. Habilidades de mobilidade na cadeira de rodas - segurança (5 minutos) Pregue o pôster de Habilidades de Mobilidade em Cadeira de Rodas Explique: segurança é muito importante ao aprender e ensinar habilidades de mobilidade em cadeira de rodas. Pergunte aos participantes – quais são os principais pontos de segurança de que já falamos ao trabalhar com cadeira de rodas? Respostas mais importantes: • não subir nos apoios para os pés ao levantar-se e sentar-se na cadeira de rodas; • manter os dedos longe dos raios da roda e dos freios; • ao aprender a subir e descer rampas, SEMPRE tenha um assistente atrás de você caso você caia para trás. Explique • Nesta sessão vocês vão praticar habilidades diferentes, inclusive subir e descer rampas e empinar parcialmente (isto é, equilibrar a cadeira de rodas apenas nas rodas traseiras). 40 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique • Tenha sempre um assistente atrás da pessoa que está na cadeira de rodas aprendendo essas habilidades. • O assistente deve ficar perto da parte de trás da cadeira. • O assistente deve estar pronto para estabilizar a cadeira de rodas se começar a cair para trás. Não deve segurar nas manoplas. • Não ajude um usuário a subir e descer degraus a menos que esteja muito seguro de que consegue controlar a cadeira de rodas com segurança. Se estiver inseguro, peça ajuda. 4. Habilidades de mobilidade na cadeira de rodas – demonstração e prática (65 minutos) Apresente o DVD: Habilidades de mobilidade em cadeira de rodas. Peça aos participantes que assistam com atenção à demonstração das diferentes habilidades de mobilidade porque vão praticá-las após assistir ao DVD. Exiba o DVD. Pergunte se existem dúvidas VIDEO Explique • Os participantes vão agora praticar as habilidades de mobilidade com a cadeira de rodas mostradas no vídeo, exceto empinar. • Empinar completamente é uma habilidade mais avançada que exige treino. Quando o usuário consegue se equilibrar nas rodas traseiras, ele pode usar essa habilidade para passar por terreno acidentado, calçadas e degraus. Não tente isso sem ter um instrutor experiente com você. • Aprender as habilidades de mobilidade que vamos praticar hoje é muito útil para qualquer um que trabalhe com usuários. Será mais fácil ensinar os usuários se você mesmo souber fazer essas coisas. 41 Atividade Grupos: Organize os participantes em duplas. Junte pessoas de peso, altura e força semelhantes. Dê a cada dupla uma cadeira de rodas. Instruções: Peça aos participantes que consultem a seção de mobilidade na cadeira de rodas de seu Manual de Referência e explique que precisam trabalhar em duplas para praticar: 1. Impulsionar e girar; 2. subir e descer rampas; 3. subir e descer escadas com ajuda; 4. Empinar parcialmente. Lembre aos participantes: • pratique usando as técnicas mostradas no vídeo e descritas no Manual de Referência; • Tenha SEMPRE uma pessoa atrás ao subir e descer rampas ou escadas ou ao tentar empinar parcialmente; • ao praticar em escadas, assegure-se de que apenas aqueles confortáveis em erguer-se façam essa manobra. Monitore/observe atentamente para garantir a segurança. Monitore: Circule pelos grupos e monitore atentamente para garantir que as técnicas são praticadas com segurança e corretamente. Interrompa os grupos para reexplicar os procedimentos de segurança se em algum momento você notar uma prática insegura. Demonstre e corrija as técnicas conforme necessário (vide técnicas abaixo). Tempo: Dê 50 minutos para prática e 15 minutos para feedback. Feedback: Reúna os grupos. Corrija qualquer erro comum na técnica que os instrutores notaram durante a prática (demonstre a técnica correta). Pergunte: O que os participantes aprenderam com a prática das habilidades de mobilidade? Explique: Durante o programa de treinamento, os participantes são bem- vindos para treinar mais com as cadeiras de rodas antes do início das sessões ou durante os intervalos para almoço. Precisam sempre garantir que treinam com alguém atrás deles se subirem ou descerem rampas ou se empinarem parcialmente a cadeira de rodas, até que estejam muito confiantes. 42 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Im pu lsi on ar • Impulsionar corretamente significa menos esforço. • Impulsionar da posição de "10 horas" para a de "2 horas". • Usar um movimento longo e suave para impulsionar. G ira r • Segure um aro de impulsão na frente e o outro atrás. • Puxe a mão da frente para trás e a mão de trás para frente ao mesmo tempo. Su bi r r am pa s • Incline-se para frente – isso ajuda a impedir o tombamento da cadeira. • Ao treinar, tenha um assistente atrás por segurança. • Para parar ou descansar – estacione a cadeira de rodas de lado. D es ce r ra m pa s • Incline-se para trás. • Deixe o aro de impulsão deslizar lentamente pelas mãos. • Usuários experientes que conseguem “empinar” (i.e., equilibrar a cadeira apenas nas rodas traseiras) podem descer uma rampa nas rodas traseiras. Isso é muito eficiente. Su bi r e sc ad as c om aj ud a • Suba de costas. • Incline a cadeira nas rodas traseiras, posicionada contra o primeiro degrau. • O assistente puxa para trás e para cima – levando a cadeira para cima. • O usuário pode ajudar puxando os aros de impulsão para trás. • Um segundo assistente pode ajudar segurando a cadeira pela frente (não no apoios para os pés). 43 D es ce r e sc ad as c om aj ud a • Desça de frente. • Incline a cadeira nas rodas traseiras. • O assistente deixa as rodas traseiras descerem lentamente um degrau por vez. • O usuário pode ajudar controlando a cadeira com os aros de impulsão. • Um segundo assistente pode ajudar estabilizando a cadeira pela frente, segurando na estrutura da cadeira (não nos apoios para os pés). Em pi na r p ar ci al m en te • Saber empinar parcialmente é muito útil para os usuários. • O usuário pode levantar as rodas dianteiras em pequenas calçadas, pedras e desníveis. • Role a cadeira de rodas para trás até que as mãos estejam em "10 horas", então empurre rapidamente para frente. • As rodas ou rodízios dianteiros levantam. • Com prática, é possível levantar as rodas dianteiras no momento certo para passar por pequenos obstáculos. • Tenha sempre uma pessoa atrás do usuário quando começar a treinar essa habilidade. 5. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 44 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.4: Sentar-se ereto O BJ ET IV O S Ao final desta sessão, os participantes saberão:  listar ao menos 10 características de “sentar-se ereto” (postura sentada neutra);  listar ao menos seis benefícios de sentar-se ereto;  demonstrar quatro formas de mover a pelve;  explicar como o movimento da pelve pode mudar a postura sentada;  reconhecer diferentes posturas sentadas e como são diferentes da postura sentada ereta. RE CU RS O S Para a sessão:  PPT: A.4 Sentar-se ereto;  Manual de Referência;  Apostila do Participante;  Meio esqueleto com pelve, coluna e fêmures (se houver). CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar e para suas necessidades de aprendizado.  Esta sessão pressupõe o conhecimento básico da pelve. Se os participantes ainda não conhecem os ósseos da pelve, inclua isso nesta sessão ou antes do programa de treinamento. PR EP A RA ÇÃ O  Reunir recursos, rever a apresentação em PPT e ler todo o plano da sessão. D ES CR IÇ Ã O 1. Introdução 2. Sentando-se em postura ereta/neutra 3. Como a pelve afeta a forma como sentamos 4. Diferentes posturas sentadas 5. Resumo dos pontos principais 2 20 10 25 3 Tempo Total da sessão 60 45 1. Introdução (2 minutos) Explique: A maioria dos usuários fica sentado durante muitas horas. Sua cadeira de rodas não é apenas um recurso de mobilidade. Também ajuda a sustentá-los confortavelmente na posição sentada ereta. Nesta sessão, vamos nos concentrar na posição sentada. Vamos falar sobre o que significa “sentar-se ereto” e como é. Vamos pensar nos benefícios de sentar-se ereto. Os participantes vão aprender a identificar a diferença entre sentar-se ereto e outras posturas. Também vamos discutir problemas causados por não sentar-se ereto. 2. Sentando-se em postura ereta/neutra (20 minutos) Pergunte: Alguém sabe o que a palavra “postura” significa? Estimule respostas. Explique: Existem várias “posturas sentadas”. Aponte as maneiras diferentes em que os participantes na sala estão sentados. Explique: • Ao fornecer uma cadeira de rodas, é importante estimular o usuário a “sentar-se ereto”. • “Sentar-se ereto” é muitas vezes chamado de “postura sentada neutra”. Peça a um voluntário do grupo que se sente em uma cadeira na frente do grupo. Peça a ele que “se sente ereto”. (Assegure-se de que ele se senta em postura ereta/neutra). Peça ao grupo que descreva a postura do voluntário. Estimule respostas. 46 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Respostas mais importantes: • pelve ereta e nivelada; • ombros nivelados, braços com movimentos livres; • tronco ereto; • costas acompanhando as três curvas naturais; • cabeça ereta e equilibrada sobre o corpo; • quadris flexionados quase 90 graus; • pernas levemente abertas (abdução); • joelhos e tornozelos flexionados quase 90 graus; • calcanhares diretamente abaixo dos joelhos ou levemente para frente ou para trás; • pés totalmente apoiados no chão. Como dizer se alguém está sentado ereto Olhe de lado e verifique:  pelve ereta;  tronco ereto, costas acompanhando as três curvas naturais;  quadris flexionados quase 90 graus;  joelhos e tornozelos flexionados quase 90 graus;  calcanhares diretamente abaixo dos joelhos ou levemente para frente ou para trás;  pés totalmente apoiados no chão ou nos apoios para os pés. Olhe de frente e verifique:  pelve nivelada;  ombros nivelados, relaxados e movimento livre dos braços;  pernas levemente abertas (abdução);  cabeça ereta e equilibrada sobre o corpo. Explique: • As pessoas não se sentam eretas de maneira exatamente igual. • Os próximos slides mostram os principais pontos a buscar – no entanto, são apenas um guia. • O ponto mais importante de sentar-se ereto é que a pessoa está relaxada, confortável e bem equilibrada. 47 Aponte os pontos principais no slide Explique: • Quadris, joelhos e tornozelos podem estar um pouco mais abertos ou flexionados – isso está certo. • A pessoa deve se sentir equilibrada e confortável. Aponte os pontos principais no slide. Peça a todos os participantes que se sentem em postura sentada neutra Pergunte: os participantes conseguiriam sentar-se assim o dia todo sem suporte (por exemplo, um encosto)? A resposta da maioria será Não. Explique: • Sem um bom suporte na cadeira seria muito difícil sentar-se assim o dia todo. É por isso que as pessoas mudam sempre a posição em que estão sentadas. • O usuário que fica na cadeira de rodas o dia todo vai precisar de um assento com bom suporte, de almofadas, encosto e apoios para os pés para manter a postura sentada ereta. Pergunte: Quais são os benefícios de sentar-se ereto? Estimule respostas e anote no quadro. Respostas mais importantes: • saúde; • estabilidade; • distribuição de peso; • conforto; • mais ativo; • pode evitar problemas de postura; • autoestima e confiança. 48 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Pergunte: como a equipe de serviços pode ajudar os usuários a sentarem-se eretos? Estimule respostas e anote no quadro. Respostas mais importantes: • assegurando que a cadeira está ajustada para eles; • ensinando os usuários como é importante sentar-se ereto, se conseguirem; • mostrando aos usuários como sentar-se na posição ereta em suas cadeiras de rodas. Explique: Nem todo usuário consegue sentar-se ereto. Falaremos sobre isso no final da sessão. 3. Como a pelve afeta a forma como sentamos (10 minutos) Explique: A pelve é a base para sentar-se ereto. Para ser forte e estável, um prédio precisa de alicerces sólidos. Da mesma forma, para estar estável enquanto sentado, a pelve precisa ser forte e estável. Explique: A pelve se move de formas diferentes com relação ao tronco e às articulações do quadril. Os movimentos são: • girar para frente (inclinação pélvica para frente). Explique: A ilustração do slide mostra uma visão lateral da pelve: • girar para trás (inclinação pélvica para trás). 49 Explique: A ilustração do slide mostra uma visão posterior da pelve: • inclinar para o lado (inclinação lateral). Explique: A ilustração do slide mostra uma visão superior da pelve: • rotação. Peça para cada pessoa colocar as mãos no topo da pelve (sobre a crista ilíaca). Coloque suas mãos em sua crista ilíaca e demonstre todos os movimentos pélvicos. Peça que os participantes imitem. 50 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Após cada movimento, peça aos participantes que descrevam o que sentiram. Movimento Ilustração Mudanças no corpo Girar para frente: (inclinação pélvica para frente). Visão lateral da pelve O corpo endireita com os ombros empurrados para trás; • Há um aumento na curva da coluna acima da pelve. Girar para trás: (inclinação pélvica para trás). Visão lateral da pelve • O corpo fica arredondado com os ombros para frente. Inclinação para o lado: (inclinação lateral). Visão posterior da pelve • O corpo pende para o lado. Rotação. Visão superior da pelve • O restante do corpo também gira. Pergunte: como foi manter as diferentes posturas? Se os participantes não tiverem certeza, peça que repitam os movimentos e mantenham a postura para sentir como é. Estimule respostas. 51 Respostas mais importantes: • desconfortável; • difícil para se mover; • sustentação desigual de peso; • difícil usar os braços para fazer atividades; • difícil para respirar; • cansativo; • pressão no interior do corpo; • difícil de equilibrar-se. Explique: Ao sentar-se ereto, a pelve também está ereta (ou levemente inclinada para frente) e nivelada. Se a pelve não estiver ereta é impossível sentar-se ereto. 4. Diferentes posturas sentadas (25 minutos) Atividade Grupos: 2–3 pessoas em cada grupo. Instruções: Peça a cada grupo que: • observe atentamente todos os exemplos de posturas da planilha da apostila; • anote como a postura é diferente de sentar-se ereto; • pense sobre as características de sentar-se ereto de frente e de lado. Monitore: Monitore os grupos e ajude se necessário. Tempo: Dê 10 minutos. Feedback: Projete o slide de cada postura, um por vez. Peça a cada grupo que relate as diferenças entre uma postura mostrada e a posição ereta. Peça aos participantes que incluam qualquer ponto que ainda não incluíram na planilha. Notas para os instrutores – respostas mais importantes: • pelve desnivelada (mais alta do lado direito); • ombros desnivelados (mais alto do lado esquerdo); • tronco curvado para um lado; • perna direita virada para dentro; • tornozelo direito virado para fora; • tornozelo esquerdo virado para dentro. 52 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Notas para os instrutores – respostas mais importantes: • pelve inclinada para trás; • tronco colapsado (curvado para frente, para um lado e torcido); • ombros desnivelados; • cabeça para trás e queixo para frente – não equilibrado sobre a pelve; • joelhos não dobrados em posição neutra; • tornozelos não dobrados em posição neutra; • um braço entre as pernas e um braço atrás da manopla – o usuário não está estável na cadeira de rodas. Notas para os instrutores – respostas mais importantes: • pelve não ereta (inclinada para trás); • tronco curvado para frente; • ombros arredondados e para frente; • cabeça não equilibrada sobre a pelve; • queixo para frente. Explique: • Os três exemplos que acabaram de ver mostram posturas diferentes de “sentar-se ereto”. Elas podem ser “fixas”. Isso significa que não podem ser corrigidas. Para outros, a postura é flexível. Isso significa que a pessoa consegue sentar-se ereta se tiver suporte. • Quando a pessoa não consegue sentar-se ereta (mesmo com apoio), e está fixa em uma postura diferente, isso pode às vezes ser “acomodado” e ajudado com modificações à cadeira de rodas. Este programa de treinamento não aborda como fazer isso. Pergunte: Quais são alguns problemas que podem ser causados por não sentar-se ereto? Estimule respostas. 53 Respostas mais importantes: • pode causar úlceras/feridas de pressão; • ao longo do tempo o corpo do usuário pode ficar travado em uma postura diferente, não ereta e ele nunca mais vai conseguir sentar-se ereto; • é mais difícil mover a cabeça e o pescoço para ver e mais difícil de fazer as coisas; • pode dificultar a respiração e afetar a digestão; • aumenta a fadiga; • dificulta a deglutição; • pode causar desconforto e dor; • dificulta o equilíbrio; • dificulta o uso de braços e mãos; • pode causar mais problemas como espasmos ou rigidez muscular; • autoestima baixa. Liste os problemas que podem ser causados por não sentar-se ereto, conforme o slide. 5. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 54 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO A.5: Úlceras/feridas de pressão O BJ ET IV O S Ao final desta sessão, os participantes saberão:  Listar os quatro estágios da úlceras/feridas de pressão;  Reconhecer quando uma pessoa com úlceras/feridas de pressão deve ser encaminhada a um especialista;  Listar serviços locais onde usuários podem tratar suas úlceras/feridas de pressão;  Listar as três principais causas de úlceras/feridas de pressão;  Identificar as principais áreas com problemas de úlceras/feridas de pressão nos usuários;  Listar os fatores de risco para úlceras/feridas de pressão;  Listar maneiras de o usuário prevenir úlceras/feridas de pressão;  Demonstrar duas técnicas de alívio de pressão. RE CU RS O S Para a sessão:  Apresentação em PPT: A.5 Úlceras/feridas de pressão;  Manual de Referência;  DVD: Depoimento sobre úlceras/feridas de pressão;  Pôster: Úlceras/feridas de pressão;  uma cadeira de rodas (com almofada) para cada 2 participantes (uma por dupla). CO N TE X TO Adapte esta sessão para o contexto no qual os participantes vão trabalhar. Pense sobre:  convidar um usuário que tenha tido úlcera/ferida de pressão para contar sua história aos participantes. PR EP A RA ÇÃ O  Reunir recursos, rever a apresentação em PPT e ler todo o plano da sessão.  Preparar uma lista de serviços locais onde os usuários podem tratar úlcera/ferida de pressão. Se os participantes vêm de locais distantes, você pode pedir a eles que tragam essa informação.  Convidar um usuário que tenha tido úlcera/ferida de pressão para contar sua história.  Digitar a lista de recursos do slide 6 desta sessão. 55 D ES CR IÇ Ã O 1. Introdução 2. Úlceras/feridas de pressão 3. Onde e quando pedir ajuda 4. O que causa úlceras/feridas de pressão? 5. Fatores de risco para úlceras/feridas de pressão 6. Como prevenir úlceras/feridas de pressão? 7. Depoimento sobre úlceras/feridas de pressão 8. Técnicas de alívio de pressão 9. Resumo dos pontos principais 2 5 5 10 10 10 5 10 3 Tempo Total da sessão 60 1. Introdução (2 minutos) Explique: nesta sessão, falaremos sobre úlceras/ feridas de pressão. Nem todo usuário apresenta fatores de risco para desenvolver úlceras/feridas de pressão. No entanto, para quem desenvolve úlceras/feridas de pressão, as consequências são muito graves. . 2. Úlceras/feridas de pressão (5 minutos) Pregue o pôster sobre Úlcera/ferida de Pressão. Pergunte: Alguém já viu uma úlcera/ferida de pressão? Discuta brevemente. 56 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Quanto maior a úlcera/ferida, maior o problema para o usuário. • Úlceras/feridas de pressão podem exigir longos períodos acamados. • Se a úlcera/ferida de pressão infeccionar, a infecção pode se alastrar para o sangue, coração ou ossos. Isso pode levar a doenças graves e morte. Explique: A úlcera/ferida de pressão se desenvolve em quatro estágios. Explique: • O estágio 1 é uma marca vermelha ou escura na pele. A vermelhidão ou mudança de cor não desaparece 30 minutos após a remoção da pressão. • O estágio 2 é uma ferida rasa, e a camada superior da pele pode começar a descamar ou formar bolhas. • O estágio 3 é uma ferida profunda; toda a camada da pele é perdida. • O estágio 4 é muito profundo, estendendo-se até o músculo e possivelmente até o osso. Pergunte: Onde é mais provável que ocorram úlceras/feridas de pressão? Estimule respostas. Respostas mais importantes: • ísquio; • cóccix; • base da coluna (sacro); • ossos do quadril; • escápula; • coluna. 57 3. Quando e onde pedir ajuda (5 minutos) Pergunte: Qual o conselho que a equipe deve dar a um usuário com úlcera/ferida de pressão estágio 1? Estimule respostas. Reforce (ou dê) a resposta correta. Respostas mais importantes: • Qualquer um com úlcera/ferida de pressão estágio 1 deve: - remover imediatamente a pressão da área; - manter sem pressão até que a pele se recupere completamente. • Isso pode significar repouso (dependendo de onde está a úlcera/ferida). • Identificar a causa e resolvê-la. • Ensinar ao usuário como as úlceras/feridas de pressão se formam e como preveni-las no futuro. Pergunte: Qual o conselho que a equipe deve dar a um usuário com úlcera/ferida de pressão estágios 2, 3 ou 4? Estimule respostas. Reforce (ou dê) a resposta correta. Respostas mais importantes: • Seguir as ações para o estágio 1. e • Encaminhar para tratamento da úlcera/ferida de pressão por um especialista. Úlceras/feridas de pressão abertas precisam de limpeza, curativo e muito monitoramento para garantir que estão cicatrizando e não estão infeccionando. As feridas estágio 4 podem precisar de cirurgia. 58 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 4. O que causa úlceras/feridas de pressão? (10 minutos) Explique: As três principais causas das úlceras/feridas de pressão são. Leia o slide. Explique: Veremos cada causa em mais detalhes. Explique: • Úlceras/feridas de pressão causadas por pressão na pele por sentar-se ou deitar-se na mesma posição por muito tempo sem se mover. • Úlceras/feridas de pressão são causa importante de morte de pessoas com lesão medular Peça aos participantes que sentem sobre as mãos e sintam a pressão dos ísquios. Pergunte: O que aconteceria se ficassem nessa posição sem se mover? Resposta: • Você logo ficaria desconfortável por ter sempre pressão na mesma parte do corpo. Explique: • Fricção ou atrito é o roçar constante na pele. Por exemplo, o braço roçando na roda/apoio quando a cadeira é movida pode causar úlcera/ ferida de pressão. • A fricção ou atrito é um problema principalmente para usuários que não têm sensibilidade. • Podem haver solavancos quando o usuário está se transferindo ou se movendo na cadeira de rodas. 59 Explique: • Cisalhamento é quando a pele está imóvel e é estirada ou pinçada quando os músculos ou ossos se movem. Peça aos participantes que se sentem novamente sobre as mãos e balancem a pelve para trás. Sintam os ossos do ísquio se movendo sobre suas mãos. Por exemplo, quando um usuário se senta “caído” na cadeira, a pele pode ser danificada por cisalhamento dos ossos do ísquio quando a pelve balança para trás, ou pelos ossos das costas comprimindo a pele contra o encosto. 5. Fatores de risco para úlceras/feridas de pressão (10 minutos) Explique • Além das três causas principais das úlceras/ feridas de pressão, existe uma série de coisas que aumentam a chance de a pessoa ter uma úlcera/ferida de pressão. São os chamados fatores de risco para úlceras/feridas de pressão Pergunte: Alguém sabe sugerir fatores de risco para úlceras/feridas de pressão? Estimule respostas Respostas mais importantes: • não poder sentir (sensibilidade diminuída); • não poder se mover; • umidade de suor, água ou incontinência; • dieta inadequada ou não beber água suficiente; • envelhecimento; • peso – acima ou abaixo do peso; • má postura; • úlcera/ferida de pressão prévia ou atual; • trauma, trancos ou batidas; • calor/febre; • picada de inseto. 60 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: Os fatores de risco mais importantes são: • não poder sentir (sensibilidade diminuída); • não poder se mover; • umidade de suor, água ou incontinência; • má postura; • úlcera/ferida de pressão prévia ou atual; • dieta inadequada e não beber água suficiente; • envelhecimento; • peso – acima ou abaixo do peso. Explique: • O fator de risco mais importante é não poder sentir. A pessoa que não tem sensibilidade não sente a pressão. Isso significa menor probabilidade de mudar de posição para aliviar a pressão. • Quem não tem sensibilidade, ou tem dificuldade de sentir um toque em suas nádegas, assento ou pernas tem risco de desenvolver úlceras/feridas de pressão. • A maioria das pessoas com lesão medular não consegue sentir abaixo do nível da lesão. Isso significa que correm risco de desenvolver uma úlcera/ferida de pressão. Pessoas com lesão medular também podem não ter controle do intestino ou da bexiga. Se não podem controlar a incontinência, seu risco é aumentado devido ao aumento de umidade. Explique: • A equipe de serviços para cadeira de rodas precisa conhecer os fatores de risco para úlceras/feridas de pressão para identificar usuários em risco de desenvolver úlceras/ feridas de pressão. • Verificar os fatores de risco é parte da avaliação da cadeira de rodas: - Quem não tem sensibilidade corre risco de desenvolver uma úlcera/ferida de pressão; - Quem tem três ou mais fatores de risco corre risco de desenvolver uma úlcera/ferida de pressão. 61 Áreas comuns sensíveis à pressão: Vista lateral Vista posterior 6. Como prevenir úlceras/feridas de pressão? (10 minutos) Explique: • A equipe de serviços para cadeira de rodas pode ajudar os usuários a prevenir úlceras/ feridas de pressão. • A prevenção evita longas internações hospitalares e a impossibilidade de os usuários usarem a cadeira de rodas, e pode evitar a morte. • As várias formas de evitar úlceras/feridas de pressão são descritas a seguir. 62 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: Usar uma almofada para alívio de pressão • a almofada para alívio de pressão ajuda a diminuir a pressão. • Todos em risco de desenvolver úlceras/feridas de pressão devem receber uma almofada para alívio de pressão. Explique: sentar-se ereto • Sentar-se ereto ajuda a distribuir igualmente o peso. Isso reduz a pressão de partes ósseas e ajuda a reduzir as úlceras/feridas causadas por pressão. • Sentar-se ereto também ajuda a prevenir úlceras/feridas de pressão causadas por cisalhamento. • Certifique-se que a cadeira se ajusta corretamente. Isso ajuda o usuário a sentar-se ereto. • Ensine ao usuário porque é importante sentar-se ereto. Explique: Usar técnicas de alívio de pressão • O alívio regular da pressão pode ser eficaz para prevenir úlceras/feridas de pressão. • Veremos isso em mais detalhes mais adiante. 63 Explique: comer adequadamente e beber boa quantidade de água • Uma dieta equilibrada com legumes frescos, frutas e carne pode ajudar a prevenir úlceras/ feridas de pressão. • Beber boa quantidade de água ajuda a manter a pele saudável e a prevenir úlceras/feridas de pressão • Se estiver preocupado com a dieta de um usuário considere encaminhá-lo a um serviço que possa ajudá-lo. Explique: evitar fricção/atrito • Certifique -se que a cadeira se ajusta corretamente e não tem bordas ásperas. • Ensine aos usuários sem sensibilidade a garantir que nenhuma parte de seu corpo está roçando na cadeira de rodas. • Ensine os usuários a tomar cuidado ao transferir-se da cadeira de rodas. Explique: evitar umidade • É preciso aconselhar os usuários a trocar imediatamente roupas molhadas ou sujas e a não usar uma almofada molhada. • Um programa de controle de intestino e bexiga pode reduzir os problemas de umidade. • Encaminhe os usuários com problemas de incontinência para um serviço que possa ajudá-los. 64 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: verificar a pele todos os dias • As úlceras/feridas de pressão podem se desenvolver rapidamente. É importante identificar a úlcera/ferida de pressão rapidamente e agir. • Estimule os usuários em situação de risco a verificar sua pele todos os dias. Podem fazer isso usando um espelho ou pedir a um familiar que verifique. • Se virem uma área vermelha ou escura na pele (estágio 1), devem aliviar a pressão naquele ponto imediatamente. Explique: Quando deitados ou sentados, mudar de posição regularmente • Mudar de posição regularmente ajuda a aliviar a pressão. • Por exemplo, mudar de sentado para deitado. • Isso é especialmente importante para quem tem vários fatores de risco para úlceras/ feridas de pressão, ou tem uma úlcera/ferida de pressão recém-cicatrizada. • Quem não consegue mudar de posição sozinho está no grupo de risco. 7. Depoimento sobre úlceras/feridas de pressão (5 minutos) Apresente o DVD: Depoimento sobre úlcera/ferida de pressão. Exiba o DVD. Pergunte se existem dúvidas. VIDEO 8. Técnicas de alívio de pressão (10 minutos) Explique: • Os usuários podem aliviar a pressão sob o osso do ísquio quando estiverem na cadeira de rodas. 65 • Como o usuário faz isso pode variar dependendo de quanta força ou equilíbrio ele tem. • Este programa de treinamento ensina dois métodos seguros de aliviar a pressão: Inclinar para frente e de lado a lado. • A equipe de serviços para cadeira de rodas deve ensinar os usuários em situação de risco de desenvolver úlceras/feridas de pressão pelo menos uma forma de aliviar a pressão. Atividade Grupos: peça aos participantes para se dividir em duplas. Instruções: Dê a cada dupla uma cadeira de rodas. Peça às duplas que se posicionem para que possam ver você. Demonstre cada método e explique que métodos diferentes vão funcionar para usuários diferentes. Peça aos participantes para treinar cada método imediatamente após cada demonstração. Monitore: Monitore atentamente e corrija as técnicas conforme necessário. Tempo: Dê 10 minutos. Notas para os instrutores: Alguns usuários aliviam a pressão erguendo-se sobre o apoio para os braços. Para que a circulação do sangue seja suficiente para a pele, o usuário precisa se manter nessa posição por dois minutos. Isso exige muita força e faz pressão nos ombros. Além disso, o usuário tem que saber controlar cuidadosamente seu peso quando volta a se sentar. Se sentar abruptamente, pode danificar a pele. Por essa razão, esse método não é ensinado neste programa de treinamento. Inclinar para frente: método adequado para todos os usuários. Estimule os usuários a usar esse método frequentemente durante o dia Independente: para pessoas com bom equilíbrio e força. Com ajuda: Para pessoas com pouco equilíbrio e força. 66 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Inclinar para os lados: método adequado para usuários com força e equilíbrio limitados Prenda o braço na manopla para suporte 9. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas 67 A.6: Cadeira de rodas apropriada O BJ ET IV O S Ao final desta sessão, os participantes saberão:  descrever ao menos quatro coisas que tornam a cadeira de rodas “apropriada”;  identificar as partes da cadeira de rodas que afetam a forma como o usuário se senta;  explicar como partes diferentes da cadeira de rodas atendem a necessidades específicas do usuário;  identificar cadeiras de rodas mais apropriadas para ambiente externo/terreno acidentado do que outras;  sugerir a cadeira de rodas mais apropriada a um usuário considerando suas necessidades. RE CU RS O S Para a sessão:  Apresentação em PPT: A.6: Cadeira de rodas apropriada;  Manual de Referência;  Apostila do Participante;  DVD: O que uma cadeira de rodas apropriada significa para mim;  DVD: Atendendo às necessidades dos usuários;  DVD: Atendendo ao ambiente dos usuários;  Pelo menos um exemplo de cada cadeira de rodas disponível localmente. CO N TE X TO  Adapte esta sessão ao contexto em que os participantes vão trabalhar.  Se houver apenas um ou dois tipos de cadeiras disponíveis no local, tenha um número suficiente de cadeiras do mesmo tipo para que todos os grupos possam trabalhar. A variedade de cadeiras de rodas pode ser apresentada com pôsteres das diferentes cadeiras  Adapte os estudos de caso ao contexto local se necessário. PR EP A RA ÇÃ O  Reunir recursos, rever a apresentação em PPT e ler todo o plano da sessão.  Escolher uma área externa com terreno acidentado (por exemplo, cascalho, areia, desníveis) e espaço suficiente para os participantes se observarem à medida que se movem pelo terreno acidentado. Se estiver calor, o ideal será um local com sombra.  Verificar se todas as cadeiras estão funcionando bem e têm uma almofada.  Ajustar uma cadeira de rodas para um dos participantes.  Organizar as cadeiras de rodas na frente da sala de treinamento. D ES CR IÇ Ã O 1. Introdução. 2. Definição de uma “cadeira de rodas apropriada” 3. Como atender às necessidades dos usuários. 4. Como atender ao ambiente dos usuários. 5. Como fazer a adequação correta e proporcionar suporte postural. 6. Como combinar a cadeira de rodas com as necessidades do usuário. 7. Resumo dos pontos principais. 2 10 30 30 15 30 3 Tempo Total da sessão 120 68 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Introdução (2 minutos) Explique: nesta sessão veremos os principais tipos de cadeiras de rodas e algumas características diferentes que podem ser encontradas nas cadeiras de rodas. Vamos entender melhor o que significa uma “cadeira de rodas apropriada” Uma cadeira de rodas que: • atende às necessidades do usuário; • atende ao ambiente do usuário; • é a combinação certa para o usuário; • garante suporte postural (ajuda o usuário a sentar-se ereto); • manutenção e reparos podem ser feitos localmente. 2. Definição de “cadeira de rodas apropriada” (10 minutos) Apresente o DVD: O que uma cadeira de rodas apropriada significa para mim. Neste DVD, Faustina, uma usuária de cadeira de rodas experiente, explica o que uma cadeira de rodas apropriada significa para ela. Exiba o DVD. Pergunte se existem dúvidas. VIDEO 3. Como atender às necessidades dos usuários (30 minutos) Pergunte: O que os usuários precisam fazer em suas cadeiras de rodas? Estimule respostas Respostas mais importantes: • Sentar-se e levantar-se da cadeira de rodas (transferência); • impulsionar a cadeira de rodas; • dobrar a cadeira de rodas para guardar ou transportar; • realizar atividades (for exemplo: trabalho, trabalho doméstico, reunir-se com amigos, ir ao banheiro, lavar, vestir-se, passar por portas, sentar-se à mesa). 69 Explique: uma cadeira de rodas apropriada deve facilitar ao usuário fazer as coisas que quer fazer. Vejamos alguns recursos da cadeira de rodas que afetam a facilidade com que o usuário pode fazer aquilo que quer. 3.1 Transferências Transferir-se da cadeira de rodas Explique: Os usuários podem transferir-se da cadeira de rodas de formas diferentes. As três partes da cadeira de rodas que afetam como as pessoas se transferem da cadeira são: Explique: (aponte para a seta em cada componente) • freios; • apoio para os pés; • apoio para os braços. Explique: • Apoios removíveis para os braços ou que acompanham a linha das rodas traseiras são mais fáceis para as pessoas se transferirem da cadeira pela lateral. 70 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Pessoas que se levantam para transferir-se da cadeira podem precisar dos apoios para os braços para ajudá-las a ficar de pé. • Apoios para os de pés que podem ser movidos para o lado são úteis para pessoas que se levantam para transferir-se da cadeira. • Pessoas que querem se transferir para o chão podem preferir cadeira de rodas com apoios para os pés removíveis. Explique: • Os freios são importantes para todos os usuários. São essenciais para manter a cadeira imóvel enquanto a pessoa se transfere. 3.2 Impulsionando a cadeira de rodas Explique: As partes da cadeira de rodas que afetam a facilidade de impulsioná-la são: Explique: (aponte para a seta em cada componente) • apoio para os braços; • encosto; • aro de impulsão; • manopla; • o peso da cadeira também pode afetar a facilidade de impulsioná-la. 71 Explique: • Para alcançar os aros de impulsão confortavelmente o usuário precisa passar com os braços, com facilidade, por cima do apoio para os braços. • O usuário mostrado neste slide não consegue atingir alcançar facilmente os aros de impulsão porque os apoios para os braços estão altos demais. Explique: • A altura do encosto pode afetar a facilidade de impulsionar a cadeira de rodas. • Se o encosto for muito alto é difícil para o usuário mover os braços e ombros para impulsionar. • O usuário deste slide terá dificuldade em impulsionar porque o encosto é alto. Explique: • Quando o encosto é mais baixo, o usuário tem liberdade para mover os ombros para impulsionar. • Para um usuário que pode sentar-se bem e tem bom equilíbrio, esta é uma boa altura de encosto. Explique: • Para usuários que impulsionam com os braços, a facilidade de alcançar as rodas (aros de impulsão) afeta a facilidade de impulsionar. • Esta mulher mostra meio impulso. Note a facilidade com que alcaça as rodas (aros de impulsão) 72 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Como regra geral, a roda traseira deve estar posicionada para que quando o usuário segure no topo do aro de impulsão os cotovelos dobrem em 90 graus. • Se as rodas estiverem muito para trás, fica difícil alcançar os aros de impulsão. Então é mais cansativo para o usuário impulsionar. Explique: • Algumas cadeiras de rodas têm posição ajustável das rodas traseiras. • A posição das rodas traseiras afeta a facilidade de impulsionar a cadeira e empiná-la. • Empinar é útil para atravessar terreno acidentado e descer rampas. • Se as rodas traseiras são colocadas para frente é mais fácil empinar. E se são movidas para trás, é mais difícil empinar. A cadeira se torna mais estável. Explique: • Alguns usuários impulsionam a cadeira com os pés. • Para impulsionar eficazmente dessa forma, o usuário precisa conseguir sentar-se com a pelve bem apoiada pelo encosto e ter os pés firmes no chão. • Para esses usuários, a altura do assento a partir do chão (levando em consideração a almofada) é muito importante. • Apoios para os pés que podem ser afastados são também essenciais. • Alguns usuários que impulsionam com os pés podem preferir uma mesa a apoios de braço para que possam se inclinar para frente enquanto empurram. 73 Explique: • Uma cadeira de rodas pesada exige mais esforço para ser impulsionada. Se for bem desenhada e equilibrada, o efeito do peso pode não ser tão grande. • O peso da cadeira de rodas é especialmente importante para crianças. Se a cadeira for pesada isso pode dificultar o controle pela criança. Explique: • Alguns usuários não conseguem impulsionar sozinhos e precisam de ajuda. • Outros usuários conseguem impulsionar sozinhos a maioria das vezes, só precisando de ajuda ocasionalmente. Por exemplo, para subir e descer degraus ou atravessar terreno acidentado. • Manoplas fortes podem facilitar que outras pessoas ajudem o usuário. Para crianças, cadeiras com manoplas mais altas facilitam o adulto que ajuda a criança. 3.3 Dobrando a cadeira de rodas Explique: uma cadeira de rodas dobrável é útil para armazenagem e transporte. Existem duas formas principais de dobrar uma cadeira de rodas. Explique: • Cadeiras de rodas com estrutura dobrável se fecham unindo os dois lados. Às vezes também é possível remover as rodas. • Cadeiras de rodas com estrutura dobrável também podem ser úteis para usuários que precisam se ‘espremer’ por passagens estreitas. • Para transporte, alguns preferem uma cadeira de rodas com estrutura dobrável. • Uma desvantagem de algumas estruturas dobráveis é que o mecanismo de dobra pode enfraquecer, tornando a cadeira instável. Fica então mais difícil impulsioná-la. 74 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Algumas cadeiras de rodas com estrutura rígida também dobram. O encosto dobra para baixo em direção ao assento e as rodas traseiras podem ser removidas. • Tanto cadeiras de rodas de estrutura rígida quanto as dobráveis têm vantagens e desvantagens. A melhor opção vai depender do estilo de vida do usuário, de como se transfere dos meios de transporte e de sua preferência pessoal. Atividade Grupos: 3 pessoas em cada grupo. Instruções: Peça a cada grupo que descubra como dobrar as diferentes cadeiras de rodas da sala. Monitore: Verifique se todos conseguem dobrar e desdobrar as diferentes cadeiras de rodas. Corrija o método se necessário. Tempo: 5 minutos. 3.4 Realizando atividades Explique: Existem vários recursos da cadeira de rodas que afetam a facilidade com que o usuário pode realizar atividades. Já falamos sobre algumas. Por exemplo, a facilidade de impulsionar a cadeira de rodas afeta a facilidade dos usuários participarem de atividades. Aqui estão outros exemplos. Explique: • O comprimento da cadeira de rodas pode facilitar ou dificultar seu uso em espaços pequenos. • O comprimento é medido da extremidade posterior até a extremidade anterior da cadeira de rodas. Pergunte aos participantes: Qual é a cadeira de rodas mais comprida da sala? 75 Explique: • Apoios para o braço altos tornam difícil para o usuário se aproximar de uma mesa ou escrivaninha. Explique: A principal coisa que se deve lembrar é que é importante pensar no que o usuário precisa fazer ao escolher a cadeira de rodas mais apropriada. Apresente o DVD: Atendendo às necessidades dos usuários. Peça aos participantes que assistam atentamente para ver as diferentes características das cadeiras de rodas que ajudam as pessoas do DVD a fazer seu trabalho ou atividade. Explique que vamos discutir isso após o DVD. Exiba o DVD. VIDEO Explique: o DVD tem muitos usuários diferentes usando cadeiras de rodas diferentes. Pergunte: quais são algumas dessas atividades? As respostas incluem: • trabalhar (no escritório, supermercado, tapeçaria); • dançar; • entrar e sair de um carro; • andar (com a mamãe e o cachorro); • jogar basquete. Pergunte: Quais são algumas características da cadeira de rodas que ajudaram Roger a fazer seu trabalho no supermercado? Estimule respostas (veja Notas para os instrutores abaixo). Pergunte: alguém pode dar outro exemplo do vídeo de como as características da cadeira de rodas foram adequadas às necessidades do usuário? Estimule respostas – lembre os participantes das pessoas diferentes do vídeo e reapresente se necessário. Pergunte: alguém pode dar mais um exemplo? Estimule respostas. 76 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Notas para os instrutores: • Não é necessário rever todos os usuários; • Damos abaixo notas sobre cada usuário do vídeo para ajudar os instrutores a responder qualquer pergunta que os participantes façam; Usuário Atividade realizada Características da cadeira que ajudaram Roger Trabalhando em um supermercado; abastecendo prateleiras. • Distância curta entre os eixos – ajudou Roger a chegar perto das prateleiras e a manobrar a cadeira de rodas em pequenos espaços. • Rodas traseiras bem posicionadas e encosto baixo facilitam o impulso de Roger (Roger não precisa de suporte mais alto). • Sem apoio para os braços – mais fácil para Roger por as coisas no colo e se mover ativamente. Ruan Passeando com sua mãe e cachorro • Manoplas – em boa altura para a mãe empurrar • A cadeira de Ruan tem suporte postural extra (não entrar em detalhes) que o ajuda a sentar mais confortável e seguramente. James (número 14) e colegas de equipe Jogando basquete em cadeira de rodas James e seus colegas estão usando cadeiras de rodas esportivas especializadas. As características são: • Rodas traseiras em ângulo (aumenta a estabilidade); • Rodas traseiras finas (ajudam a aumentar a velocidade); • Rodas dianteiras pequenas (diminuem o peso e aumentam a velocidade); • Faixas de panturrilha ou coxa – ajudam a dar estabilidade e segurança aos usuários; • Encosto baixo – dá muita liberdade de movimento durante a prática de esportes. • Rodas traseiras bem posicionadas para impulso. Mark Trabalhando em uma tapeçaria Mark consegue empurrar com um pé – o que significa que não precisa usar os dois braços. Na oficina isso libera um braço para carregar coisas. • A cadeira de rodas propicia isso porque o apoio para os pés é móvel. 77 Dawid e Pinky Trabalhando como seguranças em um supermercado. • Ambos têm distância relativamente curta entre eixos – o que os ajuda a circular pela loja. • Ambos movem a cadeira de rodas independentemente – mas Dawid usa as rodas traseiras; Pinky tem uma cadeira de rodas elétrica. Faizel Trabalha em escritório. • Rodas traseiras bem posicionadas que facilitam a impulsão. • Encosto baixo o suficiente para permitir movimento dos ombros, mas alto o suficiente para dar suporte correto. • Usa luvas de impulso – o que o ajuda a empurrar nas rodas traseiras e aros de impulsão mais facilmente. • Sem apoio para os braços – o que facilita posicionar a cadeira para baixo da mesa. Keith (cadeira de rodas de três rodas) e Ralph (cadeira de rodas de quatro rodas) Trabalham em uma oficina de montagem de cadeira de rodas. • Ralph e Keith: Sem apoio para os braços – fácil trabalhar com ferramentas e na bancada, fácil de carregar as coisas no colo. • A cadeira de rodas de três rodas de Keith permite que ele se aproxime dos objetos que precisa pegar porque a base se encaixa facilmente entre outros itens e equipamentos. • Ralph tem uma cadeira com distância curta entre eixos que permite que chegue perto da superfície de trabalho. • Ralph e Keith: Rodas traseiras bem posicionadas para impulsão e encosto baixo para liberdade de movimentos. Ryan Entrando e saindo de um carro. • A cadeira de rodas de Ryan dobra e as rodas traseiras saem (rodas de remoção rápida) – o que permite que ele coloque a cadeira no carro sozinho. Sem esse recurso ele não conseguiria entrar e sair do carro sem ajuda. Jenee Dançando. • Comprimento geral curto da cadeira – permite fazer círculos muito fechados. • Distância curta entre eixos – melhora a capacidade de manobra. • Encosto baixo dá boa liberdade de movimentos. • Dispositivo antiqueda – evita que a cadeira caia para trás (o que é mais provável com essa distância curta entre eixos). 78 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 4. Como atender às necessidades do ambiente dos usuários (30 minutos) Explique: Diferentes tipos de cadeiras de rodas são adequados para ambientes diferentes. Os principais recursos que afetam o funcionamento da cadeira de rodas em um ambiente diferente são: • Distância entre as rodas dianteiras e traseiras; • Diâmetro e largura das rodas. Aqui temos alguns exemplos: Explique: • A distância entre as rodas dianteiras e traseiras é importante. • Quando as rodas estão muito separadas, isso é chamado de ‘distância longa entre eixos’. • Quando as rodas estão muito próximas, isso é chamado de ‘distância curta entre eixos’. Explique: • Cadeiras de rodas com distância longa entre eixos são mais estáveis e menos propensas a cair para frente. • Cadeiras de rodas com distância longa entre eixos são boas para pessoas que passam a maior parte do tempo fora de casa e se movendo por superfícies acidentadas ou desniveladas. • Cadeiras de rodas de três rodas são um exemplo de cadeira com distância longa entre eixos. São em geral muito estáveis e adequadas para ambientes externos em terreno acidentado. • A cadeira de rodas de três rodas não é apropriada para todos. • Por exemplo, uma cadeira de rodas de três rodas pode não ser boa para alguém que quer ficar de pé para transferir-se da cadeira porque o apoio para os pés é fixo e o eixo central pode atrapalhar. 79 • Cadeiras de rodas de quatro rodas com longa distância entre eixos também podem ser usadas com sucesso em superfícies desniveladas. • Neste exemplo, as rodas dianteiras estão embaixo do apoio para os pés e não atrás dele. Isso dá à cadeira uma distância entre eixos maior e a torna mais estável. Explique: • Cadeiras de rodas com distâncias menores entre eixos são mais adequadas para terrenos planos e razoavelmente lisos. • Cadeiras de rodas com distâncias menores entre eixos têm maior probabilidade de cair para frente ao descer rampas ou se as rodas dianteiras baterem em um obstáculo. Explique: • Este é um exemplo de cadeira de rodas de estilo ortopédico com distância curta entre eixos. • Esta cadeira não é fácil de impulsionar em terreno acidentado. Explique: • Cadeiras de rodas com distância curta entre eixos são uma boa opção para quem passa muito tempo em ambiente fechado. 80 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Cadeiras de quatro rodas de estilo ‘ativo’ costumam ter distância curta entre eixos. • Alguns usuários com boa mobilidade em cadeira de rodas podem usar cadeiras com distância curta entre eixos em superfícies desniveladas – por exemplo equilibrando-se nas rodas traseiras para descer rampas ou atravessar terrenos acidentados. Explique: • Quanto maior a roda, mais fácil é impulsionar em terreno acidentado e sobre obstáculos como pedras e gravetos. • Rodas dianteiras e traseiras largas ajudam a evitar que a cadeira de rodas afunde em terreno arenoso ou lamacento. • Rodas traseiras normais têm 24". No entanto, em vários lugares é difícil encontrar rodas de 24". Por essa razão, alguns fabricantes produzem cadeiras com rodas de 26". • Cadeiras infantis podem ter rodas de 20" ou 22". • Rodas traseiras e dianteiras podem ser cheias de ar (pneumáticas) ou sólidas. • As rodas pneumáticas precisam estar cheias para funcionar bem. • Em alguns locais os furos são comuns. Pessoas que moram nessas localidades precisam saber reparar os furos sozinhas, ou conseguir achar facilmente alguém que saiba reparar furos. • Os pneus sólidos são outra alternativa. Eles não precisam ser calibrados e não furam. No entanto, em terrenos acidentados os pneus sólidos parecem ‘duros’ para os usuários. • Nem todos os pneus sólidos duram muito quando usados externamente. Pneus sólidos de baixa qualidade podem ‘descascar’ a borda das rodas. • Existem dois tipos de pneus sólidos: - Pneus sólidos de borracha – que são pesados, bastante duros e podem ser muito duráveis se de boa qualidade. - Pneus de poliuretano (PU) – que são leves. No entanto, se não forem de qualidade muito boa se desgastam facilmente em ambiente externo e se tornam inutilizáveis. 81 Apresente o DVD: Atendendo ao ambiente dos usuários. Peça aos participantes que observem atentamente as diferentes características das cadeiras de rodas que podem ajudar as pessoas a terem mobilidade em ambientes diferentes Explique que vamos discutir isso após o DVD. Exiba o DVD. Pergunte se existem dúvidas. VIDEO Explique: o DVD tem vários usuários se deslocando em terrenos bastante diferentes, inclusive dentro de casa em corredores e em terreno acidentado/lamacento. Pergunte: Dois usuários – Venkamarantu e Sione trafegaram por terreno bastante acidentado e lamacento. Quais as características que os ajudaram a fazer isso mais facilmente? Respostas: • Cadeira de três rodas – que lhes deu estabilidade no terreno desnivelado. • Rodas dianteiras largas – que atravessam os obstáculos e tem menor chance de afundar em lama/areia. • Rodas traseiras em boa posição para impulsionar – facilitando o impulso da cadeira. Pergunte: Jean, que estava na cozinha, e Jacques, o treinador trabalhando no ginásio, estavam em ambientes internos. Quais as características que os ajudaram a se locomover em ambientes internos? Respostas incluem: • Distância curta entre eixos e comprimento geral curto da cadeira. • Rodas dianteiras menores/mais finas – fácil locomoção em superfícies lisas. Pergunte: Outra usuária (Lalithamma) estava em ambiente externo. Seu caminho era mais suave; no entanto ela precisou atravessar uma vala. Quais as características da cadeira que facilitaram isso? Respostas incluem: • Cadeira de quatro rodas e distância longa entre eixos – distância longa entre eixos gera boa estabilidade (o que também ajudou Lalithamma a carregar água). • Rodas dianteiras largas. • Rodas traseiras em boa posição para impulsionar – facilitando a ela o impulso da cadeira. 82 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Atividade em pequenos grupos Grupos: Leve todos para o terreno acidentado com três cadeiras de rodas diferentes Instruções: Lembre os participantes das regras de segurança: não subir nos apoios para os pés, manter os dedos longe dos raios das rodas e dos freios; se subir ou descer rampas ter um assistente atrás de você caso você caia para trás. Peça dois voluntários • Peça a um voluntário que escolha a cadeira que acredita ser a mais fácil de impulsionar no terreno acidentado; • Peça ao outro voluntário que escolha a cadeira que acredita ser a mais difícil de impulsionar em terreno acidentado. • Peça aos voluntários que andem no terreno acidentado por 5 metros e voltem; • Repita com mais dois voluntários até que todos tenham participado. Monitore: Assegure-se que a atividade seja realizada com sucesso. Não estimule os participantes a correr porque isso pode ser perigoso. Tempo: Dê 20 minutos Feedback: Pergunte: Qual cadeira de rodas foi a mais fácil de impulsionar no terreno acidentado? • Por que? Estimule os participantes a pensar no tamanho e largura da roda; na distância entre eixos; na facilidade de alcançar as rodas para impulsionar; na altura do encosto. Explique: alguns participantes teriam achado mais fácil do que os outros, se tivessem tido a sorte de ter uma cadeira de rodas adequada para eles! 83 5. Proporcionando adequação correta e suporte postural (15 minutos) Explique: • Há usuários de todos os tamanhos. A cadeira de rodas precisa se ajustar corretamente ao usuário para dar o suporte adequado. Felizmente, muitas cadeiras têm vários tamanhos, ou têm ajustes de tamanho. É mais fácil ter certeza de que essas cadeiras de rodas se ajustam ao usuário do que se houver apenas um tamanho disponível. • Os componentes ou características a seguir vão afetar a precisão da adequação da cadeira de rodas e a eficiência com que ajudará o usuário a sentar-se ereto. Assento Mostre os slides: destaque também características das cadeiras de rodas da sala. Explique: • Os assentos das cadeiras podem ser rígidos ou flexíveis. • Assentos rígidos são feitos de madeira ou plástico e precisam sempre ter uma almofada em cima. • Assentos flexíveis (mostrados neste slide) são em geral feitos de lona. • O “tamanho” da cadeira costuma ser definido pela largura do assento. Explique: • Assentos flexíveis são feitos de lona e em geral estão presos aos dois lados da estrutura. • Assentos flexíveis de baixa qualidade esgarçam e cedem mais facilmente. Então o assento não dá um bom suporte. • Neste slide, o usuário não consegue sentar-se ereto porque o assento não dá bom suporte. Isso torna difícil sentar-se ereto. 84 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • A almofada dá conforto e ajuda a aliviar a pressão. • As almofadas também ajudam a impedir que o usuário escorregue para uma posição caída. • Falaremos em detalhes sobre almofadas na próxima sessão. Explique: • Os encostos podem ser rígidos ou flexíveis. Todos os encostos rígidos devem ter algum estofamento/enchimento. • As cadeiras de rodas vêm com diferentes alturas de encosto. Algumas têm altura ajustável. A altura correta do encosto deve ser selecionada para o usuário. Isso será discutido adiante. • Algumas cadeiras também têm ângulos ajustáveis no encosto. Explique: • Os apoios para os pés ajudam a sustentar o usuário. É muito importante que eles sejam ajustados corretamente. Por isso, a altura dos apoios para os pés costuma ser ajustável. • Alguns apoios para os pés também podem ser ajustados pelo ângulo e a distância entre eles e a cadeira de rodas. Explique: • Os apoios para os braços também podem ser usados para sustentação. • Alguns têm altura ajustável. • Se não forem ajustáveis, podem às vezes ser modificados para dar mais sustentação ao usuário. 85 6. Combinando as cadeiras de rodas às necessidades dos usuários (30 minutos) Atividade Grupos: Forme grupos de três pessoas. Instruções: Peça a cada grupo que: • leia as histórias dos usuários que estão na apostila; • discuta quais cadeiras disponíveis se adequam melhor às necessidades de cada usuário e por que; • anote as respostas. Monitore: Monitore os grupos e ajude se necessário. Tempo: 20 minutos e 10 minutos de feedback. Feedback: Um por vez, peça a cada grupo que venha para a frente e: • Diga qual das cadeiras disponíveis eles acham a mais adequada para aquele usuário; • Dê ao menos três razões por que acham que é a melhor opção; • Pergunte aos demais participantes se concordam com a decisão do grupo. • (2–3 minutos para cada feedback). Ao final do feedback, lembre aos participantes que sua decisão é uma recomendação a ser discutida com o usuário. A decisão final deve ser dele. História do Usuário Pontos a aprender Bao vive numa zona rural. Teve as duas pernas amputadas acima do joelho. Antes do acidente, tinha um pequeno mercado na estrada que passa por sua cidade. Agora só consegue chegar à loja com ajuda porque a distância da cidade até a estrada é longa (quase 1 km), acidentada e em geral lamacenta. Isso torna difícil para ele e sua família cuidarem da loja. Muito tempo atrás ele ganhou uma cadeira de rodas de estilo ortopédico. A cadeira está enferrujada e o estofamento do assento rasgou. As rodas dianteiras são pequenas e as traseiras são finas e estão gastas. Ele não consegue impulsionar a cadeira de sua casa até a cidade porque as rodas atolam no caminho. Ele gostaria de poder chegar sozinho até a loja, para não ter que depender da esposa ou de terceiros para ajudá-lo. • Bao precisa de uma cadeira que possa ser impulsionada por ele em terreno acidentado e arenoso. • Bom acesso às rodas para impulsão é importante. • Bom suporte postural vai ajudá-lo porque vai passar muito tempo na cadeira todos os dias na loja. • Se houver triciclos, os instrutores podem destacar que o triciclo pode ser um meio muito eficiente de mobilidade para usuários que têm bastante força e precisam atravessar longas distâncias. 86 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO História do Usuário Pontos a aprender Amanthi tem 24 anos e mora com sua família em uma cidadezinha. Sofreu um acidente automobilístico quando tinha 18 anos e ficou paraplégica. Recentemente ela teve uma úlcera/ferida de pressão que levou seis meses para cicatrizar. Ela tem uma cadeira de rodas ortopédica que não lhe dá boa sustentação e ela fica muito cansada nela. Não tem almofada. Amanthi acredita que foi por isso que ela desenvolveu a úlcera/ferida de pressão. Amanthi foi convidada para participar de um curso de secretariado e quer ir. No entanto, não tem certeza se conseguirá ficar sentada o dia todo em sua cadeira de rodas atual. • Amanthi precisa de uma cadeira que permita transferência fácil, dê bom suporte postural e tenha uma almofada de alívio de pressão. • Uma cadeira que entre sob a mesa é importante. • O tamanho da roda dianteira vai depender do tipo de estrada que ela vai percorrer. Phillip tem 62 anos e mora em uma comunidade em uma pequena ilha. Seis meses atrás teve um AVC/ trombose cerebral. Voltou para casa depois de um mês internado e sem cadeira de rodas. Fica deitado na cama ou sentado em uma cadeira na varanda de sua casa. Phillip não consegue mover o braço e a perna esquerdos. No entanto, está ficando mais forte a cada dia e agora consegue ficar de pé com a ajuda de um familiar. Está exercitando o braço direito e quer muito ter uma cadeira de rodas para tem mais mobilidade e ser menos dependente da família. Quer poder circular por sua casa, que é térrea, e pela comunidade local. O terreno é muito arenoso. Um de seus netos tem um carro e disse que vai levá-lo para passear quando ele tiver uma cadeira de rodas. • Phillip precisa de uma cadeira que permita que ele se transfira de pé. Apoios dobráveis para os pés facilitariam. • Rodas dianteiras maiores e rodas traseiras largas facilitariam a movimentação pela comunidade. • Ele pode impulsionar a cadeira por curtas distâncias com o braço e a perna direitos – então a altura do assento da cadeira (com almofada) deve permitir que ele se sente com os pés firmes no chão. • Uma cadeira dobrável, ou uma cujo encosto dobre para baixo e as rodas traseiras saiam, vai facilitar seu acesso ao carro do neto. Sabina tem 56 anos e mora em uma pequena ilha. Após o nascimento de seu quarto filho, muitos anos atrás, ela perdeu quase todos os movimentos das pernas. Consegue ficar um pouco em pé, mas não consegue andar. Nunca teve uma cadeira de rodas. Sabina mora perto do mar – e a superfície em torno de sua casa é acidentada e arenosa. Ela se dedica a cuidar dos netos, cozinhar e tecer. Não há espaço interno para uma cadeira de rodas, mas ela pode ser armazenada sob a casa construída sobre colunas. • Sabina precisa de uma cadeira que possa impulsionar facilmente por solo acidentado e arenoso. Rodas dianteiras grandes serão importantes. Longa distância entre eixos ajudará na estabilidade da cadeira de rodas. • Como ela consegue ficar de pé, pode preferir apoios móveis para os pés para que ela possa se levantar para transferir-se da cadeira de rodas. • A cadeira precisa ser forte e robusta para se adequar a seu estilo de vida ao ar livre. 87 7. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. A.7: Almofadas O BJ ET IV O S Ao final desta sessão, os participantes saberão:  listar os benefícios das almofadas para usuários;  citar os tipos diferentes de almofadas disponíveis localmente;  explicar o que é uma “almofada para alívio de pressão”;  demonstrar como saber se a almofada para alívio de pressão está reduzindo a pressão;  explicar que incluir uma “camada de elevação” de espuma na almofada para alívio de pressão pode reduzir a pressão. RE CU RS O S Para a sessão:  Apresentação em PPT: A.7 Almofadas;  Manual de Referência (Página 29);  Apostila do Participante (Página 21);  DVD: Demonstração do teste de pressão;  Uma amostra de cada almofada disponível localmente, uma almofada para alívio de pressão adaptada à cadeira para cada três participantes, uma almofada para alívio de pressão com “camada de elevação" adicionada CO N TE X TO  Adapte esta sessão ao contexto em que os participantes vão trabalhar. Pense em:  Almofadas disponíveis na localidade do participante – esta sessão dá informações sobre almofadas de espuma e líquido/gel – se houver outros tipos de almofadas na localidade do participante, inclua essas almofadas na sessão;  Se não houver almofada para alívio de pressão disponível, será difícil ensinar esta sessão – também será difícil aos participantes prescrever cadeiras de rodas com segurança após o treinamento – explore uma forma de introduzir almofadas para alívio de pressão baratas antes do treinamento, inclusive via produção local ou entrar em contato com empresas externas para ajuda. 88 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO PR EP A RA ÇÃ O  Reunir recursos, rever os slides, assista ao DVD e ler todo o plano da sessão.  Assegurar-se que algumas cadeiras de rodas disponíveis tenham uma almofada para alívio de pressão.  Ter um exemplo de cada almofada e camada de elevação disponíveis localmente na sala de treinamento. D ES CR IÇ Ã O 1. Introdução. 2. Para que servem as almofadas? 3. Tipos diferentes de almofadas. 4. Almofadas de alívio de pressão. 5. Como saber se a almofada de alívio de pressão está funcionando. 6. O que fazer para reduzir a pressão? 7. Resumo dos pontos principais. 2 5 5 25 30 5 3 Tempo Total da sessão 75 1. Introdução (2 minutos) Explique: Nesta sessão, falaremos sobre almofadas de cadeiras de rodas. Veremos por que as almofadas são importantes, os tipos diferentes de almofadas e como saber se a almofada está adequadamente ajustada. 2. Para que servem as almofadas? (5 minutos) Pergunte: Quais são os benefícios da almofada para os usuários? Estimule respostas. Respostas mais importantes: • alívio de pressão; • suporte postural; • conforto 89 Explique: • A almofada é uma parte muito importante da cadeira de rodas para todos os usuários. • O tipo de almofada mais adequado ao usuário vai depender de suas necessidades. • Pessoas com risco de desenvolver úlceras/ feridas de pressão devem sempre usar almofadas para alívio de pressão. • Nem todo usuário precisa de uma almofada para alívio de pressão. • No entanto, todos os usuários devem estar confortáveis na cadeira de rodas, e todos os usuários vão se beneficiar de suporte para sentar-se eretos facilmente. 3. Diferentes tipos de almofadas (5 minutos) Explique: Existem diferentes tipos de almofadas para cadeira de rodas. Pergunte: Quais são os tipos de almofada que os participantes já viram ou já ouviram falar? Estimule respostas e anote no quadro. Respostas podem ser: • almofadas de espuma; • almofadas de fibra de coco; • almofadas cheias de ar; • almofadas cheias de líquido ou gel; • almofadas planas; • almofadas esculpidas; • almofadas moldadas; • almofadas em camadas. 90 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: Existem várias almofadas diferentes. Elas podem ser descritas de várias formas, inclusive: • pelo material de que são feitas (espuma, fibra de coco); • pelo material com que são preenchidas (ar, líquido ou gel); • por sua função principal (alívio de pressão, conforto, suporte postural); • por seu formato (plana ou moldada); • Como são feitas (almofadas de espuma podem ser “esculpidas” de uma peça de espuma ou “em camadas” – feitas de diferentes camadas de espuma). Mostre as almofadas disponíveis localmente, uma por uma. Descreva cada almofada pelo material, função principal, formato e se é esculpida ou em camadas. Circule os exemplos pelo grupo. 4. Almofadas para alívio de pressão (25 minutos) Explique: na sessão sobre úlceras/feridas de pressão, falamos sobre garantir que todos os usuários em risco de desenvolver úlceras/feridas de pressão tenham uma almofada para alívio de pressão. Nesta sessão, veremos o que é uma almofada para alívio de pressão. Pergunte: Qual das almofadas mostradas pode ser uma almofada para alívio de pressão? Respostas: • qualquer almofada de espuma moldada; • qualquer almofada cheia de ar ou líquido. 91 Almofadas para alívio de pressão ajudam a reduzir a pressão: • Distribuindo o peso do usuário o mais igualmente possível na superfície do assento; • Reduzindo a pressão em áreas de risco de alta pressão (ossos do ísquio, quadril, cóccix); • Reduzindo o cisalhamento pois ajuda o usuário a sentar-se ereto. Almofadas de espuma para alívio de pressão Explique: Falaremos primeiro sobre almofadas de espuma para alívio de pressão. Explique: Base estável firme: • A base de uma almofada para alívio de pressão deve ser firme. • Isso garante que a almofada ofereça bom suporte ao usuário e não se mova quando ele se move. Explique: Camada superior • É uma camada (ou mais de uma) de espuma mais macia. • A camada superior deve ser macia o suficiente para que o osso do ísquio afunde nela, mas não deve ser tão macia a ponto de o osso do ísquio afundar até o fim e se apoiar na base sólida ou no assento da cadeira de rodas Explique: Muitas almofadas de espuma para alívio de pressão tem algum formato (contorno) no assento. O formato pode: • Ajudar a sustentar o usuário; • Ajudar a distribuir o peso do usuário mais igualmente sobre o assento; • Ajudar a aliviar a pressão do osso do ísquio e do cóccix. 92 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Os formatos que podemos encontrar em uma almofada para alívio de pressão podem ser os seguintes: (clique para mostrar as setas no slide): • Um “poço” sob o osso do ísquio – para reduzir a pressão; • Uma plataforma na frente do osso do ísquio – para manter a pelve mais ereta e impedir seu deslizamento para frente; • Suporte sob a parte superior dos ossos da coxa para ajudar a distribuir o peso; • Sulcos ou calhas para apoio das coxas. Almofadas de ar/líquido/gel para alívio de pressão Explique: Agora veremos almofadas de ar/líquido/gel. Explique: • Almofadas de flutuação são aquelas cheias de ar e as que têm uma bolsa de líquido ou gel. • Almofadas com bolsa de gel devem ter uma base firme de espuma, muito semelhante à almofada de espuma moldada. • Sobre a base há uma bolsa de gel/líquido. • A bolsa de gel se adapta automaticamente ao formato do corpo do usuário. Isso ajuda a distribuir o peso do usuário igualmente e reduz a pressão nas áreas ósseas. Qual almofada usar? Explique: Tanto as almofadas de espuma moldada quanto as almofadas com ar/gel/ líquido têm vantagens e desvantagens. Desenhe a tabela abaixo no quadro (sem as respostas). Pergunte: Quais são algumas vantagens e desvantagens? Anote as sugestões dos participantes. Assegure-se de cobrir todos os itens abaixo. 93 Vantagens Desvantagens Almofada de espuma moldada • Pode ser feita localmente (onde exista espuma de alta qualidade). • Pode ser modificada localmente para acomodar necessidades diferentes. • Não está sujeita a “colapso súbito” (um furo que libere o ar ou líquido pode impedir que a almofada alivie a pressão, causando “colapso súbito” da almofada). • A camada superior da almofada de espuma em camadas pode ser substituída facilmente a baixo custo (ao invés de substituir toda a almofada) • A espuma comprime (fica mais chata e firme) ao longo do tempo. Por isso, almofadas de espuma devem ser verificadas com frequência e trocadas a cada 1-2 anos. • Pode demorar um pouco para secar (problema para quem é incontinente) • A espuma isola e pode aumentar a temperatura da pele Almofadas de ar/ líquido/gel • A pressão é distribuída por igual na superfície do assento. • A bolsa de gel se adapta automaticamente ao corpo quando o usuário se move ou muda de posição • Almofadas de ar/líquido/gel costumam ser mais caras e menos disponíveis do que as de espuma • Alguns usuários se sentem instáveis com almofadas de ar/líquido/gel • Sujeitas a “colapso súbito”. Em qualquer contexto onde o usuário não consiga substituir a almofada rapidamente, isso pode ser um problema. Capas de almofadas Explique: todas as almofadas devem ter uma capa. O tipo de capa é importante. Circule uma capa de cada tipo disponível. Peça aos participantes que observem bem as capas e considerem as perguntas do slide. • A capa é resistente à água ou é à prova d’água? • A capa parece ser durável? • A capa é elástica? • A capa é feita de material fino ou grosso? • A capa pode ser removida e substituída facilmente para lavagem? 94 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Pergunte: • Qual capa de almofada (se houver) é resistente à água ou à prova d’água? • Quando esse recurso é importante? Respostas: • Para usuários incontinentes; • Para usuários que precisam deixar as cadeiras ao ar livre ou que permaneçam muito tempo ao ar livre. Explique: • Umidade é um fator de risco que pode aumentar a chance de o usuário desenvolver úlceras/feridas de pressão. Então manter a almofada seca é muito importante. • Sempre aconselhe os usuários a secar a almofada imediatamente se ela molhar. Deve-se secar a almofada à sombra e sem a capa. • Pense em fornecer duas almofadas para usuários incontinentes. Notas para os instrutores: Os participantes podem perguntar o que fazer se não houver capas resistentes à água ou à prova d’água e o usuário for incontinente. As opções são: • Pesquisar que ajuda pode ser dada para que o usuário reduza a incontinência; • Fornecer uma segunda almofada – para que enquanto uma seca o usuário use a outra; • Proteger a almofada com um saco plástico bem fino dentro da capa; Se usar um saco plástico: - Verifique se o saco plástico não faz com que o usuário “escorregue” na almofada; - O usuário precisa garantir que o líquido não “acumule” sobre o plástico – isso aumenta o risco para úlceras/feridas de pressão. - O usuário deve garantir que a capa seja seca se ficar molhada e que o saco plástico seja limpo ou substituído. Pergunte: • Qual das capas de almofada (se houver) parece ser durável? Explique: uma capa durável é importante para qualquer almofada. Pergunte: • Qual capa (se houver) é elástica? • Por que isso é útil? Resposta: • A capa elástica acompanha melhor os contornos da almofada – se a capa não for elástica é preciso mais “espaço” para a capa se adaptar aos contornos. 95 Pergunte: • Qual é o tecido mais fino? Qual é o tecido mais grosso? • Por que a grossura do tecido é importante? Respostas: • Tecidos grossos podem durar muito, mas podem não acompanhar facilmente os contornos da almofada e pregas em tecido grosso podem causar úlceras/feridas de pressão; • Tecidos finos acompanham melhor os contornos da almofada e têm menor probabilidade de causar úlceras/feridas de pressão, mas podem não durar muito – vai depender da qualidade do tecido. Pergunte: Quais capas podem ser tiradas e recolocadas após a lavagem? Explique: Isso é importante para usuários que são incontinentes, que passam muito tempo ao ar livre ou que guardam a cadeira ao ar livre. Explique: Assim como as cadeiras de rodas, as almofadas têm tamanhos diferentes. É importante que a almofada escolhida para cada usuário se adapte ao tamanho do assento, que deve ser do tamanho certo para o usuário. 5. Como saber se a almofada para alívio de pressão está funcionando (30 minutos) Explique: Sempre que um usuário recebe uma almofada para alívio de pressão, é essencial verificar se ela está realmente funcionando para aliviar a pressão. Pergunte: Qual é a parte do corpo do usuário que corre maior risco de desenvolver úlceras/feridas de pressão quando ele está sentado? Estimule respostas. Respostas mais importantes: • osso do ísquio; • cóccix – particularmente se o usuário sentar em posição caída. Apresente o DVD: Demonstração de teste de pressão. O DVD mostra um teste simples para verificar se a almofada para alívio de pressão está reduzindo a pressão sob o osso do ísquio do usuário. Observem atentamente porque vocês vão treinar isso após o DVD. Exiba o DVD. Pergunte se existem dúvidas. VIDEO 96 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Nível 1: • As pontas dos dedos se movem para cima e para baixo. Existe alguma pressão nos tecidos, mas os ossos da ponta dos dedos conseguem se mover 5 mm ou mais. Nível 2: • As pontas dos dedos não se movem, mas deslizam facilmente sob o osso do ísquio. Nível 3: • As pontas dos dedos são apertadas firmemente. É difícil tirar os dedos da posição. Explique: sempre verifique um osso por vez. Nível Pressão Ação 1 Seguro Não 2 Atenção Sim, se houver vários fatores de risco 3 Inseguro Sim Explique: Falaremos sobre as ações necessárias no final da sessão. Atividade Grupos: 2–3 pessoas em cada grupo. Tente fazer pares do mesmo sexo. Dê a cada grupo uma cadeira de rodas com almofada para alívio de pressão. Instruções: Peça a cada grupo que: • treine verificar a pressão sob cada osso do ísquio; • anote o nível de pressão de cada pessoa do grupo na apostila delas. Assegure-se que todos treinem na função de “avaliador” e de “usuário”. Monitore: • Circule pelos grupos e monitore/observe atentamente. • Corrija as técnicas se necessário. Tempo: 15 minutos mais 5 minutos para feedback. Feedback: Pergunte: Como foi ser um usuário? Explique: É importante explicar claramente ao usuário o que você está fazendo, por que é importante, e verificar se ele se sente bem com o teste. Pergunte: Alguém tem dúvidas sobre essa técnica? 97 Notas para os instrutores: Ao monitorar os pequenos grupos certifique-se que as etapas seguintes são executadas A • Explique brevemente ao usuário o que você vai fazer e por que é importante. B • Peça ao usuário que se erga ou incline para frente para que você possa colocar as pontas dos dedos sob o osso do ísquio direito ou esquerdo (palma da mão para cima). • Isso é melhor se feito por trás da cadeira, por baixo do estofamento do encosto, com uma mão. C • Peça ao usuário que se sente sobre seus dedos. • Ele deve sentar-se ereto, rosto para frente, e por as mãos sobre as coxas. Isso garante que ele se sente na mesma posição sempre que você for verificar um outro local. • Se os dedos não estiverem em boa posição para sentir a pressão sob o osso, peça ao usuário para se erguer novamente e reposicione seus dedos. D • Identifique a pressão sob o primeiro osso do ísquio como nível 1, 2 ou 3. Nível 1 = seguro: Os dedos podem mover-se para cima e para baixo 5 mm ou mais. Nível 2 = atenção: Os dedos não podem se mover mas podem deslizar facilmente. Nível 3 = inseguro: Os dedos são apertados firmemente. É difícil retirá-los. E Repita para o segundo osso do ísquio. 98 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 6. O que fazer para reduzir a pressão? (5 minutos) Explique: • Quando identificar pressão insegura sob o osso do ísquio é preciso agir para reduzir a pressão • Uma solução simples para alta pressão sob o osso do ísquio é incluir uma camada extra de espuma firme. Isso é chamado de “camada de elevação”. • A camada de elevação deve ter cerca de 20 mm de espessura e ter um orifício recortado sob a área do osso do ísquio. • A camada de elevação é colocada no topo da camada de base e sob a camada de conforto. Explique: Às vezes é preciso mais de uma camada. A equipe de atendimento deve incluir uma camada e testar a pressão. Se a pressão se manter em nível 2 ou 3, inclua outra camada. Circule uma camada de elevação e um exemplo de almofada que recebeu uma camada de elevação para reduzir a pressão. Explique: Vamos treinar a inclusão de uma camada extra de espuma mais adiante. 7. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 99 A.8: Transferências Sentar-se e levantar-se da cadeira de rodas O BJ ET IV O S Ao final da sessão, os participantes saberão:  listar os pontos de segurança a serem considerados ao transferir-se da cadeira de rodas;  demonstrar formas diferentes de transferir-se da cadeira de rodas;  escolher no mínimo um método de transferência que seja melhor para um determinado usuário. RE CU RS O S Para a sessão:  Apresentação em PPT: A.8:Transferências;  Manual de Referência;  Apostila do Participante;  DVD: demonstração de transferência;  Cadeiras de rodas – uma para cada grupo de três.  Cama de avaliação para treino de transferência – uma para cada grupo de três;  Prancha de transferência (se houver); CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar. Pense sobre:  As cadeiras de rodas disponíveis localmente, que podem afetar as técnicas de transferência ensinadas – por exemplo, uma transferência em pé com cadeira de três rodas ao invés de uma de quatro rodas com apoios para os pés dobráveis requer mudanças no método;  Quais métodos de transferência são mais comumente usados na localidade dos participantes – os instrutores podem decidir mudar os métodos ensinados ou incluir mais métodos.  Se ensinar mais de três métodos de transferência, dê 20-25 minutos para ensinar cada transferência adicional. PR EP A RA ÇÃ O  Reunir recursos, rever os slides, assistir ao vídeo e ler todo o plano da sessão.  Treinar todos os métodos de transferência da cadeira de rodas para estar confortável durante a demonstração.  Se possível, convidar um usuário que possa demonstrar as transferências e ajudar no treino. 100 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO D ES CR IÇ Ã O 1. Introdução 2. Por que os usuários precisam aprender como se transferir? 3. Transferir-se da cadeira de rodas com segurança 4. Três formas de transferir-se da cadeira de rodas e feedback individual 5. Transferência independente do chão para a cadeira de rodas 6. Escolha das transferências 7. Resumos dos pontos principais 2 5 10 60 20 20 3 Tempo Total da sessão 120 1. Introdução (2 minutos) Explique: • A habilidade de transferir-se da cadeira de rodas de forma fácil e segura, com ou sem ajuda, vai auxiliar o usuário em sua vida diária. • O ato de sentar-se e levantar-se da cadeira é às vezes chamado de “transferência”. • Nesta sessão, os participantes vão treinar quatro formas diferentes que os usuários podem usar para transferir-se da cadeira de rodas. 2. Por que os usuários precisam aprender como se transferir? (5 minutos) Pergunte: Quais são alguns exemplos de situações em que os usuários precisam transferir-se da cadeira de rodas? Estimule respostas e anote no quadro. Respostas podem ser: • deitar e levantar da cama; • ir ao banheiro; • passar de e para cadeira/cama/triciclo/chão, etc.; • entrar e sair do carro/ônibus/taxi/riquixá, etc. 101 Explique: • Os usuários podem precisar transferir-se da cadeira de rodas várias vezes por dia. • Por essa razão, os usuários precisam de um método seguro, rápido e que não exija muito esforço. • Os usuários usam métodos diferentes dependendo de suas habilidades. Alguns podem transferir-se da cadeira sozinhos e outros precisam de ajuda. Alguns podem ficar em pé para a transferência e para outros isso não é possível. • A equipe de serviços pode ajudar os usuários a aprender o melhor método para eles. 3. Transferir-se da cadeira de rodas com segurança (10 minutos) Explique: Segurança na transferência é importante. Pergunte: Quais são alguns pontos de segurança a serem considerados durante a transferência? Estimule respostas e anote no quadro. Respostas mais importantes: • acionar o freio; • verificar onde você está indo – ter certeza de que não há nada no caminho; • sempre se levantar – nunca dar solavancos ou arrastar-se – isso pode causar lesões na pele e levar a uma úlceras/ feridas de pressão; • antes de ajudar alguém, tenha certeza que vai suportar seu peso; • não ajude se estiver grávida ou tiver problema de coluna. Reforce os três principais pontos de segurança: • acionar o freio; • verificar onde está indo; • sempre se erguer – não dar solavancos ou arrastar-se. 102 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 4. Três maneiras de transferir-se da cadeira de rodas e feedback individual (60 minutos) Explique: • Vamos agora observar e praticar três maneiras diferentes de transferir-se da cadeira de rodas. • Uma transferência é “independente” e as outras duas são “assistidas”. Antes de recomendar ou praticar uma transferência com um usuário de cadeira de rodas, você precisa saber se ele pode se transferir sozinho ou se precisa de ajuda. Se não tiver certeza, verifique ou pergunte a ele. • Para se transferir sozinho sentado, verifique se o usuário consegue levantar seu peso erguendo-se com os braços. Se não conseguir, precisará de ajuda para a transferência. • Para se transferir sozinho ficando em pé, verifique se o usuário consegue levantar e apoiar seu peso nas pernas. Se não conseguir, vai precisar de ajuda para a transferência. Explique: Para qualquer transferência, os participantes sempre devem lembrar o seguinte: • Verificar se o usuário pode se transferir sozinho ou se precisa de ajuda; • Posicionar a cadeira de rodas perto da cama/ superfície para onde o usuário vai se transferir; • Acionar os freios; • Se a cadeira de rodas tiver apoios para os braços que atrapalham – verificar se são removíveis. • Para transferências em pé, afaste os apoios para os pés (se possível). • Sempre levante – nunca arraste. Arrastar pode danificar a pele e levar a uma úlcera/ ferida de pressão. • Durante transferências assistidas, estimule o usuário a fazer o máximo possível da transferência independentemente. • Ao ajudar a erguer um usuário – não agarre roupas ou cintos. Puxar as roupas pode ser muito desconfortável para o usuário. 103 Atividade Grupos: Faça grupos de três. Dê a cada grupo uma cadeira de rodas e uma cama. Instruções: VIDEO Explique – os participantes vão assistir a uma demonstração de três transferências diferentes. Após cada demonstração, o vídeo será parado. Os participantes vão praticar a transferência que acabaram de ver em pares. Podem consultar o Manual de Referência se quiserem. Exiba o DVD Pergunte se existem dúvidas. Monitore: Após cada demonstração do DVD destaque os pontos principais descritos abaixo. Monitore e corrija as técnicas se necessário. Assegure-se que todos tiveram a chance de se transferir e de assistir. Tempo: 60 minutos. Feedback: Pergunte se existem dúvidas. Esclareça qualquer problema ou erro comum que os grupos tenham cometido durante a prática. 1.Transferência independente sentada (da cadeira para a cama) Destaque esses pontos principais após a demonstração do DVD e antes da prática. • Posicionar a cadeira perto da cama, acionar os freios. • Tirar os pés do apoio e afastar ou remover (quando for o caso) os apoios para os pés. • Remover o apoio para os braços mais próximo à cama. • Erguer-se com as mãos e se mover para a frente da cadeira de rodas. • Com uma mão na cama e a outra a cadeira, erguer-se em direção à cama. • Se o usuário tiver pouco equilíbrio, ou não conseguir erguer-se alto o suficiente ou se mover para o lado longe o suficiente, talvez precise de uma prancha de transferência. Explique • Ao se transferir para a cama, alguns usuários preferem colocar suas pernas na cama antes de se transferir. 104 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 2.Transferência sentada assistida com prancha de transferência (da cadeira para a cama) Destaque esses pontos após o DVD e antes da prática • Posicionar a cadeira perto da cama, acionar os freios. • Tirar os pés do apoio e afastar ou remover (quando for o caso) os apoios para os pés. • Remover o apoio para os braços mais próximo à cama. • Auxiliar o usuário a se mover para frente. • Colocar uma prancha de transferência sob as nádegas entre a cadeira e a cama. • O usuário deve ajudar o máximo possível erguendo-se para sustentar o próprio peso. • O assistente fica atrás do usuário e move a pelve do usuário para a cama. 3. Transferência em pé assistida ( da cama para a cadeira de rodas) Destaque esses pontos após o DVD e antes da prática • Posicionar a cadeira perto da cama, acionar os freios. • Tirar os pés da cama e afastar ou remover (quando for o caso) os apoios para os pés. • Remover o apoio para os braços mais próximo à cama. • Auxiliar o usuário a se mover para frente na cama e por os pés no chão. • Dar apoio aos joelhos do usuário pela lateral (não empurre contra os joelhos pela frente). • Trazer o corpo do usuário para frente e para cima segurando-o pelas escápulas. • Girar o usuário em direção à cadeira de rodas e deixar que se sente suavemente. 5. Transferência independente do chão para a cadeira de rodas (20 minutos) Explique: • Essa transferência requer que o usuário tenha braços fortes e bom equilíbrio. Usuários com risco de desenvolver úlceras/feridas de pressão devem sempre sentar-se na almofada para alívio de pressão quando se sentarem no chão. 105 Atividade Grupos: Faça grupos de duas pessoas. Dê a cada dupla uma cadeira de rodas. Instruções: Demonstre a transferência se souber (ou peça a um usuário para demonstrar). Destaque os pontos principais apresentados abaixo. Peça aos participantes que pratiquem em pares. Monitore: Monitore e corrija as técnicas se necessário. Assegure-se que todos tiveram chance de praticar. Tempo: 10 minutos. Feedback: Quantas pessoas conseguiram fazer essa transferência? Reconheça que é preciso boa força na parte superior do corpo. Para usuários ativos e em boa forma física com força nos braços, essa é uma aptidão que vale a pena treinar. Transferência independe do chão para a cadeira de rodas Explique: Ao transferir do chão para a cadeira de rodas: • Sente na frente da cadeira de rodas e leve os joelhos para perto do corpo; • Olhe para baixo e continue olhando para baixo durante toda a elevação; • Coloque uma mão no chão e uma mão na frente do assento da cadeira; • Empurre para baixo com os ombros e mãos para elevar as nádegas em direção ao assento da cadeira de rodas; • Sente na cadeira e abaixe para pegar a almofada; • Deslocando seu peso para um lado, coloque a almofada no lugar. Explique: Ao transferir-se da cadeira de rodas para o chão: • Sente na frente da cadeira de rodas; • Tire os pés do apoio para os pés e coloque-os na sua frente e levemente para o lado (longe da direção para onde está se transferindo); • Ponha a almofada no chão; • Com uma mão no assento da cadeira de rodas, alcance o chão com a outra mão; • Usando os ombros e os braços, controle o movimento das nádegas até a almofada colocada no chão. 106 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 6. Escolha das transferências (20 minutos) Explique: • Quando a equipe de serviços para cadeira de rodas fornece uma cadeira de rodas a um usuário, é parte de sua função garantir que o usuário consiga se transferir de maneira segura e fácil. • Muitos usuários já têm sua maneira de transferir. • Sempre peça ao usuário para demonstrar como costuma transferir-se da cadeira de rodas. • Se o método de transferência que usa é seguro e eficaz, não é preciso fazer mais nada. • Se não, a equipe de serviços para cadeira de rodas pode ensinar ao usuário como transferir-se da cadeira de rodas de maneira mais segura e fácil. • A primeira etapa é decidir qual método de transferência será melhor para o usuário. Esta próxima atividade vai ajudar os participantes a pensar sobre o melhor método de transferência para usuários diferentes. Atividade Grupos: Faça grupos de três pessoas. Instruções: Peça a cada grupo que: • leia as histórias dos usuários na apostila; • decida qual é o melhor método de transferência para cada um deles. Monitore: Monitore os grupos e ajude se necessário. Tempo: 10 minutos. Feedback: Peça a cada grupo que diga qual método de transferência eles escolheram para cada usuário e que expliquem brevemente por que. 107 História do usuário Pontos a aprender Faridah tem 60 anos. Foi encaminhada ao serviço para cadeira de rodas pelo hospital local. Recentemente teve um AVC/ trombose cerebral e precisa de cadeira de rodas porque não consegue andar. Ela consegue ficar em pé um pouco e sustentar seu peso. No entanto fica muito instável quando em pé. Faridah mora com sua filha e sua família. A filha não trabalha e pode ajudar a mãe em casa. Ela tem uma cadeira de quatro rodas com apoios para os pés dobráveis. • Faridah deve poder se transferir em pé com ajuda. • A filha fica em casa e pode ajudar. Ela deve ser envolvida no treinamento de transferência. José tem 45 anos e é usuário de cadeira de rodas há dez anos. Ele amputou as duas pernas acima do joelho e trabalha em uma oficina de conserto de rádios no mercado local. José veio ao serviço para cadeira de rodas para obter uma cadeira nova porque a dele é velha e gasta. • José deve poder se transferir sentado sem ajuda. Tahir tem 14 anos e foi encaminhado recentemente para o serviço para cadeira de rodas após cair de uma árvore e sofrer uma lesão medular. Tahir usa muito bem seus braços, mas não é muito forte. Não consegue usar as pernas de modo algum. • Tahir deve poder se transferir sentado com ajuda ou com uma prancha de transferência. Com prática ele vai poder se transferir sozinho. 7. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 108 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO B: Etapas do serviço para cadeira de rodas 109 B.1: Encaminhamento e agendamento O BJ ET IV O S Ao final desta sessão os participantes saberão:  descrever como os usuários devem ser encaminhados ao serviço para cadeira de rodas;  descrever o sistema de agendamento usado pelo serviço local para cadeira de rodas. RE CU RS O S Para a sessão:  Apresentação em PPT: B.1 Encaminhamento e agendamento;  Manual de Referência;  Formulário de encaminhamento ao serviço de cadeira de rodas (se houver). CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar. Pense sobre:  como os usuários são encaminhados aos serviços na área dos participantes;  se os serviços de onde os participantes vêm tem um método definido de encaminhamento e sistema de agendamento, fale sobre isso como parte da sessão – mostre quaisquer formulários em uso e dê aos participantes uma chance de praticar o seu uso. PR EP A RA ÇÃ O  Reunir recursos, rever os slides e ler todo o plano da sessão.  Preparar ou pedir aos participantes que tragam uma lista das formas diferentes como os usuários são encaminhados ao serviço de cadeira de rodas. D ES CR IÇ Ã O 1. Introdução. 2. Encaminhamento. 3. Agendamento. 4. Resumo dos pontos principais. 2 12 13 3 Tempo Total da sessão 30 110 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Introdução (2 minutos) Explique: Encaminhamento e agendamento é a primeira etapa da prestação de serviços para cadeira de rodas. Nesta sessão, vamos discutir as diferentes formas como o usuário pode ser encaminhado ao serviço e os diferentes sistemas de agendamento. 2. Encaminhamento (12 minutos) Pergunte: O que significa “encaminhamento”? Estimule respostas. Resposta mais importante: • enviar ou dirigir a pessoa ao local certo para atendimento ou assistência Mostre o slide. Explique: Existem maneiras diferentes de encaminhar o usuário ao serviço de cadeira de rodas. Por exemplo, os usuários podem: • ouvir falar do serviço e ir sozinhos; • ser dirigidos ao serviço pelo hospital local, centro de saúde comunitário, serviços de reabilitação da comunidade, líderes da cidade/conselho/igreja, organizações de pessoas com deficiências, outros usuários. Pergunte: Quais outras organizações, serviços ou pessoas podem encaminhar usuários a um serviço de cadeira de rodas? Estimule respostas. 111 Respostas podem ser: • médicos; • líderes da cidade/conselho/igreja; • centros de reabilitação; • organizações de pessoas com deficiências; • outros usuários; • organizações não governamentais. Explique: Essas organizações, serviços ou pessoas são “fontes de encaminhamento”. Os serviços de cadeira de rodas podem ajudar a aumentar o número de usuários encaminhados ao serviço garantindo que todas as fontes possíveis de encaminhamento conheçam o serviço. Peça aos participantes que olhem o modelo de formulário de encaminhamento ao serviço de cadeira de rodas no Manual de Referência dos participantes Ou Distribua o formulário de encaminhamento local, se houver um. Explique: • Dar às fontes de encaminhamento um formulário de encaminhamento ao serviço de cadeira de rodas pode ajudar a dar ao serviço algumas informações simples sobre o usuário. • Cada serviço de cadeira de rodas deve decidir se o formulário de encaminhamento ao serviço é útil para ele, quais informações incluir e como o formulário será entregue (por exemplo, enviado por correio ou entregue ao usuário para levá-lo). 112 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3. Agendamento (13 minutos) Explique: • Quando um usuário é encaminhado ao serviço de cadeira de rodas, deve ser agendada uma consulta de avaliação. A consulta pode ser para o usuário visitar o serviço/centro, ou para a equipe de atendimento visitar o usuário. • O sistema de agendamento de consultas ajuda à equipe de serviços de cadeira de rodas a organizar seu tempo. Também ajuda a evitar que o usuário fique esperando para ser atendido. • A forma de agendamento depende da facilidade de fazer chegar uma comunicação ao usuário. Pergunte: Quais são algumas formas de o serviço de cadeira de rodas fazer chegar um comunicado ao usuário? Estimule respostas. Respostas podem ser: • telefone; • correio; • enviar um recado pelo assistente social; • rádio; • enviar um recado para a fonte de encaminhamento pedindo que entre em contato com o usuário; • enviar um recado por um amigo/familiar. Explique: às vezes, o usuário pode chegar sem consulta agendada. Se ele vier de longe, é importante tentar achar uma forma de atendê-lo. Se houver um sistema específico de agendamento de consultas no serviço de cadeira de rodas local do participante, explique o sistema. 113 4. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. B.2: Avaliação O BJ ET IV O S Ao final desta sessão, os participantes saberão:  explicar o objetivo da avaliação;  listar as duas partes da avaliação da cadeira de rodas;  listar as informações coletadas durante a avaliação. RE CU RS O S Para a sessão:  Apresentação em PPT: B.2 Avaliação;  Manual de Referência. CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar. Pense sobre:  como é feita a avaliação no serviço dos participantes. PR EP A RA ÇÃ O  Reunir recursos, rever os slides e ler todo o plano da sessão. 114 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO D ES CR IÇ Ã O 1. Introdução. 1. Quem precisa de cadeira de rodas? 1. Por que você precisa de uma avaliação? 1. Quando fazer avaliação. 1. Duas partes da avaliação básica. 1. Resumo dos pontos principais. 2 5 10 5 5 3 Tempo Total da sessão 30 1. Introdução (2 minutos) Explique: • A avaliação é a segunda etapa da prestação de serviços para cadeira de rodas. • Nesta sessão vamos explicar por que a avaliação é importante e apresentar as duas partes da avaliação. • Durante as sessões de avaliação, lembre-se que os usuários devem ser envolvidos ativamente na avaliação – pergunte e ouça suas respostas e opiniões. 2. Quem precisa de cadeira de rodas? (5 minutos) Explique: Quando alguém procura o serviço em busca de uma cadeira de rodas, é importante ter certeza de que o que ele precisa é mesmo uma cadeira de rodas. Pergunte: Como saber se alguém precisa de uma cadeira de rodas? Estimule respostas e anote no quadro. Respostas mais importantes: • a pessoa não consegue andar; • a pessoa consegue andar – no entanto andar é difícil ou só consegue andar curtas distâncias. 115 Explique: • Mesmo que a pessoa consiga andar por curtas distâncias, ela pode precisar de cadeira de rodas para distâncias mais longas. • Usar cadeira de rodas nem sempre impede alguém de usar sua capacidade de andar. • A escolha certa é aquela que ajuda o usuário a ganhar a maior mobilidade possível e ter melhor qualidade de vida. É direito do usuário fazer a escolha. 3. Por que você precisa de uma avaliação? (10 minutos) Pergunte: Por que você precisa de uma avaliação? Estimule respostas e anote no quadro. Respostas mais importantes: • Para ajudar a escolher a cadeira de rodas mais apropriada ao usuário dentre as disponíveis; • Para ajudar a escolher os componentes mais adequados da cadeira de rodas dentre os disponíveis; • Para saber qual treinamento o usuário e/ou sua família precisam para o melhor uso da cadeira de rodas. Pergunte: Quais são as informações que os participantes acham que devem coletar durante a avaliação? Estimule respostas e anote no quadro. Respostas mais importantes: • nome, idade, endereço; • onde o usuário mora – tipo de terreno, tamanho da casa, degraus, etc.; • onde trabalha ou vai à escola; • coisas que faz ou quer fazer (estilo de vida); • qual distância o usuário percorre todos os dias; • como o usuário se transfere da cadeira de rodas; • com quem ele mora; • incapacidade ou deficiência do usuário; • suas habilidades físicas; • quanto tempo o usuário passa na cadeira de rodas todos os dias; • saúde – inclusive risco de úlceras/feridas de pressão; • condição física; • se o usuário já tem cadeira de rodas e se ela atende às suas necessidades; • como o usuário se locomove - – por exemplo, usa transporte público? 116 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Todas essas informações ajudam o usuário e a equipe de serviços a: - Escolher a cadeira de rodas e a almofada mais apropriada; - Escolher as partes/características mais adequadas da cadeira de rodas e; - Identificar o treinamento ou suporte que o usuário pode precisar. • Por exemplo: - o usuário que passa o dia inteiro na cadeira de rodas e percorre longas distâncias vai precisar de uma cadeira de rodas que seja confortável, sustente-o bem e seja forte e boa para ambientes ao ar livre. - O usuário que não tem uma forma eficiente de transferir-se da cadeira de rodas pode precisar de ajuda para aprender como se transferir. 4. Onde fazer a avaliação (5 minutos) Explique: • As avaliações devem ser sempre feitas em um local silencioso e limpo. • Pode ser um espaço no serviço de cadeira de rodas, em outro serviço de saúde local, ou na casa do usuário. Pergunte: Onde os participantes fazem as avaliações em seu serviço de cadeira de rodas? Agradeça as respostas. Se os participantes não souberem, lembre-os que precisam garantir que seja um local silencioso e limpo. 117 5. Duas partes da avaliação básica (5 minutos) Explique A avaliação é feita em duas partes: • Entrevista de avaliação; • Avaliação física As informações são anotadas em um formulário de avaliação da cadeira de rodas. Nas próximas sessões, os participantes vão começar a treinar como fazer a avaliação da cadeira de rodas. 6. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 118 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO B.3: Entrevista de avaliação O BJ ET IV O S Ao final desta sessão, os participantes saberão:  demonstrar uma entrevista de avaliação;  anotar as informações da entrevista de avaliação no formulário de avaliação para serviços de cadeira de rodas;  explicar como as perguntas da entrevista de avaliação podem ajudar a selecionar a cadeira de rodas mais apropriada e a identificar o que o usuário precisa aprender. RE CU RS O S Para a sessão:  Apresentação em PPT: B.3 Entrevista de avaliação;  Manual de Referência;  Apostila do Participante;  Uma cadeira de rodas para cada grupo de três. CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar.  Se houver um tipo de deficiência muito comum no contexto local, e que não esteja coberto no formulário de avaliação da cadeira de rodas, inclua-o no formulário e na sessão.  Mude as histórias dos usuários se não se adequarem ao contexto local. PR EP A RA ÇÃ O  Colete recursos, reveja os slides e leia todo o plano da sessão. D ES CR IÇ Ã O 1. Introdução. 2. Informações sobre o usuário. 3. Condições físicas. 4. Estilo de vida e ambiente. 5. Cadeira de rodas atual. 6. Prática da entrevista de avaliação. 7. Resumo dos pontos principais. 2 10 15 15 5 40 3 Tempo Total da sessão 90 119 1. Introdução (2 minutos) Explique: Nesta sessão os participantes vão: • Aprender como fazer a primeira parte da avaliação – a entrevista; • Analisar todas as partes da entrevista de avaliação e aprender como as respostas às perguntas da entrevista de avaliação afetam a escolha da cadeira de rodas. Todos os participantes terão a chance de ser o entrevistador. 2. Informações sobre o usuário (10 minutos) Explique: Antes de vermos as perguntas da entrevista, existem algumas coisas que temos que lembrar quando estivermos fazendo as perguntas. • Sempre explique ao usuário antes de começar a fazer perguntas que as perguntas vão ajudar você e ele a escolher a cadeira de rodas mais apropriada. • Sempre fale com o usuário (não com o assistente/familiar) a menos que seja uma criança pequena ou incapaz de entender ou responder às perguntas. • Use boas técnicas de comunicação. Pergunte: Quais são alguns exemplos de boas técnicas de comunicação? Estimule respostas e anote no quadro. Respostas mais importantes: • falar claramente; • usar termos objetivos; • explicar o que vai acontecer antes que aconteça; • depois de explicar alguma coisa, verificar se o usuário entendeu; • ouvir atentamente e conferir para ter certeza de que entendeu o usuário corretamente; • fazer contato visual (quando adequado); • ser respeitoso; • não pressupor que você sabe mais; • mostrar interesse. 120 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Dê um formulário de avaliação da cadeira de rodas para cada participante. Comece a projetar os slides da apresentação em PPT B3 Entrevista de Avaliação. Explique: • A entrevista de avaliação coleta informações de quatro áreas. • Veremos agora todas as áreas e vamos explicar como as respostas às perguntas da entrevista de avaliação afetam a escolha da cadeira de rodas. • As perguntas não precisam ser feitas na mesma ordem do formulário. Às vezes os usuários dão informações voluntárias antes de serem perguntados, ou pode ser mais natural fazer as perguntas em ordem diferente. Explique: • As perguntas de “informações sobre o usuário” garantem que o usuário possa ser encontrado para acompanhamento futuro. • Também ajudam o serviço a reunir estatísticas sobre os usuários atendidos pelo serviço. 3. Condições físicas (15 minutos) Explique • Sob o título “condições físicas”, a equipe de serviços vai determinar a condição do usuário, se for conhecida, e registrar se o usuário tem alguma condição física que afete a escolha da cadeira de rodas. • Algumas condições mais comuns têm uma caixa para ser marcada. São elas: paralisia cerebral, pólio, lesão medular e AVC/trombose cerebral. • Também há uma caixa para “outros”. Se você marcar “outros”, pode anotar a condição ao lado da caixa. 121 Explique: • É útil (embora nem sempre necessário) conhecer a condição física do usuário. • Isso porque algumas características de condições diferentes podem afetar a escolha da cadeira de rodas. • Veremos agora as coisas mais importantes a lembrar sobre as diferentes condições ao prescrever (selecionar) uma cadeira de rodas. • Essas informações estão no manual de referência. Explique: • A paralisia cerebral afeta as pessoas de formas muito diferentes. • Para uma pessoa com paralisia cerebral que consiga sentar-se ereta, é importante lembrar que ela pode ter dificuldade em manter a posição sentada porque pode se cansar. Isso torna as atividades mais difíceis e mais cansativas. • Boa sustentação é muito importante. • As pessoas com paralisia cerebral podem precisar de suporte postural adicional na cadeira de rodas. É preciso treinamento de nível intermediário para fazer isso com segurança e eficácia. Aponte esses itens no slide para enfatizar os pontos principais a serem lembrados. 122 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Pessoas com poliomielite podem ter fraqueza ou “flacidez” em partes do corpo. A poliomielite pode afetar as pernas, os braços ou o tronco, mas em geral afeta as pernas. • Músculos e ossos ficam mais frágeis e o membro não cresce tão rapidamente, por isso fica mais curto. • Quando o tronco é afetado, pode parecer mais curto. • Embora as pessoas com poliomielite tenham sensibilidade a almofada é importante para o conforto. • Uma almofada mais alta pode proporcionar uma posição mais confortável para impulsionar a cadeira. Aponte esses itens no slide para enfatizar os principais pontos a lembrar. Explique: • Pessoas com lesão medular têm muita probabilidade de desenvolver úlceras/feridas de pressão. • Isso porque a maioria das pessoas com lesão medular não tem sensibilidae abaixo do nível da lesão. • Sempre prescreva uma almofada para alívio de pressão. Aponte no slide para enfatizar os principais pontos a lembrar. 123 Explique: • Pessoas que sofreram um AVC/trombose cerebral costumam ser afetadas em um dos lados do corpo. Isso significa que podem pender para um lado na cadeira de rodas. • Pessoas que sofreram AVC/trombose cerebral podem não ter sensibilidade normal do lado afetado do corpo. • Pessoas que sofreram AVC/trombose cerebral podem conseguir transferir-se da cadeira de rodas em pé. • Bom suporte é importante. • Verifique se a pessoa tem sensibilidade – pode precisar de uma almofada de alívio de pressão. • Alguém com AVC/trombose cerebral pode preferir uma cadeira de rodas com descanso para os pés que se afaste para que possa fazer a transferência em pé. Aponte os itens no slide para enfatizar os pontos principais a lembrar. Explique: • Vamos ver agora como outras condições podem afetar a escolha da cadeira de rodas. Explique: • Pessoas duplamente amputadas não têm o peso das pernas para impedir a cadeira de cair para trás. • Seja muito cuidadoso quando um amputado usar a cadeira de rodas pela primeira vez. • Verifique o equilíbrio da cadeira de rodas. As rodas traseiras talvez precisem ser deslocadas para trás para dar mais estabilidade. Aponte no slide para enfatizar os principais pontos a lembrar. 124 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Os idosos podem precisar de cadeira de rodas por várias razões. Em geral é porque têm dificuldade para andar. A cadeira de rodas ajuda que continuem a fazer parte da vida familiar e comunitária. • Os idosos podem conseguir fazer transferência de pé e vão preferir uma cadeira de rodas com apoios para os pés que podem ser dobrados ou rebatidos. • Os idosos sempre devem receber cadeiras de rodas que ofereçam bom conforto e sustentação. Isso vai ajudá-los a sentar-se corretamente e a evitar problemas causados por má postura. • Apoios para os pés que possam ser dobrados ou rebatidos podem ser a melhor opção. Aponte os itens no slide para enfatizar os principais pontos a lembrar. Explique: • Algumas pessoas têm problemas com movimentos súbitos e abruptos que não conseguem controlar (espasmos). • Os espasmos podem atirar o peso da pessoa para trás, o que pode fazer com que a cadeira caia. Nesse caso, deve-se considerar uma posição segura das rodas traseiras. • Os espasmos podem fazer os pés “saltarem” para fora do apoio. Isso pode ser perigoso durante a movimentação. Uma faixa de panturrilha pode ajudar a manter os pés em posição. Uma faixa abdominal também pode ajudar. • As faixas devem ser presas com velcro para que elas abram se o usuário cair da cadeira de rodas. Aponte no slide para enfatizar os principais pontos a lembrar. 125 Explique: • Algumas pessoas podem ter dificuldade para controlar a bexiga ou o intestino. Isso é muito comum em pessoas com lesão medular. • Esses problemas podem ser superados com equipamento certo, medicamentos e treinamento de controle urinário e intestinal. Identifique quem em sua área pode dar orientações e treinamento no controle do intestino ou da bexiga, por exemplo, médicos e enfermeiros especialistas • Pessoas com problemas urinários ou intestinais não devem sentar sobre uma almofada molhada ou suja, porque a pele pode se deteriorar rapidamente. Além disso, as bactérias presentes nas fezes levam rapidamente a úlceras/feridas de pressão infeccionadas. • Forneça uma almofada com capa a prova d’água. Ensine o usuário como lavar e secar a almofada. • Pode ser necessária uma segunda almofada para que o usuário continue com suas atividades diárias enquanto espera que a almofada seque. Aponte os itens no slide para enfatizar os principais pontos a lembrar. 4. Estilo de vida e ambiente (15 minutos) Explique • As perguntas sobre estilo de vida e ambiente coletam informações sobre onde o usuário mora e as coisas que precisa fazer na cadeira de rodas. Leia cada pergunta/tópico e pergunte: Como as respostas vão ajudar na escolha da cadeira de rodas mais apropriada, ou a identificar o que o usuário precisa aprender? Agradeça as respostas e dê exemplos se necessário 126 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Pergunta: Respostas mais importantes Descreva onde o usuário vai usar a cadeira de rodas • A cadeira de rodas precisa ser prática para a casa, trabalho ou escola do usuário. Por exemplo: - Se a cadeira de rodas for usada em casa, o usuário precisa poder se mover facilmente pela casa para fazer importantes atividades diárias; - O usuário que trabalha em escritório vai precisar de uma cadeira que se adapte facilmente ao espaço do escritório; - O usuário que vai à escola precisa de uma cadeira de rodas que caiba confortavelmente na sala de aula e sob a carteira, ou precisará de uma mesa instalada na cadeira de rodas; - O usuário que precisa ir trabalhar no mercado trafegando por terrenos acidentados precisa de uma cadeira de rodas que funcione bem em terreno acidentado. Distância percorrida por dia • Assim como alguém pode ir a pé uma curta distância, mas usar uma bicicleta para distâncias mais longas, o usuário pode usar cadeira de rodas para distâncias mais curtas e um triciclo para distâncias mais longas. • O triciclo consome menos energia para cobrir a mesma distância e é mais rápido. Horas por dia usando a cadeira de rodas • Quanto mais tempo a pessoa permanece na cadeira de rodas, maior o risco de fadiga ou úlceras/feridas de pressão. Pense sobre o suporte que a pessoa precisa e se a almofada oferece alívio de pressão e conforto suficientes. • Para qualquer pessoa que seja “ativa” na cadeira de rodas durante o dia, a cadeira de rodas deve ser ajustada para tornar o impulso e outras atividades o mais eficientes possível. A posição das rodas é importante. Também é importante verificar se o encosto sustenta o usuário sem restringir a liberdade de movimento dos ombros. Transferência utilizada • Os apoios para os braços e pés podem afetar a forma como o usuário se transfere da cadeira de rodas. - Para transferências em pé, é útil que os apoios para os pés se afastem e os apoios para os braços possam ser usados para o usuário erguer-se; - Para transferências não realizadas em pé, apoios removíveis para os braços ou que sigam o perfil das rodas podem facilitar a transferência. Tipo de banheiro O tipo de banheiro e de acesso físico a ele vai afetar a facilidade de o usuário usar o banheiro. Pode não ser possível usar o banheiro devido ao seu projeto. Por exemplo, a maioria dos usuários acha difícil usar banheiros de cócoras (no caso de latrinas). Perguntando ao usuário sobre o banheiro e onde ele se localiza, a equipe de serviços pode aconselhar como fazer essa transferência. Também podem aconselhar sobre como adaptar o banheiro. 127 O usuário costuma usar transporte público/privado? Se o usuário costuma usar transporte, precisa poder transportar facilmente a cadeira de rodas. As várias características que facilitam o transporte da cadeira de roda incluem os seguintes: • Cadeiras de rodas mais leves são mais fáceis de carregar; • Rodas removíveis e estrutura/encosto dobráveis facilitam o transporte da cadeira de rodas. Se usar transporte público, partes removíveis podem ser uma vantagem porque facilitam o transporte da cadeira de rodas. No entanto, partes removíveis também podem ser uma desvantagem, porque podem ser perdidas ou furtadas. 5. Cadeira de rodas atual (5 minutos) Explique • Se o usuário já tem uma cadeira de rodas, é importante que ela seja avaliada para ver por que não atende às suas necessidades • Leia cada uma das perguntas do formulário de avaliação da cadeira de rodas “cadeira de rodas atual” Se a resposta a qualquer pergunta for “não”, a equipe de serviços de cadeira de rodas deve descrever o problema em “comentários”. Dependendo dos recursos disponíveis, pode-se considerar uma forma de modificar ou reparar a cadeira de rodas atual durante a prescrição. Se a resposta a todas as perguntas for “sim”, é muito provável que o usuário não precise de uma cadeira de rodas nova. Isso deve ser discutido com o usuário. 6. Prática da entrevista de avaliação (40 minutos) Atividade Grupos: Faça grupos de três pessoas. Instruções: Peça a cada grupo que dramatize a entrevista de avaliação usando as histórias dos usuários da apostila. Enfatize – se possível apenas a pessoa representando o usuário deve ler a história. Cada vez uma pessoa diferente deve assumir o papel do usuário e usar as informações de sua história para responder às perguntas da avaliação. O usuário não deve ler a história em voz alta. Os outros dois participantes trabalham juntos para fazer a entrevista e anotar as informações nos formulários de entrevista de avaliação da cadeira de rodas da apostila. 128 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Monitore: Monitore os grupos e ajude se necessário. Tempo: 10 minutos para cada entrevista e 10 minutos para o feedback do grupo. Feedback: Discuta brevemente cada usuário representado nas histórias. Mostre o slide de cada usuário e faça aos participantes as perguntas do slide. • O que os entrevistadores descobriram que ajudou a escolher a melhor cadeira de rodas para Felicia/Anton/Chantou? • O que os entrevistadores descobriram que ajudou a identificar coisas que Felicia/Anton/Chantou precisam aprender para poder usar a cadeira de rodas? • As cadeiras de rodas atuais de Anton e Chantou atendem a suas necessidades? Por que/Por que não? Os instrutores podem mencionar os pontos de aprendizado sugeridos abaixo. História do usuário Pontos de aprendizado sugeridos Felicia é uma senhora idosa com artrite severa. Tem dor nos braços, mãos e pernas. Não consegue andar mais do que alguns passos devido à dor e porque acha difícil cuidar de si própria. Felicia foi à avaliação com a filha que também a ajuda em casa. Ela mora em uma cidadezinha e sua casa tem três degraus na entrada da frente. Ela não tem outros problemas de saúde além da artrite. Costumava ir à igreja regularmente, mas já não consegue ir. Sua família não tem carro e depende do transporte público. Para ir à avaliação, a família contratou um taxi. No entanto isso é caro para eles. Atualmente ela não tem cadeira de rodas. Informações para ajudar a escolher a melhor cadeira de rodas. • Felicia sente muita dor – é possível que precise ser empurrada devido à dor. • Felicia pode dar alguns passos – é possível que use transferência em pé e vai se beneficiar de apoios para os pés que possam ser rebatidos. • A família de Felicia não tem carro – ela precisa levar a cadeira de rodas para o transporte público então uma cadeira dobrável será útil. Informações para ajudar a identificar o que Felicia precisa aprender. • A filha de Felicia a ajuda em casa – Felicia e sua filha precisam aprender técnicas seguras de transferência e como subir e descer degraus em cadeira de rodas. 129 História do usuário Pontos de aprendizado sugeridos Anton tem pólio. Tem 26 anos e mora em uma cidadezinha. Está estudando computação e quer muito ter seu próprio negócio no futuro. Foi à avaliação com sua mulher. Muito tempo atrás ele ganhou uma cadeira de rodas estilo ortopédico. A cadeira está enferrujada e o estofamento do assento rasgou. As rodas dianteiras são pequenas e finas. As rodas traseiras são muito finas e estão gastas. A cadeira de rodas é desconfortável e difícil de impulsionar As ruas da cidade são muito acidentadas e sua cadeira de rodas vive atolando. No entanto, ele gostaria de poder ir de casa ao centro de treinamento profissional sozinho. A distância é de cerca de ½ km. Atualmente, ele precisa da ajuda de seu irmão mais novo – que nem sempre pode levá-lo no horário. Informações para ajudar a escolher a melhor cadeira de rodas. • Anton mora em um lugar onde as ruas são acidentadas e quer poder ir sozinho de casa para o centro de treinamento - precisa de uma cadeira de rodas que possa impulsionar sozinho por terreno acidentado. • Anton passa muito tempo na cadeira de rodas – bom suporte postural é importante porque passará muito tempo na cadeira durante as aulas. Informações para ajudar a identificar o que Anton precisa aprender. • Anton precisa de mobilidade muito boa em terreno difícil – treinamento em habilidades de mobilidade na cadeira de rodas pode realmente ajudá-lo. • Anton usa muito a cadeira de rodas em terreno acidentado – aprender como manter a cadeira de rodas funcionando pode ser muito útil. Cadeira de rodas atual de Anton. • A cadeira de rodas atual de Anton está em más condições e não atende a suas necessidades físicas ou ambientais. Nota especial: Se houver triciclos, os instrutores podem destacar que um triciclo seria uma boa solução para este usuário percorrer a distância até o centro de treinamento. 130 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO História do usuário Pontos de aprendizado sugeridos Chantou tem 13 anos. Ela perdeu as duas pernas (acima do joelho) durante um terremoto. Mora com sua família em um apartamento em uma cidade vizinha. Vai à avaliação com sua mãe e a irmã mais velha. Tem uma cadeira de rodas que ganhou. É uma cadeira de tamanho adulto e ortopédica. É grande demais para Chantou. Ela tem que passar o braço por cima do apoio para os braços para alcançar o aro de impulsão. Isso é difícil para ela. O encosto também é muito alto e não há almofada. Chantou gostaria de voltar para a escola, mas não se sente confortável na cadeira de rodas. Também tem vergonha de não conseguir se locomover sozinha. Gostaria de uma cadeira de rodas que ela pudesse impulsionar e que desse melhor sustentação. Ela diz que poderia usar o ônibus escolar se a cadeira de rodas pudesse ir com ela. Informações para ajudar a escolher a melhor cadeira de rodas. • Chantou está desconfortável em sua cadeira de rodas atual e passa muito tempo na cadeira – Chantou precisa de uma cadeira de rodas que se ajuste a ela corretamente para que seja bem sustentada – bom suporte postural vai ajudá-la a ter mais energia durante o dia, que ela vai precisar para ir à escola. • Chantou precisa ir à escola de ônibus escolar – precisa de uma cadeira de rodas que possa ir com ela. Cadeira de rodas atual de Chantou. • Sua cadeira de rodas atual é grande demais e não a ajuda a se locomover sozinha; uma cadeira leve com bom suporte postural seria mais adequada às suas necessidades atuais do que a cadeira atual 7. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 131 B.4: Avaliação física O BJ ET IV O S Ao final da sessão, os participantes saberão:  registrar a presença, risco ou histórico de úlceras/feridas de pressão;  explicar as medidas a serem tomadas se o usuário tiver úlceras/feridas de pressão ou correr risco de desenvolver úlceras/feridas de pressão;  identificar e registrar como o usuário impulsionará a cadeira de rodas;  demonstrar a maneira correta de tirar medidas do usuário para a cadeira de rodas (largura do assento, profundidade do assento, comprimento da panturrilha, altura das costas);  descrever como as medidas do corpo se relacionam ao tamanho da cadeira de rodas. RE CU RS O S Para a sessão:  Apresentação em PPT B.4: Avaliação Física;  Manual de Referência;  Apostila do Participante;  DVD: Demonstração das medidas;  Cadeira de rodas com apoio móvel para os pés (se houver) – 1 para cada 3 participantes;  Formulários de avaliação da cadeira de rodas – 1 para cada usuário;  Fitas métricas para a prática de medição – 1 por participante.  Blocos de apoio para os pés CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar. Pense sobre:  onde os participantes farão as avaliações – por exemplo, na casa do usuário, em clínicas comunitárias ou espaço dedicado ao serviço de cadeira de rodas. PR EP A RA ÇÃ O  Reunir recursos, rever os slides PPT, assistir ao DVD e ler todo o plano da sessão.  Arrumar as cadeiras de rodas em torno da sala.  Assegurar-se que pelo menos uma cadeira de rodas tenha apoio de pé móvel ou dobrável (para o exercício de impulso com os pés). 132 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO D ES CR IÇ Ã O 1. Introdução. 2. Preparação. 3. Presença, risco ou histórico de úlceras/feridas de pressão. 4. Método de impulso. 5. Como tirar medidas. 6. Como tirar medidas corporais. 7. Resumo dos pontos principais. 2 5 10 20 30 20 3 Tempo Total da sessão 90 1. Introdução (2 minutos) Explique: nesta sessão, vamos praticar a parte física da avaliação da cadeira de rodas. Vamos: • aprender como registrar a presença, risco ou histórico de úlceras/feridas de pressão para o usuário; • discutir as várias formas como o usuário pode impulsionar a cadeira de rodas e praticar o impulso com os pés; • aprender como tirar as medidas corporais mais importantes para escolher o tamanho correto da cadeira de rodas para o usuário. 2. Preparação (5 minutos) Explique: Para a avaliação física, peça ao usuário que se transfira da cadeira de rodas (se estiver em uma) para uma cama de avaliação. Isso vai facilitar a observação da postura do usuário e como tirar as medidas. Também é uma oportunidade de ver como o usuário se transfere. Listamos abaixo algumas coisas a serem lembradas. 133 Explique: • Como a entrevista, o exame deve ser feito em local limpo e silencioso. • A privacidade é importante se for necessário avaliar úlceras/feridas de pressão. • Sempre explique ao usuário o que vai fazer e por que. • Quando o usuário se transferir, esteja pronto para oferecer ajuda se perceber que ele não consegue se transferir de maneira segura e fácil. • Quando o usuário estiver na cama de avaliação: - Forneça blocos de apoio para os pés se os pés não alcançarem confortavelmente o chão; - Esteja sempre por perto até ter certeza que o usuário está seguro e confortável, sentado ereto por si. 3. Presença, risco ou histórico de úlceras/feridas de pressão (10 minutos) Explique: Já falamos em detalhe sobre a importância de prevenir úlceras/feridas de pressão. Pergunte: alguém lembra quais são os fatores de risco mais importantes – as coisas que tornam mais provável o desenvolvimento de úlceras/feridas de pressão? Estimule Respostas. Tente explicar todos os riscos de úlceras/feridas de pressão relacionados abaixo. Respostas mais importantes: • não consegue sentir (sensibilidade diminuída); • não consegue se mover; • umidade de suor, água ou incontinência; • má dieta e não beber água suficiente; • envelhecimento; • má postura; • úlcera/ferida de pressão prévia ou atual; • peso – acima ou abaixo. 134 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: O formulário de avaliação vai ajudar os participantes a avaliar o risco de úlceras/feridas de pressão. Mostre o slide e aponte os itens para explicar os seguintes pontos: • A pessoa que não tem sensibilidade corre risco de desenvolver úlceras/feridas de pressão; • A pessoa que tem três ou mais de quaisquer outros fatores de risco corre risco de desenvolver úlceras/feridas de pressão. Peça aos participantes que consultem o formulário de avaliação da cadeira de rodas. Explique: Os participantes devem fazer as perguntas do formulário aos usuários. • Tem sensibilidade normal? • Já teve úlcera/ferida de pressão? Se sim, pergunte onde. Marque isso no corpo desenhado no formulário. • Tem atualmente uma úlcera/ferida de pressão? - Se sim, pergunte se pode vê-la para ter certeza de onde está a úlcera/ferida e de sua gravidade; - Seja cuidadoso ao pedir para ver a úlcera/ ferida de pressão de alguém; - Garanta a privacidade do usuário com um biombo em torno da área de avaliação; - Anote se a úlcera/ferida está aberta ou não, e marque onde está a úlcera/ferida de pressão no corpo desenhado no formulário; - Pergunte ao usuário se ele sabe o que causou a úlcera/ferida e há quanto tempo ele a tem. • Circule qualquer fator de risco. • Marque se o usuário corre ou não risco de desenvolver uma úlcera/ferida de pressão. 135 Pergunte: Qual atitude tomar se o usuário tiver uma úlcera/ferida de pressão instalada estágio 2 ou mais? Estimule respostas. Respostas mais importantes: • encaminhar para tratamento; • aconselhar o usuário a remover a pressão da úlcera/ferida – isso pode significar não usar a cadeira de rodas. Pergunte: Qual atitude tomar se o usuário correr risco de desenvolver uma úlcera/ferida de pressão? Estimule respostas. Respostas mais importantes: • fornecer uma almofada para alívio de pressão – verificar se a almofada é eficaz fazendo o teste do osso do ísquio; • educar sobre prevenção – ensinar técnicas de alívio de pressão e a importância de ser ativo e mudar periodicamente de posição e verificar diariamente se há marcas na pele. Notas para os instrutores: Essa pergunta diz respeito a se a pessoa “corre risco” de desenvolver úlceras/feridas de pressão. Se a pessoa já tiver uma úlcera/ferida de pressão, as ações serão diferentes. 4. Método de impulsão (20 minutos) Explique: • É importante saber como o usuário vai impulsionar a cadeira de rodas. Isso pode afetar a escolha da cadeira de rodas. • Os usuários impulsionam a cadeira de rodas de várias formas. • Alguns usam os braços, outros as pernas e alguns são empurrados por alguém. Pergunte: Quais habilidades físicas afetam como o usuário empurra a cadeira de rodas? Estimule respostas. 136 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Respostas: • força e controle dos braços; • força e controle das pernas; • habilidade de sentar-se ereto; • estabilidade e controle gerais – se alguém não é estável ou não tem bom equilíbrio pode precisar dos braços para se “segurar” e não vai conseguir impulsionar. • Força e controle de braços e pernas são tão importantes quanto estabilidade geral. Uma cadeira de rodas que se ajuste corretamente e dê bom suporte postural pode facilitar a impulsão da cadeira de rodas por alguém com mau equilíbrio ou estabilidade. Pergunte: Qual é a posição ideal das rodas traseiras com relação ao usuário que impulsiona com os braços? Resposta: • Quando o usuário toca o topo do aro de impulsão, o cotovelo deve dobrar cerca de 90 graus. Explique: • Para impulsionar com os pés, a cadeira de rodas precisa ser ajustada para que os calcanhares do usuário alcancem o chão confortavelmente, enquanto a pelve é sustentada pelo encosto. • É importante ter apoios móveis para os pés. O usuário pode precisar dos apoios de pé para ser empurrado por alguém por distâncias mais longas. • Os apoios para os braços também podem ser úteis porque o usuário pode se apoiar neles ao inclinar para frente para impulsionar a cadeira. • Se o usuário precisar impulsionar a cadeira com os pés e a cadeira de rodas não estiver adequada para isso, o usuário terá que mudar de posição para impulsionar. Isso será muito cansativo e pode causar problemas posturais no futuro. 137 Explique: Praticamos o impulso com os braços durante a sessão de mobilidade com a cadeira de rodas. Agora todos terão a oportunidade de treinar impulsionando com as pernas. Atividade Grupos: Faça grupos de três pessoas (o ideal é ter pessoas de alturas diferentes porque isso vai levantar questões sobre conseguir alcançar o chão). Dê uma cadeira de rodas para cada grupo. Instruções: Peça a cada grupo que se reveze para tentar impulsionar cadeira de rodas com os pés. O ideal é que se sentem com a pelve tocando o encosto. Se não for possível, devem tentar descobrir como alcançar o chão para impulsionar. Isso vai ajudá-los a sentir o que acontece se a cadeira de rodas não estiver ajustada corretamente para impulsionar com os pés. Peça aos participantes que tentem impulsionar com os pés inclinando-se para frente, inclinando-se para trás, com o calcanhar e com o dedão do pé. Monitore: Monitore os grupos. Assegure-se que a atividade seja realizada com segurança. Tempo: 10 minutos para prática e 5 minutos para feedback. Feedback: Pergunte aos grupos: • Para aqueles que não conseguiram alcançar facilmente o chão – o que tiveram que fazer para colocar os pés no chão? (Resposta: deslizar ou sentar-se mais para frente) • Foi mais fácil impulsionar inclinando para frente ou para trás? (Resposta: para frente – de preferência com a pelve contra o encosto); • O que estimula alguém a inclinar para frente? (Resposta: apoios para os braços ou uma mesa que proporcione apoio para se inclinar para frente); • Foi mais fácil impulsionar com o dedão ou o calcanhar? (Resposta: com o calcanhar). Explique: • Através da atividade os participantes viram como impulsionar com os pés pode ser difícil e cansativo se a cadeira de rodas não estiver ajustada para ser impulsionada com os pés. • Ajustar corretamente a cadeira de rodas significa assegurar que a altura do assento até o chão está correta para o usuário. Algumas formas de fazer isso são: - Escolher a cadeira de rodas que tenha a altura correta do assento até o chão para o usuário (leve em consideração a altura da almofada); - Tornar a almofada mais fina – o que pode reduzir a altura geral; - Adicionar um assento rígido mais baixo do que o assento original. • Se o usuário vai impulsionar com os pés, a equipe de serviços deve mostrar a ele como sentar-se com a pelve contra o encosto, inclinar-se para frente e “puxar” para frente pisando com o calcanhar primeiro. • Sempre ensine o impulso para frente, não para trás. 138 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Pergunte: se o usuário vai ser empurrado o tempo todo ou algumas vezes por um assistente, como isso vai afetar a escolha da cadeira de rodas? Resposta: • manoplas fortes são importantes; • para crianças – manoplas altas facilitam aos adultos empurrar a criança. Explique: O método de impulsionar também afeta o treinamento necessário ao usuário e (se adequado) aos familiares ou cuidadores. 5. Como tirar medidas (30 minutos) Explique • Durante a avaliação, a equipe de serviços para cadeira de rodas tira as medidas do usuário. Com isso, podem comparar com as medidas das cadeiras de rodas disponíveis para ver qual será a melhor. • As medidas são anotadas no formulário de avaliação. • O Manual de Referência explica como tirar cada medida Apresente o DVD: Demonstração das medidas. Este DVD vai lhes mostrar como tirar as cinco medidas básicas do usuário. Peça aos participantes que assistam com atenção porque vão praticar essa habilidade depois do vídeo. Exiba o DVD. Pergunte se existem dúvidas. VIDEO 139 Atividade Grupos: Faça grupos de três pessoas. Instruções: Peça a cada grupo que: • meça cada pessoa e registre as medidas; • todos os membros do grupo devem ser medidos pelos outros dois– para que as medidas possam ser comparadas ao final do exercício; • registrar as medidas no espaço existente na apostila. Monitore: Circule pelos grupos e monitore atentamente. Use o guia abaixo para verificar se os participantes estão usando as técnicas corretas. Confira as medidas para avaliar a precisão com que os participantes estão medindo. O instrutor pode anotar as medidas no quadro branco para destacar quaisquer diferenças. Tempo: 15 minutos (5 minutos por pessoa) para prática e 15 minutos para feedback. Feedback: • Pergunte: Todas as medidas de uma mesma pessoa foram iguais? • Pergunte: O que pode causar diferenças? (Resposta: não usar a técnica correta – por exemplo, não pedir ao usuário para sentar-se ereto, não colocar a fita métrica na posição correta, não ler corretamente a fita métrica). • Pergunte: Quais problemas poderiam ser causados por medidas erradas? (Resposta: a cadeira pode não se ajustar ao usuário). Instrutores – usem este guia para verificar se os participantes estão usando as técnicas corretas Para todas as medidas, verifique se a fita métrica está esticada e se o usuário está sentado ereto. Os pés devem estar apoiados no chão ou em blocos de apoio se ele não conseguir alcançar o chão totalmente. A Verifique se há algo no bolso do usuário antes de medir. Meça os quadris ou a parte mais larga das coxas. Segurar duas pranchetas ou livros contra cada lateral do usuário pode ajudar a fazer uma medição correta. B Ponha uma prancheta ou livro nas costas do usuário para ajudar a fazer uma medição correta. Meça da parte de trás da pelve até a parte de trás do joelho em uma linha reta. Sempre meça as duas pernas. Se houver diferença entre as pernas, verifique se o usuário está sentado com a pelve nivelada. Se ainda houver diferença, faça a prescrição da cadeira de rodas para o lado mais curto. 140 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO C Meça da parte de trás do joelho até a base do calcanhar. Certifique-se que os tornozelos do usuário estejam dobrados a 90 graus (se possível). Sempre meça as duas pernas. Se o usuário usar sapatos, meça com os sapatos que usa mais frequentemente (se houver). D Meça do assento até a última costela. Para encontrar a última costela, coloque as mãos nos dois lados da pelve. Aperte as mãos suavemente para dentro e deslize para cima. A última costela está logo acima da cintura. E Meça do assento até o ângulo inferior da escápula, em linha vertical. Para encontrar o ângulo inferior da escápula, peça ao usuário que encolha os ombros. 6. Como tirar medidas corporais (20 minutos) Explique: Agora que praticamos tirar as medidas do usuário, vamos ver como essas medidas se relacionam à cadeira de rodas. Peça aos participantes que consultem sua cópia do formulário de avaliação da cadeira de rodas. Destaque a terceira coluna da tabela de medidas Explique: Isso explica como as medidas corporais se relacionam à cadeira de rodas. Veremos agora cada uma. Explique: • Medida A: Largura do quadril igual à largura do assento da cadeira. • A largura do assento da cadeira deve ser a mais próxima possível da largura do quadril do usuário, mas nunca deve ser menor. • Se o usuário não tiver sensibilidade, é importante assegurar que as laterais da cadeira de rodas não pressionem a pelve nem as coxas. 141 Explique: • Medida B: a profundidade do assento menos cerca de 30-60 mm é a profundidade ideal do assento da cadeira de rodas. • O ajuste correto dá bom suporte às coxas. Isso reduz a pressão sob o osso do ísquio e ajuda a evitar úlceras/feridas de pressão. • Para usuários com pernas longas, pode haver um espaço maior. Até 60 mm é aceitável. • Se o assento for muito longo, o usuário não conseguirá sentar-se ereto. A parte de trás da panturrilha poderá roçar na borda frontal do assento, causando desconforto e/ou úlceras/ feridas de pressão. • Se houver diferença entre os lados direito e esquerdo, use a medida da perna mais curta para fazer opções de prescrição. Explique: • Medida C igual a: - Medida do topo da almofada do assento até o apoio para os pés; ou - Medida do topo da almofada até o chão (para impulsionar com os pés). • A altura correta dos apoios para os pés é importante porque garante que as coxas estejam bem sustentadas e os pés totalmente sustentados pelos apoios. • Quase sempre é preciso ajustar a altura dos apoios para os pés no final, porque é difícil calcular quanto a almofada vai comprimir quando o usuário sentar-se nela. • A altura correta do assento para alguém que impulsiona a cadeira de rodas com os pés é importante para garantir que o usuário estará bem sustentado na cadeira de rodas e poderá alcançar o chão confortavelmente para impulsionar com eficiência. 142 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Medida D ou E é igual à distância entre o topo da almofada do assento e o topo do encosto. • O ajuste correto deve dar ao usuário o suporte que precisa e dar ao usuário ativo liberdade para mover os ombros e impulsionar. Explique: • Medida D – gera a altura do encosto nivelado com a última das costelas do usuário. • É uma boa altura se o usuário: - está em boa forma e é ativo; - pode sentar-se ereto facilmente com bom equilíbrio. • Medida E – gera a altura do encosto nivelado com o ângulo inferior da escápula do usuário. • É uma boa altura se o usuário: - costuma se cansar rapidamente; - tem dificuldade para sentar-se ereto. • Explique: sempre tire as duas medidas de altura do encosto porque às vezes não fica claro durante o exame qual altura do encosto será mais confortável para o usuário. 143 Explique: Vamos ver agora como preencher a tabela de medidas. Mostre a tabela de medidas com os campos preenchidos com os dados dos usuário. Pergunte: para esta pessoa, qual seria: • a largura do assento da cadeira de rodas? (aponte para mostrar a resposta); • a profundidade do assento da cadeira de rodas? (aponte para mostrar a resposta) • altura do apoio para os pés? (aponte para mostrar a resposta); • altura do encosto até a última das costelas (aponte para mostrar a resposta); • altura do encosto até o ângulo inferior da escápula (aponte para mostrar a resposta). Pergunte: O que os participantes fariam se o usuário tivesse profundidade diferente do assento na perna esquerda e na direita? Estimule respostas. Respostas mais importantes: • quando existe diferença na profundidade do assento de um lado, a profundidade final deve ser a necessária para o lado mais curto. Explique: Lembrem-se – todas essas medidas seriam as ideais. A equipe precisa conhecer as medidas das cadeiras de rodas existentes para poder escolher o tamanho que seja mais próximo do usuário. Falaremos mais sobre isso na próxima sessão. 7. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. 144 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO B.5: Prescrição (seleção) O BJ ET IV O S Ao final desta sessão os participantes saberão:  listar o que está incluído no processo de prescrição (seleção);  descrever as principais características das cadeiras de rodas disponíveis localmente;  relacionar as necessidades do usuário à melhor cadeira de rodas disponível localmente;  escolher o tamanho correto de cadeira de rodas para o usuário;  registrar as decisões de prescrição no formulário de prescrição (seleção) de cadeira de rodas. RE CU RS O S Para a sessão:  Apresentação em PPT : B.5 Prescrição (seleção);  Manual de Referência;  Apostila do Participante (note que existem duas seções B5 na Apostila do Participante);  pelo menos um exemplo de cada cadeira de rodas disponível localmente com almofada, e a brochura da cadeira de rodas ou resumo das especificações, se houver;  fitas métricas e qualquer ferramenta necessária para afrouxar peças ajustáveis (ex.: apoio para os pés). CO N TE X TO Adapte esta sessão ao contexto em que os participantes vão trabalhar. Pense sobre:  ajustar o tempo dependendo do número de cadeiras de rodas localmente disponíveis;  preparar e incluir qualquer formulário específico de prescrição (seleção) de cadeira de rodas – um formulário específico de prescrição (seleção) de cadeira de rodas é útil para cadeiras de rodas que ofereçam muitas opções ou ajustes. PR EP A RA ÇÃ O  Reunir recursos, rever os slides e ler todo o plano da sessão.  Preencher um formulário de resumo da cadeira de rodas para todas as cadeiras disponíveis como referência.  Examinar todas as cadeiras de rodas disponíveis e acostumar-se com suas características, abrangência de ajuste, opções e como a cadeira é ajustada.  Adaptar o formulário de prescrição (seleção) da cadeira de rodas para incluir qualquer opção ou ajuste para cadeiras de rodas localmente disponíveis (a menos que exista um formulário específico de prescrição (seleção) para tal produto).  Arrumar as cadeiras de roda em torno da sala, com qualquer material sobre a cadeira de rodas que seja fornecido pelo fabricante (por exemplo, brochura ou informações sobre o produto). 145 D ES CR IÇ Ã O 1. Introdução. 2. O que é ‘prescrição/seleção’? 3. Cadeiras de rodas e almofadas localmente disponíveis. 4. Como escolher a cadeira de rodas e as partes certas. 5. Como escolher o tamanho certo de cadeira de rodas. 6. Como registrar a prescrição. 7. Resumo dos pontos principais. 2 5 60 15 25 10 3 Tempo Total da sessão 120 1. Introdução (2 minutos) Explique: • Prescrição (seleção) é a terceira das oito etapas de prestação de serviço para cadeiras de rodas. • Nesta sessão, os participantes vão aprender como prescrever (selecionar) uma cadeira de rodas usando as informações obtidas durante a avaliação. 2. O que é prescrição (seleção)? (5 minutos) Explique: • Prescrição (seleção) significa encontrar a melhor combinação possível entre as cadeiras de rodas e almofadas disponíveis e as necessidades do usuário. • A prescrição (seleção) deve ser sempre decidida com o usuário, inclusive familiares ou cuidadores, se for o caso. • Prescrição (seleção) inclui: - Escolher o tamanho certo da cadeira de rodas e da almofada - Escolher a cadeira de rodas, a almofada e as partes da cadeira certas; - Combinar com o usuário o treinamento que ele precisa para usar e cuidar da cadeira de rodas e da almofada. 146 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: Para isso, primeiro a equipe precisa: • entender as necessidades do usuário – fazendo a avaliação da cadeira de rodas e escutando atentamente o que dizem; • conhecer as diferentes cadeiras de rodas e almofadas disponíveis; • discutir as opções com o usuário. 3. Cadeiras de rodas e almofadas localmente disponíveis (60 minutos) Explique: A equipe de serviço precisa conhecer muito bem as cadeiras de rodas e almofadas localmente disponíveis. Precisam saber o seguinte: • Estrutura – por exemplo, se a distância entre eixos é longa ou curta; se é uma estrutura dobrável ou rígida. • Características – inclusive tipo de assento, encosto, apoio para os pés, apoio para os braços, rodas dianteiras e traseiras. • Tamanho da cadeira de rodas: Em geral é descrito pela largura do assento e às vezes pela profundidade. Conhecer a altura do assento até o chão também é útil. • Opções de ajuste: Quais componentes são ajustáveis e qual a abrangência dos ajustes? Em geral é possível ajustar para duas ou mais posições diferentes. Por exemplo, a maioria das cadeiras de rodas tem apoios para os pés que podem ser ajustados para alturas diferentes, afastadas uniformemente. A “abrangência” de ajustes é da medida menor para a maior. • Almofada: qual tipo de almofada (se houver) é fornecido com a cadeira de rodas ou está disponível separadamente? 147 • Alguns fabricantes de cadeiras de rodas fornecem: a. brochuras ou um resumo do produto; b. especificações do produto (cadeira de rodas). • Medidas, pesos, características e às vezes partes opcionais costumam ser listados nessas informações. • Sempre verifique se existem informações sobre a cadeira que está prescrevendo (selecionando). Leia as informações para conhecer melhor o produto. • se o fabricante não der as informações, peça Explique: Nesta sessão, os participantes vão examinar de perto algumas cadeiras de rodas disponíveis localmente. Vão preencher o formulário de resumo da cadeira de rodas de sua apostila. Isso inclui medir as cadeiras de rodas. É assim que se mede uma cadeira de rodas. Explique • Medir a largura do assento de uma parte externa do trilho do assento até a outra. • Se o apoio de braço fica no topo do trilho do assento, medir entre os apoios de braço. • Medir a profundidade do assento da base do encosto até a frente do assento. 148 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO • Medir a altura do assento da frente do assento diretamente até o chão. • Medir a altura do encosto (sem a almofada) do meio da parte de trás do assento até o topo do encosto. • Medir a variação de altura do apoio para os pés medindo da parte de trás do apoio para os pés diretamente até o assento. • Para medir a altura do apoio para os pés, medir com o apoio de pé ajustado no ponto mais baixo e novamente com ele ajustado no ponto mais alto. • Medir o comprimento geral da estrutura da cadeira de rodas medindo da parte de trás das rodas traseiras até a frente do apoio para os pés (ou rodas dianteiras se estiverem na frente do apoio para os pés). 149 • Medir a distância entre eixos medindo do meio da roda traseira até o meio da roda dianteira. Explique: • As medidas e a abrangência dos ajustes da cadeira de rodas em geral se encontram no material impresso sobre o produto. • Mas é bom saber como medir porque as informações nem sempre estão disponíveis. • Sempre verifique se uma determinada cadeira de rodas está disponível em vários tamanhos. Atividade Grupos: Faça grupos de três pessoas. Dê a cada grupo uma das cadeiras de rodas disponíveis localmente. Se não houver tipos diferentes o suficiente, alguns grupos podem receber o mesmo tipo de cadeira de rodas. Instruções: Peça a cada grupo que: • estude com cuidado a cadeira de rodas que receberam; • preencha o formulário de resumo da cadeira de rodas da apostila para aquela cadeira de rodas (isso inclui medir a cadeira de rodas); • descubram a abrangência de ajustes que vão precisar para ajustar a cadeira de rodas para o maior e o menor ajuste de cada parte ajustável. Monitore: Circule pelos grupos e monitore atentamente. Mostre qualquer características/componente que os participantes não tenham notado. Certifique-se que os participantes trabalhem com a abrangência de ajustes. Esclareça as dúvidas. Tempo: Dê 20 minutos, mais 20 minutos para feedback de todo o grupo. Se houver apenas uma ou duas cadeiras de rodas disponíveis, esta sessão pode não precisar de tanto tempo. 150 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Feedback: • Peça a cada grupo que apresente a cadeira de rodas que revisaram (5 minutos no máximo). Certifique-se que destacaram as principais características, componentes, opções de tamanho, os componentes ajustáveis e sua abrangência. Não é necessário apresentar as medidas reais. • Reforce as vantagens e desvantagens das diferentes características e inclua qualquer informação não coberta pelo grupo. • Por exemplo – se a cadeira de rodas tem um assento flexível de lona e não tem almofada – explique que não é adequada para alguém com lesão medular, embora possa ser adequada para um usuário temporário ou por curto prazo. Explique: Os participantes podem querer preencher um formulário de resumo da cadeira de rodas para cada cadeira de rodas de sua apostila (existem três formulários no total). Notas para os instrutores: É uma boa ideia pregar uma cópia do formulário preenchido do resumo de cada cadeira de rodas após esta sessão. Eles poderão ser consultados durante as sessões práticas com usuários. 4. Como escolher a cadeira de rodas e as partes certas (15 minutos) Explique: • Os participantes já treinaram como obter informações sobre o usuário e têm informações sobre as cadeiras de rodas disponíveis localmente. Agora é hora de treinar como selecionar a melhor cadeira de rodas para o usuário. • Vamos ver agora as histórias de dois usuários. Vamos trabalhar juntos para encontrar a melhor cadeira de rodas e os melhores componentes para cada usuário. • Lembrem-se – em uma situação real, o usuário seria parte da equipe escolhendo a cadeira de rodas. Leia a história do primeiro usuário (e projete o slide da história, se quiser). Pergunte: Qual é o melhor tipo de cadeira de rodas e componentes para Peter? Por quê? Estimule respostas. 151 Peter Cadeira de rodas e componentes Motivo Peter mora na zona rural. É muito ativo e forte. Tem bom equilíbrio. Todos os dias ele percorre 1 km em uma estrada de terra para ir e voltar do trabalho. Quando chove o caminho fica muito lamacento. Distância longa entre eixos (rodas traseiras e dianteiras bem afastadas) Quando disponível: triciclo Bom para ar livre Triciclos são uma boa opção para longas distâncias Rodas dianteiras largas Bom para terra/lama/areia Posição ativa das rodas traseiras Mais fácil de levantar as rodas dianteiras para passar por terreno acidentado/pequenos obstáculos. Ele tem bom equilíbrio Encosto baixo Não restringirá a impulsão Leia a história do segundo usuário (e projete o slide da história se quiser). Pergunte: Qual é o melhor tipo de cadeira de rodas e componentes para Natasha? Por quê? Estimule respostas. Natasha Cadeira de rodas e componentes Motivo Natasha mora em um apartamento na cidade. Teve um AVC/trombose cerebral e consegue se transferir em pé. Não consegue impulsionar a cadeira de rodas porque seus braços são muito fracos. Às vezes Natasha escorrega para a lateral do assento e os familiares acham que ela fica desconfortável. Apoio móvel para os pés Para permitir transferência em pé Pode permitir/estimular impulso com os pés Altura do assento até o chão – não muito alto Para Natasha alcançar o chão confortavelmente quando sentar na frente da cadeira de rodas, pronta para levantar Almofada para alívio de pressão Alivia pressão, dá conforto e suporte postural Encosto firme Para dar bom suporte postural Apoio para os braços alto Pode ajudar a postura Manoplas Para que familiares/ cuidadores empurrem com maior facilidade 152 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: às vezes não é possível encontrar uma cadeira de rodas que atenda a todas as necessidades do usuário. Nesse caso, converse com o usuário e tente atender às necessidades mais importantes. 5. Como escolher o tamanho certo de cadeira de rodas (25 minutos) Pergunte: Por que é importante ter o tamanho certo de cadeira de rodas? Estimule respostas. Respostas mais importantes: • o tamanho correto permite que o usuário sente-se corretamente na cadeira de rodas; • com o tamanho correto, o peso do usuário é distribuído por igual; • a cadeira de rodas será mais confortável e fácil para o usuário impulsionar. Atividade Grupos: Faça grupos de três pessoas. Instruções: Peça a cada grupo que: • consulte as medidas do usuário em sua apostila; • decida qual será o tamanho ideal de cadeira de rodas para esse usuário, e então; • escolha a melhor entre as cadeiras de rodas disponíveis. Explique: • Podem usar 50 mm como altura da almofada. • Devem pressupor que o usuário impulsiona a cadeira com os braços, não com os pés. Monitore: Monitore os grupos e ajude se necessário. Tempo: 25 minutos. Feedback: Verifique com cada grupo se escolheram o “tamanho ideal” correto e a mais adequada entre as cadeiras de rodas disponíveis. Pergunte: Se o segundo usuário quisesse empurrar a cadeira de rodas com os pés, qual seria a altura ideal do assento da cadeira até o chão? (Resposta: 310 mm) Pergunte: Se a altura do assento até o chão das cadeiras de rodas disponíveis for maior do que isso, o que podem fazer? (Resposta: reduzir a altura da almofada.) 153 Explique: Além de verificar a largura e a profundidade do assento e a altura do encosto, a equipe de serviço precisa verificar a abrangência de ajustes da altura do apoio para os pés para atender ao usuário. Às vezes o usuário tem coxas particularmente longas ou pernas particularmente curtas. Se estiverem fora da abrangência de ajuste da cadeira de rodas, será preciso uma modificação. Isso será discutido na próxima sessão. Respostas para os instrutores: 1 Medidas do corpo Medidas (mm) Mudar medida do corpo para tamanho ideal de cadeira de rodas Medida da cadeira de rodas A Largura do quadril 380 mm Largura quadril = largura assento 380 mm B Profundidade do assento E 400 mm B menos 30-60 mm = profundidade do assento (se o comprimento é diferente use o mais curto) 370 mm D 400 mm C Comprimento da perna E 420 MM = topo da almofada do assento até a altura do apoio para os pés ou = topo da almofada do assento até o chão para impulso com os pés 370 mm (almofada de 50 mm)D 420 mm D Altura da última costela - = topo da almofada até o topo do encosto (medida D ou E – dependendo da necessidade do usuário) - E Altura do ângulo inferior da escápula 380mm 430 mm (almofada de 50 mm) Tamanho ideal de cadeira de rodas para esse usuário: Largura do assento: 380 mm Profundidade do assento: 370 mm Altura do encosto: 430 mm Das cadeiras disponíveis, qual cadeira e tamanho são os melhores para o usuário? 154 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1 Medidas do corpo Medidas (mm) Mudar medida do corpo para tamanho ideal de cadeira de rodas Medida da cadeira de rodas A Largura do quadril 420 mm Largura quadril = largura assento 420 mm B Profundidade do assento E 460 mm B menos 30-60 mm = profundidade do assento (se o comprimento é diferente, use o mais curto) 430 mm D 460 mm C Comprimento da perna E 360 MM = topo da almofada do assento até a altura do apoio para os pés ou = topo da almofada do assento até o chão para impulsionar com os pés 310 mm (almofada de 50 mm)D 360 mm D Altura da última costela 260 mm = topo da almofada até o topo do encosto (medida D ou E – dependendo da necessidade do usuário) 310 mm (almofada de 50 mm) E Altura do ângulo inferior da escápula - - Tamanho ideal de cadeira de rodas para esse usuário: Largura do assento: 420 mm Profundidade do assento: 430 mm Altura do encosto: 310 mm Das cadeiras disponíveis, qual cadeira e tamanho são os melhores para o usuário? 6. Como registrar a prescrição (seleção) (10 minutos) Explique: A prescrição (seleção) da cadeira de rodas deve ser registrada. Os serviços de cadeira de rodas precisam de um formulário para registrar as decisões de prescrição (seleção). O formulário de prescrição (seleção) de cadeira de rodas usado neste treinamento é um exemplo que pode precisar ser adaptado para diferentes serviços de cadeira de rodas. 155 Explique: • O formulário de prescrição (seleção) de cadeira de rodas tem quatro partes. • A primeira parte são informações do usuário. Elas podem ser obtidas do formulário de avaliação. • Também há espaço para anotar a data de adequação. Explique: • A segunda parte registra o tipo e tamanho de cadeira de rodas escolhidos. • Quando a cadeira de rodas tem opções (encosto ajustável ou tipos diferentes de apoio para os pés) deve-se registrar a opção feita • Alguns fornecedores de cadeira de rodas possuem um formulário detalhado de prescrição (seleção) de cadeira de rodas. Ele também deve ser preenchido e anexado ao formulário geral de prescrição. Explique: • A terceira parte registra o tipo da almofada escolhida 156 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Finalmente, há espaço para todos os envolvidos assinarem que concordam com a prescrição (seleção) da cadeira de rodas. • A lista de pessoas que assinam vai depender do serviço. No entanto, é muito importante que o usuário e a pessoa que fez a avaliação assinem. Pergunte: Alguém tem dúvidas sobre como preencher o formulário de prescrição (seleção) de cadeira de rodas? Responda a qualquer pergunta. Explique: Prescrição (seleção) também inclui combinar com o usuário o treinamento ou orientação que precisa para usar e cuidar da cadeira de rodas. 7. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. B.6: Financiamento e Aquisição O BJ ET IV O S Ao final desta sessão os participantes saberão:  requisitar a cadeira de rodas prescrita de acordo com o sistema de requisições de seu serviço. RE CU RS O S Para a sessão:  Manual de Referência;  Formulário de requisição (não incluído no pacote de treinamento, só use se houver um localmente disponível). 157 CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar.  Use esta sessão para ensinar aos participantes as etapas de requisição de cadeira de rodas do serviço em que vão trabalhar.  Quando não houver um sistema claro de requisição de cadeira de rodas, os instrutores são estimulados a trabalhar com os serviços para estabelecer um processo de requisição.  Dê aos participantes a oportunidade de treinar como fazer a requisição. Isso inclui preencher um formulário de requisição (se houver um localmente disponível). PR EP A RA ÇÃ O  Reunir recursos e ler todo o plano da sessão. D ES CR IÇ Ã O 1. Introdução 2. Financiamento 3. Requisição/aquisição 2 3 10 Tempo Total da sessão 15 1. Introdução (2 minutos) Explique: Financiamento e aquisição é a quarta etapa do serviço de fornecimento de cadeira de rodas. 2. Financiamento (3 minutos) Explique: Quando a cadeira de rodas é prescrita, o custo do produto recomendado pode ser calculado com precisão. É essencial saber quem vai financiar a cadeira de rodas. Ela pode ser financiada pelo próprio usuário, por um subsídio do governo, por uma organização não governamental ou agência doadora, ou pelo pagamento de uma companhia de seguros. No mundo em desenvolvimento, muitas pessoas que precisam de cadeira de rodas não podem comprar uma. Apesar disso, todos que precisam de cadeira de rodas têm direito a uma, independente de poder pagar ou não. Portanto, é preciso haver recursos para usuários que precisam de assistência financeira. Para a maioria dos serviços, é essencial identificar a fonte de financiamento antes de requisitar a cadeira de rodas. 158 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Em geral, isso é responsabilidade do pessoal administrativo ou dos gestores do programa e não da equipe clínica ou técnica. Inclua qualquer sistema de identificação da fonte de financiamento cadeira de rodas, se isso for parte da função da equipe de serviço de cadeira de rodas. Os participantes podem anotar as diferentes possibilidades de financiar cadeiras de rodas em seu programa. 3. Aquisição/Requisição (10 minutos) Quando a melhor cadeira de rodas para o usuário tiver sido selecionada e a prescrição (seleção) preparada, a cadeira de rodas precisa ser requisitada. Se o serviço de cadeira de rodas mantém cadeiras de rodas em estoque, isso pode significar preencher um formulário de requisição a ser autorizado pelo gestor do serviço. A cadeira de rodas pode então ser preparada pela equipe responsável pela preparação de cadeiras de rodas. Se o serviço de cadeira de rodas não tiver cadeiras em estoque, isso pode significar a aquisição de um fornecedor externo. O sistema de requisição de cadeira de rodas varia de serviço para serviço. Anote abaixo as coisas que precisa lembrar para requisitar uma cadeira de rodas no seu serviço local de cadeira de rodas. Explique: Após escolher a melhor cadeira de rodas para o usuário e preparar a prescrição, a equipe de serviços de cadeira de rodas deve requisitar a cadeira de rodas. O pedido deve ser feito o mais rápido possível para evitar atrasos. Explique os diferentes sistemas de requisição de cadeira de rodas. Os participantes podem anotar o sistema de requisição no Manual de Referência, no espaço adequado. 159 Prática 1: Avaliação e prescrição (seleção) O BJ ET IV O S Ao final desta sessão os participantes saberão:  Demonstrar uma avaliação de nível básico de cadeira de rodas trabalhando em grupo e com assistência.  Demonstrar como fazer a prescrição (seleção) de nível básico de cadeira de rodas trabalhando em grupo e com assistência. RE CU RS O S  Lista de verificação das observações do instrutor: Prática 1;  Formulários em branco de avaliação e prescrição (seleção) de cadeira de rodas;  Local de avaliação limpo e privado com cama de avaliação para cada usuário;  Amostras de cadeiras de rodas (a menos que a avaliação seja realizada na comunidade);  fita métrica, blocos de apoio para os pés. CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar. Pense sobre:  fatores culturais – por exemplo, se é adequado formar grupos de avaliação com pessoas de sexos diferentes;  fatores de idioma – por exemplo, se os usuários participantes falam um idioma comum com todos os participantes;  qualquer documentação que o serviço possa precisar ao avaliar e prescrever uma cadeira de rodas – por exemplo, qualquer informação adicional que o serviço precisa ter sobre os usuários que acessam seu serviço (ex.: fonte de encaminhamento);  como os instrutores vão administrar problemas que possam surgir durante a avaliação e que não possam ser abordados durante a sessão ou treinamento. PR EP A RA ÇÃ O  Confirme arranjos de horário e viagem com os usuários voluntários. Não se esqueça de providenciar um lanche para os usuários voluntários e seus familiares/cuidadores.  Designe uma pessoa para receber os usuários na chegada e mostrar a eles onde podem esperar até que a sessão comece.  Prepare uma cama de avaliação com um biombo para garantir a privacidade para cada dupla de participantes e usuário voluntário. Ponha todos os equipamentos necessários para a avaliação, inclusive formulários de avaliação e prescrição (seleção) da cadeira de rodas sobre a cama de avaliação.  Certifique-se que os modelos de cadeiras de rodas e almofadas que serão mostrados aos usuários estejam funcionando bem.  Se houver mais de três duplas de participantes, peça a outro instrutor para ajudar no monitoramento dos grupos.  Decida quais participantes vão trabalhar juntos e com qual usuário. D ES CR IÇ Ã O 1. Prática de avaliação e prescrição: • Instruções e montagem • Avaliação • Prescrição • Feedback 5 45 30 10 Tempo Total da sessão 90 160 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Prática de avaliação e prescrição (90 minutos) Notas para os instrutores: Use a “Lista de Verificação das Observações do Instrutor” para a Prática 1 para garantir que os grupos realizem todas as etapas da prática e para anotar exemplos comuns de boas ou más práticas que possam ser destacados na sessão de feedback na lista de verificação da sessão (espaço fornecido). Atividade Grupos: • Organize os participantes em grupos (no máximo três pessoas por grupo). • Designe um líder para cada grupo. • Diga a cada grupo o nome do usuário com quem vão trabalhar. • Designe um local para cada grupo trabalhar. • Explique que todos os equipamentos estão sobre a cama de avaliação. Explique o seguinte: Objetivo da sessão: • O objetivo desta sessão prática é fazer a avaliação e prescrever uma cadeira de rodas para um usuário. • Os participantes vão trabalhar com o mesmo usuário com que vão trabalhar hoje, mais adiante no curso, para adequar a cadeira de rodas escolhida hoje e dar treinamento ao usuário. • Se não for possível, durante o curso, terminar a cadeira de rodas do usuário, serão feitos arranjos com ele para que sua cadeira de rodas seja terminada. No entanto, os participantes devem tentar fazer o máximo possível do trabalho. Líder: • O líder é responsável por garantir que todas as etapas sejam cumpridas. • O líder será a principal pessoa falando com o usuário e seus familiares/ cuidadores. Isso para evitar ter gente demais falando ao mesmo tempo, o que pode ser confuso para todos. 161 Instruções: Formulários de serviço: • Distribua um formulário de avaliação e um de prescrição para cada líder de grupo. Observação e suporte do instrutor: • Os participantes podem pedir ajuda ou esclarecimentos a qualquer momento. • Durante a sessão, os instrutores vão monitorar todos os grupos e dar todo o suporte e orientação necessários. • Após terminar a avaliação, os participantes devem pedir a um instrutor que confira sua avaliação e seus formulários de avaliação da cadeira de rodas. • Após terminar a prescrição (seleção) da cadeira de rodas, os participantes devem pedir a um instrutor que confira sua prescrição e seu formulário de prescrição (seleção) da cadeira de rodas. Tempo: • Devem tentar terminar a avaliação em 40 minutos e a prescrição (seleção) em 20 minutos. Pergunte aos participantes: Quais são as etapas da avaliação? Elogie respostas corretas. Pergunte aos participantes: Quais são as etapas da prescrição? Elogie respostas corretas. Lembre aos participantes que devem envolver ativamente o usuário em todas as etapas do processo. Pergunte aos participantes: existem dúvidas? Responda qualquer pergunta. Peça a cada grupo que prepare a área onde vão trabalhar; então se apresentem ao usuário com quem vão trabalhar e comecem. Monitore e apoie: Monitore atentamente os grupos, garanta práticas seguras, observe e avalie as habilidades dos participantes. Use a lista de verificação das observações do instrutor para anotar suas observações sobre cada grupo. Durante a sessão: • Dê alertas de tempo para ajudar os participantes a administrar seu tempo. • Assegure-se que os usuários estejam envolvidos ativamente. Ao final da sessão, peça aos participantes para agradecer a participação dos usuários e explique que a cadeira de rodas prescrita (selecionada) será agora preparada e estará pronta para eles experimentarem na próxima sessão prática. 162 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Tempo: Dê 45 minutos para terminar a avaliação; 30 minutos para terminar a prescrição (seleção), 10 minutos para feedback. Controle o tempo com a Lista de Verificação das Observações do Instrutor. Feedback: Comente os exemplos de boas práticas que observou durante as sessões práticas. Destaque qualquer área em particular em que os participantes podem melhorar – não identifique as pessoas. Pergunte: Existem dúvidas? B.7: Preparação do produto (cadeira de rodas) O BJ ET IV O S Ao final desta sessão os participantes saberão:  Ajustar a cadeira de rodas para atender à prescrição (seleção) da cadeira de rodas;  Usar a lista de verificação da “cadeira de rodas segura e pronta para uso” para ter certeza da que ela é segura de usar e que todas as partes estão funcionando. RE CU RS O S Para a sessão:  Apresentação em PPT: B.7 Preparação do produto (cadeira de rodas);  Manual de Referência;  Apostila do Participante;  DVD: Demonstração de verificação da cadeira de rodas segura e pronta para uso;  Cadeiras de rodas escolhidas para cada usuário de acordo com avaliação da Prática 1;  Formulários preenchidos de prescrição (seleção) de cadeira de rodas (da Prática 1);  Lista de verificação da cadeira de rodas segura e pronta para uso (1 cópia por participante);  Fitas métricas e qualquer ferramenta necessária para fazer os ajustes (1 por dupla). CO N TE X TO Adapte esta sessão ao contexto em que os participantes vão trabalhar. Pense no seguinte.  Tempo necessário para ajustar cadeiras de rodas localmente disponíveis. Se elas tiverem poucas opções de ajuste, o tempo necessário será menor. Se tiverem muitas opções de ajuste, o tempo necessário será maior.  Se qualquer cadeira de rodas localmente disponível precisar ser montada antes de ser preparada, é preciso tempo para que a montagem seja feita antes desta sessão. 163 PR EP A RA ÇÃ O  Reunir recursos, rever os slides, assistir ao DVD e ler todo o plano da sessão.  Praticar como ajustar as cadeiras de rodas localmente disponíveis para saber como são ajustadas e poder demonstrar ou auxiliar os participantes conforme necessário. D ES CR IÇ Ã O 1. Introdução. 2. Preparando a cadeira de rodas. 3. Lista de verificação da cadeira de rodas segura e pronta para uso. 4. Resumo dos pontos principais. 2 40 30 3 Tempo Total da sessão 75 1. Introdução (2 minutos) Explique: nesta sessão, os participantes vão aprender como preparar a cadeira de rodas para o usuário experimentar. Esta é a quinta etapa do serviço de fornecimento de cadeira de rodas. A preparação da cadeira de rodas inclui: • preparar a cadeira de rodas montada para atender à prescrição (seleção) do usuário; • verificar a cadeira de rodas para ter certeza de que é segura e está pronta para ser usada e que todas as partes estão funcionando normalmente. 2. Como preparar a cadeira de rodas (40 minutos) Explique: Os participantes vão preparar a cadeira de rodas prescrita para o usuário com quem trabalharam na prática anterior. Estas são as etapas para preparar a cadeira de rodas. 164 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Verificar se a largura e a profundidade do assento estão corretas para a prescrição (seleção). • Verificar se a largura e a profundidade da almofada estão de acordo com o assento. Ajustar (quando possível): • altura do encosto; • altura dos apoios para os braços; • posição das rodas traseiras; • posição dos freios (sempre reposicione os freios após mudar a posição das rodas traseiras); • altura dos apoios para os pés; • altura dos aros de impulsão; • qualquer outro ajuste possível. 165 Atividade Grupos: Peça aos mesmos grupos que trabalharam na Prática 1 que trabalhem juntos agora. Dê a cada grupo: • o formulário de prescrição (seleção) de cadeira de rodas que preencheram para o seu usuário; • uma fita métrica; • a cadeira de rodas que prescreveram (selecionaram) para o usuário. Certifique-se que todas as ferramentas necessárias para ajustar as cadeiras de rodas estejam disponíveis na sala de treinamento. Instruções: Peça a cada grupo que leia a prescrição (seleção) e prepare a cadeira de rodas. Lembre-os de seguir todas as etapas: • verificar a largura e profundidade do assento; • verificar se a almofada está de acordo; • fazer qualquer ajuste para adequar a cadeira ao usuário. Lembre-os que todas as ferramentas necessárias estão na frente da sala de treinamento. Explique: se algum grupo precisar fazer qualquer pequena modificação para atender às necessidades do usuário, isso será feito em outra sessão. Monitore: Monitore atentamente os grupos. Verifique se todas as etapas foram cumpridas. Quando os grupos terminarem, verifique se ajustaram a cadeira de rodas o mais próximo possível para atender às necessidades da prescrição (seleção) do usuário. Se forem necessárias pequenas modificações, discuta com o grupo o que é preciso. Explique que isso será discutido em uma próxima sessão. Tempo: 20 minutos ou mais, dependendo dos ajustes necessários e que podem ser feitos, e 10 minutos para feedback. Feedback: Pergunte: • Os grupos conseguiram preparar a cadeira de rodas para atender à prescrição (seleção) de seus usuários? • Se não, qual foi o problema? Pergunte aos grupos que soluções eles têm para o problema. Explique até que todos entendam. 166 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3. Lista de verificação da cadeira de rodas segura e pronta para uso (30 minutos) Explique: A segunda parte da preparação do produto (cadeira de rodas) é verificar se a cadeira de rodas é segura e está pronta para uso e se todas as partes estão funcionando normalmente. Dê a cada participante uma lista de verificação da cadeira de rodas segura e pronta para uso. Explique: • Esta lista ajuda a garantir que nada foi esquecido. • Os participantes podem usar a lista como uma referência fácil cada vez que prepararem uma cadeira de rodas • Os serviços podem usar a lista de verificação como um formulário a ser preenchido para cada cadeira de rodas prescrita (selecionada). Isso fica a critério da equipe do serviço. Apresente o DVD: Demonstração de verificação da cadeira de rodas segura e pronta para uso. Este DVD vai mostrar como verificar a cadeira de rodas para ter certeza de que é segura e está pronta para o usuário experimentar. Peça aos participantes que: • observem atentamente as verificações feitas na cadeira de rodas; • à medida que assistem, devem ticar na sua lista de verificação da cadeira de rodas segura e pronta para uso da apostila se acharem que a cadeira de rodas foi aprovada. Exiba o DVD. Pergunte se existem dúvidas. VIDEO Atividade Grupos: Mesmos grupos da Prática 1. Designe a cada grupo uma cadeira de rodas preparada por outro grupo. Instruções: Peça a cada grupo que verifique a cadeira de rodas que receberam para garantir que é segura e está pronta para o usuário experimentar. Devem usar a lista de verificação para lembrar as verificações a fazer. Anotem qualquer problema e discutam com o instrutor. Monitore: Monitore os grupos e auxilie se necessário. Estimule os participantes a corrigir qualquer problema identificado, se possível durante a sessão. Se não, qualquer problema deve ser anotado – e corrigido antes da Prática 2. 167 Tempo: 15 minutos. Feedback: Peça a cada grupo que explique aos demais se sua cadeira de rodas era segura e estava pronta para o usuário utilizar (2-3 minutos por grupo). Pergunte: se houvesse um problema, o que fariam? Estimule respostas. Respostas mais importantes: • reparar/corrigir o problema; • devolver a cadeira de rodas para a oficina para ser consertada; • entrar em contato com o fornecedor e pedir ajuda para resolver o problema. 4. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se existem dúvidas. Lista de verificação: A cadeira de rodas é segura e está pronta para uso? Cadeira de rodas inteira: Não há arestas pontiagudas  Verifique toda a cadeira de rodas com os olhos e com as mãosNenhuma parte está danificada ou arranhada  A cadeira de rodas anda em linha reta  Empurre a cadeira de rodas, verificando se as rodas dianteiras estão em posição de “trilha”. Rodas dianteiras Giram livremente  Apoie a cadeira nas rodas traseiras. Gire as rodas dianteirasGira sem tocar no garfo  Parafusos estão apertados.  Verifique. Devem estar firmes, mas não apertados demais. 168 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Encaixe das rodas dianteiras: Garfo gira livremente  Apoie a cadeira nas rodas traseiras. Gire o garfo Rodas traseiras: Giram livremente  Apoie a cadeira em uma roda traseira. Gire a outra roda. Verifique o outro lado. Parafusos do eixo estão apertados  Verifique. Devem estar firmes. Não apertados demais. Pneus (se forem pneumáticos) estão calibrados corretamente  Aperte os pneus com o polegar. Devem afundar um pouco, mas não mais de 5 mm Aros de impulso estão seguros  Verifique. Freios: Funcionam apropriadamente  Acione os freios. Certifique-se de que a cadeira não pode ser movida. Apoios para os pés: Os apoios para os pés estão presos com segurança  Verifique. Estrutura dobrável: a cadeira abre e fecha com facilidade  Dobre a cadeira para ver se o mecanismo está funcionando bemEncosto dobrável – encosto abre e fecha com facilidade  Estrutura Para cadeira de rodas dobrável - a cadeira abre e fecha com facilidade  Dobre a cadeira para ver se o mecanismo está funcionando bem.Para cadeira de rodas com encosto dobrável - o encosto abre e fecha com facilidade  Almofada Almofada está corretamente na capa  Em geral a capa é fechada na parte de trás e embaixo. Almofada está colocada corretamente na cadeira de rodas.  Se a almofada é moldada, a caixa de acomodação do osso do ísquio deve estar na parte de trás do assento. A capa da almofada está justa, mas não muito apertada.  A capa não deve esticar demais em qualquer contorno da almofada. A almofada cobre totalmente o assento  Verifique se nenhuma parte do assento está visível sob a almofada. Isso é particularmente importante para assentos rígidos. 169 B.8: Fabricação da almofada O BJ ET IV O S Ao final desta sessão, os participantes saberão:  apontar as características de uma almofada básica para alívio de pressão.  fazer uma almofada básica para alívio de pressão de espuma  descrever como inserir uma "camada de elevação" na almofada para usuários com pressão perigosa sob o osso do ísquio. RE CU RS O S  Apresentação em PPT: B.8 Fabricação da almofada;  Manual de Referência;  Apostila do Participante;  DVD: Fabricação da almofada;  Exemplo de almofada para alívio de pressão, capa da almofada e camada de elevação;  Kit de fabricação de almofada (veja “Fabricação da almofada – materiais e ferramentas" acima para maiores detalhes);  Amostras de tecidos disponíveis localmente e adequados para capas de almofada. CO N TE X TO Adapte esta sessão para o contexto em que os participantes vão trabalhar. Por exemplo:  fazer e ajustar uma almofada para um usuário;  adaptar as dimensões e desenho da almofada dependendo da disponibilidade de materiais recomendados e seu desempenho ou com base no tamanho médio das pessoas da população local;  preparar uma lista de almofadas localmente disponíveis e materiais alternativos – deve-se pedir aos participantes que tragam amostras de seus locais de origem. PR EP A RA ÇÃ O  Reunir recursos, rever os slides, assistir ao DVD e ler todo o plano da sessão.  Montar uma bancada/mesa para cada grupo de três participantes com os materiais e ferramentas necessários para testar a firmeza de amostras de espuma, cortar e colar uma base de almofada. D ES CR IÇ Ã O 1. Introdução. 2. Características e dimensões da almofada. 3. Como fazer uma base de almofada - demonstração. 4. Como fazer uma base de almofada - prática. 5. Como cuidar da almofada. 6. Perguntas frequentes sobre almofadas de espuma para alívio de pressão. 7. Resumo dos pontos principais. 5 20 20 60 5 5 5 Tempo Total da sessão 120 170 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Introdução (5 minutos) Explique: • Nesta sessão, os participantes vão aprender como fazer uma almofada básica de espuma para alívio de pressão. Se feita e ajustada corretamente, essa almofada pode ajudar a aliviar a pressão de vários usuários. • É importante lembrar que a mesma almofada não é adequada para todos os usuários. • Ao fornecer uma almofada para alívio de pressão, sempre verifique a pressão sob o osso do ísquio do usuário durante a adequação. Poderão ser necessários alguns ajustes para garantir que a caixa de acomodação do osso do ísquio tenha largura, profundidade e altura corretas. Pergunte: alguém já teve experiência em fazer e fornecer almofadas para alívio de pressão? Estimule e agradeça as respostas. 2. Características e dimensões da almofada (20 minutos) Circule a amostra da base da almofada para alívio de pressão. Tenha a camada superior e a capa por perto. Para cada característica da almofada mostrada nos slides, pergunte: qual é a finalidade dessa característica da almofada? Lembre os participantes o quê foi visto na sessão “almofadas” no início do programa de treinamento. Estimule respostas. Para cada característica mostrada no slide, aponte essa característica no exemplo de almofada. 171 Característica Anotações do Instrutor: Qual é a função desta característica? • Dar forma à almofada Caixa de acomodação do osso do ísquio • Reduz a pressão sob o osso do ísquio e o cóccix. • Ajuda a manter a pelve ereta na parte traseira da almofada. Explique: • o osso do ísquio do usuário deve estar acomodado na caixa – e não na borda ou sobre a almofada. • verifique sempre se o osso do ísquio está bem acomodado na caixa quando o usuário experimentar a cadeira de rodas. Coloque suas mãos debaixo do usuário e sinta onde está o osso do ísquio. Verifique a pressão através do teste de pressão apresentado neste treinamento. • se a almofada for usada em assento flexível, um corte chanfrado deve ser feito na base da almofada. • Isto faz com que a almofada se encaixe no assento flexível, de modo que a parte superior da almofada fique plana. • O corte “ chanfrado” é feito somente quando a almofada for usada em um assento flexível. • Em assentos rígidos, a base da almofada é plana· 172 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO • A camada superior de espuma oferece conforto. • Mostre uma amostra da camada superior • Às vezes é necessário ter mais alívio de pressão. • neste caso, a equipe pode fazer uma camada de “elevação” feita da mesma espuma usada para fazer a base. • Essa camada de “elevação” é colocada em cima da camada base da almofada e embaixo da camada de espuma de conforto. Isto vai proporcionar mais alívio de pressão na caixa de acomodação do osso do ísquio. • Faça sempre uma verificação física da pressão depois de ter colocado a almofada, aplicando o teste de pressão sob o osso do ísquios. • Circule a amostra da camada de “elevação” da almofada entre os participantes. Explique: A última característica da almofada é a capa. Essa capa é muito importante, pois protege a almofada. Pergunte: que tipo de tecido pode ser usado para fazer a capa da almofada? Incentive respostas e escreva no quadro quais tecidos seriam adequados ou “aceitáveis”. Explique quais tecidos seriam os melhores e quais poderiam ser usados se não houver nenhuma alternativa. Respostas possíveis: • nylon fino/tecido de guarda chuva (bom); • tecido com elasticidade /Lycra (bom); • tecido de algodão (tipo camiseta) (aceitável); • neoprene (aceitável); • tafetá (aceitável); • vinil/imitação de couro (ruim); • lona ou nylon grosso (ruim); • tecido felpudo/atoalhado (ruim); • linho/lençol (ruim); • saco plástico/polietileno (ruim). 173 Explique: • Um bom tecido para capa de almofada para alívio de pressão é, em geral, resistente à água ou elástico. • O tecido impermeável para a capa da almofada deve ser bem fino (como tecido de paraquedas ou de guarda-chuva) para que as dobras não façam marcas na pele • Se a capa for feita de tecido elástico que não é impermeável, pode se colocar um pedaço fino de plástico (tipo sacola de plástico) sobre a espuma e embaixo da capa para proteger a almofada. • A capa deve ser mais solta na parte traseira da almofada para evitar o esticamento do tecido na caixa de acomodação do osso do ísquio. Circule a amostra da capa de almofada entre os participantes. Explique: • A caixa de acomodação deve ter a largura, profundidade e altura adequadas para funcionar corretamente. Para calcular o tamanho da caixa de acomodação do osso do ísquio, os participantes devem usar as regras a seguir. Explique cada dimensão da caixa de acomodação conforme demonstrado no slide. 174 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Atividade em pequenos grupos: Grupos: Duas pessoas por grupo. Instruções: Peça para cada dupla: • preencher a tabela no inicio da folha de exercícios na apostilha. Explique que os participantes terão que calcular a largura, profundidade, e altura da caixa de acomodação do osso do ísquio para três cadeiras de rodas com assentos de larguras diferentes. Monitore: Monitore os grupos e ajude-os se for necessário. Enquanto trabalham, desenhe a tabela abaixo no quadro branco, sem incluir as respostas. Largura Profundidade Altura Usuário adulto – largura do assento 360 mm 180 mm 180 mm 35 mm Usuário adulto – largura do assento 460 mm 200 mm 200 mm 35 mm Usuário infantil – largura do assento 280 mm 140 mm 140 mm 20–25 mm Tempo: 5 minutos. Feedback: Desenhe a tabela no quadro branco Pergunte: Qual é a largura, profundidade, e altura da caixa de acomodação do osso do ísquio de cada usuário? Escreva a resposta correta na tabela no quadro branco. Pergunte: Como se pode saber se o tamanho é adequado para aquele usuário? Resposta: é sempre necessário verificar se a caixa de acomodação do osso do ísquio se encaixa corretamente quando o usuário estiver experimentando a cadeira de rodas. Coloque suas mãos sob o usuário e sinta seu osso do ísquio. Verifique a pressão usando o teste de pressão explicado neste treinamento. Certifique-se de que o osso do ísquio esteja encaixado dentro da caixa de acomodação do osso do ísquio e não na borda ou em cima da almofada. 3. Como fazer a base da almofada – demonstração (20 minutos) Apresente o DVD: Fabricação da almofada. Trata-se de uma breve apresentação sobre como fabricar uma almofada básica de espuma para alívio de pressão. Exiba o DVD. Pergunte se existem dúvidas. VIDEO 175 Circule uma amostra de espuma de alta densidade (dura) e outra de baixa densidade (macia) entre os participantes. Peça para que coloquem a espuma sobre uma superfície sólida (por exemplo, em cima de uma bancada) e sintam a firmeza dos dois pedaços de espuma, pressionando as espumas com os punhos fechados. Explique: • A base e a camada superior são colocadas juntas dentro da capa da almofada. • As duas camadas não precisam ser coladas uma na outra. • Se a camada superior ficar suja ou desgastada, poderá ser lavada e seca ou substituída. • Mostre como uma “camada de elevação” pode ser adicionada dentro da capa para aumentar a profundidade da caixa de acomodação do osso do ísquio. 4. Como fazer a base da almofada – exercício prático (60 minutos) Explique: Os participantes vão aprender como cortar a base da almofada. Atividade Grupos: Coloque duas a três pessoas em cada grupo. Acomode cada grupo em uma bancada/mesa com os materiais e ferramentas necessárias para cortar uma base de espuma. Instruções: Peça a cada grupo: • para trabalharem juntos e cortar a base da almofada • usar a folha de exercícios em suas apostilas para lembrar cada passo. Enfatize os pontos de segurança: • lembre aos participantes que as ferramentas para cortar espuma são muito afiadas e precisam ser manuseadas com cuidado Monitore: Monitore os grupos, e ajude se for necessário. Tempo: 50 minutos e 10 minutos para feedback. Feedback: Pergunte aos grupos: • Quais técnicas úteis para cortar ou colar espuma vocês aprenderam? • O que acontece se você cortar um pedaço em direções diferentes? (Resposta: Os dois pedaços cortados podem não se encaixar, formando um degrau na superfície.) 176 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 5. Cuidando da almofada (5 minutos) Explique: os usuários precisam aprender a cuidar de suas almofadas. Isso inclui: • Manter a almofada limpa – a almofada pode ser lavada com água morna e sabão. Seque a almofada longe do sol antes de recolocá-la • Verificar a camada superior – essa camada deve voltar ao formato anterior quando pressionada. Se a espuma não voltar ao formato anterior e ficar dura e achatada, ela terá que ser substituída. • Verificar a camada de base – verificar se a base continua com o mesmo formato e se não está lascada ou desgastada. Se estiver, talvez tenha que ser substituída. • A camada superior pode ser substituída duas ou três vezes antes que a base tenha que ser substituída 6. Perguntas frequentes sobre almofadas de espuma para alívio de pressão (5 minutos) Pergunte: alguém tem alguma dúvida sobre essa almofada? Responda as perguntas. Possíveis Perguntas: Respostas Como você decide qual tecido usar para a capa da almofada? • Se possível, escolha um tecido com elasticidade. O tecido impermeável também é uma boa opção, se estiver disponível. Se o tecido for impermeável, certifique-se de que não seja muito grosso, pois as dobras podem causar marcas na pele do usuário, o que pode resultar em úlceras/feridas de pressão. • A escolha vai depender do tecido disponível. Às vezes, a escolha é limitada. • Se você tiver que fazer uma escolha e não tiver certeza, peça aos usuários que experimentem diferentes opções. • A equipe de serviços ganhará experiência à medida em que experimenta tecidos variados. Essa almofada serve para todos os usuários? • Não. Essa almofada não serve para todos usuários. • Entretanto, uma das vantagens dessa almofada é que ela pode ser facilmente adaptada. 177 Essa almofada esquenta ou causa suor? • As almofadas de espuma podem esquentar e causar suor. Entretanto, essa almofada funciona muito bem para outras coisas, portanto o calor é o de menos. Todo usuário precisa de uma almofada para alívio de pressão? • Não, nem todo usuário precisa de almofada para alívio de pressão, mas toda cadeira de rodas com assento rígido precisa de uma almofada. • Leve em consideração os fatores de risco de pressão abordados neste treinamento para decidir se o usuário corre risco de ter úlceras/ feridas de pressão. • Embora essa almofada não seja necessária para alívio de pressão, ela também pode proporcionar conforto e melhorar a postura, até para usuários que não correm risco de ter úlceras/feridas de pressão. O que acontece se a almofada for usada de maneira invertida ou de ponta cabeça? • A almofada não vai funcionar corretamente e pode até aumentar o risco do usuário ter úlceras/feridas de pressão. • Certifique-se de que os usuários e seus familiares (onde for relevante) entendem como usar e cuidar da almofada corretamente. • Se necessário, marque na almofada “ frente” e “ trás” ou “ para cima” e “ para baixo.”. Essa almofada serve para crianças? • Sim, essa almofada serve para crianças que conseguem sentar-se eretas e que correm risco de ter úlceras/feridas de pressão. • Muitos usuários crianças precisam de suporte adicional para manter a postura que só a almofada não oferece. 7. Resumo dos pontos principais (5 minutos) Leia os pontos principais. Pergunte se alguém tem alguma dúvida. 178 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO B.9: Adequação O BJ ET IV O S Ao terminar esta sessão, os participantes serão capazes de:  enumerar as etapas de adequação na sequência correta;  demonstrar como verificar o tamanho e os ajustes normais de uma cadeira de rodas para cada usuário. RE CU RS O S Para esta sessão:  Apresentação em PPT: B.9 Adequação;  Manual de Referência;  DVD: Demonstração da Adequação;  uma cadeira de rodas para cada grupo de três participantes;  lista de verificação de adequação da cadeira de rodas (1 por participante). CO N TE X TO Adapte esta sessão ao contexto no qual cada participante irá trabalhar. Considere o seguinte:  Onde será feita a adequação. Se os participantes fizerem a adequação na comunidade, os instrutores poderão incluir conselhos sobre as ferramentas que devem ser levadas nas visitas de adequação e outras considerações. PR EP A RA ÇÃ O  Reunir os recursos, rever os slides, assistir o DVD , e ler o plano da sessão. D ES CR IÇ Ã O 1. Introdução 2. Boas práticas de adequação. 3. Prática de adequação. 4. Resumo dos pontos principais. 2 30 25 3 Tempo Total da sessão 60 179 1. Introdução (2 minutos) Explique: • A adequação é a sexta das oito etapas da prestação de serviços para cadeiras de rodas. Nesta sessão, os participantes irão aprender o que fazer durante a adequação. 2. Boas práticas de adequação (30 minutos) Explique: Durante a adequação, o usuário e a equipe verificam se: • o tamanho da cadeira de rodas está certo, e se foram feitos todos os ajustes corretamente; • a cadeira de rodas e a almofada oferecem o suporte necessário para que o usuário se sente ereto; • caso tenha sido prescrita (selecionada) uma almofada para alívio de pressão, se ela alivia a pressão. Explique: boas práticas de adequação incluem: • verificar tamanho e ajustes; • verificar a postura; • verificar a pressão; • verificar a adequação com o usuário em movimento. Verifique se a cadeira de rodas está pronta Explique: • Certifique-se de que a cadeira de rodas foi verificada, é segura, e todas as partes estão funcionando. 180 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Verificar tamanho e ajustes Explique: • Já falamos um pouco sobre como a cadeira de rodas deve ser ajustada. Durante a adequação, é necessário verificar fisicamente se o tamanho da cadeira de rodas está correto. Para tanto, siga as etapas a seguir. Explique: Para verificar a largura do assento: • Passe seus dedos entre a parte exterior das coxas do usuário e as laterais internas da cadeira de rodas. Seus dedos devem se encaixar confortavelmente sem que sejam espremidos. Para verificar a profundidade do assento: • Verifique se o usuário está sentado em posição ereta. • Passe sua mão entre a almofada e a parte traseira do joelho do usuário. Conte quantos dedos cabem neste espaço. O espaço deve ser suficientemente grande para colocar dois dedos (30 mm). Pode haver um espaço maior se as pernas do usuário forem compridas. Até 60 mm é um espaço aceitável. • Passe sua mão por trás da panturrilha do usuário e verifique se a panturrilha não está tocando o assento nem a almofada. • Sempre verifique ambos os lados. Para verificar a altura do apoio para os pés: • passe sua mão entre a coxa e a almofada – a pressão deve ser igual ao longo da coxa, e não deve ter nenhum espaço sobrando; • verifique cada pé no apoio para os pés – cada pé deve estar apoiado na frente e atrás sem nenhum espaço entre o pé e o apoio. 181 Para verificar a altura do encosto: • Pergunte ao usuário se o encosto está confortável; • Observe se o tronco está bem posicionado sobre os quadris; • O usuário consegue impulsionar a cadeira de rodas sem a interferência do encosto? Para verificar a posição das rodas traseiras para impulsionar a cadeira de rodas com as mãos: • Peça ao usuário para segurar o aro de impulsão em cima das rodas – seu cotovelo deve estar dobrado a um ângulo de 90 graus; • pergunte ao usuário se as rodas traseiras estão posicionadas corretamente (para frente, para uma postura ativa, e para trás, para uma postura mais segura). Para verificar a altura do assento para que o usuário possa impulsionar a cadeira com os pés: • Peça ao usuário para sentar-se com a pelve encostada no encosto e o pé que vai impulsionar a cadeira bem apoiado no chão. Verifique se os dois pés conseguem ficar completamente apoiados no chão. • Se o assento estiver muito alto, pode-se tentar: - diminuir a altura da almofada; - fixar um assento rígido em posição mais baixa do que o assento original (peça ajuda ou suporte técnico para fazer isto). Para o usuário que está impulsionando a cadeira com apenas um pé enquanto o outro pé permanece no apoio para os pés: • Verifique se a pressão sob o osso do ísquio no lado apoiado no apoio para os pés não está no nível 3 182 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Verificar a postura Explique: depois de verificar o tamanho e os ajustes, a equipe de serviços deve verificar se a postura do usuário está correta e se ele está sentando na posição mais ereta possível. Pergunte: Como se pode verificar se o usuário está sentado em posição ereta? Incentive respostas. Respostas mais importantes: • a pelve está ereta e nivelada; • ombros nivelados e os braços podem se movimentar livremente; • tronco ereto; • as costas seguem as três curvas naturais; • a cabeça está ereta e equilibrada sobre o corpo; • os quadris estão flexionados em 90 graus; • as pernas estão ligeiramente separadas (abdução); • os joelhos e os tornozelos estão flexionados em aproximadamente 90 graus; • os calcanhares estão diretamente sob os joelhos ou posicionados ligeiramente para frente ou para trás; • os pés estão totalmente apoiados no chão. Explique: Lembrem que nem todo usuário se senta exatamente da mesma maneira. Por exemplo - alguns usuários gostam de ficar com os pés para trás, com os joelhos dobrados em ângulo maior que 90 graus. 183 Verificar a pressão Explique: • Para todos os usuários com risco de desenvolver úlceras/feridas de pressão – verifique se a pressão sob o osso do ísquio está segura. Verificar a adequação com o usuário em movimento Explique: A etapa final da adequação é verificar tudo enquanto o usuário está se movendo. Coisas a serem observadas, incluem: • o encosto deixa o usuário com liberdade para mexer os ombros para impulsionar a cadeira de rodas? • o encosto oferece o suporte adequado? • os pés do usuário permanecem no apoio para os pés? • a posição das rodas traseiras está correta para o usuário? Explique: se o usuário não conseguir impulsionar a cadeira de rodas, peça ajuda a um familiar ou cuidador para empurrá-lo. Apresente o DVD: Agora vamos assistir toda a sequência de adequação. Isso inclui a verificação dos ajustes, da postura, e a verificação com o usuário em movimento. Distribua a lista de verificação de adequação da cadeira de rodas. Explique: Os participantes podem ficar com a lista, para que eles se lembrem das etapas da adequação. Peça aos participantes para assistir o vídeo, e veja se eles conseguem ver a execução de cada um dos itens que estão na lista. Exiba o DVD. Pergunte se alguém tem alguma dúvida. VIDEO Verifique se existem outras ações a serem realizadas 184 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3. Prática de Adequação (25 minutos) Atividade Grupos: Coloque duas a três pessoas em cada grupo. Cada grupo receberá uma cadeira de rodas e uma lista de verificação. Instruções: • Cada grupo deverá escolher uma pessoa para ser o usuário. Os outros participantes do grupo trabalharão com o usuário para verificar se a cadeira de rodas é adequada. • Lembre aos participantes que eles devem verificar o usuário parado e em movimento. Eles devem verificar a postura do usuário, se o usuário está bem ajustado na cadeira de rodas, sua postura e a pressão. Monitore: Monitore os grupos e ajude se necessário. Tempo: 10 minutos para feedback Feedback: Peça para cada grupo apresentar um breve relatório: • o usuário ficou bem ajustado ou não na cadeira de rodas? • se não ficou bem ajustado, que parte não se ajustou bem? • seria possível ajustar a cadeira de rodas para uma boa adequação, ou seria necessário trocar a cadeira de rodas? Explique: se a cadeira não está adequada corretamente depois dos ajustes, existem maneiras simples de modificá-la. Isto será explicado na próxima sessão. 4. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Veja se alguém tem alguma dúvida. 185 B.10: Solução de problemas O BJ ET IV O S Ao terminar esta sessão, os participantes saberão:  enumerar os problemas mais frequentes relacionados à adequação da cadeira de rodas  descrever soluções simples para problemas relacionados à adequação e ajustes da cadeira de rodas. RE CU RS O S Para esta sessão:  Apresentação em PPT: B.10 Solução de Problemas;  Manual de Referência;  DVD: Solução de problemas de adequação e ajustes (parte 1 e parte 2);  uma cadeira de rodas;  dois blocos de espuma (de aproximadamente 100 mm x 100 mm x 50 mm) para fins de demonstração;  faixa para tornozelo/panturrilha (se disponível). CO N TE X TO Adapte esta sessão ao contexto no qual os participantes estarão trabalhando. Considere o seguinte:  as cadeiras de rodas disponíveis no local – e quaisquer soluções específicas que possam ser aplicadas a essas cadeiras de rodas;  os materiais e as instalações no local de trabalho dos participantes. PR EP A RA ÇÃ O  Reunir os recursos, rever os slides, assistir ao DVD e ler o plano da sessão.  Preparar fotos ou slides de exemplos locais das soluções descritas nesta sessão. D ES CR IÇ Ã O 1. Introdução. 2. Profundidade do assento – muito curto ou muito longo. 3. Altura do apoio para os pés – baixa demais ou alta demais. 4. As pernas tendem a girar para dentro ou para fora. 5. Os pés tendem a escorregar do apoio para os pés. 6. A cadeira de rodas é muito larga. 7. Resumo dos pontos principais. 3 10 5 10 10 5 2 Tempo Total da sessão 45 186 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Introdução (3 minutos) Explique: às vezes, a equipe de serviços pode ter problemas para adequar a cadeira de rodas disponível ao usuário. As razões desse problema podem ser: • variedade limitada de tipos e tamanhos de cadeira de rodas; • o usuário precisa de suporte adicional para se sentar confortavelmente ereto. • Nesta sessão, vamos aprender sobre algumas soluções simples para os problemas comuns causados pela limitação de tamanho e variedade das cadeiras de rodas disponíveis. • Quais modificações podem ser feitas e como oferecer mais suporte para a postura são temas que serão abordados em mais detalhe no nível intermediário. Todas as soluções que serão discutidas nesta sessão presumem que o tamanho mais adequado da cadeira de rodas para o usuário já foi escolhido. Sempre verifique isto antes de modificar a cadeira de rodas. Pergunte: quais são alguns problemas de adequação que já foram vistos pela equipe de serviços, ou que poderiam acontecer? Respostas mais relevantes: • a profundidade do assento é muito longa ou muito curta; • não é possível elevar ou abaixar o apoio para os pés suficientemente; • os pés tendem a escorregar do apoio para os pés; • a cadeira de rodas é muito larga. Explique: Nesta sessão, vamos analisar cinco problemas que podem ocorrer. 187 1. Profundidade do assento: muito longo ou muito curto (10 minutos) Problema: Profundidade do assento muito curta Descreva: as soluções possíveis são apresentadas abaixo. Use a cadeira de rodas para fazer a demonstração. • Aumentar a profundidade do assento da cadeira de rodas estendendo os trilhos do assento e substituindo o estofado: - Se a cadeira de rodas tem uma estrutura dobrável, verifique se os trilhos do assento são “ exclusivos.” Isto significa que os trilhos do assento não fazem parte da estrutura da cadeira de rodas. - Neste caso, pode-se fazer uma extensão dos trilhos do assento e colocar um novo estofado. • Aumentar a profundidade da cadeira de rodas substituindo o estofado: - Se a cadeira de rodas tiver uma estrutura rígida com estofado, verifique se os trilhos do assento se estendem além do assento. - Neste caso, é possível substituir o estofado do assento e colocar um estofado novo, do tamanho correto, que será apoiado pelos trilhos existentes. • Aumentar a profundidade do assento da cadeira de rodas adicionando uma tábua rígida com uma almofada: - Pode ser feito um assento rígido, de madeira, plástico, ou qualquer outro material rígido que não flexiona nem racha. - Esse assento pode ser fixado sobre os trilhos do assento. - Adicione uma almofada da mesma largura e profundidade do assento novo. 188 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: Quando tiver que substituir o assento de uma cadeira de rodas, lembre se do seguinte: • Certifique-se de que o novo assento aguenta o peso do usuário. • Se for um assento rígido (sólido): - verifique se o assento não flexiona ou racha na parte que sobra além do assento original da cadeira de rodas; - verifique sempre se o assento rígido possui uma almofada – para todos os usuários; - verifique durante a adequação se o encosto e o apoio para os pés estão na altura certa – um assento rígido e uma almofada vão elevar o usuário na cadeira de rodas. Problema: a profundidade do assento é muito longa Explique: se a profundidade do assento disponível for muito longa para o usuário, será impossível para ele se sentar ereto. A profundidade do assento terá que ser diminuída. Descreva as possíveis soluções apresentadas abaixo. Use a cadeira de rodas para fazer a demonstração: • Marque a profundidade necessária no assento existente e diminua esta profundidade. • se o assento for estofado, remova o estofado, diminua o estofado (usando uma máquina de costura industrial) e recoloque-o. • se o assento for rígido, remova o assento, diminua e recoloque-o. • diminua a almofada para que se encaixe no novo assento encurtado. Explique: Quando diminuir a profundidade do assento, lembre-se: • quando recortar um assento rígido, certifique se de que as bordas estão lisas e sem farpas; • quando cortar uma almofada, sempre corte a partir da frente para que o alívio de pressão na parte de trás da almofada continue o mesmo. 189 Explique: se a profundidade do assento for mais do que 60 mm mais curta (para um adulto) do que a profundidade ideal para o assento do usuário – isto pode ser um problema. O usuário não terá suporte suficiente do assento para poder se sentar de maneira confortável. Existe também um risco maior de pressão nas áreas de alto risco, como o osso do ísquio. 3. Apoio para os pés – altura muito baixa ou muito alta (5 minutos) Problema: A altura do apoio para os pés é muito baixa Explique: se o apoio para os pés for muito baixo, o usuário não conseguirá colocar seus pés confortavelmente sobre o apoio. Isto poderá fazer com que escorregue para frente na cadeira de rodas, ou que sinta instabilidade. Ele não terá o suporte necessário para manter-se confortavelmente sentado e ereto. Descreva as possíveis soluções apresentadas abaixo: Use a cadeira de rodas para fazer a demonstração. • Levante o apoio para os pés encurtando o seu suporte: - na maioria das cadeiras de quatro rodas, o suporte do apoio para os pés pode ser encurtado. • Eleve a altura do apoio para os pés colocando calços: - use madeira ou qualquer outro material robusto para aumentar a altura do apoio para os pés. Explique: • Quando encurtar a altura do apoio para os pés, verifique se o mecanismo de ajuste ainda está funcionando. • se adicionar um calço de outro material para aumentar a altura do apoio para os pés, verifique se isso não compromete a movimentação do apoio. 190 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Problema: A altura do apoio para os pés é muito alta Explique: se a altura do apoio para os pés for muito alta, as coxas do usuário não se acomodarão de forma confortável no assento. Um apoio para os pés muito alto pode aumentar a pressão sob o osso do ísquio. Descreva as soluções possíveis a seguir: Use a cadeira de rodas para fazer a demonstração. 1. Diminua a altura do apoio para os pés estendendo o tubo de extensão interno: - verifique se o tubo de extensão interno pode ser substituído por um tubo mais comprido; - se a resposta for sim, substitua esse tubo por outro tubo com o mesmo diâmetro e a mesma resistência. 2. Aumente a altura da almofada: - aumente a altura da almofada adicionando algo rígido sob a mesma. Explique: • se abaixar o apoio para os pés – certifique-se de que o apoio para os pés está na altura certa para não tocar o chão. Se isto acontecer, tente a opção 2. Se a opção 2 não solucionar o problema, significa que a cadeira de rodas não é adequada para o usuário. • Ao aumentar a altura da almofada: - não use espuma de baixa densidade (macia) para aumentar a altura da almofada – isto vai causar compressão e instabilidade; - verifique durante a adequação se o encosto e os apoios para os braços estão na altura certa - uma almofada mais alta vai elevar o usuário na cadeira de rodas; - verifique se não há nenhum problema funcional causado pelo levantamento da almofada – por exemplo, o usuário pode ter dificuldade em se encaixar sob mesas ou escrivaninhas. 191 4. As pernas tendem a girar para dentro ou para fora (10 minutos) Explique: • Às vezes, as pernas do usuário tendem a girar para dentro ou para fora. A razão pode ser a maneira como ele se senta na cadeira, ou pode ser uma razão física (por exemplo, fraqueza muscular). • Pequenos ajustes no assento da cadeira de rodas, ou na almofada ajudam a mitigar este problema. Apresente o DVD: Solução de problemas de adequação. Esse vídeo mostra um usuário, chamado Gary, cujas pernas tendem a girar para fora. Mostre o DVD: (parte 1 – Gary) Após a exibição do vídeo, pergunte: Qual foi a solução encontrada pelo terapeuta? Incentive respostas. VIDEO Explique que no exemplo a solução foi colocar cunhas na almofada para apoiar as coxas em posição neutra. A elevação na parte exterior das pernas foi aumentada. Poderia também ser usada uma almofada moldada. Se as pernas girassem para dentro, a solução seria aumentar a elevação na parte interna. Descreva as outras soluções possíveis a seguir. Use a cadeira de rodas para fazer a demonstração. • Verifique de novo a altura do apoio para os pés: - certifique-se de que a altura do apoio para os pés está dando suporte correto ao usuário (a pressão sob os pés e sob as coxas deve ser igual). • Verifique se o assento da cadeira de rodas está tensionado corretamente: - se a cadeira de rodas tiver um assento estofado, certifique-se de que o assento esteja firmemente tensionado; - se o assento estiver frouxo, isso fará com que as pernas do usuário girem para dentro • Coloque cunhas na almofada para dar suporte às coxas em posição neutra (como mostrado no DVD e na ilustração), ou forneça uma almofada moldada. Modifique-a se necessário. 192 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 5. Os pés tendem a escorregar do apoio para os pés (10 minutos) Explique: • Os pés do usuário podem às vezes escorregar do apoio para os pés, geralmente por razões físicas (por exemplo, fraqueza muscular ou espasmos musculares). • A colocação de faixas pode ajudar a solucionar este problema. Descreva as soluções possíveis apresentadas abaixo. Use a cadeira de rodas para fazer a demonstração. • Verifique novamente a altura do apoio para os pés: - certifique-se de que a altura do apoio para os pés está dando o suporte correto ao usuários (a pressão sob os pés e coxas deve ser igual). • ajuste o ângulo do apoio para os pés (se possível): - verifique se o ângulo do apoio para os pés pode ser ajustado; - se sim, tente aumentar o ângulo do apoio para os pés. Isto pode ajudar a manter os pés do usuário no lugar certo. • acrescente uma faixa: - coloque uma faixa no suporte do apoio para os pés na altura do tornozelo; - se os pés tendem a escorregar para trás, coloque uma faixa por trás das pernas; - se os pés tendem a escorregar para frente, coloque a faixa na frente das pernas. Explique: • Certifique-se de que seja fácil remover a faixa, para que o usuário possa levantar e transferir-se da cadeira sem dificuldade. • Verifique se o usuário pode alcançar a faixa sem precisar de ajuda, e se pode tirá-la e recolocá-la sem dificuldade. 193 Explique: outro problema que pode acontecer é quando os pés não estão apoiados uniformemente no apoio para os pés. Isso normalmente acontece porque os pés do usuário não conseguem ficar em uma postura neutra. Apresente o DVD: Solução de problemas de adequação. Esse DVD mostra Arun, um usuário cujos pés não estão devidamente apoiados no apoio de pés. Mostre o DVD: (parte 2 – Arun) Após a exibição do vídeo pergunte: Qual foi a solução do terapeuta? Incentive respostas. VIDEO 6. A cadeira de rodas é muito larga (5 minutos) Explique: às vezes, a menor cadeira de rodas disponível ainda é larga demais para o usuário. Se o assento da cadeira de rodas for muito largo, o usuário terá dificuldade em sentar-se ereto, e poderá cair para um lado. A colocação de blocos de espuma pode dar o suporte para o usuário sentar-se ereto. Descreva as soluções possíveis apresentadas abaixo. Use a cadeira de rodas para fazer a demonstração. • coloque blocos de espuma em cada lado da pelve: - meça o espaço entre o usuário (quando ele estiver sentado no centro da cadeira de rodas com as costas encostada no encosto) e a lateral de cada apoio para os braços; - corte os blocos de espuma e coloque-os no espaço entre cada lado do usuário e a lateral da cadeira de rodas; - verifique a adequação; - cubra os blocos com estofado e fixe-os. Se os apoios de braço forem rígidos, os blocos podem ser fixados nos apoios de braço. Os blocos também podem ser fixados na parte superior da almofada. 194 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Os blocos de espuma podem ter a mesma profundidade do tronco do usuário. • Verifique se a largura da almofada é a mesma do assento. • Se a cadeira de rodas for muito larga, o usuário terá dificuldade em alcançar os aros de impulsão. • O esforço para alcançar os aros de impulsão pode causar lesão nos ombros. Verifique cuidadosamente se a cadeira de rodas é segura para o usuário antes de prescrevê-la. 7. Resumo dos pontos principais (2 minutos) Leia os pontos principais. Pergunte se alguém tem dúvidas. B.11: Treinamento de usuários O BJ ET IV O S Ao concluir esta sessão, os participantes poderão:  fazer uma lista de técnicas que eles podem ensinar aos usuários quando eles receberem uma cadeira de rodas nova ;  fazer uma lista das “boas práticas de métodos de treinamento”;  fazer uma demonstração sobre como ensinar uma habilidade referente à cadeira de rodas para um colega. RE CU RS O S Para esta sessão:  Apresentação em PPT: B.11 Treinamento de usuários;  Manual de Referência;  Apostila do Participante;  uma cadeira de rodas para cada grupo de três participantes;  Lista de verificação do treinamento de usuários de cadeiras de rodas (1 por participante). 195 CO N TE X TO Adapte esta sessão para o contexto no qual os participantes irão trabalhar. Considere:  grupos locais que podem oferecer mais treinamentos ou conselhos aos usuários. PR EP A RA ÇÃ O  Reunir os recursos, rever os slides, e ler o plano da sessão. D ES CR IÇ Ã O 1. Introdução. 2. Quais são algumas técnicas úteis para os usuários? 3. Treinamento prático de usuários. 4. Resumo dos pontos principais. 2 10 45 3 Tempo Total da sessão 60 1. Introdução (2 minutos) Explique: • O treinamento de usuários é a sétima etapa da prestação de serviços de cadeira de rodas. Informações e treinamento sobre cadeira de rodas podem ajudar muitos usuários a se beneficiarem mais de suas cadeiras de rodas. • Sem esta etapa, a cadeira de rodas possivelmente não beneficiará o usuário tanto quanto poderia. • Nesta sessão, vamos abordar as técnicas que a equipe de serviço pode ensinar aos usuários quando eles forem usar uma cadeira de rodas pela primeira vez. Vamos ver a lista de verificação de treinamento de usuário e praticar a realização do treinamento. 196 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 2. Quais são algumas habilidades úteis para os usuários? (10 minutos) Pergunte: O que os participantes aprenderam neste treinamento que poderia ser útil para os usuários? Pense sobre coisas que poderão ajudar os usuários a: • cuidar da saúde; • usar sua cadeira de rodas dentro e fora de casa; • cuidar bem da sua cadeira de rodas para que dure o máximo de tempo possível. Lembre aos participantes sobre o vídeo da Sai, falando sobre as coisas que a ajudaram a ir para a escola. Incentive respostas. Respostas mais importantes: • maneiras de prevenir o desenvolvimento de úlceras/feridas de pressão; • como manusear a cadeira de rodas ; • como transferir-se da cadeira de rodas ; • mobilidade na cadeira de rodas; • o que fazer quando surgir um problema; • como cuidar da cadeira de rodas e da almofada; • outras organizações e serviços que podem ser úteis para os usuários. Explique: Os seis itens mais importantes para ensinar aos usuários são: • Como manusear a cadeira de rodas. • Como prevenir úlceras/feridas de pressão e o que fazer se aparecer uma úlcera/ferida de pressão. 197 • Como sentar-se e levantar-se da cadeira de rodas (transferência). • Mobilidade em cadeira de rodas – atender às necessidades do usuário. • Como cuidar da cadeira de rodas e da almofada em casa. Explique: Vamos abordar essa questão na próxima sessão. • O que fazer se surgir um problema. 198 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Distribua uma lista de verificação de treinamento de usuários para cada participante. Explique: • A lista tem uma relação das habilidades específicas que podem ser úteis para os usuários. Entretanto, alguns usuários já têm essas habilidades, e nem todas as habilidades são importantes para todos os usuários. • Alguns serviços podem usar essa lista como um formulário a ser mantido no prontuário/processo clínico do usuário. A equipe de serviços pode especificar quais são as instruções que o usuário necessita. Isto é decidido através de uma avaliação e de uma conversa com o usuário. Essa lista também pode ser usada para registrar o treinamento que foi realizado. • Verifique com o usuário se ele gostaria que seus cuidadores também aprendessem as habilidades que você está ensinando. Muitos usuários precisam da ajuda dos familiares ou cuidadores e seria muito útil se todas as pessoas envolvidas aprendessem as técnicas usadas para usar e cuidar da cadeira de rodas. 3. Treinamento prático de usuários (45 minutos) Pergunte: Quais são os itens de um treinamento bem sucedido? Participantes podem refletir sobre alguns bons métodos de treinamento que já conhecem (talvez até os deste treinamento!). Incentive respostas. Respostas mais importantes: • Descobrir o que o usuário já sabe. • Explicar, demonstrar e depois permitir que o usuário execute a tarefa. • Usar linguagem que todos entendem. • Pedir aos usuários que ensinem outros usuários. • Usar boas técnicas de comunicação. • Incentivar. 199 Explique: A prática é importante quando se está aprendendo uma nova técnica. Quando estiver ensinando, faça sempre uma demonstração e depois ofereça ao aprendiz a oportunidade de praticar a técnica. Atividade Grupos: Coloque duas a três pessoas em cada grupo. Instruções: • Peça para cada grupo ler as histórias que se encontram nas apostilas e identificar ao menos três habilidades que os usuários poderiam aprender em seu benefício. • O grupo deverá ensinar ao menos uma daquelas habilidades para cada usuário. Cada membro do grupo deverá desempenhar o papel do usuário, do familiar, e do instrutor. • Lembre os participantes de terem em mente “uma boa comunicação” e “boas maneiras de ensinar.” Enfatize a importância da “demonstração” seguida pela “prática.” Monitore: • Monitore os grupos, ajude se for necessário. Tempo: 30 minutos para a atividade e 15 minutos para feedback. Feedback: • Peça para cada grupo relatar uma boa técnica de ensino que já experimentaram ou observaram. Moses Notas para instrutores Moses tem 23 anos. Há dois anos, ele caiu de um caminhão e ficou paraplégico. Passou um ano no hospital, e depois voltou para sua cidadezinha natal com uma cadeira de rodas usada, que alguém havia doado. A cadeira de rodas quebrou logo em seguida e ele não conseguia se locomover. Ele desenvolveu uma úlcera/ferida de pressão que já sarou. Moses acabou de ganhar uma cadeira de rodas nova, com uma almofada para alívio de pressão, através do serviço de cadeira de rodas. Essa cadeira de rodas foi projetada para andar em terreno muito acidentado. Moses está muito entusiasmado com essa cadeira de rodas, e espera tornar-se mais independente. Habilidades mais importantes: • manuseio da cadeira de rodas e como usar a almofada para alívio de pressão, principalmente porque Moses é um novato no uso da cadeira de rodas ; • como prevenir úlceras/feridas de pressão; • como transferir-se da cadeira de rodas; • habilidades de mobilidade na cadeira de rodas; • como cuidar da cadeira de rodas e da almofada em casa; • outras organizações e serviços que podem ser úteis. 200 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Sian Observações para os instrutores Sian tem 40 anos e teve as duas pernas amputadas acima do joelho. É usuário há 20 anos e já teve cinco cadeiras de rodas ao longo desse tempo. Ele acha que as cadeiras de rodas quebram muito rápido. Ele é muito ativo e trabalha numa loja nas redondezas. Todos os dias, ele vai e volta da loja e passa por caminhos esburacados e frequentemente cheios de lama. Ele já demonstrou à equipe de atendimento como consegue empinar a cadeira Em breve, ele vai receber uma cadeira de rodas nova. Sua esperança é que essa cadeira de rodas dure mais tempo que a anterior, que só durou seis meses. As técnicas mais importantes: • Como cuidar da cadeira de rodas e da almofada em casa. Uma manutenção frequente poderá ajudar Sian a usar sua cadeira de rodas por mais tempo. Zoe Observações para os instrutores Zoe tem 16 anos. Teve poliomielite quando criança e agora não consegue andar. Ela é muito tímida e não tem ido à escola. Sua mãe tem dado algumas aulas para ela em casa e ela sabe ler e escrever bem. Zoe acabou de ganhar uma cadeira de rodas e já demonstrou à equipe de atendimento que consegue transferir-se da cadeira de rodas com bastante facilidade. Zoe gostaria de se matricular na escola técnica local. Mas ela acha que não vai conseguir entrar e sair da escola. O prédio tem vários degraus na entrada. Ela também se preocupa com o fato de ir ao banheiro enquanto ela estiver na escola. As técnicas mais importantes: • técnicas de mobilidade com a cadeira de rodas, especialmente subir e descer degraus; • transferência – como se transferir da cadeira de rodas para o vaso sanitário/sanita e vice versa. 4. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se alguém tem dúvidas. 201 B.12: Manutenção e reparos O BJ ET IV O S Ao concluir esta sessão, os participantes poderão:  demonstrar como cuidar da cadeira de rodas em casa;  identificar problemas comuns da cadeira de rodas e explicar como esses problemas podem ser solucionados dentro da comunidade/contexto local. RE CU RS O S Para esta sessão:  Apresentação em PPT: B.12 Manutenção e reparos;  Manual de Referência;  Apostila do Participante;  DVD: Como cuidar da cadeira de rodas em casa;  Pôster: como cuidar da cadeira de rodas em casa;  cadeiras de rodas que necessitam de reparos, incluindo pneu furado, freios com defeito, almofada danificada, ferrugem, estofado solto, pinos soltos, raios da roda soltos ou faltando, rolamentos danificados, aros de impulsão danificados. Mais de um reparo poderá ser necessário para qualquer cadeira de rodas;  1 kit de manutenção caseiro (veja a lista de equipamentos acima). CO N TE X TO Adapte esta sessão de acordo com o contexto no qual os participantes irão trabalhar. Considere:  onde as cadeiras de rodas poderão ser consertadas na localidade dos participantes;  quaisquer necessidades específicas de manutenção ou reparos para cadeira de rodas que devem se destacadas  se o serviço de cadeiras de rodas onde os participantes trabalham oferece serviços de reparo – Se sim, como os usuários podem acessar este serviço de reparos e se é necessário pagar uma taxa. PR EP A RA ÇÃ O  Reunir os recursos, rever os slides, assistir DVD e ler o plano da sessão.  Pendurar o pôster “Como Cuidar da Cadeira de Rodas em Casa” para que todos os participantes possam vê-lo.  Preparar as cadeiras de rodas para reparos e colar etiquetas A, B, C, etc. nas cadeiras. Espalhe as cadeiras pela sala.  Convidar alguém com experiência técnica para assistir a esta sessão e responder perguntas detalhadas sobre reparos de cadeira de rodas (caso os instrutores não se sintam seguros para tanto). D ES CR IÇ Ã O 1. Introdução. 2. Como prevenir reparos: manutenção caseira. 3. Os reparos mais comuns de cadeiras de rodas e almofadas. 4. Resumo dos pontos principais. 2 60 55 3 Tempo Total da sessão 120 202 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Introdução (2 minutos) Explique: • Cuidar da cadeira de rodas e da almofada economiza gastos com reparos e evita lesões e danos de longo prazo ao corpo do usuário. • Uma cadeira de rodas bem cuidada será mais confortável e fácil de usar. • Uma almofada bem cuidada vai continuar proporcionando suporte e alívio de pressão. • A equipe de serviços tem a responsabilidade de ensinar aos usuários como cuidar da sua cadeira de rodas e da sua almofada em casa. • Nesta sessão, vamos aprender como cuidar da cadeira de rodas e da almofada em casa e o que fazer se a cadeira de rodas ou a almofada precisarem de reparos. 2. Prevenindo reparos: manutenção em casa (60 minutos) Pendure o pôster “Como cuidar da cadeira de rodas em casa.”. Notas para os instrutores: Os slides a seguir explicam como cuidar da cadeira de rodas em casa. Cada slide explica porque a tarefa é importante, como executá-la e com que frequência. Os instrutores devem incluir os itens adicionais relacionados a seguir. Explique: • Há seis coisas que os usuários podem fazer em casa para a manutenção de suas cadeiras de rodas e almofadas. • Liste (ver slide). 203 Explique: • Por que, com que frequência, e como (ver slide). Acrescente: • Preste atenção nas peças móveis e nos locais onde o estofado está preso à estrutura. Explique • Por que, com que frequência e como (ver slide). Acrescente: • Não borrife os rolamentos com lubrificante, pois isso pode eliminar a graxa que faz com que os rolamentos funcionem bem * Não use um tipo penetrante de óleo para lubrificar a cadeira de rodas, pois isso pode danificá-la. Pergunte: Que tipo de óleo está disponível na sua área? Explique: • Por que, com que frequência e como (ver slide). Acrescente: • verifique se os pneus são pneumáticos. • Quando for verificar a pressão, pressione o pneu com firmeza com o dedão. Deve ser possível comprimí-lo em aproximadamente 5mm • A pressão deve ser a mesma em cada pneu. 204 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Explique: • Por que, com que frequência e como (ver slide). Acrescente: • Não aperte demais. • Cuidado com alinhamento do parafuso e da porca. Explique: • Por que, com que frequência e como (ver slide). Acrescente: • Verificar os raios: aperte dois raios em toda a volta da roda. Se um raio “ceder” quando você esticá-lo cuidadosamente, ele pode estar solto. • Uma chave de raio é uma ferramenta muito importante para o usuário. O usuário pode comprá-la em oficinas de bicicleta. • Os raios podem estar excessivamente apertados. Se o raio parece muito rígido, provavelmente está muito apertado e deve ser afrouxado. Explique: • Por que, com que frequência e como (ver slide). Acrescente: • Se o estofado estiver solto, ou abrindo nas costuras, é necessário consertá-lo, antes que piore. • Se houver ferrugem, ela pode ser removida com uma lixa ou uma escova de aço. Depois, pinte a peça de metal ou lubrifique-a. 205 Explique • Por que, com que frequência e como (ver slide). Acrescente: • verifique se há pontos desgastados, manchas e furos no estofado ou na espuma. • se a almofada estiver gasta, ela precisa ser verificada pela equipe do serviço de cadeira de rodas. Talvez a almofada tenha que ser substituída. Apresente o DVD: Como cuidar da cadeira de rodas em casa. Esse vídeo vai mostrar um usuário cuidando da cadeira de rodas em casa. É importante ensinar aos usuários como executar essas tarefas. Mostre o DVD. Pergunte se alguém tem perguntas. VIDEO Atividade Grupos: Coloque três pessoas em cada grupo. Cada grupo deverá ter uma cadeira de rodas. Coloque equipamentos e ferramentas em número suficiente no meio da sala. Instruções: Peça para cada grupo executar as tarefas de “Como cuidar da cadeira de rodas em casa”. Mostre o pôster “Como cuidar de uma cadeira de rodas em casa” e peça que sigam todas as etapas. Monitore: Monitore os grupos. Responda perguntas e, se necessário, explique as técnicas com mais detalhes. Tempo: 30 minutos. Feedback: Pergunte: alguém tem alguma dúvida sobre as tarefas de manutenção? 3. Reparos mais comuns de cadeiras de rodas e almofadas (55 minutos) Explique: As cadeiras de rodas às vezes precisam de reparos. A equipe de serviço de cadeiras de rodas deve estar apta para fazer os reparos ou recomendar aos usuários onde achar esse serviço. Alguns usuários conseguem fazer os reparos. Outros usuários podem precisar de ajuda. Todos os usuários se beneficiarão se souberem onde consertar as cadeiras de rodas. Pergunte: Onde os usuários podem consertar suas cadeiras de rodas? 206 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Incentive respostas e escreva no quadro branco. Respostas mais importantes: • oficina mecânica para bicicletas; • oficina mecânica para motocicletas ou automóveis; • oficinas – soldador, encanador (peças de metal), marceneiro, moveleiro (peças de madeira); • usuário, familiar, parente ou vizinho do usuário; • estofador para consertar o estofado; • central de serviços para cadeiras de rodas Pergunte: Quais são as coisas mais comuns que podem acontecer com a cadeira de rodas? Estimule respostas e escreva no quadro branco. Respostas mais importantes: • almofada comprimida ou danificada; • estofado gasto ou rasgado • corrosão ou ferrugem nas peças de metal; • raios frouxos, perdidos, ou quebrados; • porcas e parafusos soltos ou perdidos; • rodas dianteiras prestes a quebrar; • pneu murcho ou furado; • rodas dianteiras e pneus gastos; • rolamentos sujos, gastos, ou danificados; • aros de impulsão danificados; • freios não funcionam. Atividade Grupos: Coloque três pessoas em cada grupo Instruções: Peça para cada grupo: • avaliar cada cadeira de rodas para verificar o que está quebrado e precisa de reparos • lembre ao grupo que levem em consideração os problemas enumerados no quadro branco • responder às perguntas, em suas apostilas, referentes a cada cadeira de rodas. Monitore: Monitore os grupos. Responda as perguntas e, se for necessário, ajude os participantes a identificar as necessidades de reparo. Alguns participantes terão mais facilidade de fazer isso do que os outros, dependendo de sua experiência técnica. Não é necessário que cada pessoa saiba como consertar a cadeira de rodas. A técnica mais importante é saber identificar o que está errado e ter certeza do que pode ser feito para ter certeza de que a cadeira seja consertada. Tempo: 30 minutos. Feedback: Pergunte aos grupos quais foram os problemas em cada cadeira de rodas que necessitava de reparos. Certifique-se que cada grupo tenha a oportunidade de dar opinião sobre pelo menos uma cadeira de rodas. Para cada item de reparo, pergunte: por que isso é um problema para o usuário? 207 4. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se alguém tem dúvidas. Prática 2: Adequação e treinamento de usuários O BJ ET IV O S Após a conclusão desta sessão, os participantes poderão:  Demonstrar ajustes de nível básico – com ajuda.  Demonstrar como treinar o usuário para ajudá-lo na manutenção e uso eficazes de sua cadeira de rodas. RE CU RS O S  Lista de Verificação de Observações do Instrutor: Prática 2;  formulários de avaliação e prescrição da cadeira de rodas (seleção) da Prática 1preenchidos;  listas de verificação de adequação da cadeira de rodas e de treinamento de usuários (já distribuídas aos participantes);  sala limpa e silenciosa para que cada grupo possa trabalhar com seu usuário  cadeira de rodas pronta para a primeira adequação;  fita métrica e ferramentas para ajustar a cadeira de rodas – um conjunto por grupo. CO N TE X TO Adapte esta sessão ao contexto no qual os participantes irão trabalhar. Considere:  fatores culturais – por exemplo, se seria apropriado ter grupos mistos (homens e mulheres) executando as adaptações e instruindo os usuários;  fatores de idioma: – por exemplo, os usuários participando da sessão falam o mesmo idioma dos outros participantes?  qualquer documentação exigida pelo prestador de serviços para fornecer a cadeira de rodas – por exemplo, o número de série da cadeira de rodas;  como os instrutores devem lidar com questões que podem surgir durante a sessão de adequação e treinamento e que não poderão ser abordadas dentro do contexto do treinamento. 208 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO PR EP A RA ÇÃ O  Convide outro instrutor para ajudar no monitoramento dos grupos caso haja mais de três pares de participantes.  Confirme o horário e a organização das viagens dos usuários voluntários. Confirme que haverá alimentação disponível para os usuários e seus familiares/ cuidadores  Indique uma pessoa para dar as boas-vindas aos usuários e acompanhá-los até a sala de espera, onde poderão permanecer até o inicio da sessão.  Prepare uma área de adequação para cada grupo (cama de avaliação e biombo). Coloque todo o equipamento necessário para adequação em cima da cama de avaliação. (Ou organize as viagens se a avaliação for realizada na comunidade).  Certifique-se de que as cadeiras de rodas a serem ajustadas estejam totalmente prontas (confira com as respectivas prescrições e confirme se as verificações referentes à segurança foram feitas e se as cadeiras estão prontas para uso). D ES CR IÇ Ã O 1. Adequação e treinamento do usuário: • Instruções e organização • Adequação • Treinamento do usuário • Feedback. 5 45 50 20 Tempo Total da sessão 120 2. Feedback do Usuário (opcional – depende dos usuários e do tempo disponível) 30 1. Adequação e treinamento de usuários, incluindo feedback (120 minutos) Observações para os instrutores: Use a lista de verificação para instrutores da Prática 2 para sua orientação, à medida em que você observa os participantes durante a prática. Anote exemplos de boas ou más práticas que devem ser destacadas durante a sessão de feedback. Faça suas anotações na lista. Atividade Grupos: • Os grupos devem ser os mesmos da Prática 1. • Indique um líder para cada grupo (pode ser a mesma pessoa que liderou o grupo na Prática 1, ou outra pessoa). • Providencie um local de trabalho para cada grupo. • Explique onde podem encontrar o material e as ferramentas. • Verifique se cada grupo tem as listas de verificação de adequação e de treinamento de usuários. 209 Instruções: Explique os itens a seguir: Objetivo desta sessão: • O objetivo desta sessão prática é executar os passos seis e sete dos oito passos dos serviços referentes à entrega da cadeira de rodas, ou seja, adequação e treinamento de usuários. O treinamento será feito com o mesmo usuário da sessão prática anterior. • É possível que os participantes não consigam concluir os ajustes da cadeira de rodas para o usuário durante o tempo disponível. Isso vai depender dos primeiros ajustes e quais modificações/ajustes serão necessários. Entretanto, os participantes devem usar o tempo da melhor maneira possível para executar as tarefas. Se não for possível concluir os ajustes da cadeira de rodas, as providências necessárias serão tomadas para que a cadeira de rodas seja concluída após o treinamento. Líder: • O líder de cada grupo será responsável pela execução de cada passo. • O líder será a pessoa designada para conversar com o usuário e seus familiares/cuidador, para evitar que todos falem ao mesmo tempo, o que pode causar confusão Observações e apoio do instrutor: • Os participantes podem pedir ajuda e esclarecimentos a qualquer momento. • Durante a sessão, o instrutor deve monitorar cada grupo e dar o apoio necessário. • Se forem identificados problemas relacionados a adequação, por favor, peça ao instrutor que verifique o que está acontecendo e converse sobre quais modificações/ajustes seriam necessários. • Após a conclusão da adequação, os participantes devem pedir ao instrutor que verifique. NÃO COMEÇE O TREINAMENTO DO USUÁRIO antes que a verificação tenha sido concluída por um dos instrutores. • Após a conclusão do treinamento de usuários, os participantes devem pedir ao instrutor que converse com o grupo e o usuário sobre que tipo de treinamento foi realizado. 210 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Tempo: • O objetivo é concluir a adequação em 45 minutos, e o treinamento de usuários em 50 minutos. Formulários de prestação de serviço: • Distribua para cada líder os formulários de avaliação da cadeira de rodas e de prescrição (seleção) de cadeira de rodas da Prática 1 (usados na Prática 2). • Verifique se cada grupo tem pelo menos uma cópia das listas de verificação de adequação da cadeira de rodas e do treinamento de usuário. Pergunte aos participantes: Quais são os passos para a execução da adequação? Agradeça as respostas corretas. Lembre aos participantes: eles só podem ensinar aos usuários as habilidades que são relevantes para eles. Por exemplo, não é necessário ensinar habilidades de alívio de pressão para o usuário que não corre risco de desenvolver úlceras/feridas de pressão. Lembre aos participantes que eles devem envolver o usuário de forma ativa em cada etapa do processo. Pergunte se alguém tem perguntas. Responda as perguntas. Peça a cada grupo que prepare seu local de trabalho; em seguida, eles devem se apresentar ao usuário com quem irão trabalhar e começar o trabalho. Monitore e apoie: Monitore os grupos de perto; certifique-se de que as práticas sejam seguras, observe e avalie as técnicas dos participantes. Use a lista de verificação das observações do instrutor para anotar suas observações sobre cada grupo. Durante a sessão: • Avise sobre o tempo restante (verbalmente ou escrevendo no quadro branco para que todos os participantes vejam o aviso) para ajuda-los a administrarem seu tempo. • Certifique-se de que os usuários estão envolvidos de maneira ativa. Ao fim desta sessão, peça aos participantes que agradeçam aos usuários pela sua participação e pergunte se gostariam de permanecer e dar seu feedback ao grupo sobre sua experiência nas sessões de avaliação, prescrição (seleção), adequação e treinamento de usuário. 211 Tempo: 45 minutos para concluir a adequação, 50 minutos para concluir o treinamento de usuários, e 20 minutos para feedback. Feedback: Comente sobre as boas práticas que você observou durante a sessão prática. Comente qualquer área em particular que os participantes poderiam melhorar – não destaque os participantes individualmente. Peça para cada grupo resumir brevemente quaisquer mudanças que tiveram que ser feitas para garantir o ajuste perfeito da cadeira de rodas (3 minutos para cada grupo). Pergunte se alguém tem perguntas 2. Feedback do Usuário (opcional – dependendo dos usuários e do tempo disponível) (30 minutos) Observações para os instrutores: Se os usuários que participaram das Práticas 1 e 2 concordarem, convide cada um para dar seu feedback sobre o processo pelo qual acabaram de passar. Isto pode ser feito informalmente, por exemplo, com sucos/bolo para comemorar a conclusão das primeiras duas práticas. A seguir, exemplos de perguntas para os usuários: Peça aos usuários para darem feedback sobre os itens a seguir. • Como se sentiram durante a avaliação (Por exemplo, se sentiram envolvidos; como se sentiram ao responder as perguntas da entrevista; eles acharam que as perguntas foram úteis para ajudá-los a conseguir uma cadeira de rodas melhor?) • Estão satisfeitos com a cadeira de rodas que foi prescrita? • Aprenderam algo novo no treinamento? Vão usar esse aprendizado em casa/no trabalho no futuro? 212 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO B.13: Acompanhamento O BJ ET IV O S Após concluir esta sessão, os participantes saberão como:  explicar o que significa “acompanhamento” e como é feito;  preencher um formulário de acompanhamento da cadeira de rodas. RE CU RS O S Para esta sessão:  Apresentação em PPT: B.13 Acompanhamento;  Manual de Referência;  Apostila do Participante; CO N TE X TO Todos os usuários se beneficiarão das visitas de acompanhamento, realizadas, de preferência, no local onde moram. Adapte esta sessão ao contexto no qual os participantes trabalharão. Considere as questões a seguir:  Como será feito o acompanhamento dos usuários (visitas a domicílio, no centro de serviços ou feitas pela equipe de Reabilitação Baseada na Comunidade (RBC)) e adapte o treinamento de acordo com o contexto. Por exemplo, se os participantes vêm de um serviço de cadeira de rodas que tem um plano de acompanhamento, este plano deve ser explicado aos participantes PR EP A RA ÇÃ O  Reunir os recursos, rever os slides e ler o plano da sessão. D ES CR IÇ Ã O 1. Introdução. 2. O que é um acompanhamento e como é feito 3. Introdução do formulário de acompanhamento. 4. Praticando o acompanhamento. 5. Resumo dos pontos principais. 2 10 5 25 3 Tempo Total da sessão 45 213 1. Introdução (2 minutos) Explique: o “Acompanhamento” faz parte da oitava etapa do serviço de cadeira de rodas. Nesta sessão, vamos abordar o que deve ser incluído no acompanhamento. Vamos apresentar o formulário para acompanhamento de cadeira de rodas e praticar o seu uso. 2. O que é um acompanhamento e como é feito? (10 minutos) Pergunte: na opinião dos participantes, o que deveria estar incluído no acompanhamento? Incentive respostas. Respostas mais importantes: • coletar informações do usuário; • verificar se a cadeira de rodas está em boas condições de funcionamento ; • verificar a adequação da cadeira de rodas. Explique: • todos os usuários se beneficiarão do acompanhamento. Entretanto, o acompanhamento é mais importante para: - crianças; - usuários com risco de desenvolver úlceras/ feridas de pressão; - usuários com uma doença progressiva; - usuários que tenham tido dificuldade com qualquer parte do treinamento que fizeram. 214 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO • Não existe regra sobre a frequência do acompanhamento, embora um acompanhamento dentro de seis semanas após a data de entrega seja muito útil. Tudo depende das necessidades do usuário. Para crianças, por outro lado, o acompanhamento deve ser feito a cada seis meses, porque as necessidades das crianças mudam muito rapidamente, à medida que as elas crescem. • Os acompanhamentos podem ser realizados: - na residência do usuário; - no centro de serviços de cadeira de rodas; - qualquer outro lugar que seja conveniente para o usuário e para a equipe de serviços. Pergunte: Como deve ser feito o acompanhamento ( ou como o acompanhamento é feito) no serviço de cadeira de rodas dos participantes? Estimule perguntas e escreva no quadro branco. Respostas mais importantes: • agendar uma visita de acompanhamento com o usuário quando ele receber sua cadeira de rodas; • visitar o usuário em sua casa para realizar o acompanhamento (quando possível); • fazer com que o acompanhamento seja parte das visitas de rotina da equipe de serviços das comunidades, que foi treinada para realizar o acompanhamento; • agendar um acompanhamento por telefone, se o usuário tiver acesso a um, em locais onde o transporte é complicado. 3. Introdução do formulário de acompanhamento de cadeira de rodas (5 minutos) Explique: O conhecimento e as habilidades necessárias para realizar uma visita de acompanhamento já foram abordadas no treinamento. Para realizar uma visita de acompanhamento, a equipe deve: • coletar informações sobre o usuário; • verificar se a cadeira de rodas está funcionando bem; • verificar a adequação da cadeira de rodas. 215 Peça aos participantes que leiam em suas apostilas o formulário de acompanhamento de cadeira de rodas Explique: O formulário de acompanhamento de cadeira de rodas ajuda a equipe a lembrar as perguntas que devem ser feitas, e o que fazer durante uma visita de acompanhamento. O formulário também tem um campo para ser preenchido com quaisquer “ações” que possam ser necessárias. A seguir, algumas ações mais comuns. • Mais aconselhamento ou treinamento. Por exemplo, se um usuário não estiver usando a cadeira de rodas como esperado, pode ser que não se sinta confiante em transferir-se sozinho da cadeira de rodas. Mais treinamento de transferência poderia ser útil. • Reajustar a cadeira de rodas • Executar pequenos reparos. Por exemplo, encher os pneus. Motive os usuários a fazer a manutenção da cadeira de rodas cuidando dela em casa • Executar reparos ou ajudar o usuário a encontrar alguém que possa executá-los. Pergunte: o que deve ser feito se o usuário se queixar de úlcera/escara de pressão? Respostas mais importantes: • peça para ver a úlcera/ferida de pressão e anote o local e o estágio da mesma; • se a úlcera/ferida de pressão estiver localizada em alguma parte do corpo que fica em contato com a cadeira de rodas, o usuário terá que parar de usar a cadeira de rodas até a úlcera/ferida cicatrizar; • se a úlcera/ferida de pressão for de estágio 2 ou mais, será necessário consultar um especialista para tratá-la; • identifique por que a úlcera/ferida de pressão se formou (por exemplo: o usuário não usa a almofada, a almofada não está aliviando a pressão, o método de transferência não é o adequado, incontinência, etc.) e tente solucionar o problema. 216 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 4. Praticando o acompanhamento (25 minutos) Atividade Grupos: Três pessoas em cada grupo. Instruções: Cada grupo deve: • ler a história de cada usuário que se encontra nas apostilas e discutir as medidas que poderiam ser tomadas; • preencher o formulário de acompanhamento de cadeira de roda, referente a cada usuário (a apostila tem três formulários de acompanhamento). Monitore: Monitore os grupos e ajude se necessário. Tempo: 20 minutos e 5 minutos para a opinião sobre a sessão. Feedback: Pergunte: Quais foram as medidas sugeridas pelos participantes para Hala, Daarun e Talha? Pontos de aprendizado Hala mora em casa com sua filha, que já é adulta, e sua família. Ela recebeu sua cadeira de rodas há seis meses. Ela teve um AVC/ trombose cerebral há pouco mais de um ano e não consegue andar. Quando sua cadeira de rodas chegou, Hala aprendeu como fazer a transferência, ficando em pé com a ajuda da filha. Ela havia dito que queria ter uma cadeira de rodas para poder ajudar mais em casa e conseguir ir para a igreja. Durante a visita de acompanhamento, Hala disse que há alguns meses não saía de casa. O caminho até sua casa é acidentado e tem um degrau na entrada da casa. Mas ela está usando a cadeira de rodas em casa, e tem conseguido tomar conta dos netos para ajudar a filha. Ela senta de forma ereta na cadeira de rodas e a cadeira de rodas está bem cuidada. Ela já consegue fazer a transferência sozinha. • Descubra por que Hala não está indo à igreja como gostaria. • Se a razão for o caminho acidentado e o degrau, providencie aconselhamento e treinamento para Hala e sua filha para que Hala possa lidar com mais segurança com o caminho e com o degrau. Daarun tem uma lesão medular. Ele trabalha em uma oficina de conserto de rádios no mercado local. Há dois anos ele recebeu a cadeira de rodas e a almofada para alívio de pressão. Durante a visita de acompanhamento, ele disse que usa sua cadeira de rodas todos os dias para ir de casa ao trabalho e voltar. Ele não tem úlceras/feridas de pressão. Daarun já consertou dois pneus furados da sua cadeira de rodas. Durante a visita, a equipe notou que os raios estavam soltos e que faltavam dois parafusos da base do assento. A espuma de baixa densidade da almofada estava achatada. Ele consegue sentar confortavelmente na cadeira de rodas e diz que está muito satisfeito com ela. • Substitua a camada superior da espuma da almofada. • Aconselhe sobre como cuidar da cadeira de rodas em casa, incluindo a verificação dos raios e apertar os parafusos. 217 Pontos de aprendizado Talha tem 10 anos. Ele tem uma forma leve de paralisia cerebral, mas consegue ir para a escola. Há um ano, ele recebeu uma cadeira de rodas com uma almofada para suporte postural. Durante a visita de acompanhamento, Talha disse que usa sua cadeira de rodas todos os dias para ir à escola. Seu pai empurra a cadeira, pois Talha não tem força suficiente para impulsioná-la. A cadeira de rodas está em bom estado. Seu pai disse que havia consertado o pneu apenas uma vez. A equipe de atendimento do serviço de cadeira de rodas notou que Talha cresceu, e suas pernas não estão sendo apoiadas corretamente pelo assento da cadeira de rodas pois o apoio para os pés está muito alto para ele. • As visitas de acompanhamento no caso de crianças devem ser realizadas a cada 3-6 meses, se possível. • Crianças crescem muito rápido. É importante informar os pais ou cuidadores que as crianças precisam ser levadas para passar por uma revisão se o serviço não puder visitá-las. • Talha precisa passar por uma reavaliação e a cadeira de rodas precisa ser ajustada ou substituída por outra maior. 5. Resumo dos pontos principais (3 minutos) Leia os pontos principais. Pergunte se alguém tem perguntas. Prática 3: Acompanhamento O BJ ET IV O S Após concluir esta sessão, os participantes poderão:  fazer uma demonstração do acompanhamento. 218 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO RE CU RS O S  local e cama de avaliação limpos e privados (a menos que a sessão seja realizada na comunidade);  avaliação anterior da cadeira de rodas e formulários de prescrição (seleção) para cadeira de rodas de cada usuário;  formulário de acompanhamento para cadeira de rodas (1 por usuário);  lista de verificação de cadeira de rodas segura e pronta para uso;  lista de verificação das observações do instrutor;  fita métrica e conjunto de ferramentas para ajustar a cadeira de rodas. CO N TE X TO Adapte esta sessão ao contexto no qual os participantes irão trabalhar. Considere as questões a seguir:  fatores culturais que precisam ser levados em consideração;  fatores relacionados ao idioma – por exemplo, se os usuários falam o mesmo idioma dos participantes;  qualquer documentação exigida pelo serviço durante a realização do acompanhamento;  como os instrutores devem lidar com questões identificadas durante o acompanhamento e que não podem ser resolvidas durante a sessão; por exemplo, se a cadeira de rodas precisa ser substituída. PR EP A RA ÇÃ O  Considere a possibilidade de realizar esta sessão na comunidade.  Contate os usuários que receberam cadeiras de rodas nos últimos 3–6 meses e precisam do acompanhamento. Convide-os para agendar uma visita em suas casas ou na clínica.  Confirme o horário e a organização da viagem. Certifique-se de que haverá alimentação à disposição dos usuários e seus familiares/cuidadores se eles vieram de outro local.  Se a avaliação for realizada no local do treinamento, prepare a cama de avaliação e um biombo para cada dupla de participantes e o usuário voluntário. Coloque todos os equipamentos necessários sobre a cama de avaliação.  No caso de mais de três duplas de participantes, convide outro instrutor para ajudar no monitoramento dos grupos.  Decida quais participantes deverão trabalhar juntos e com qual usuário. D ES CR IÇ Ã O 1. Acompanhamento: • Instruções. • Acompanhamento. • Feedback 5 60 25 Tempo Total da sessão 90 219 1. Acompanhamento (90 minutos) Observações para os instrutores: Use a Lista de Verificação de Observações do Instrutor da Prática 3 como guia enquanto você observa os participantes durante a sessão prática. Anote (no campo adequado) exemplos de práticas boas e ruins que devem ser destacadas na sessão de feedback. Atividade Grupos: • Coloque os participantes nos mesmos grupos (no máximo 3 pessoas em cada grupo). • Indique um líder para cada grupo. • Diga aos participantes o nome do usuário com o qual irão trabalhar e forneça informações relevantes - por exemplo, o formulário anterior de avaliação da cadeira de rodas. • Indique o local onde cada grupo vai trabalhar e explique que todos os equipamentos já estão colocados em cima das camas de avaliação (ou explique o esquema de transportes se o trabalho for feito na comunidade). Instruções: Explique os itens a seguir: Objetivo da sessão: • O objetivo desta sessão é realizar um acompanhamento. Líder: • O líder de cada grupo será responsável pela execução de todas as etapas. • O líder será o interlocutor com o usuário e sua família/cuidador, para evitar que todos falem ao mesmo tempo, o que poderia causar confusão para todos. Observação e apoio do instrutor: • Os participantes poderão pedir ajuda ou esclarecimentos a qualquer momento. Tempo: • O objetivo é concluir o acompanhamento em até 60 minutos. Formulários: • Entregue o formulário de acompanhamento para cadeira de rodas ao líder de cada grupo. • Certifique-se de que cada grupo tem pelo menos uma cópia da lista de verificação de cadeira de rodas segura e pronta para uso. Lembre aos participantes que eles devem incluir o usuário de forma ativa em cada etapa do processo. Pergunte: alguma pergunta? Responda as perguntas. Peça a cada grupo que prepare seu local de trabalho, que cada membro do grupo se apresente ao usuário com quem irá trabalhar e convide a todos para que sigam para o local de trabalho. 220 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Monitore e apoie: Monitore os grupos de perto, certifique-se de que usam práticas seguras, observe e avalie as habilidades dos participantes. Use a lista de verificação de observações do instrutor para anotar suas observações sobre cada grupo. Durante a sessão: • Informe o tempo restante (verbalmente ou escreva o aviso no quadro branco onde todos os participantes possam ver). Isto vai ajudar os participantes a de administrarem o tempo. • Certifique-se de que todos os usuários estão participando de forma ativa. No fim da sessão, peça aos participantes que agradeçam aos usuários pela sua participação e explique como será feito o acompanhamento das ações identificadas (e que ainda não tiverem sido abordadas). Tempo: 60 minutos para realizar o acompanhamento e 25 minutos para feedback. Feedback: Comente as boas práticas que você observou durante a sessão prática. Comente qualquer área em particular que pode ser melhorada – não destaque ninguém individualmente. Peça a cada grupo que faça um breve relato sobre o que descobriram durante o acompanhamento, incluindo: • até que ponto a cadeira de rodas atendeu às necessidades do usuário; • quaisquer questões/preocupações; • recomendação de quaisquer outras ações de acompanhamento (5 minutos para cada grupo). Pergunte: Alguma pergunta? Prática 4: Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação e treinamento de usuários. O BJ ET IV O S Após concluir esta sessão, os participantes poderão trabalhar em equipe para:  demonstrar, em nível básico, a avaliação de uma cadeira de rodas, a prescrição (seleção), a preparação do produto, a adequação e o treinamento de usuários 221 RE CU RS O S  cadeiras de rodas disponíveis no local;  espaço limpo e privativo, com cama de avaliação (uma para cada usuário);  formulários: formulário de avaliação da cadeira de rodas, formulário de prescrição (seleção) de cadeira de rodas, lista de verificação da cadeira de rodas segura e pronta para uso, lista de verificação da adequação, lista de verificação de treinamento de usuários (1 por usuário);  lista de verificação de observações do instrutor;  câmera digital e formulário de consentimento para fotos;  fita métrica. CO N TE X TO Adapte esta sessão ao contexto no qual os participantes irão trabalhar. Considere os itens a seguir:  fatores culturais e de idioma;  tipos de cadeiras de rodas disponíveis – e o tempo necessário para prepará-las;  qualquer documentação exigida pelo serviço, além das informações coletadas dos formulários de avaliação e prescrição (seleção) das cadeiras de rodas;  de que maneira os instrutores devem lidar com as ações identificadas durante a sessão prática e que não podem ser abordadas durante a sessão;  como será feito o acompanhamento de cada usuário após a conclusão do treinamento. PR EP A RA ÇÃ O  Convide um novo grupo de usuários voluntários, um para cada grupo. Confirme data, horário, e outros assuntos referentes à viagem, com o usuário; providencie alimentação.  Indique uma pessoa que dará as boas-vindas aos usuários à medida em que eles chegam.  Providencie um local onde os usuários e seus familiares possam esperar após a avaliação e a prescrição (seleção), enquanto esperam pela preparação de suas cadeira de rodas.  Certifique-se de que as cadeiras de rodas e as almofadas que serão usadas estão funcionando corretamente.  Prepare a sala de treinamento (ou organize a viagem/transporte se o treinamento for realizado na comunidade).  Caso haja mais de três duplas de participantes, convide outro instrutor para ajudar a monitorar os grupos.  Decida quais participantes irão trabalhar juntos e com qual usuário. D ES CR IÇ Ã O 1. Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação, e treinamento de usuários: • Instruções e organização. • Avaliação. • Prescrição (seleção). • Preparação do produto (cadeira de rodas) • Adequação. • Treinamento de usuários. • Feedback. • Tempo extra. 5 30 20 60 30 45 30 20 Tempo Total da sessão 240 222 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 1. Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação e treinamento de usuários (240 minutos). Notas para os instrutores: 1. Fotografias: • Verifique se cada usuário recebeu o formulário de consentimento, e se já o entregou assinado, para permitir que seja fotografado. Certifique-se de que os usuários entenderam que esse consentimento é voluntário e que as fotografias serão usadas durante o treinamento. • Tire fotografias durante a prática de cada usuário que deu seu consentimento da seguinte maneira: - uma foto de frente e outra de lado, do usuário sentado em sua cadeira de rodas atual (se tiver uma); - foto durante a avaliação (observação da postura); - foto (uma de frente e outra de lado) do usuário na cadeira de rodas selecionada após a adequação. 2. Atendendo as necessidades dos usuários participando da sessão prática: • Nem todas as cadeiras de rodas serão concluídas durante o tempo disponível para a sessão prática. • se for necessário agendar outro horário para os usuários observados durante a sessão prática, o instrutor deve certificar-se de que o horário seja agendado pela organização/ serviço e de que todas as informações referentes à avaliação, prescrição (seleção) e adequação foram entregues. 3. Observando a prática dos participantes: Use a Lista de Verificação de Observações do Instrutor da Prática 4 para verificar se os grupos executaram todas as etapas da sessão prática e anote exemplos na lista de verificação de práticas boas ou ruins que devem ser destacadas durante a avaliação da sessão. • As fotografias podem ser usadas na sessão final B.14: Juntando tudo (se houver tempo disponível). Atividade Grupos: • Coloque os participantes em grupos (2 ou 3 pessoas em cada grupo). • Indique um líder para cada grupo. • Diga o nome do usuário com o qual cada grupo irá trabalhar. • Indique o local de trabalho de cada grupo e explique que todos os equipamentos estão em cima da cama de avaliação. 223 Instruções: Explique os itens a seguir: Objetivo da sessão: • O objetivo desta sessão é trabalhar com o usuário para realizar uma avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação e treinamento de usuários. • Se não for possível concluir a cadeira de rodas do usuário durante o tempo estipulado para a sessão, deve-se tomar as providências com o usuário para garantir que a cadeira de rodas será concluída. Entretanto, os participantes devem fazer o possível para concluir o trabalho dentro do tempo estipulado. Líder: • O líder de cada grupo será responsável pela execução de todas as etapas. • O líder será o interlocutor com o usuário e sua família/cuidador para evitar que todos falem ao mesmo tempo, o que pode causar confusão. Observação e apoio do instrutor: • Os participantes podem pedir ajuda e esclarecimentos a qualquer momento. • Os instrutores irão monitorar cada grupo durante a sessão e fornecerão ajuda e esclarecimentos sempre que necessário. • Após a conclusão de CADA ETAPA DO SERVIÇO, os participantes deverão pedir ao instrutor que verifique a execução da etapa ANTES de passar para a etapa seguinte. Lembre aos participantes que devem incluir o usuário de forma ativa em cada etapa do processo. Pergunte: Alguém tem alguma pergunta? Responda as perguntas. Peça a cada grupo para preparar seu local de trabalho; se apresentar para o usuário com quem vai trabalhar e começar o trabalho. Monitore e apoie: Monitore de perto os grupos durante a sessão prática. Use a lista de verificação das observações do instrutor para anotar suas observações sobre cada grupo. Durante a sessão: • Avise sobre o tempo restante (verbalmente ou escreva no quadro branco para que todos os participantes possam ver o aviso) para ajudar os participantes a administrar seu tempo. • Verifique se os usuários estão envolvidos de forma ativa. • Verifique o trabalho dos participantes durante cada etapa. Ao fim da sessão, peça aos participantes para agradecerem o usuário por sua participação e explique que a cadeira de rodas selecionada será preparada e estará pronta para ser experimentada durante a próxima sessão prática. 224 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Tempo: Explique o tempo estipulado: • avaliação – 30 minutos; • prescrição (seleção) – 20 minutos; • preparação do produto (cadeira de rodas) – 60 minutos; • adequação – 30 minutos; • treinamento de usuários – 45 minutos; • feedback – 30 minutos. Notas para os instrutores: É importante ficar de olho no relógio durante a sessão prática. Os minutos especificados acima são um guia – entretanto, o tempo estipulado para a atividade pode variar, dependendo da experiência dos participantes, das necessidades dos usuários ou do tempo necessário para preparar os produtos. É possível que os instrutores tenham que fazer alguns ajustes. • 20 minutos a mais para resolver quaisquer questões e para que os instrutores verifiquem cada etapa. Feedback: Comente sobre exemplos de boas práticas que você observou durante a sessão prática. Comente qualquer área em particular que possam ser melhoradas – não destaque nenhum participante individual. Pergunte: Alguém tem perguntas? B.14: Juntando tudo O BJ ET IV O S Após esta sessão, os participantes poderão:  Preparar um resumo sobre o usuário com quem trabalharam na última sessão prática (Prática 4), incluindo: avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação, treinamento de usuários, e manutenção, reparos e acompanhamento. RE CU RS O S  Apostila do Participante;  DVD: Mensagens Importantes  Post-it ou caderno de anotações. 225 PR EP A RA ÇÃ O  Reunir os recursos, assistir ao DVD e ler o plano da sessão. D ES CR IÇ Ã O 1. Introdução e instruções. 2. Perguntas dos participantes. 3. Preparação dos participantes. 4. Apresentações dos participantes. 5. Sessão de perguntas e respostas 6. Pontos principais. 2 5 25 40 20 13 Tempo Total da sessão 105 1. Introdução e instruções (2 minutos) Explique: • Nesta sessão, os participantes terão a oportunidade de: - compartilhar o que aprenderam durante a última sessão prática; - falar sobre dúvidas que ainda possam ter em relação à prestação de serviços de cadeiras de rodas de nível básico. 2. Perguntas dos participantes (5 minutos) Atividade Grupos: Coloque três pessoas em cada grupo. Distribua para cada grupo um bloco de “Post-it” ou folhas pequenas de papel para anotações (por exemplo, folha A4 cortada em 4 partes) Instruções: Peça para cada grupo discutir se eles ainda têm alguma dúvida sobre a prestação de serviços de cadeiras de rodas de nível básico. Eles devem escrever as dúvidas que ainda têm, seja do grupo todo ou de apenas uma pessoa. Monitore: Monitore os grupos. Tempo: 10 minutos no total. Feedback: Peça para que cada grupo entregue suas dúvidas aos instrutores. 226 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3. Preparação dos participantes (25 minutos) Atividade Grupos: Peça aos grupos que trabalharam juntos durante as duas últimas sessões práticas para que trabalhem juntos novamente. Instruções: Peça para cada grupo preparar uma apresentação de 10 minutos sobre o usuário com quem trabalharam e o que aprenderam. Eles devem responder as perguntas na folha de exercício dentro de suas apostilas. Explique que as fotos dos usuários estão no computador e que eles podem utilizá-las para ilustrar suas apresentações. Notas para os instrutores: Se os participantes não se sentirem à vontade para usar o computador, explique que os instrutores podem fornecer as fotos e mostrá-las quando for necessário. Monitore: Enquanto os grupos estiverem se preparando, os instrutores devem rever as perguntas que foram feitas por escrito pelos grupos. Algumas perguntas podem ser parecidas ou iguais. Coloque as perguntas em uma sequência lógica (por exemplo, na sequência das etapas do serviço). Prepare as respostas para as perguntas. Tempo: 25 minutos para a preparação. Feedback: Ver 4. Apresentações pelos participantes. 4. Apresentações pelos participantes (40 minutos) Peça para cada grupo fazer sua apresentação. Incentive os grupos a fazer perguntas no fim de cada apresentação. Estipule 10 minutos para cada apresentação e 5 minutos para perguntas. Agradeça ao participante por sua apresentação. 5. Sessão de perguntas e respostas (20 minutos) Leia em voz alta as perguntas de cada participante (ver 2. Perguntas dos participantes). NÃO DIGA O NOME da pessoa que fez a pergunta. Responda a pergunta ou esclareça a dúvida e pergunte se outros participantes do grupo gostariam de responder a pergunta. Se mais de uma pessoa /grupo fez a pergunta – explique que é uma pergunta feita por várias pessoas. 227 Explique: • O fornecimento de uma cadeira de rodas que realmente atende às necessidades do usuário é uma habilidade que exige prática, bom trabalho em equipe (entre a equipe de serviços e o usuário) e alguns recursos básicos. • Este treinamento deu uma visão geral sobre as etapas deste processo. Entretanto, cada usuário é diferente e, portanto, é difícil abordar todas as possibilidades em um treinamento como este. • Os participantes aprenderão alguma coisa de cada usuário novo com quem trabalharem. Também vão aprender com seus erros e com aquilo que fizeram corretamente. • Eles perceberão que o processo se tornará mais rápido à medida que forem adquirindo prática. • O importante é praticar continuamente e sempre ouvir o usuário! 6. Pontos principais (13 minutos) Apresente o DVD: Mensagens Importantes. Este vídeo destaca a importância do programa de treinamento sobre cadeira de rodas. Mostre o DVD. Pergunte se alguém tem alguma pergunta. VIDEO Cerimônia de encerramento e entrega de certificados. 228 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Anexos Anexo 1: Cronograma do pacote de treinamento em serviços para cadeiras de rodas Cinco dias completos Dia 1 Dia 2 Dia 3 Dia 4 Dia 5 8:30 Introdução A.6 Cadeira de rodas apropriada B.4 Avaliação Física B.9 Adequação Prática 3: Acompanha- mento 8:45 9:00 A.7 Almofadas B.5 Prescrição (seleção) 9:15 9:30 A.1 Usuários de cadeiras de rodas B.10 Solução de problemas 9:45 10:00 Prática 4: Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação e treinamento do usuário 10:15 A.2 Serviços de cadeiras de rodas A.8 Transferências10:30 10:45 A.3 Mobilidade em cadeira de rodas 11:00 – 11:15: Intervalo para o café (ajuste o horário de acordo com o context local e com o plano da sessão) 11:15 A.3 Mobilidade em cadeira de rodas A.8 Transferências B.6 Financiamento e aquisição B.11 Treinamento de usuários Prática 4: Avaliação, prescrição (seleção), preparação do produto (cadeira de rodas), adequação e treinamento de usuário 11:30 Prática 1: Avaliação e prescrição (seleção) B.12 Manutenção e reparos 11:45 12:00 12:15 12:30 A.4 Sentar-se ereto B.1 Encaminha- mendo e agendamento 12:45 229 13:00 – 14:00 Almoço (ajuste o horário para se adequar ao contexto local e ao plano da sessão) 14:00 A.4 Sentar-se ereto B.2 Avaliação B.7 Preparação do produto (cadeira de rodas) B.12 Manutenção e reparos Prática 4: Avaliação, prescrição (seleção) do produto (cadeira de rodas) adequação e treinamento de usuários 14:15 14:30 A.5 Úlceras/ feridas de pressão B.3 Entrevista de Avaliação Prática 2: Adequação e treinamento de usuários 14:45 15:00 15:15 –15:30: Intervalo para o café (ajuste o horário para se adequar ao contexto local e ao plano da sessão 15:30 A.5 Úlceras/ feridas de pressão B.3 Entrevista de Avaliação B.8 Fabricação da almofada Prática 2: Adequação e treinamento de usuários B.14 Juntando tudo 15:45 A.6 Cadeira de rodas apropriada 16:00 16:15 B.4 Avaliação Física16:30 16:45 B.13 Acompa- nhamento17:00 17:15 Entrega de certificados 230 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Anexo 2: Formulário de Encaminhamento de Serviços de Cadeira de rodas É necessário ter o formulário de encaminhamento para realizar a sessão B.I. Se o serviço não tiver um formulário de encaminhamento, os instrutores podem usar ou adaptar o formulário abaixo. No CD do pacote de treinamento há uma versão do formulário em Word. É importante que o usuário tenha sido claramente informado sobre o serviço e ele tem que concordar com o encaminhamento. Com este formulário, o serviço de cadeira de rodas entrará em contato com o usuário para marcar uma consulta. Nem sempre isso é possível. Nesse caso, o serviço poderá aceitar os encaminhamentos sem marcação de consulta. Um formulário de encaminhamento deve conter detalhes claros sobre a forma de contato com o serviço, incluindo o nome do serviço, endereço e telefone. 231 Anexo 3: Formulário de Avaliação para Serviços de Cadeira de Rodas Para a avaliação de usuários que conseguem sentar-se eretos sem dificuldade. Os usuários que não conseguem sentar-se eretos sem dificuldade devem ser avaliados por uma pessoa com nível intermediário de treinamento. Este formulário deve ser guardado nos registros do usuário. Nome do avaliador: Data da avaliação: 1: Entrevista de avaliação Informações sobre o usuário Nome: Numero: Idade: Masculino  Feminino  Telefone: Endereço: Metas: Condições físicas Paralisia cerebral  Poliomielite  Lesão medular  AVC/trombose cerebral  Fragilidade  Espasmos ou movimentos involuntários  Amputação: D acima do joelho  D abaixo do joelho  E acima do joelho  E abaixo do joelho  Problemas de bexiga  Problemas intestinais  Se o usuário tem problemas de bexiga ou intestinais, estão sendo gerenciados? Sim  Não  Outros: Estilo de vida e ambiente Descreva onde o usuário utilizará sua cadeira de rodas: Distância percorrida por dia: Até 1 km  1–5 km  Mais de 5 km  Horas de uso da cadeira de rodas por dia: Menos de 1  1–3  3–5  5–8  Mais de 8 horas  232 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Quando fora da cadeira de rodas, onde o usuário se senta ou deita, e como (postura e superfície)? Transferência: Independente  Assistida  Fica em pé  Não fica em pé  Erguido  Outros  Tipo de banheiro (em casa de tranferência): Latrina  Vaso sanitário/sanita  Adaptado  O usuário usa transporte público/privado com regularidade? Sim  Não  Se sim, que tipo: Carro  Táxi  Ônibus/Autocarro  Outro Cadeira de rodas atual (se a pessoa já possui uma cadeira de rodas) A cadeira de rodas atende às necessidades do usuário? Sim  Não  A cadeira de rodas atende às condições do ambiente do usuário? Sim  Não  A cadeira de rodas oferece adequação correta e suporte postural? Sim  Não  A cadeira de rodas é segura e durável? (verifique se há uma almofada) Sim  Não  A almofada alivia adequadamente a pressão (se o usuário corre risco de úlceras/feridas de pressão)? Sim  Não  Observações: Se a resposta for Sim para todas as perguntas, é possível que o usuário não precise de uma cadeira de rodas nova. Se a resposta for Não para qualquer pergunta, o usuário precisa de uma cadeira de rodas ou almofada diferente; ou a cadeira de rodas ou a almofada atuais precisam de reparos ou modificações. 2: Avaliação Física Presença, risco, ou histórico de úlceras/feridas de pressão /// = Não sente  = úlcera/ferida de pressão prévia • = úcera/ferida de pressão existente Tem sensibilidade normal? Sim  Não  Úlcera/ferida de pressão prévia? Sim  Não  Úlcera/ferida de pressão atual? Sim  Não  Se Sim, é uma ferida instalada? (Estágio 1– 4)? Sim  Não  Duração e causa: 233 Esta pessoa corre risco * de desenvolver úlceras/feridas de pressão? Sim  Não  *A pessoa que não tem sensibilidade ou tem 3 ou mais fatores de risco, corre o risco de desenvolver úlcera/ferida de pressão. Fatores de risco: imobilidade, umidade, postura inadequada, úlcera/ferida de pressão prévia ou atual, dieta inadequada, envelhecimento, abaixo ou acima do peso. Método de impulso Como o usuário impulsionará sua cadeira de rodas? Os dois braços  Braço esquerdo  Braço direito  Membros inferiores  Membro inferior esquerdo  Membro inferior direito  conduzido por um assistente  Observação: Medidas Medidas do corpo Medidas (mm) Transforme a medida do corpo no tamanho ideal da cadeira de rodas Medidas da cadeira de rodas A Largura do quadril Largura do quadril = largura do assento B Profundidade do assento E B menos 30–60 mm = profundidade do assento (se o comprimento for diferente, use o menor) D C Comprimento da perna E = topo da almofada do assento * até a altura do apoio para os pés ou = topo da almofada do assento * até o chão para impulso com o/os pé/s D D Altura da última costela = topo da almofada até o topo do encosto * (medir D ou E – dependendo da necessidade do usuário) E Altura do ângulo inferior da escápula *Verifique a altura da almofada que será usada pelo usuário. 234 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Anexo 4: Formulário de prescrição (seleção) de cadeira de rodas Este formulário de prescrição deve ser usado para registrar a escolha da cadeira de rodas, seus componentes, e a almofada para um usuário que consegue sentar-se confortavelmente ereto. 1. Informações sobre o usuário Nome do usuário: Numero: Data da avaliação: Data da adequação: Nome do avaliador: 2. Tipo e tamanho da cadeira de rodas selecionada Para escolher o tipo de cadeira de rodas: • Converse com o usuário. • Pense sobre as principais necessidade do usuário. • Verifique: estrutura da cadeira de rodas, rodas dianteiras e traseiras, apoio para os pés, apoio para os braços, altura do encosto (ou possibilidade de ajustes), posição das rodas traseiras, suporte e conforto. Tipo de cadeira de rodas Tamanho      3. Tipo de almofada selecionada Tipo de almofada Tamanho Almofada de espuma para alívio de pressão  Almofada de espuma plana   4. De acordo Assinatura do usuário: Assinatura do avaliador: Assinatura do gerente: 235 Anexo 5: Formulário de Resumo da Cadeira de rodas Nome da cadeira de rodas: Insira a fotografia aqui Fabricante/fornecedor: Tamanhos disponíveis: Peso total: Descrição: Estrutura Fixa/Rígida  Dobrável  Comprimento da estrutura: Encosto: Flexível/lona  Rígido  Tensão ajustável  Assento: Flexível/lona  Rígido  Tensão ajustável  Almofada: Sem almofada  Espuma plana  Espuma moldada  Apoio para os pés Fixo  Removível/ móvel  Outro: Rodas dianteiras ou rodízios: Diâmetro Largura: Rodas traseiras Pneumáticas  Diâmetro Aros de impulsão  Sólidas  Largura Eixo ajustável  Tubo interno sólido  Removível  Freios: Alavanca curta  Alavanca longa Outro: Apoio para os braços: Fixo  Removível  Outro: Manoplas: Manoplas  Peças extras/ opcionais Faixa de panturrilha  Dispositivo anti-queda Mesa  Outro: Medidas, opções e abrangência dos ajustes: Medida (se a cadeira de rodas estiver disponível em tamanhos diferentes, lista todos os tamanhos) Ajustável? Abrangência do ajuste (o quanto é possível ajustar a cadeira)Sim Não Largura do assento:   Profundidade do assento   Altura do assento:   Altura do encosto:   Ângulo do encosto   Altura do apoio para os pés   Ângulo do apoio para os pés   Altura da manopla:   Comprimento da estrutura:   Distância entre os eixos:   236 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Anexo 6: Lista de verificação da cadeira de rodas segura e pronta para uso Nome do serviço de cadeira de rodas: Nome do usuário: Tipo de cadeira de rodas: Nº de série da cadeira de rodas: Cadeira de rodas inteira Não há arestas pontiagudas  Nenhuma parte está danificada ou arranhada  A cadeira de rodas anda em linha reta  Rodas dianteiras Giram livremente  Giram sem tocar o garfo  Os parafusos estão apertados  Encaixe das rodas dianteiras O garfo gira livremente  Rodas traseiras Giram livremente  Os parafusos do eixo estão apertados  Pneus calibrados corretamente (com pressão do polegar, a roda pode ser comprimida em menos de 5 mm)  Aros de impulsão estão seguros  Freios Funcionam apropriadamente  Apoio para os pés Apoios para os pés estão presos com segurança  Estrutura Para cadeira de rodas dobrável– a cadeira de rodas abre e fecha com facilidade  Para cadeira de rodas com encosto dobrável – o encosto abre e fecha com facilidade  Almofada A almofada está corretamente na capa  A almofada está colocada corretamente na cadeira de rodas  A capa da almofada está justa, mas não muito apertada  Se a cadeira de rodas tem um assento rígido: a almofada cobre completamente o assento  Nome da pessoa que verificou a cadeira de rodas: Assinatura: Data: 237 Anexo 7: Lista de verificação de adequação da cadeira de rodas 1. A cadeira de rodas está pronta? A cadeira de rodas já foi verificada para garantir que está segura e todas as partes estão funcionando? 2. Verificação do tamanho e ajustes Largura do assento: deve ficar bem ajustado  Profundidade do assento: espaço livre de dois dedos entre a parte de trás do joelho e o assento/almofada  Altura do apoio para os pés: A coxa está totalmente apoiada no assento, sem espaço livre. Os pés estão totalmente apoiados no apoio para os pés, sem espaço livre.  Altura do encosto: O usuário tem suporte necessário e liberdade para mover os ombros para impulsionar a cadeira (se for capaz de impulsioná-la sozinho).  Posição das rodas traseiras (para impulso com as mãos): Quando pendentes ao lado do corpo, os membros superiores do usuário devem estar alinhados com o eixo traseiro da cadeira de rodas. Quando as mãos são colocadas no aro de impulsão, o cotovelo do usuário deve estar em ângulo reto.  Freios: Os freios estão funcionando?  Altura do assento (para impulso com os pés): Com o usuário sentado ereto, suas costas devem estar confortavelmente apoiadas pelo encosto e seus pés inteiramente apoiados no chão.  238 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO 3. Verificação da postura O usuário está apto a sentar-se ereto de forma confortável  Verifique a postura pela lateral  Verifique a postura pela frente/costas  4. Verificação de pressão Verifique a pressão sob o osso do ísquio de todos os usuários em risco de desenvolver úlceras/feridas de pressão A Explique o teste ao usuário. B Peça ao usuário que se incline para frente ou erga o corpo. Coloque as pontas dos dedos sob o osso do ísquio do usuário. C Peça ao usuário para sentar-se normalmente sobre seus dedos. Tenha certeza de que ele sentou-se ereto, com as mãos sobre a coxa. D Identifique a pressão: Nível 1 = Seguro: As pontas dos dedos podem mover-se 5 mm ou mais para cima e para baixo. Nível 2 = Atenção: As pontas dos dedos não podem mover-se para cima e para baixo, mas deslizam facilmente para fora. Nível 3 = Inseguro: A ponta dos dedos está comprimida firmemente. É difícil deslizar os dedos E Repita em ambos os lados do osso do ísquio. 239 5. Verificação da adequação enquanto a cadeira de rodas se move O encosto permite que o usuário movimente seus ombros livremente para impulsionar a cadeira de rodas?  O encosto oferece suporte suficiente ao usuário?  Os pés do usuário ficam no apoio para os pés?  As rodas traseiras estão na posição correta para o usuário?  4. Ações? Outras ações são necessárias? Anote quaisquer outras ações nos registros do usuário.  Lembre-se: A próxima etapa depois da adequação é o treinamento do usuário. Anexo 8: Lista de verificação do treinamento de usuário Habilidades a ensinar Habilidades ensinadas Manuseio da cadeira de rodas Dobrar a cadeira de rodas   Erguer a cadeira de rodas   Usar rodas de remoção rápida   Usar os freios   Usar a almofada, incluindo posicioná-la corretamente   Transferências Transferência independente   Transferência assistida   Outra   Mobilidade na cadeira de rodas Impulsionar corretamente   Subir e descer rampas   Subir e descer escadas   Impulsionar em terreno irregular   Empinar parcialmente   Prevenção de úlceras/feridas de pressão Verificar a existência de úlceras/feridas de pressão   Elevação para alívio de pressão   Comer adequadamente e tomar boa quantidade de água   O que fazer se aparecerem úlceras/feridas de pressão   240 CADEIRAS DE RODAS PACOTE DE TREINAMENTO EM S ERVIÇOS NÍVEL BÁSICO Cuidados com a cadeira de rodas em casa Limpar a cadeira de rodas e a almofada   Lubrificar as partes móveis   Calibrar os pneus   Apertar porcas e parafusos (se frouxos)   Apertar os raios (se frouxos)   Verificar estofado   Verificar se há ferrugem   Verificar a almofada   O que fazer se houver problemas A cadeira de rodas precisa de reparos   A cadeira de rodas não é adequada ou não é confortável   Anexo 9: Formulário de acompanhamento de serviços de cadeira de rodas Formulário para coletar informações durante a visita de acompanhamento 1. Informações sobre o Usuário Nome do usuário: Número: Data da adequação: Data do acompanhamento: Nome da pessoa realizando o acompanhamento: Acompanhamento realizado na: residência do usuário  Centro de serviços de cadeira de rodas  Outro  2. Entrevista Registre as ações: Você usa a cadeira de rodas tanto quanto gostaria? Sim  Não  Se Não – Por quê? Você tem problemas para usar sua cadeira de rodas? Sim  Não  Se Sim – quais são os problemas? Você tem alguma dúvida sobre o uso de cadeira de rodas? Sim  Não  Se Sim, quais? É necessário algum outro treinamento? O usuário possui alguma úlcera/ferida de pressão? Sim  Não  Se Sim – Descrever (local e estágio) 241 Atribua uma nota de 1 a 5 para sua satisfação com sua cadeira de rodas (1 = não satisfeito 5 = muito satisfeito) Nota: Comentário: 3. Verificação da cadeira de rodas e da almofada A cadeira de rodas é segura e funciona bem? Sim  Não  A almofada é segura e funciona bem? Sim  Não  Se Não para qualquer pergunta, qual é o problema? 4. Verificação da adequação A cadeira de rodas se ajusta corretamente ao corpo do usuário? Sim  Não  Se não, qual é o problema? Teste de nível de pressão (1 = seguro, 2 = atenção, 3 = inseguro): (se o usuário correr risco de desenvolver úlcera/feridas de pressão) Esquerda: Direita: O usuário senta-se ereto de forma confortável quando está parado, se movendo e no decorrer do dia? Sim  Não  Se não, qual é o problema? 24 2 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O A n ex o 1 0: L is ta d e V er ifi ca çã o d as O b se rv aç õ es d o I n st ru to r Es te s fo rm ul ár io s fo ra m p re pa ra do s pa ra a ju da r o s in st ru to re s du ra nt e a ob se rv aç ão d as s es sõ es p rá tic as L is ta d e V er ifi ca çã o d as O b se rv aç õ es d o I n st ru to r: P rá ti ca 1 : A va lia çã o e P re sc ri çã o ( se le çã o ) N om e do in st ru to r: D at a da S es sã o Pr át ic a: M on ito ra m en to d o te m po d a se ss ão : A no te e xe m pl os d e bo as p rá tic as p ar a fe ed ba ck : A no te e xe m pl os d e pr át ica s q ue p re cis am se r m el ho ra da s p ar a fe ed ba ck : M in  A va lia çã o 45  Pr es cr iç ão ( se le çã o ) 30  Fe ed ba ck 10  V er ifi q u e as h ab ili d ad es a b ai xo à m ed id a em q u e o b se rv a as d em o n st ra çõ es f ei ta s p el o g ru p o . A n o te s u as o b se rv aç õ es p ar a fe ed b ac k . G ru po : Um D oi s Tr ês N om e d os p ar tic ipa nt es : N om e d o us uá rio :  Co m en tá rio s  Co m en tá rio s  Co m en tá rio s O bs er va çõ es g er ai s: Bo as té cn ic as d e co m un ic aç ão c om o u su ár io e s ua fa m ília    U su ár io p ar tic ip a de fo rm a at iv a de c ad a et ap a e na s de ci sõ es    Se ss ão P rá tic a co nc lu íd a de nt ro d o te m po e st ip ul ad o    24 3 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O A va lia çã o: Pr in ci pa is in fo rm aç õe s co le ta da s du ra nt e a en tr ev ist a    G ru po m on ito ra a tr an sfe rê nc ia d o us uá rio a té a c am a de a va lia çã o pa ra g ar an tir a s eg ur an ça    Id en tifi ca çã o da p re se nç a, ris co e h ist ór ic o de ú lc er a/ fe rid as d e pr es sã o    M ét od o de im pu lsi on ar a c ad ei ra id en tifi ca do c or re ta m en te    M ed ida s t ira da s c or re tam en te    Fo rm ul ár io d e av al ia çã o da c ad ei ra d e ro da s pr ee nc hi do c or re ta m en te    Pr es cr iç ão (s el eç ão ): Tip o e t am an ho d e c ad eir a d e r od as e alm of ad a e sc olh ido s s ão o s m ais ap ro pr iad os    M od ifi ca çõ es o u ne ce ss id ad e de s ol uc io na r pr ob le m as c or re ta m en te id en tifi ca da s    Fo rm ul ár io d e Pr es cr iç ão d e ca de ira d e ro da s (s el eç ão ) pr ee nc hi do c or re ta m en te    L is ta d e V er ifi ca çã o d as O b se rv aç õ es d o I n st ru to r: P rá ti ca 2 : A d eq u aç ão e T re in am en to d e U su ár io s N om e do in st ru to r: D at a da S es sã o Pr át ic a : M on ito re a te nt am en te o te m po d a se ss ão : A no ta r e xe m pl os d e bo as p rá tic as p ar a fe ed ba ak A no ta r e xe m pl os d e pr át ic as q ue ne ce ss ita m se r m el ho ra da s p ar a fe ed ba ck M in  A de qu aç ão 45  Tr ein am en to d e u su ár ios 50  Fe ed ba ck 20  Fe ed ba ck o pc io na l d o us uá rio 30  24 4 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O V er ifi q u e as t éc n ic as a s eg u ir à m ed id a em q u e vo cê o b se rv a o g ru p o . A n o te o s co m en tá ri o s p ar a fe ed b ac k G ru po : Um D oi s Tr ês N om es d os p ar tic ipa nt es : N om e d o us uá rio :  Co m en tá rio s  Co m en tá rio s  Co m en tá rio s Co m en tá rio s g er ai s: Bo as té cn ic as d e co m un ic aç ão c om o u su ár io e s ua fa m ília    U su ár io e nv ol vi do d e fo rm a at iv a em c as a et ap a e na s de ci sõ es    Pr át ic a co nc lu íd a de nt ro d o te m po e st ab el ec id o    A de qu aç ão : C ad a et ap a do p re ce ss o de a de qu aç ão c on cl uí da d e fo rm a se gu ra ( po r ex em pl o, tr an sfe rê nc ia s se gu ra s) e li st a de a de qu aç ão s eg ui da d et al ha da m en te    Pr ob le m as n a ad eq ua çã o fo ra m id en tifi ca do s e so lu ci on ad os a de qu ad am en te    Pr ob le m as fo ra m s ol uc io na do s e a ca de ira fo i a ju st ad a pa ra p ro po rc io na r ad eq ua çã o co rre ta    Tr ei na m en to d e us uá rio s: As ha bil ida de s m ais ap ro pr iad as fo ra m se lec ion ad as e en sin ad as ao us uá rio e su a fa m ília u sa nd o a lis ta d e ve rifi ca çã o co m o gu ia    Bo as té cn ic as d e en sin o de m on st ra da s du ra nt e o tr ei na m en to d as h ab ilid ad es (e xp lic ar , d em on st ra r, pr at ic ar )    Tr ei na m en to r ea liz ad o de fo rm a se gu ra ( as sis te nt e at rá s da c ad ei ra d e ro da s us an do té cn ic as d e m ob ilid ad e; tr an sfe rê nc ia s en sin ad as d e fo rm a se gu ra )    24 5 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O L is ta d e V er ifi ca çã o d as O b se rv aç õ es d o I n st ru to r: P rá ti ca 3 : A co m p an h am en to N om e do in st ru to r: D at a da S es sã o Pr át ic a: M on ito re o te m po es tip ul ad o pa ra a se ss ão : A n o te e xe m p lo s d e b o a s p rá ti ca s p ar a fe ed b ac k: A n o te e xe m p lo s d e p rá ti ca s qu e p re ci sa m s er m el h o ra d as p ar a fe ed b ac k: M in  Ac om pa nh am en to 60  Fe ed ba ck 20  V er ifi q u e ca d a h ab ili d ad e ab ai xo à m ed id a em q u e o b se rv a o g ru p o . E sc re va o s co m en tá ri o s q u e ti ve r p ar a d ar fe ed ba ck a o gr up o. G ru po : Um D oi s Tr ês N om es d os p ar tic ipa nt es : N om e d o us uá rio :  Co m en tá rio s  Co m en tá rio s  Co m en tá rio s O bs er va çõ es G er ai s: Bo as té cn ic as d e co m un ic aç ão c om o u su ár io e s ua fa m ília    U su ár io e nv ol vi do d e m an ei ra a tiv a em c ad a et ap a e na s de ci sõ es    Se ss ão P rá tic a co nc lu íd a de nt ro d o te m po e st ip ul ad o    24 6 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O A co m pa nh am en to : O e st ad o da c ad ei ra d e ro da s fo i v er ifi ca do fi sic am en te p el o gr up o    O g ru po v er ifi co u fis ic am en te a a de qu aç ão d a ca de ira d e ro da s ao u su ár io    A s aç õe s de a co m pa nh am en to fo ra m id en tifi ca da s e re gi st ra da s de fo rm a ad eq ua da    To da s as a çõ es d e ac om pa nh am en to fo ra m d ev id am en te e xe cu ta da s du ra nt e a se ss ão    L is ta d e V er ifi ca çã o d as O b se rv aç õ es d o I n st ru to r: P rá ti ca 4 : A va lia çã o d o U su ár io , P re sc ri çã o (s el eç ão ), P re pa ra çã o do P ro du to ( ca de ir a de r od as ), A de qu aç ão e T re in am en to d e us uá ri o. N om e do in st ru to r: D at a da S es sã o Pr át ic a: M on ito re a te nt am en te o te m po es tim ad o pa ra a se ss ão : A no te e xe m pl os d e bo as p rá tic as p ar a fe ed ba ck A no te e xe m pl os d e pr át ic as q ue pr ec isa m m el ho ra r p ar a fe ed ba ck : M inu to s1  A va lia çã o 30  Pr es cr iç ão ( se le çã o) 20  Pr ep ar aç ão d o pr od ut o (c ad ei ra d e ro da s) 60  A de qu aç ão 30  Tr ein am en to d e u su ár ios 45  Fe ed ba ck 30  1 O bs er va çã o: O s pa rt ic ip an te s te rã o 20 m in ut os a di ci on ai s pa ra s ol uc io na r pr ob le m as e p ar a qu e os in st ru to re s po ss am v er ifi ca r a ex ec uç ão d e ca da e ta pa . 24 7 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O V er ifi q u e ca d a h ab ili d ad e ab ai xo à m ed id a em q u e vo cê o b se rv a o g ru p o . A n o te o s co m en tá ri o s p ar a fe ed b ac k G ru po : Um D oi s Tr ês N om es d os p ar tic ipa nt es : N om e d o us uá rio :  Co m en tá rio s  Co m en tá rio s  Co m en tá rio s O bs er va çõ es g er ai s: Bo as té cn ic as d e co m un ic aç ão c om o u su ár io e s ua fa m ília    U su ár io p ar tic ip ou d e fo rm a at iv a em c ad a et ap a e em to da s as d ec isõ es    Pr át ic a co nc lu íd a de nt ro d o te m po e st ip ul ad o    A va lia çã o: In fo rm aç õe s pr in ci pa is co le ta da s du ra nt e a en tr ev ist a    G ru po m on ito ra a tr an sfe rê nc ia d o us uá rio a té a c am a de a va lia çã o pa ra g ar an tir a se gu ra nç a    Id en tifi ca çã o da p re se nç a, ris co o u hi st ór ic o de ú lc er as /fe rid as d e pr es sã o    M ét od o de im pu lsi on ar a c ad ei ra id en tifi ca do c or re ta m en te    M ed ida s t ira da s c or re tam en te    Fo rm ul ár io d e av al ia çã o da c ad ei ra d e ro da s pr ee nc hi do c or re ta m en te    Pr es cr iç ão (s el eç ão ): Tip o e o ta m an ho d a c ad eir a d e r od as e da al m of ad a e sc olh ido s s ão o s m ais ad eq ua do s    M od ifi ca çõ es o u ne ce ss id ad e de s ol uc io na r pr ob le m as c or re ta m en te id en tifi ca do s    Fo rm ul ár io d e pr es cr iç ão d e ca de ira d e ro da s (s el eç ão ) fo i p re en ch id o co rr et am en te    24 8 C A D EI R A S D E R O D A S PA C O T E D E T R EI N A M EN T O E M S ER V IÇ O S N ÍV EL B Á SI C O Pr ep ar aç ão d o pr od ut o (c ad ei ra d e ro da s) : C ad ei ra d e ro da s m on ta da c or re ta m en te , d e ac or do c om a p re sc riç ão ( se le çã o)    Li st a de v er ifi ca çã o da c ad ei ra d e ro da s se gu ra e p ro nt a pa ra u so p re en ch id a co rre tam en te    A de qu aç ão : C ad a et ap a do p ro ce ss o de a de qu aç ão c on cl uí da d e fo rm a se gu ra ( ex . tr an sfe rê nc ia s se gu ra s) e li st a de a de qu aç ão s eg ui da d et al ha da m en te    Pr ob le m as n a ad eq ua çã o fo ra m id en tifi ca do s e so lu ci on ad os a de qu ad am en te    Pr ob le m as fo ra m s ol uc io na do s e a ca de ira fo i a ju st ad a pa ra p ro po rc io na r ad eq ua çã o co rr et a    Tr ei na m en to d e us uá rio s: As ha bil ida de s m ais ap ro pr iad as fo ra m so luc ion ad as e en sin ad as ao us uá rio e su a fa m ília u sa nd o a lis ta d e ve rifi ca çã o co m o gu ia    Bo as té cn ic as d e en sin o de m on st ra da s du ra nt e o tr ei na m en to d as h ab ilid ad es (e xp lic ar , d em on st ra r, pr at ic ar )    Tr ei na m en to r ea liz ad o de fo rm a se gu ra ( as sis te nt e at rá s da c ad ei ra d e ro da s us an do té cn ic as d e m ob ilid ad e; tr an sfe rê nc ia s en sin ad as d e fo rm a se gu ra )   

NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREINAM ENTO EM SERVIÇOS Manual do Instrutor

NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREIN AMENTO EM SERV IÇOS Ú LC ER A S / F ER ID A S D E PR ES SÃ O 1 C S C ➊ ➋ ➌ ➎ ➏ As pessoas que não podem sentir (perderam a sensibilidade) têm maior risco de desenvolver úlceras / feridas por pressão. A úlcera / ferida é uma área danificada da pele e de tecidos profundos causada por: Áreas comuns de desenvolvimento de úlceras / feridas: Como prevenir as úlceras / feridas? Use almofadas de alívio de pressão Verifique a pele todos os dias Use técnicas de alívio de pressão Evite fricção Evite umidade Sente-se ereto Vista lateral Vista traseira 2 . Fricção / Atrito1. Pressão 3 . Cisalhamento E➍ Alimente-se adequadamente e beba boa quantidade de água Troque a posição com frequência quando deitado ou sentado NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREIN AMENTO EM SERV IÇOS C O M O C U ID A R D A C A D EI R A D E R O D A S EM C A SA ➌ ➍ Calibre os pneus (se pneumáticos) Aperte porcas e parafusos (se frouxos) ➎ Aperte os raios (se frouxos) ➏ Faça revisões regulares: Ferrugem e estofamento Almofada ➊ ➋ Lubrifique as partes móveisLimpe a cadeira de rodas e a almofada NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREIN AMENTO EM SERV IÇOS ET A PA S D E SE R V IÇ O P A R A C A D EI R A D E R O D A S Encaminhamento e agendamento Prescrição (seleção) Treinamento do usuário Manutenção, reparos e acompanhamento Preparação do produto (cadeira de rodas) Financiamento e aquisição ➊ ➋ ➌ ➍ ➎ ➏ Avaliação Adequação NÍVEL BÁSICO CADEIRA DE RODAS PACOTE DE TREIN AMENTO EM SERV IÇOS H A B IL ID A D ES D E M O B IL ID A D E EM C A D EI R A D E R O D A S Para fazer menos esforço durante o impulso, impulsione da posição “10 horas” para a posição de “2 horas” com um movimento longo e suave. Segure um aro de impulsão na frente e o outro atrás; Puxe a mão à frente para trás e empurre a mão atrás para frente, ao mesmo tempo. Incline-se para frente – isso ajuda a impedir que a cadeira de rodas caia para trás; Para parar ou descansar – pare a cadeira de rodas de lado. Incline-se para trás; Deixe que o aro de impulsão deslize suavemente em suas mãos. Suba de costas; Incline a cadeira de rodas sobre as rodas traseiras; O assistente puxa para trás e para cima; O usuário pode ajudar puxando o aro de impulsão para trás. Desça de frente; Incline a cadeira de rodas sobre as rodas traseiras; O assistente ajuda a girar as rodas traseiras lentamente, um degrau por vez; O usuário pode ajudar controlando o aro de impulsão. Usuários experientes que conseguem “empinar” a cadeira de rodas podem descer uma rampa apoiados nas rodas traseiras. Isso é bastante eficaz. IM PU LS IO N AR GI RA R SU BI R RA M PA S DE SC ER R AM PA S SU BI R DE GR AU S CO M A JU DA DE SC ER D EG RA US CO M A JU DA

หลักสูตรอบรมการให้บริการรถนั่งคนพิการ: สมุดงานส าหรับผู้เข้าอบรม - ระดับพื้นฐาน เนื้อหา: คู่มือผู้สอน ระดับพ้ืนฐาน - คู่มือประกอบการอบรม ระดับพ้ืนฐาน - สมุดงานส าหรับผู้เข้าอบรม ระดับพ้ืนฐาน - โปสเตอร์และสไลด์น าเสนอ คู่มือผู้สอนและสไลด์น าเสนออยู่ในดีวิดีเท่านั้น 1.รถนั่งคนพิการ – มาตรฐาน 2.คนพิการ – การฟื้นฟูสมรรถภาพ 3.เอกสารการสอน Published by the World Health Organization in 2012 under the title Wheelchair service training package: participant's workbook. Basic level © World Health Organization 2012 The World Health Organization has granted translation and publication rights for an edition in Thai to the Sirindhorn National Medical Rehabilitation Centre, which is solely responsible for the quality and faithfulness of the Thai translation. In the event of any inconsistency between the English and the Thai editions, the original English edition shall be the binding and authentic edition. หลักสูตรอบรมการให้บริการรถนั่งคนพิการ: สมุดงานส าหรับผู้เข้าอบรม - ระดับพื้นฐาน © Sirindhorn National Medical Rehabilitation Centre 2014 (of English version) เป้าประสงค์ A.4 : การน่ังตัวตรง (sitting upright) A.6 : รถน่ังคนพิการท่ีเหมาะสม (appropriate wheelchair) A.7: เบาะรองน่ัง (cushions) A.8: การเคลื่อนย้ายตัว(transfers) B.3: การสัมภาษณ์ (assessment interview) B.4: การประเมินทางร่างกาย (physical assessment) B.5: การพิจารณา (เลือก) – สรุปรายละเอียดรถน่ังคนพิการ B.5: การพิจารณา (เลือก) – เลือกขนาดรถน่ังคนพิการท่ีถูกต้อง B.7: การเตรียมผลิตภัณฑ์ (รถน่ังคนพิการ) (Product (wheelchair) preparation) B.8: การผลิตเบาะรองน่ัง (cushion fabrication) B.11: การฝึกผู้ใช้รถน่ังคนพิการ (user training) B.12: การดูแลรักษาและซ่อมแซม (maintenance and repairs) B.13: การติดตามผล (follow up) B.14: สรุปท้ังหมดด้วยกัน (putting it all together) 1 เป้าประสงค์ หลักสูตรอบรมเรื่องการให้บริการรถนั่งคนพิการ ได้ออกแบบมาเพื่อช่วยในการอบรมแก่บุคลากรหรือ อาสาสมัครเพื่อให้บริการรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคน(manual wheelchair) และเบาะรองนั่งที่ เหมาะสมแก่บุคคลทุกเพศทุกวัย ที่มีความบกพร่องทางการเคลื่อนไหวที่สามารถนั่งตรงได้โดยไม่ต้องมีการ รองรับท่าทางเพิ่มเติม เป้าประสงค์ของสมุดงานนี้เพื่อพัฒนาทักษะและความรู้ของบุคลากรที่เกี่ยวข้องกับบริการรถนั่งคนพิการ ใน สมุดงานนี้ประกอบด้วยแบบฝึกหัดซึ่งจะช่วยในการทดสอบและเพิ่มความรู้และทักษะของผู้เข้าอบรม สมุด งานเล่มนี้มีเนื้อหาที่มาจากเนื้อหาที่บรรยาย สไลด์น าเสนอ และคู่มือประกอบการอบรม ผู้เข้าอบรมอาจเก็บ สมุดงานนี้ไว้ส าหรับการอ้างอิงในอนาคตหากจ าเป็น 2 A.4: การนั่งตัวตรง (sitting upright)  พิจารณาท่าน่ังของกรณีศึกษาที่ให้ไว้สมุดงานส าหรบัผู้เข้าอบรมอย่างละเอียด  เขียนบรรยายความแตกต่างของท่านั่งของกรณีศึกษา ว่าแตกต่างจากท่านั่งตัวตรงอย่างไร  ให้พิจารณาถึงลักษณะของการนัง่ตัวตรงจากทางด้านหน้าและด้านข้าง 1. บรรยายว่าท่าน่ังของกรณีศึกษาแตกต่างจากท่า”น่ังตัวตรง” อย่างไร 2. บรรยายว่าท่าน่ังของกรณีศึกษาแตกต่างจากท่า”น่ังตัวตรง” อย่างไร 3 3. บรรยายว่าท่าน่ังของกรณีศึกษาแตกต่างจากท่า”น่ังตัวตรง” อย่างไร 4. ปัญหาท่ีอาจเกิดจากการไม่น่ังในท่าน่ังตัวตรง 4 6: รถนั่งคนพิการท่ีเหมาะสม (appropriate wheelchair)  อ่านเรื่องเล่าของผู้ใช้รถนั่งคนพิการในสมุดงานส าหรับผู้เข้าอบรม  อภิปรายว่ารถนั่งคนพิการแบบใดที่เหมาะสมกับผู้ใช้งานแต่ละคน รวมทัง้ให้เหตุผลประกอบด้วย  ให้เหตผุลในการเลือกรถนั่งคนพกิารแบบนั้นมาอยา่งน้อย 3 เหตผุล  พิจาณราถึงวิถีชีวิตและสภาพแวดล้อมของผู้ใช้งานรถนั่งคนพิการ – และลักษณะของรถนัง่คน พิการที่พวกเขาต้องการ  เขียนค าตอบลงในช่องว่าง บาว รถน่ังคนพิการที่มีอยู่แบบใดเหมาะสมกับ บาวที่สุด? เพราะอะไร? บาว อาศัยอยู่ในหมู่บ้านในเขตชนบท เขาได้รับการตัดขาระดับ เหนือเข่าทั้งสองข้าง ก่อนที่จะประสบอุบัติเหตุเขาเป็นเจ้าของ ร้านขายของช าที่ตั้งอยู่ติดกับถนนที่วิ่งผ่านหมู่บ้าน ปัจจุบันน้ีเขา ไปที่ร้านโดยมีผู้อ่ืนช่วยเหลือเน่ืองจากเส้นทางจากบ้านไปร้านขาย ของมีระยะทางไกล (ประมาณ 1 กิโลเมตร) มีลักษณะขรุขระ เป็น หลุมเป็นบ่อและโคลน ซ่ึงท าให้ยากล าบากส าหรับเขาและ ครอบครัวท่ีจะด าเนินกิจการร้านขายของ นานมาแล้ว เขาได้รับบริจาครถน่ังคนพิการแบบธรรมดา (orthopaedic wheelchair) ปัจจุบันน้ีรถน่ังคนพิการของเขา เป็นสนิม ที่น่ังขาด ล้อหน้ามีขนาดเล็ก ยางล้อหลังหน้าแคบและ สึกหรอมาก เขาไม่สามารถปั่นรถน่ังคนพิการจากกระท่อมไปยัง หมู่บ้านเน่ืองจากล้อของรถน่ังคนพิการมักติดหล่มบนทางเดิน เขา ต้องการไปที่ ร้านของเขาด้วยตัวเองโดยไม่ต้องอาศัยความ ช่วยเหลือจากภรรยาและผู้อ่ืน อมันธี รถน่ังคนพิการที่มีอยู่แบบใดเหมาะสมกับ อมันธีที่สุด? เพราะอะไร? อมันธ ีอายุ 21 ปี อาศยัอยู่กับครอบครัวในเมืองเล็กๆ เธอเป็น อัมพาตคร่ึงท่อนจากอุบัตเิหตเุม่ืออาย ุ18 ปี อมันธีเพิ่งหายจาก แผลกดทบัซึ่งใชเ้วลา 6 เดือนในการรักษา เธอได้รับรถน่ังคน พิการแบบธรรมดา ซ่ึงท าใหเ้ธอน่ังในท่าทางไม่ดแีละเหน่ือยง่าย เม่ือใช้งาน อมันธ ีคิดว่าการที่เธอเป็นแผลกดทบัเน่ืองมาจากการ ที่ไม่มีเบาะรองน่ัง อมันธ ีได้รับการชักชวนให้เข้ารับการอบรมในหลักสตูร เลขานุการและเธอต้องการเข้ารับการอบรมเช่นกัน อยา่งไรก็ตาม เธอเกรงว่าจะไม่สามารถน่ังไดท้ั้งตลอดวันในรถน่ังคนพิการคัน ปัจจุบันของเธอ 5 ฟิลลิป รถน่ังคนพิการที่มีอยู่แบบใดเหมาะสม กับฟิลลิปที่สุด? เพราะอะไร? ฟิลลิป อายุ 62 ปีและอาศัยอยู่ในชุมชนบนเกาะเล็กๆ เม่ือ 6 เดือนก่อนเขามีอาการของโรคหลอดเลือดสมองโดยใช้เวลารักษา ในโรงพยาบาล 1 เดือนโดยไม่ได้รับรถน่ังคนพิการเม่ือออกจาก โรงพยาบาล เขาต้องนอนอยู่บนเตียงหรือน่ังบนเก้าอ้ีที่ระเบียง บ้าน ฟิลลิปไม่สามารถเคลื่อนไหวแขนและขาข้างซ้ายได้ แต่มี ความแข็งแรงมากขึ้นเร่ือยๆ ปัจจุบันเขาสามารถยืนได้ด้วยการ ช่วยเหลือของสมาชิกในครอบครัว เขาก าลังออกก าลังแขนขวา และต้องการรถน่ังคนพิการอย่างมากเพื่อสามารถเคลื่อนที่ไปมา ได้มากขึ้นและงพึ่งการช่วยเหลือจากครอบครัวน้อยลง เขาต้องการเคลื่อนที่ในบ้านซ่ึงไม่มีพื้นต่างระดับและเคลื่อนที่ ในชุมชนของเขาที่มีพื้นที่เป็นทราย หลานชายคนหน่ึงของเขามี รถยนต์และจะให้การช่วยเหลือเขาออกสู่ในการเดินทางออกจาก บ้านถ้ามีรถน่ังคนพิการ ซาบิน่า รถน่ังคนพิการท่ีมีอยู่แบบใดเหมาะสม กับซาบิน่าท่ีสุด? เพราะอะไร? ซาบิน่า อายุ 56 ปี และอาศัยอยู่ในชุมชนบนเกาะเล็กๆ หลังจากคลอดลูกคนที่ 4 เมื่อหลายปีก่อน ขาทั้งสองข้างของ เธอใช้งานไม่ได้ เธอยืนได้ช่ัวครู่แต่ไม่สามารถเดินได้ เธอไม่ เคยได้รับรถนั่งคนพิการมาก่อน ซาบิน่า อาศัยอยู่ในหมู่บ้านเล็กๆ ใกล้ทะเล-พื้นที่รอบๆ บ้านและในชุมชนมีลักษณะขรุขระและเป็นทราย เธอใช้เวลา ส่วนใหญ่ในการเลี้ยงดูหลาน ท าอาหารและถักผ้า พื้นที่ ภายในบ้านแคบจนไม่สามารถใช้รถนั่งคนพิการได้ แต่รถนั่ง คนพิการสามารถเก็บไว้ใต้ถุนบ้านได้ เนื่องจากเป็นบ้านที่มี ลักษณะยกพื้นสูง รถน่ังคนพิการท่ีมีอยู่แบบใดจะเหมาะสมสภาพแวดล้อมของท่านท่ีสุด? และเพราะอะไร? 1. 2. 3. 4. 5. 6 A.7: เบาะรองนั่ง (cushions)  ฝึกปฏิบัตกิารตรวจสอบแรงกดบนกระดูกรองนั่งที่ละข้าง  ต้องแน่ใจว่าทุกคนในกลุ่มสลบักันเป็นบทบาทผู้ตรวจประเมนิและผู้ใช้รถนัง่คนพิการ  บันทึกระดับแรงกดทับของแตล่ะคนในกลุ่มลงในสมุดงานส าหรบัผูเ้ข้าอบรมของแตล่ะคน ตรวจสอบแรงกดทับใต่ปุ่มกระดูรองน่ังส าหรับผู้ใช้รถน่ังคนพิการทุกรายท่ีมีความเสี่ยงต่อการเกิดแผล กดทับ A  อธิบายต่อผู้ใช้รถน่ังคนพิการว่าจะประเมินอะไร ท าอย่างไรและมีความส าคัญ อย่างไร โดยใช้ค าอธิบายง่ายๆ B  ให้ผู้ใช้รถน่ังคนพิการยกตัวขึ้นหรือโน้มตัวไปข้างหน้าเพื่อให้ปลายน้ิวของผู้ ประเมินอยู่ใต้ปุ่มกระดูกรองน่ัง (หงายมือขึ้น)  ท าประเมินโดยการสอดมือจากด้านหลัง C  ให้ผู้ใช้รถน่ังคนพิการเอนตัวกลับไปน่ังทับบนมือของผู้ประเมิน  ให้ผู้ใช้รถน่ังคนพิการน่ังตัวตรงและวางมือลงบนหน้าขา เพื่อให้ม่ันใจว่าผู้ใช้รถ น่ังคนพิการจะน่ังในท่าเดิมขณะที่ท าการประเมินอีกด้านหน่ึง  ในกรณีที่ปลายน้ิวของผู้ประเมินไม่อยู่ในต าแหน่งที่ถูกต้องและไม่สามารถรับรู้ แรงกดทับได้ดี ให้ผู้ใช้รถน่ังคนพิการยกตัวขึ้นและผู้ประเมินเปลี่ยนต าแหน่ง ของน้ิวใหม่ D ระบุระดับของแรงกดทับใต้ปุ่มกระดูกรองน่ังข้างที่หน่ึง ว่าอยู่ระดับที่ 1, 2, หรือ 3: ระดับที่ 1 = ปลอดภัย: สามารถกระดิกปลายน้ิวขึ้นลงได้ มีแรงกดบนเน้ือเยื่อแต่ไม่ถึงกระดูก ปลายน้ิวสามารถเคลื่อนไหวขึ้นลงได้ไม่น้อยกว่า 5 มม. ระดับที่ 2 = เตือน: ไม่สามารถกระดิกปลายน้ิวขึ้นลงได้แต่สามารถเลื่อนมือออกจากปุ่ม กระดูกรองน่ังได้ง่าย ระดับที่ 3 = ไม่ปลอดภัย: ปลายน้ิวมีแรงกดอย่างมากจนท าให้การเลื่อนมือออกจากปุ่ม กระดูกรองน่ังได้ยาก E ท าการประเมินซ้ าที่ปุ่มกระดูกรองน่ังอีกข้างหน่ึง บันทึกระดับแรงกดทับของแต่ละคนในกลุ่มลงในสมุดงานส าหรับผู้เข้าอบรมของแต่ละคนลงในตาราง ปุ่มกระดูกรองน่ังข้างซ้าย ปุ่มกระดูกรองน่ังข้างขวา คนที่ 1 ระดับที่ 1: ระดับที่ 2: ระดับที่ 3: ระดับที่ 1: ระดับที่ 2: ระดับที่ 3: คนที่ 2 ระดับที่ 1: ระดับที่ 2: ระดับที่ 3: ระดับที่ 1: ระดับที่ 2: ระดับที่ 3: คนที่ 3 ระดับที่ 1: ระดับที่ 2: ระดับที ่3: ระดับที่ 1: ระดับที่ 2: ระดับที่ 3: คนที่ 4 ระดับที่ 1: ระดับที่ 2: ระดับที ่3: ระดับที่ 1: ระดับที่ 2: ระดับที่ 3: 7 A 8: การเคลื่อนย้ายตัว (transfers)  อ่านเรื่องเล่าของผู้ใช้รถนั่งคนพิการในสมุดงานส าหรับผู้เข้าอบรม  อภิปรายว่าวิธีการเคลือ่นย้ายตัววิธีไหนที่เหมาะสมกับผู้ใช้งานรถนั่งคนพิการแต่ละรายมากทีสุ่ด  เขียนค าตอบลงในช่องว่าง ฟาริดา วิธีการเคลื่อนย้ายตัววิธีใดเหมาะสมกับฟาริดา มากท่ีสุด? เพราะอะไร? ฟาริดา อายุ 60 ปี เธอถูกส่งต่อมาเพื่อรับบริการรถ นั่งคนพิการโดยโรงพยาบาลในท้องถ่ิน เธอมีภาวะ โรคหลอดเลือดสมองและต้องการรถนั่งคนพิการ เนื่องจากไม่สามารถเดินได้ เธอสามารถยืนลง น้ าหนักได้ช่วงเวลาสั้นๆ อย่างไรก็ตามเธอยังยืน ได้ ไม่มั่ นคง ฟาริดาอาศัยอยู่ กับลูกสาวและ ครอบครัว ลูกสาวของเธอไม่ได้ท างานและสามารถ ให้การช่วยเหลือมารดาได้เมื่ออยู่บ้าน เธอได้รับรถ นั่งคนพิการแบบสี่ล้อที่สามารถเหว่ียงที่วางเท้า ออกไปด้านข้างได้ โจเซ ่ วิธีการเคลื่อนย้ายตัววิธีใดเหมาะสมกับโจเซ่มาก ท่ีสุด? เพราะอะไร? โจเซ่ อายุ 45 ปแีละใช้รถนั่งคนพกิารมา 10 ปี เขา ได้รับการตัดขาทัง้สองข้างในระดับเหนือเข่าและ ท างานที่ร้านซ่อมวิทยุในตลาดท้องถ่ิน โจเซ่ มาเพื่อ รับรถนั่งคนพิการคันใหมเ่นื่องจากรถคันเก่าช ารุด มาก ทาไฮ วิธีการเคลื่อนย้ายตัววิธีใดเหมาะสมกับทาไฮมาก ท่ีสุด? เพราะอะไร? ทาไฮ อายุ 14 ปีถูกส่งต่อมาเพื่อรับบริการรถนั่ง คนพิการหลังจากตกต้นไม้และมีภาวะบาดเจ็บที่ไข สันหลัง ทาไฮ สามารถใช้แขนทั้งสองข้างได้ดีแต่ยัง ไม่ค่อยแข็งแรงเท่าที่ควร เขาไม่สามารถเคลื่อนไหว ขาทั้งสองข้างได้เลย 8 B.3: การสัมภาษณ์ (assessment interview)  สมาชิกในกลุ่มแต่ละคนเลอืกอ่านเรื่องเล่าคนละเรื่อง – และแสดงบทบาทสมมติเป็นผู้ใช้รถนั่งคนพกิารที่ อ่าน เมื่อถูกสมัภาษณ์ให้ผู้แสดงบทบาทสมมติใช้ข้อมูลจากเรื่องทีเ่ลือก ในกาตอบค าถามทีส่ัมภาษณ์  อย่าอ่านเรื่องเล่าเสียงดัง จนเพ่ือนคนอ่ืนในกลุ่มได้ยิน และอย่าอ่านเรื่องเล่าท่ีผู้อ่ืนเลือก  หมุนเวียนกันเป็นผู้สมัภาษณ์และผู้ถูกสัมภาษณ์และกรอกแบบประเมิน ตามหน้าถัดไป เฟลิเซีย เป็นหญิงสูงอายุที่มีปัญหาข้ออักเสบรุนแรง เธอมีอาการปวดตามแขน มือ และขา ไม่สามารถเดิน ได้เกินกว่า 2-3 ก้าวเนื่องด้วยอาการปวดและส่งผลให้เกิดความยากล าบากในการดูแลตนเอง เฟลิเซียเข้ารับการประเมินพร้อมกับลูกสาวซึ่งเป็นผู้ดูแลเธอที่บ้าน เธออาศัยอยู่ในเมืองเล็กๆแห่งหนึ่ง ทางเข้าบ้านของเธอมีบันไดสามข้ัน เธอไม่มีปัญหาด้านสุขภาพอื่นใดนอกจากปัญหาข้ออักเสบ เธอเคยไป โบสถ์เป็นประจ า แต่ตอนน้ีไม่สามารถไปได้แล้ว ครอบครัวของเธอไม่มีรถยนต์จึงต้องพึ่งพาขนส่งสาธารณะ เธอต้องจ้างรถแท็กซี่เพื่อมารับการประเมิน และ ต้องจ่ายค่าแท็กซี่เป็นจ านวนเงินที่แพงมากส าหรับครอบครัวของเธอ เฟลิเซียไม่เคยมีรถนั่งคนพิการมาก่อน แอนตัน มีภาวะโปลิโอ เขาอายุ 26 ปีและอาศัยอยู่ในเมืองเล็กๆแห่งหนึ่ง แอนตันก าลังศึกษาเกี่ยวกับ คอมพิวเตอร์และใฝ่ฝันอยากจะมีกิจการเป็นของตนเองในอนาคต เขาเข้ามารับการประเมินในครั้งนี้กับภรรยา เมื่อนานมาแล้ว แอนตันได้รับบริจาครถนั่งคนพิการแบบธรรมดา(orthopaedic style) ตัวรถข้ึนสนิม เบาะที่ หุ้มฉีกขาด ล้อหน้ามีขนาดบางและเล็ก ล้อหลังมีขนาดบางมากและเปื่อย รถนั่งไม่สบายและยากต่อการปั่น ทางเดินในเมืองที่แอนตันอาศัยอยู่ขรุขระมาก รถนั่งคนพิการของเขาจึงติดหลุมเป็นประจ า อย่างไรก็ตาม แอนตันต้องการเดินทางจากบ้านไปยังศูนย์ฝึกอาชีพซึ่งมีระยะทางทั้งหมดประมาณ 1.5 กิโลเมตรด้วยตนเอง แต่ในตอนน้ีเขายังต้องอาศัยความช่วยเหลือจากน้องชาย – บ่อยครั้งไม่สามารถพาเขาไปอบรมได้ทันเวลา ชันตู เป็นเด็กหญิงอายุ 13 ปี เธอสูญเสียขาทั้งสองข้าง (ระดับเหนือเข่า) จากเหตุการณ์แผ่นดินไหว เธออาศัย อยู่กับครอบครัวในอพาตเมนท์ใกล้กับตัวเมือง ชันตูมารับการประเมินพร้อมกับแม่และพี่สาวของเธอ รถนั่งคน พิการที่เธอได้รับบริจาคมาเป็นแบบธรรมดา และเป็นขนาดส าหรับผู้ใหญ่ มันจึงมีขนาดใหญ่กว่าตัวเธอมาก ชันตูต้องเอื้อมแขนข้ามที่พักแขนเพื่อปั่นรถซึ่งเป็นสิ่งที่ยากล าบากมากส าหรับเธอ พนักพิงสูงมากและไม่มีเบาะ รองนั่ง ชันตู อยากกลับไปเรียนหนังสือทีโ่รงเรียน แต่เธอมีความรู้สกึว่าร่างกายของเธอไม่สะดวกสบายเมือ่ต้องนั่งอยู่ บนรถนั่งคนพกิาร นอกจากนี้เธอยังรูส้ึกอับอายที่ไมส่ามารถไปไหนมาไหนได้ ชันตูอยากได้รถนั่งคนพิการที่ เธอสามารถปั่นเองได้และรองรบัร่างกายเธอได้มากกว่าน้ี ชันตูบอกว่าถ้าเธอสามารถเอารถนั่งคนพิการของ เธอไปด้วยได้เธอจะเดินทางไปโรงเรียนโดยทางรถเมล ์ 9 สัมภาษณ์สมาชิกในกลุ่มที่แสดงบทบาทสมมติเป็นผู้ใช้รถนั่งคนพิการและบันทึกข้อมูลที่ได้ลงในแบบประเมิน ช่ือผู้ประเมิน: วันที่ประเมิน: ข้อมูลเกี่ยวกับผู้ใช้รถน่ังคนพิการ ช่ือผู้รับบรกิาร หมายเลข .. อายุ เพศ  ชาย  หญิง โทรศัพท ์ ที่อยู ่ . เป้าหมาย: . สภาวะทางรา่งกาย  สมองพิการ โปลโิอ  บาดเจ็บไขสันหลัง  โรคหลอดเลอืดสมอง  กล้ามเนื้ออ่อนแรว  กล้ามเนือ้เกร็ง/มีการเคลื่อนไหวที่ควบคุมไม่ได้  ขาขาดเหนือเข่าขวา  ขาขาดใต้เข่าขวา  ขาขาดเหนือเข่าซ้าย  ขาขาดใต้เข่าซ้าย  มีปัญหาการขับถ่ายปสัสาวะ  มีปัญหาการขับถ่ายอจุจาระ ถ้ามีปัญหาการขับถ่ายปัสสาวะ/อุจจาระ คนพิการได้รับการจัดการทีเ่หมาะสม?  ใช่  ไม่ใช่ อื่นๆ: __________________________________________________________________ วิถีชีวิตและสภาพแวดล้อมท่ีอยู่ อธิบายสภาพแวดล้อมที่คนพิการจะใช้รถนั่งคนพกิาร ______________________________________________________________________________ ระยะทางที่ใช้รถนั่งคนพกิารในแต่ละวัน:  ประมาณ1ก.ม.  1-5 ก.ม.  มากกว่า 5 ก.ม. ระยะเวลาที่นั่งในรถนั่งคนพิการ?  น้อยกว่า 1 ช.ม.  1-3 ช.ม.  3-5 ช.ม.  5-8 ช.ม.  มากกว่า 8 ช.ม. 10 ขณะที่ไม่ได้นั่งในรถนั่งคนพิการ คนพิการนอน/นั่งอยูอ่ย่างไร (ท่าทาง และลักษณะพื้นผิวที่นั่ง/นอน) ______________________________________________________________________________ การเคลื่อนย้ายตัว ท าได้เอง  ต้องมีผู้ช่วยเหลือ  ท่ายืน  ท่านั่ง อุ้ม อื่นๆ ลักษณะส้วม  แบบนั่งยอง  แบบชักโครก  ดัดแปลง คนพิการเดินทางโดยรถสาธารณะบ่อยหรือไม?่  ใช่  ไม่ใช่ ถ้าใช่ ชนิดไหน:  รถยนต์  แท็กซี่  อื่นๆ _____________________________________ รถน่ังคนพิการท่ีใช้อยู่ (กรณีเคยได้รับรถน่ังคนพิการแล้ว) รถนั่งคนพิการตรงตามความต้องการของคนพิการหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการตรงกับสภาพแวดล้อมที่อยู่อาศัยของคนพิการหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการมีขนาดเหมาะสมและช่วยให้คนพิการอยู่ในทา่ทางที่ดีหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการปลอดภัยและคงทนหรือไม?่  ใช่  ไม่ใช่ เบาะรองนัง่ที่ใช้ช่วยป้องกันแผลกดทับไดห้รือไม?่ (กรณีคนพิการรายนีม้ีความเสี่ยงต่อการเกิดแผล)?  ใช่  ไม่ใช่ ความเห็น: _____________________________________________________________________ ถ้าตอบ “ใช่” ทุกข้อ หมายความว่า คนพิการรายนี้ไมจ่ าเปน็ต้องเปลี่ยนรถนั่งคนพิการ ถ้าตอบ “ไม่ใช่” ข้อใดข้อหนึ่ง หมายความว่า คนพิการรายนี้สมควรได้รบัการพิจารณาเปลี่ยนรถนัง่คนพิการ หรือเบาะรองนั่ง หรือพิจารณาซ่อมแซมรถนัง่คนพิการ 11 สัมภาษณ์สมาชิกในกลุ่มที่แสดงบทบาทสมมติเป็นผู้ใช้รถนั่งคนพิการและบันทึกข้อมูลที่ได้ลงในแบบประเมิน ช่ือผู้ประเมิน: วันที่ประเมิน: ข้อมูลเกี่ยวกับผู้ใช้รถน่ังคนพิการ ช่ือผู้รับบรกิาร หมายเลข .. อายุ เพศ  ชาย  หญิง โทรศัพท ์ ที่อยู ่ . เป้าหมาย: . สภาวะทางรา่งกาย  สมองพิการ โปลโิอ  บาดเจ็บไขสันหลัง  โรคหลอดเลอืดสมอง  กล้ามเนื้ออ่อนแรว  กล้ามเนือ้เกร็ง/มีการเคลื่อนไหวที่ควบคุมไม่ได้  ขาขาดเหนือเข่าขวา  ขาขาดใต้เข่าขวา  ขาขาดเหนือเข่าซ้าย  ขาขาดใต้เข่าซ้าย  มีปัญหาการขับถ่ายปสัสาวะ  มีปัญหาการขับถ่ายอจุจาระ ถ้ามีปัญหาการขับถ่ายปัสสาวะ/อุจจาระ คนพิการได้รับการจัดการทีเ่หมาะสม?  ใช่  ไม่ใช่ อื่นๆ: __________________________________________________________________ วิถีชีวิตและสภาพแวดล้อมท่ีอยู่ อธิบายสภาพแวดล้อมที่คนพิการจะใช้รถนั่งคนพกิาร ______________________________________________________________________________ ระยะทางที่ใช้รถนั่งคนพกิารในแต่ละวัน:  ประมาณ1ก.ม.  1-5 ก.ม.  มากกว่า 5 ก.ม. ระยะเวลาที่นั่งในรถนั่งคนพิการ?  น้อยกว่า 1 ช.ม.  1-3 ช.ม.  3-5 ช.ม.  5-8 ช.ม.  มากกว่า 8 ช.ม. 12 ขณะที่ไม่ได้นั่งในรถนั่งคนพิการ คนพิการนอน/นั่งอยูอ่ย่างไร (ท่าทาง และลักษณะพื้นผิวที่นั่ง/นอน) ______________________________________________________________________________ การเคลื่อนย้ายตัว ท าได้เอง  ต้องมีผู้ช่วยเหลือ  ท่ายืน  ท่านั่ง อุ้ม อื่นๆ ลักษณะส้วม  แบบนั่งยอง  แบบชักโครก  ดัดแปลง คนพิการเดินทางโดยรถสาธารณะบ่อยหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ ชนิดไหน:  รถยนต์  แท็กซี่  อื่นๆ _____________________________________ รถน่ังคนพิการท่ีใช้อยู่ (กรณีเคยได้รับรถน่ังคนพิการแล้ว) รถนั่งคนพิการตรงตามความต้องการของคนพิการหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการตรงกับสภาพแวดล้อมที่อยู่อาศัยของคนพิการหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการมีขนาดเหมาะสมและช่วยให้คนพิการอยู่ในทา่ทางที่ดีหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการปลอดภัยและคงทนหรือไม?่  ใช่  ไม่ใช่ เบาะรองนัง่ที่ใช้ช่วยป้องกันแผลกดทับไดห้รือไม่? (กรณีคนพิการรายนีม้ีความเสี่ยงต่อการเกิดแผล)?  ใช่  ไม่ใช่ ความเห็น: _____________________________________________________________________ ถ้าตอบ “ใช่” ทุกข้อ หมายความว่า คนพิการรายนี้ไมจ่ าเปน็ต้องเปลี่ยนรถนั่งคนพิการ ถ้าตอบ “ไม่ใช่” ข้อใดข้อหนึ่ง หมายความว่า คนพิการรายนี้สมควรได้รบัการพิจารณาเปลี่ยนรถนัง่คนพิการ หรือเบาะรองนั่ง หรือพิจารณาซ่อมแซมรถนัง่คนพิการ 13 B.4: การประเมินทางร่างกาย (physical assessment) สมาชิกในกลุ่มแต่ละคนควรได้วัดตัวของสมาชิกคนอื่นในกลุม่ทุกคน และบันทึกในตาราง โดยเขียนช่ือผู้วัดไว้ ด้วย 1. ชื่อสมาชิกท่ีถูกวัดตัว................................................................................. ผู้วัดที่ 1 ผู้วัดที่ 2 การวัดขนาดร่างกาย ผลการวัด (มม.) ผลการวัด (มม.) A ความกว้างของสะโพก B ความลึกของ ที่น่ัง ซ้าย ขวา C ความยาวของน่อง ซ้าย ขวา D ระยะจากที่น่ังถึงชายโครง E ระยะจากที่น่ังถึงฐานสะบัก 2. ชื่อสมาชิกท่ีถูกวัดตัว................................................................................. ผู้วัดที่ 1 ผู้วัดที่ 2 การวัดขนาดร่างกาย ผลการวัด (มม.) ผลการวัด (มม.) A ความกว้างของสะโพก B ความลึกของ ที่น่ัง ซ้าย ขวา C ความยาวของน่อง ซ้าย ขวา D ระยะจากที่น่ังถึงชายโครง E ระยะจากที่น่ังถึงฐานสะบัก 3. ชื่อสมาชิกท่ีถูกวัดตัว................................................................................. ผู้วัดที่ 1 ผู้วัดที่ 2 การวัดขนาดร่างกาย ผลการวัด (มม.) ผลการวัด (มม.) A ความกว้างของสะโพก B ความลึกของ ที่น่ัง ซ้าย ขวา C ความยาวของน่อง ซ้าย ขวา D ระยะจากที่น่ังถึงชายโครง E ระยะจากที่น่ังถึงฐานสะบัก 14 B.5: การพิจารณา (เลือก) – สรุปรายละเอียดรถนั่งคนพิการ (Prescription (selection) – wheelchair summaries)  กรอกรายละเอียดรถนั่งคนพิการที่ได้รบัมอบหมายลงในแบบฟอรม์  เพื่อกรอกแบบฟอร์ม ท่านจ าเป็นต้อง - ดูรถนั่งคนพิการอย่างละเอียด - ดูข้อมูลต่างๆที่มมีากับรถนั่งคนพิการ - วัดขนาด (กรณีไม่มีข้อมูลมาให้) ซึ่งอาจต้องปรบัขนาดจากระยะทีเ่ลก็ทีสุ่ดและระยะใหญ่ทีสุ่ดเพื่อวัด ระยะทีป่รบัได้ กรอกแบบสรุปรายละเอียดรถน่ังคนพิการท่ีมีในท้องถิ่น ชื่อรุ่นรถนั่งคนพิการ: บริษัทผู้ผลิต: ขนาดที่มี: น าหนกัรวม: ค าอธิบาย: โครงรถ: พับได้  ยึดติด/แข็ง  ระยะโครงรถ พนักพิง: ยืดหยุ่น/ผ้าใบ  แบบแข็ง  ปรับความตึงได้  ท่ีรองน่ัง: ยืดหยุ่น/ผ้าใบ  แบบแข็ง  ปรับความตึงได้  เบาะรองน่ัง: ไม่มีเบาะรองน่ัง  แบบฟองน้ าเรียบ  แบบฟองน้ าโค้งเข้ารูป  ท่ีพักเท้า: เหว่ียงออกด้านข้างได้  ยึดติด  อ่ืนๆ: ล้อหน้า: เส้นผ่าศูนย์กลาง: ความกว้าง: ล้อหลัง: ยางลม  เส้นผ่าศูนย์กลาง: วงปั่น  ยางตัน  ความกว้าง: แกนล้อปรับได้  ยางตันอยู่ด้านใน  ถอดล้อได้  เบรค: แบบก้านสั้น  แบบก้านยาว อ่ืนๆ:  ท่ีพักแขน: ยึดติด  ถอดออกได้  อ่ืนๆ:  ด้ามจับเข็น: ด้ามจับเข็น  ส่วนประกอบ พิเศษ ผ้าใบรองน่อง  แกนกันหงายหลัง ถาด  อ่ืนๆ: 15 การวัด การปรับและระยะของการปรับ การวัด (ถ้ามีหลายขนาด ให้ระบุทุกขนาดท่ีมี) ปรับได้หรือไม่? ระยะของการปรับ (ระยะท่ีสามารถปรับได้) ใช่ ไม่ใช ่ ความกว้างของท่ีรองน่ัง:   ความลึกของท่ีรองน่ัง:   ความสูงของท่ีรองน่ัง:   ความสูงของพนักพิง:   มุมของพนักพิง:   ความสูงของท่ีพักเท้า:   มุมของท่ีพักเท้า:   ความสูงของด้ามจับเข็น:   ความยาวของโครงรถ:   ระยะฐานล้อ:   กรอกแบบสรุปรายละเอียดรถน่ังคนพิการท่ีมีในท้องถิ่น ชื่อรุ่นรถน่ังคนพิการ: บริษัทผู้ผลิต: ขนาดท่ีมี: น าหนักรวม: 16 ค าอธิบาย: โครงรถ: พับได ้  ยึดติด/แข็ง  ระยะโครงรถ พนักพิง: ยืดหยุ่น/ผ้าใบ  แบบแข็ง  ปรับความตงึได้  ท่ีรองน่ัง: ยืดหยุ่น/ผ้าใบ  แบบแข็ง  ปรับความตงึได้  เบาะรองน่ัง: ไม่มีเบาะรองนั่ง  แบบฟองน้ าเรียบ  แบบฟองน้ าโค้งเข้ารูป  ท่ีพักเท้า: เหว่ียงออกด้านข้างได้  ยึดติด  อื่นๆ: ล้อหน้า: เส้นผ่าศูนย์กลาง: ความกว้าง: ล้อหลัง: ยางลม  เส้นผ่าศูนย์กลาง: วงปั่น  ยางตัน  ความกว้าง: แกนล้อปรับได ้  ยางตันอยู่ด้านใน  ถอดล้อได้  เบรค: แบบก้านสั้น  แบบก้านยาว อื่นๆ:  ท่ีพักแขน: ยึดติด  ถอดออกได้  อื่นๆ:  ด้ามจับเข็น: ด้ามจับเข็น  ส่วนประกอบ พิเศษ ผ้าใบรองน่อง  แกนกันหงายหลงั ถาด  อื่นๆ: การวัด การปรับและระยะของการปรับ การวัด (ถ้ามีหลายขนาด ให้ระบุทุกขนาดท่ีมี) ปรับได้หรือไม่? ระยะของการปรับ (ระยะท่ีสามารถปรับได้) ใช่ ไม่ใช ่ ความกว้างของท่ีรองน่ัง:   ความลึกของท่ีรองน่ัง:   ความสูงของท่ีรองน่ัง:   ความสูงของพนักพิง:   มุมของพนักพิง:   ความสูงของท่ีพักเท้า:   มุมของท่ีพักเท้า:   ความสูงของด้ามจับเข็น:   ความยาวของโครงรถ:   ระยะฐานล้อ:   17 กรอกแบบสรุปรายละเอียดรถน่ังคนพิการท่ีมีในท้องถิ่น ชื่อรุ่นรถน่ังคนพิการ: บริษัทผู้ผลิต: ขนาดท่ีมี: น าหนักรวม: ค าอธิบาย: โครงรถ: พับได ้  ยึดติด/แข็ง  ระยะโครงรถ พนักพิง: ยืดหยุ่น/ผ้าใบ  แบบแข็ง  ปรับความตงึได้  ท่ีรองน่ัง: ยืดหยุ่น/ผ้าใบ  แบบแข็ง  ปรับความตงึได้  เบาะรองน่ัง: ไม่มีเบาะรองนั่ง  แบบฟองน้ าเรียบ  แบบฟองน้ าโค้งเข้ารูป  ท่ีพักเท้า: เหว่ียงออกด้านข้างได้  ยึดติด  อื่นๆ: ล้อหน้า: เส้นผ่าศูนย์กลาง: ความกว้าง: ล้อหลัง: ยางลม  เส้นผ่าศูนย์กลาง: วงปั่น  ยางตัน  ความกว้าง: แกนล้อปรับได ้  ยางตันอยู่ด้านใน  ถอดล้อได้  เบรค: แบบก้านสั้น  แบบก้านยาว อื่นๆ:  ท่ีพักแขน: ยึดติด  ถอดออกได้  อื่นๆ:  ด้ามจับเข็น: ด้ามจับเข็น  ส่วนประกอบ พิเศษ ผ้าใบรองน่อง  แกนกันหงายหลงั ถาด  อื่นๆ: 18 การวัด การปรับและระยะของการปรับ การวัด (ถ้ามีหลายขนาด ให้ระบุทุกขนาดที่มี) ปรับได้หรือไม่? ระยะของการปรับ (ระยะที่สามารถปรับได้) ใช ่ ไม่ใช่ ความกว้างของที่รองนั่ง:   ความลึกของที่รองนั่ง:   ความสงูของที่รองนั่ง:   ความสูงของพนักพิง:   มุมของพนักพิง:   ความสูงของที่พักเท้า:   มุมของที่พักเท้า:   ความสูงของด้ามจับเข็น:   ความยาวของโครงรถ:   ระยะฐานล้อ:   B.5: การพิจารณา (เลือก) – เลือกขนาดรถนั่งคนพิการท่ีถูกต้อง (Prescription (selection) – selecting the right wheelchair size) ข้อมูลตัวอย่างทีก่ าหนดให้ต่อไปนี ้  ค านวณขนาดรถนั่งคนพิการที่เหมาะสมที่สุด และ  เลือกขนาดรถนั่งคนพิการที่มอียู่ที่ดีทีสุ่ดส าหรบัผู้ใช้รถนั่งคนพิการ (สมมติว่าเบาะรองนัง่ของทุกรายหนา 50 มม.) การวัดขนาดร่างกาย ขนาดร่างกาย (มม.) การค านวณขนาดร่างกายไปสู ่ ขนาดของรถนั่งคนพิการที่เหมาะสม ขนาดของ รถนั่งคนพกิาร A ความกว้างของสะโพก 380 มม. ความกว้างของสะโพก= ความกว้างของที่รองน่ัง B ความลึกของ ที่น่ัง ซ้าย 400 มม. B ลบออก 30 – 50 มม. = ความลึกของที่รองน่ัง ขวา 400 มม. C ความยาว ของน่อง ซ้าย 420 มม. = จากขอบบนของเบาะรองน่ังถึงขอบหลังของที่วาง เท้า หรือ = จากขอบบนของเบาะรองน่ังถึงพื้น กรณีคนพิการ ใช้เท้าเข็นรถ ขวา 420 มม. 19 D ระยะจากที่น่ังถงึชาย โครง = ระยะจากขอบบนของเบาะรองน่ังถึงขอบบน ของพนักพิง (วัดระยะ D หรือ E – ขึ้นอยู่กับความต้องการของ คนพิการ) E ระยะจากที่น่ังถงึฐาน สะบัก 380 มม. ขนาดรถนั่งคนพิการที่เหมาะสมทีสุ่ด ความกว้างของที่รองนั่ง ความลึกของทีร่องนั่ง ความสูงของพนกัพิง รถนั่งคนพิการที่มีอยู่คันไหนขนาด ใกล้เคียงที่สุด? การวัดขนาดร่างกาย ขนาดรา่งกาย (มม.) การค านวณขนาดร่างกายไปสู ่ ขนาดของรถน่ังคนพิการที่เหมาะสม ขนาดของ รถน่ังคนพิการ A ความกว้างของสะโพก 420 มม. ความกว้างของสะโพก= ความกว้างของที่รองน่ัง B ความลึก ของที่น่ัง ซ้าย 460 มม. B ลบออก 30 – 50 มม. = ความลึกของที่รองน่ัง ขวา 460 มม. C ความยาว ของน่อง ซ้าย 360 มม. = จากขอบบนของเบาะรองน่ังถงึขอบหลงัของที่ วางเทา้ หรือ = จากขอบบนของเบาะรองน่ังถงึพื้น กรณีคน พิการใช้เท้าเข็นรถ ขวา 360 มม. D ระยะจากที่น่ังถงึชาย โครง 260 มม. = ระยะจากขอบบนของเบาะรองน่ังถึงขอบบน ของพนักพิง (วัดระยะ D หรือ E – ขึ้นอยู่กับความต้องการของ คนพิการ) E ระยะจากที่น่ังถงึฐาน สะบัก - ขนาดรถนั่งคนพิการที่เหมาะสมทีสุ่ด ความกว้างของที่รองนั่ง ความลึกของทีร่องนั่ง ความสูงของพนกัพิง รถนั่งคนพิการที่มีอยู่คันไหนขนาด ใกล้เคียงที่สุด? 20 B.7: การจัดเตรียมผลิตภัณฑ์ (รถนั่งคนพิการ) (Product (wheelchair) preparation) แบบตรวจสอบความพร้อมใช้งานของรถนั่งคนพิการ ชื่อหน่วยบริการ ชื่อผู้ใช้รถนั่งคนพิการ ชนิดของรถนั่งคนพิการ หมายเลขรถ รถนั่งคนพกิารทั งคัน ไม่มีขอบคม  ไม่มีส่วนใดฉีกขาดหรือช ารุด  รถน่ังคนพิการเคลื่อนที่ในแนวตรง  ล้อหน้า หมุนโดยอิสระ  หมุนโดยไม่สัมผัสตะเกียบ  น๊อตขันแน่น  ลูกปืนล้อหน้า ตะเกียบหมุนโดยอิสระ  ล้อหลัง หมุนโดยอิสระ  น๊อตยึดแกนล้อขันแน่น  ยางมีลมพอเหมาะ (ใช้น้ิวหัวแม่มือกดแล้วยางยุบลงน้อยกว่า 5 มม.)  วงปั่นมีความม่ันคง  เบรค ท าหน้าที่อย่างเหมาะสม  ที่พักเท้า ที่พักเท้ายึดอย่างม่ันคง  โครงรถ ส าหรับรถน่ังคนพิการแบบพับได้ – สามารถพับและกางได้โดยง่าย  ส าหรับรถน่ังคนพิการแบบพับพนักพิงลง – สามารถพับและกางได้โดยง่าย  เบาะรองนั่ง เบาะรองน่ังอยู่ในผ้าหุ้มอย่างถูกต้อง  เบาะรองน่ังวางบนที่รองน่ังอย่างถูกต้อง  ผ้าหุ้มเบาะรองน่ังตึงแต่ไม่ตึงเกินไป  ถ้ารถน่ังคนพิการเป็นแบบที่รองน่ังแข็ง: เบาะรองน่ังคลุมทั่วที่รองน่ังแข็ง  ชื่อผู้ตรวจสอบรถนั่งคนพิการ ลงช่ือ: วันที่: 21 B.8: การผลิตเบาะรองนั่ง (cushion fabrication) แอ่งรองรับปุ่มกระดูกรองน่ัง (Seat bones well) ค านวณขนาดของแอ่งที่เหมาะสมกับผู้ใช้รถนั่งคนพิการแต่ละรายที่ก าหนดให้ในตาราง ความกว้าง ความลึก ความสูง ผู้ใหญ่ – ความกว้างของที่รองนั่ง 360 มม. ผู้ใหญ่ – ความกว้างของที่รองนั่ง 460 มม. เด็ก – ความกว้างของที่รองนั่ง 280 มม. ค ำ การผลิตเบาะรองน่ัง Adult wheelchair user – 360 mm  ฝึกปฏิบัติจัดท าเบาะรองนั่งร่วมกับกลุ่ม  ท าตามขั้นตอนที่ให้ไว้ หากมีค าถามให้ถามผู้สอน 1. ขีดเส้นท่ีจะตัดลงบนแผ่นฟองน าแน่น  ใช้ฟองน้ าชนิดเนื้อแน่น ขนาด 400 มม. x 400 มม. x 50 มม.  จุดกึ่งกลางของแอ่งรองรับปุ่มกระดูกรองนั่งต้องอยู่กึ่งกลางของเบาะรองนั่ง  แอ่งรองรับปุ่มกระดูกรองนั่งควรมีขนาด 200 มม. x 200 มม. x 35 มม.  วาดเส้นที่จะตัดด้วยหมึกสีด าบนฟองน้ าทั้ง 6 ด้าน 22 2. ตัดส่วนแอ่งรองรับปุ่มกระดูกรองน่ัง: ใช้เลื่อยหรือมีดยาวที่คมตัดช้าๆเป็นแถบยาว การดึงแล้วตัดจะท าให้ ควบคุมการตัดได้ดี เริ่มจากตัดผ่านด้านหลังของเบาะไปถึงส่วนลึกของ แอ่งรองรบัปุ่มกระดกูรองนั่ง จากนั้นตัดขอบด้านข้างของแอ่งรองรับปุ่มกระดูก รองนัง่ออก ทากาวที่ขอบฟองน้ าแน่นด้านข้างแอ่งทัง้ 2 ข้าง ปล่อยให้กาวเกอืบแหง้สนทิแล้วกดฟองน้ าเข้าหากัน 3. ตัดส่วนลาดเอียงท่ีมุมด้านในของแอ่งรองรับปุ่มกระดูกรองน่ัง 4. ส าหรับท่ีรองน่ังแบบหย่อน: ตัดเป็นมุมลาดเอียงท่ีฐาน(ด้านล่าง)ทั ง 2 ข้าง  ท าเครื่องหมายดังตัวอย่าง แล้วตัด  การตัดส่วนน้ีจะช่วยให้เข้ากับรูปร่างของทีร่อง นั่งที่หย่อน 5. วางฟองน าชั นบนสุดทับลงบนเบาะรองน่ัง  วางส่วนฐานและส่วนบนของเบาะรองนั่งเข้าด้วยกัน  ไม่จ าเป็นต้องติดกาวระหว่างฟองน้ าทั้งสองช้ัน  หากช้ันบนสุดเปื้อนหรือขาด สามารถซัก ตากให้แห้งหรือเปลี่ยนใหม่ได้  อาจเพิ่มแผ่นฟองน้ าเสริมในผ้าหุ้มเพื่อเพิ่มความลึกของที่รองรับปุ่มกระดูกรองนั่งได้ 23 B.11: การฝึกผู้ใช้รถนั่งคนพิการ (user training)  อ่านเรื่องของผู้ใช้รถนั่งคนพิการแต่ละราย  ระบุทักษะที่จ าเป็นต้องสอนอย่างน้อย 3 ทักษะส าหรับผู้ใช้รถนั่งคนพิการแต่ละราย  ผู้เข้าอบรมควรเลือกอย่างน้อย 1 ทักษะ จากผู้ใช้รถนั่งคนพิการแต่ละคนในเรื่องที่อ่าน แล้วเปลี่ยนกันฝึก ปฏิบัติการสอนเทคนิคนั้นๆ โดยเปลี่ยนกันเป็น ผู้ใช้รถนั่งคนพิการ ญาติ และผู้สอน โมเสส ท่านคิดว่าทักษะใดมีประโยชน์กับโมเสส? โมเสสอายุ 23 ปี เขาตกจากรถบรรทุกเมื่อ 2 ปีก่อน และเป็นอัมพาตท่อนล่าง เขารักษาตัวในโรงพยาบาล 1 ปีแล้วกลับมาอยู่บ้านโดยได้รับบริจาครถนั่งคนพิการ เก่ามา 1 คัน แต่รถได้ช ารุดอย่างรวดเร็ว เขาจึงไม่ สามารถไปไหนมาไหนได้จนเกิดแผลกดทับข้ึนแต่ ขณะนี้รักษาแผลจนหายแล้ว โมเสสเพิ่งได้รับรถนั่งคนพิการพร้อมเบาะรองนั่งลด แรงกดทับจากหน่วยบริการรถนั่งคนพิการ ซึ่งรถคันนี้ ได้ออกแบบมาเพื่อใช้บนพื้นผิวขรุขระได้ เขาตื่นเต้น มากที่จะได้รถคันนี้ไปใช้ที่บ้าน และหวังว่าตนเองจะ เป็นอิสระมากข้ึน ไซแอน ท่านคิดว่าทักษะใดมีประโยชน์กับไซแอน? ไซแอนอายุ 40 ปีและขาขาดระดับเหนือเข่าทั้งสองข้าง เขาใช้รถนั่งคนพิการมาตลอด 20 ปีที่ผ่านมา และ เปลี่ยนรถนั่งคนพิการมาแล้ว 5 คัน เขาพบว่ารถนั่งคน พิการของเขาช ารุดเร็วมาก ไซแอนเป็นคนคล่องแคล่วมากและท างานในร้านค้าใน ท้องถ่ิน เขาต้องเดินทางจากบ้านของเขาไปที่ท างาน ทุกวันบนถนนที่ขรุขระเป็นหลุมบ่อ และมักเป็นโคลน เขาสาธิตให้ผู้ให้บริการดูว่าเขาสามารถยกล้อหน้า ช่ัวคราวได้อย่างไร เขาเพิ่งได้รับการสั่งรถนั่งคนพิการ เขาหวังว่ารถนั่งคน พิการคันใหม่ที่ได้รับนี้จะมีอายุการใช้งานนานกว่าคัน เดิม ซึ่งมีอายุการใช้งานเพียงแค่ 6 เดือนเท่านั้น 24 โซอี ท่านคิดว่าทักษะใดมีประโยชน์กับโซอี ? โซอี้อายุ 16 ปี เธอมีภาวะโปลิโอตั้งแต่ยังเด็ก ปัจจุบัน เธอไม่สามารถเดินได้ เธออายมากและไม่เคยไป โรงเรียน แม่ของโซอี้สอนหนังสือให้เธอที่บ้าน เธอ สามารถอ่านและเขียนได้ดี โซอี้เพิ่งได้รับรถนั่งคน พิการคันใหม่ และเธอสาธิตให้ผู้ให้บริการเห็นว่าเธอ สามารถเข้าและออกจากรถนั่งคนพิการได้โดยง่าย โซอี้สนใจเข้าเรียนในโรงเรียนฝึกอาชีพที่ในชุมชน อย่างไรก็ตามเธอไม่คิดว่าเธอจะสามารถไปและกลับ โรงเรียนได้เอง ทางเข้าตัวอาคารที่โรงเรียนมีบันได อยู่ 2-3 ข้ัน นอกจากนี้เธอยังกังวลเกี่ยวกับการเข้า ห้องน้ าในระหว่างที่อยู่ในโรงเรียนด้วย B.12: การดูแลรักษาและซ่อมแซม (maintenance and repairs) การดูแลรักษา  ระบุวิธีดูแลรักษารถนั่งคนพิการที่บ้าน 1. . . 2. . . 3. . . 4. . . 5. . . 6. . . การซ่อมแซม  ประเมินสภาพรถนั่งคนพิการแต่ละคันโดยละเอียด  ระบุว่าต้องซ่อมแซมอะไรบ้าง (หากมี) พร้อมบอกวิธีการซ่อมแซมในพื้นที่ของท่าน 25 รถน่ังคนพิการ A สิ่งท่ีต้องซ่อมแซม วิธีการซ่อมแซมในพื นท่ีของท่าน รถน่ังคนพิการ B สิ่งท่ีต้องซ่อมแซม วิธีการซ่อมแซมในพื นท่ีของท่าน รถน่ังคนพิการ C สิ่งท่ีต้องซ่อมแซม วิธีการซ่อมแซมในพื นท่ีของท่าน 26 B.13: การติดตามผล (follow up)  อ่านเรื่องเล่าของผู้ใช้รถนั่งคนพิการ  อภิปรายถึงสิ่งที่ควรปฏิบัติ  กรอกแบบฟอร์มติดตามผลส าหรับผู้ใช้รถนั่งคนพิการแต่ละราย พร้อมทั้งบันทึกสิ่งที่ต้องปฏิบัติด้วย ฮาล่า ฮาล่า อาศัยอยู่กับครอบครัวและลูกสาวที่ก าลังโตของเธอ เธอได้รับรถนั่งคนพิการเมื่อ 6 เดือนก่อน เธอ ป่วยด้วยโรคหลอดเลือกสมองมาประมาณ 1 ปี และไม่สามารถเดินได้ ตอนได้รับรถนั่งคนพิการ เธอได้ฝึก การเคลื่อนย้ายตัวในท่ายืนโดยมีลูกสาวช่วย เธอพูดว่าเธอต้องการรถนั่งคนพิการเพื่อจะได้ช่วยเหลือที่บ้าน ได้และสามารถไปโบสถ์ได้ ในการติดตามผล ฮาล่าบอกว่าเธอไม่ได้ออกไปนอกบ้านมาหลายเดือนแล้ว พื้นถนนไปบ้านเธอขรุขระและ มีพื้นต่างระดับจากบ้านเธอไปถีงถนน อย่างไรก็ตามเธอสามารถใช้รถนั่งคนพิการในบ้านได้และสามารถ ช่วยเหลือลูกสาวในการดูแลหลานๆได้ เธอนั่งตัวตรงในรถนั่งคนพิการและรถได้รับการดูแลอย่างดี ปัจจุบันน้ีเธอสามารถเคลื่อนย้ายตัวจากรถนั่งคนพิการได้ด้วยตัวเอง ดารัน ดารัน มีภาวะบาดเจ็บไขสันหลัง เขาท างานในร้านซ่อมวิทยุในตลาดท้องถ่ิน เขาได้รับรถนั่งคนพิการและ เบาะรองนั่งลดแรงกดทับเมื่อ 2 ปีก่อน ในการติดตามผล เขาบอกว่าเขาใช้รถนั่งคนพิการทุกวันในการไป และกลับจากตลาด และเขาไม่มีแผลกดทับ ยางรถเขาเคยรั่ว แต่เขาซ่อมเองได้ เมื่อตรวจสอบรถนั่งคนพิการ เจ้าหน้าที่พบว่าซี่ล้อหลวม และบริ เวณ ฐานที่นั่งมีน๊อตหาย 2 ตัว แผ่นฟองน้ านิ่มช้ันบนของเบาะรองนั่งเขาแบนแฟบ เขานั่งได้ดีในรถนั่งคน พิการและบอกว่ารู้สึกพอใจกับรถคันน้ี ตาวฮา ตาวฮา อายุ 10 ปี เขามีภาวะสมองพิการเล็กน้อย และเข้ารเยนที่โรงเรียนท้องถ่ิน เขาได้รับรถนั่งคนพิการ พร้อมด้วยเบาะรองนั่งส าหรับจัดท่าทางเมื่อ 1 ปีที่ผ่านมา ในการติดตามผล ตาวฮาบอกว่าเขาใช้รถนั่งคนพิการไปโรงเรียนทุกวัน โดยพอ่เขนรถให้เขาเนื่องจากเขาไม่ แข็งแรงพอที่จะปั่นรถด้วยตัวเอง รถนั่งคนพิการของเขาได้รับการซ่อมแซมอย่างดี พ่อของเขาบอกว่าเขา เคยซ่อมยางรถแล้ว 1 ครั้ง ผู้ให้บริการสังเกตเห็นว่าตาวฮาตัวโตข้ึน และขาของเขาเริ่มไม่อยู่บนที่รองนั่ง อย่างเหมาะสมเนื่องจากที่พักเท้าสูงเกินไปส าหรับเขา 27 บันทกึสิ่งที่ต้องปฏิบตั ิ แบบฟอร์มติดตามผล แบบฟอร์มนี ใช้บันทึกข้อมูลที่ได้จากการติดตามผล 1. ข้อมูลเกี่ยวกับผู้ใช้รถนั่งคนพิการ ชื่อผูใ้ช้รถน่ังคนพิการ หมายเลข .. วันที่ลองอุปกรณ์ วันที่ติดตามผล . ชื่อผู้ติดตามผล การติดตามผลด าเนินการที่:  บ้านของผู้ใช้รถน่ังคนพิการ  หน่วยบริการรถน่ังคนพิการ  อ่ืนๆ 2. การสัมภาษณ์ คุณได้ใช้รถน่ังคนพิการมากเท่าที่คุณต้องการหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่- เพราะอะไร? คุณมีปัญหาจากการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ – มีปัญหาอะไร? คุณมีค าถามเก่ียวกับการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช้ – ค าถามเก่ียวกับอะไร? จ าเป็นต้องฝึกเพิ่มเติมหรือไม่? ผู้ใช้รถน่ังคนพิการทีแผลกดทับหรือมไม่?  ใช่  ไม่ใช่ บรรยาย (ต าแหน่งและระยะของแผล) คุณจะให้คะแนนความพึงพอใจต่อรถน่ังคนพิการของคุณก่ีคะแนน จาก 1-5? (1 =ไม่พึงพอใจ และ 5 = พึงพอใจมาก) คะแนน: ความเห็น: 3. ตรวจสอบรถนั่งคนพิการและเบาะรองนั่ง รถน่ังคนพิการอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ เบาะรองน่ังอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ ถ้าข้อใดข้อหน่ึงตอบไม่ใช่ – มีปัญหาอะไร? 4. ตรวจสอบความพอดี รถน่ังคนพิการขนาดพอดีหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? การทดสอบแรงกดทับ (1=ปลอดภัย 2=เตือนภัย 3=ไม่ปลอดภัย) (กรณีที่ผู้ใช้รถน่ังคนพิการมีความเสี่ยงต่อการเกิดแผลกดทับ) ซ้าย: ขวา: ผู้ใช้รถน่ังคนพิการน่ังตัวตรงทั้งขณะอยู่น่ิง ขณะเคลื่อนที่และ ระหว่างวันหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? 28 บันทกึสิ่งที่ต้องปฏิบตั ิ แบบฟอร์มติดตามผล แบบฟอร์มนี ใช้บันทึกข้อมูลที่ได้จากการติดตามผล 1. ข้อมูลเกี่ยวกับผู้ใช้รถนั่งคนพิการ ชื่อผูใ้ช้รถน่ังคนพิการ หมายเลข .. วันที่ลองอุปกรณ์ วันที่ติดตามผล . ชื่อผู้ติดตามผล การติดตามผลด าเนินการที่:  บ้านของผู้ใช้รถน่ังคนพิการ  หน่วยบริการรถน่ังคนพิการ  อ่ืนๆ 2. การสัมภาษณ์ คุณได้ใช้รถน่ังคนพิการมากเท่าที่คุณต้องการหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่- เพราะอะไร? คุณมีปัญหาจากการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ – มีปัญหาอะไร? คุณมีค าถามเก่ียวกับการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช้ – ค าถามเก่ียวกับอะไร? จ าเป็นต้องฝึกเพิ่มเติมหรือไม่? ผู้ใช้รถน่ังคนพิการทีแผลกดทับหรือมไม่?  ใช่  ไม่ใช่ บรรยาย (ต าแหน่งและระยะของแผล) คุณจะให้คะแนนความพึงพอใจต่อรถน่ังคนพิการของคุณก่ีคะแนน จาก 1-5? (1 =ไม่พึงพอใจ และ 5 = พึงพอใจมาก) คะแนน: ความเห็น: 3. ตรวจสอบรถนั่งคนพิการและเบาะรองนั่ง รถน่ังคนพิการอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ เบาะรองน่ังอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ ถ้าข้อใดข้อหน่ึงตอบไม่ใช่ – มีปัญหาอะไร? 4. ตรวจสอบความพอดี รถน่ังคนพิการขนาดพอดีหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? การทดสอบแรงกดทับ (1=ปลอดภัย 2=เตือนภัย 3=ไม่ปลอดภัย) (กรณีที่ผู้ใช้รถน่ังคนพิการมีความเสี่ยงต่อการเกิดแผลกดทับ) ซ้าย: ขวา: ผู้ใช้รถน่ังคนพิการน่ังตัวตรงทั้งขณะอยู่น่ิง ขณะเคลื่อนที่และ ระหว่างวันหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? 29 บันทกึสิ่งที่ต้องปฏิบตั ิ แบบฟอร์มติดตามผล แบบฟอร์มนี ใช้บันทึกข้อมูลท่ีได้จากการติดตามผล 1. ข้อมูลเกี่ยวกับผู้ใช้รถนั่งคนพิการ ชื่อผูใ้ช้รถน่ังคนพิการ หมายเลข .. วันที่ลองอุปกรณ์ วันที่ติดตามผล . ชื่อผู้ติดตามผล การติดตามผลด าเนินการที่:  บ้านของผู้ใช้รถน่ังคนพิการ  หน่วยบริการรถน่ังคนพิการ  อ่ืนๆ 2. การสัมภาษณ์ คุณได้ใช้รถน่ังคนพิการมากเท่าที่คุณต้องการหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่- เพราะอะไร? คุณมีปัญหาจากการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ – มีปัญหาอะไร? คุณมีค าถามเก่ียวกับการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช้ – ค าถามเก่ียวกับอะไร? จ าเป็นต้องฝึกเพิ่มเติมหรือไม่? ผู้ใช้รถน่ังคนพิการทีแผลกดทับหรือมไม่?  ใช่  ไม่ใช่ บรรยาย (ต าแหน่งและระยะของแผล) คุณจะให้คะแนนความพึงพอใจต่อรถน่ังคนพิการของคุณก่ีคะแนน จาก 1-5? (1 =ไม่พึงพอใจ และ 5 = พึงพอใจมาก) คะแนน: ความเห็น: 3. ตรวจสอบรถนั่งคนพิการและเบาะรองนั่ง รถน่ังคนพิการอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ เบาะรองน่ังอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ ถ้าข้อใดข้อหน่ึงตอบไม่ใช่ – มีปัญหาอะไร? 4. ตรวจสอบความพอดี รถน่ังคนพิการขนาดพอดีหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? การทดสอบแรงกดทับ (1=ปลอดภัย 2=เตือนภัย 3=ไม่ปลอดภัย) (กรณีที่ผู้ใช้รถน่ังคนพิการมีความเสี่ยงต่อการเกิดแผลกดทับ) ซ้าย: ขวา: ผู้ใช้รถน่ังคนพิการน่ังตัวตรงทั้งขณะอยู่น่ิง ขณะเคลื่อนที่และ ระหว่างวันหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? 30 B.14: สรุปทั งหมดด้วยกัน (putting it all together) เตรียมการน าเสนอกลุ่มละ 10 นาท ี การน าเสนอควรประกอบด้วย 1. ข้อมูลท่ีได้จากการประเมิน  เป้าหมายของผู้ใช้รถนั่งคนพิการ (เพราะอะไรเขา/เธอจึงต้องการรถนั่งคนพิการ)  ความจ าเป็นทางร่างกายของเขา/เธอ  ความจ าเป็นด้านวิถีชีวิตของเขา/เธอ  เขา/เธอมีรถนัง่คนพิการอยู่หรือไม่ – รถนั่งคนพิการนั้นตอบสนองความต้องการของเขา/เธอหรอืไม ่  การมีแผลกดทับ ความเสี่ยงต่อแผลกดทบั หรือประวัติการเป็นแผล  วิธีการปั่นรถนั่งคนพกิาร  ท่าทางการนั่งโดยไมม่ีการประคองร่างกาย  ผลการคัดกรองท่าทางของเชิงกรานและข้อสะโพก 2. รถน่ังคนพิการและเบาะรองน่ังท่ีพิจารณาให้  ชนิดของรถนั่งคนพิการ  ชนิดของเบาะรองนัง่  อุปกรณ์ประคองร่างกายทีพ่ิจารณาให ้ 3. การลองอุปกรณ์  ระหว่างลองอุปกรณ์พบปัญหาอะไรบ้างที่ต้องแก้ไข – และแก้ไขอย่างไร 4. การฝึกผู้ใช้รถน่ังคนพิการ  ทักษะใดบ้างที่ผูเ้ข้าอบรมกบัผู้ใช้รถนัง่คนพิการได้เลือกส าหรับการฝกึ? 5. การสะท้อนความคิดเห็นของผู้ใช้รถน่ังคนพิการ  หลงัจากไดร้ับรถนั่งคนพิการ – ผู้ใช้รถนั่งคนพิการมีความเหน็หรือสะทอ้นข้อมลูอะไรหรอืไม่? 6. การดแูลรักษาและซ่อมแซม  หลงัจากไดร้ับรถนั่งคนพิการ – ต้องดูแลรักษาอย่างไรและบอ่ยเพียงใด?  หากรถนั่งคนพิการหรอืเบาะรองนั่งจ าเป็นต้องได้รบัการซ่อมแซม – จะต้องท าอย่างไร? 7. แผนการติดจามผล  มีการนัดหมายติดตามผลอย่างไร? Sirindhorn National Medical Rehabilitation Centre, Department of Medical Services, Ministry of Public Health, 88/26, Bumratnaradul, Tiwanon road, Meuang, Nonthaburi, Thailand 11000 www.snmrc.go.th

หลักสูตรอบรมการให้บริการรถนั่งคนพิการ: คู่มือประกอบการอบรม - ระดับพื้นฐาน เนื้อหา: คู่มือผู้สอน ระดับพ้ืนฐาน - คู่มือประกอบการอบรม ระดับพ้ืนฐาน - สมุดงานส าหรับผู้เข้าอบรม ระดับพ้ืนฐาน - โปสเตอร์และสไลด์น าเสนอ 1.รถนั่งคนพิการ – มาตรฐาน 2.คนพิการ – การฟื้นฟูสมรรถภาพ 3.เอกสารการสอน Published by the World Health Organization in 2012 under the title Wheelchair service training package: reference manual for participants. Basic level © World Health Organization 2012 The World Health Organization has granted translation and publication rights for an edition in Thai to the Sirindhorn National Medical Rehabilitation Centre, which is solely responsible for the quality and faithfulness of the Thai translation. In the event of any inconsistency between the English and the Thai editions, the original English edition shall be the binding and authentic edition. หลักสูตรอบรมการให้บริการรถนั่งคนพิการ: คู่มือประกอบการอบรม - ระดับพื้นฐาน © Sirindhorn National Medical Rehabilitation Centre 2014 (of English version) นิยามศัพท ์ ค าศัพท์ท่ีใช้ในหลักสูตรอบรมน้ี รถน่ังคนพิการท่ีเหมาะสม (Appropriate wheelchair) รถนั่งคนพิการที่ตอบสนองความต้องการของผู้ ใ ช้งาน ตลอดจนเหมาะสมกับสภาพแวดล้อม มีขนาดพอดีและให้การ รองรับร่างกาย มีความปลอดภัยและทนทาน สามารถจัดหา ได้ในประเทศนั้นๆ สามารถเข้าถึงและการดูแลรักษา และมี บริการที่ยั่งยืนภายในประเทศ ในราคาประหยัดและสามารถ ซื้อได ้ รถน่ังคนพิการแบบขับเคลื่อนด้วยแรงคน (manual wheelchair) รถนั่งคนพิการที่ขับเคลื่อนโดยผู้ใช้งาน หรือเข็นโดยผู้อื่น รถน่ังคนพิการ (wheelchair) อุปกรณ์เครื่องช่วยในการเคลื่อนที่ด้วยลอ้และมีที่นั่งส าหรับ บุคคลที่มีความยากล าบากในการเดินหรือการเคลือ่นที่ การจัดหารถน่ังคนพิการ (wheelchair provision) เป็นศัพทก์ว้างๆที่ครอบคลุมการออกแบบ การผลิต การ สนับสนุนและให้บริการรถนั่งคนพกิาร บริการรถน่ังคนพิการ (wheelchair service) เป็นส่วนหนึ่งของการให้บริการรถนั่งคนพกิาร เน้นการท าให้ ผู้ใช้งานได้รับรถนั่งคนพิการที่เหมาะสม บุคลากรผู้ท่ีให้บริการรถน่ังคนพิการ (wheelchair service personnel) บุคคลที่มทีักษะด้านการให้บริการรถนัง่คนพิการที่เหมาะสม ผู้ใช้รถน่ังคนพิการ (wheelchair user) บุคคลที่มีความยากล าบากในการเดินหรือการเคลือ่นที่และใช้ รถนั่งคนพิการเพื่อการเคลื่อนที ่ ค าน า เกี่ยวกบัหลักสูตรการอบรมเรือ่งการใหบ้ริการรถนั่งคนพิการ: ระดับพื้นฐาน A. ความรู้หลกั A .1 : ผู้ใช้รถนั่งคนพิการ ประโยชน์ของรถนั่งคนพกิาร “รถนั่งคนพิการทีเ่หมาะสม” คืออะไร? อนุสัญญาว่าด้วยสิทธิคนพิการขององค์การสหประชาชาติ A.2 : บริการรถนั่งคนพกิาร A.3 : การใช้รถนั่งคนพิการ A.4 : การนั่งตัวตรง A.5 : แผลกดทับ A.6 : รถนั่งคนพิการทีเ่หมาะสม ตรงกับความต้องการของผู้ใช้ เหมาะสมกบัสภาพแวดลอ้มของผู้ใช้ ขนาดพอดีและให้การรองรบัร่างกาย A.7: เบาะรองนั่ง A.8: การเคลื่อนย้ายตัว B. ข้ันตอนการให้บริการรถนั่งคนพกิาร ข้ันตอนที่ 1 การส่งต่อและนัดหมาย ข้ันตอนที่ 2 การประเมิน ข้ันตอนที่ 3 การพิจารณา (เลือก) รถนัง่คนพิการ ข้ันตอนที่ 4 งบประมาณและการสั่งซือ้ ข้ันตอนที่ 5 การเตรียมผลิตภัณฑ์ (รถนั่งคนพิการ) ข้ันตอนที่ 6 การลองอปุกรณ์ ข้ันตอนที่ 7 การฝึกผู้ใช้รถนั่งคนพิการ ข้ันตอนที่ 8 : การดูแลรักษา ซ่อมแซม และติดตามผล ค าน า รถนั่งคนพิการเป็นหนึ่งในอุปกรณ์เครื่องช่วยที่มีการใช้อย่างแพร่หลายเพื่อส่งเสริมความสามารถด้านการเคลื่อนที่ ของบุคคล ซึ่งเป็นส่วนหนึ่งของสิทธิมนุษยชน และการด ารงชีวิตอย่างมีศักดิ์ศรี ทั้งนี้เพื่อให้คนพิการสามารถเป็น สมาชิกที่มีคุณค่าของสังคม การได้รับรถนั่งคนพิการที่มีการออกแบบและขนาดที่เหมาะสม จึงเป็นก้าวแรกในการ มีส่วนหนึ่งและมีส่วนร่วมในสังคมของคนพิการ องค์การสหประชาชาติได้ออกกฎ Standard Rules on the Equalization of Opportunities for Persons with Disabilities, the Convention on the Rights of Persons with Disabilities and World Health Assembly resolution WHA58.23 ซึ่งเกี่ยวข้องกับความพิการ ทั้งด้านการป้องกัน การดูแลและฟื้นฟู สมรรถภาพ และเน้นความส าคัญของรถนั่งคนพิการและอุปกรณ์เครื่องช่วยต่างๆ เพื่อให้มั่นใจว่าคนพิการสามารถ เข้าถึงรถนั่งคนพิการที่เหมาะสม โดยเฉพาะอย่างยิ่งในภูมิภาคต่างๆของโลกที่มีทรัพยากรจ ากัด องค์การอนามัย โลกได้พัฒนาแนวทางการให้บริการรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคนในพื้นที่ที่มีทรัพยากรจ ากัด (Guidelines on the provision of manual wheelchairs in less resourced settings)ทั้งนี้โดยได้รับความ ร่วมมือจาก United States Agency for International Development (USAI D) and the International Society for Prosthetics and Orthotics (ISPO). องค์การอนามัยโลกได้พัฒนาหลักสูตรการอบรมเรื่องการให้บริการรถนั่งคนพิการ : ระดับพื้นฐาน ข้ึนเพื่อใช้ ฝึกอบรมบุคคากรที่เกี่ยวข้องอย่างเหมาะสม และมีระบบการให้บริการรถนั่งคนพิการบนพื้นฐานของแนวทางการ ให้บริการฯ ขององค์การอนามัยโลกดังกล่าว 1 เกี่ยวกับหลักสูตรการอบรมเร่ืองการให้บริการรถนั่งคนพิการระดับพ้ืนฐาน บทน า หลังจากมีการเผยแพร่ แนวทางการให้บริการรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคนในพื้นทีท่ีม่ทีรพัยากร จ ากัด (Guidelines on the provision of manual wheelchairs in less resourced settings)1 ในปี 2008 แล้ว ต่อมาองค์การอนามัยโลกได้พัฒนา หลักสูตรอบรมเรื่องการให้บริการรถนั่งคนพิการ – ระดับพื้นฐาน (Wheelchair Service Training Package – Basic Level) ข้ึน รถนั่งคนพิการเป็นหนึ่งในอุปกรณ์เครื่องช่วยที่มีการใช้อย่างแพร่หลาย เพื่อส่งเสริมความสามารถด้านการ เคลื่อนที่ ในบุคคลที่มีความยากล าบากในการเดิน รถนั่งคนพิการที่ตอบสนองความต้องการด้านกายภาพ เหมาะสมกับวิถีชีวิตและสภาพแวดล้อมถือเป็นเครื่องมือที่มีความจ าเป็นในการส่งเสริมพวกเขาให้มีสุขภาวะ ที่ดี ทั้งด้านสุขภาพ สังคมและเศรษฐกิจ การเคลื่อนที่เป็นการเปิดโอกาสให้บุคคลสามารถเข้ารับ การศึกษา ไปท างาน เข้าร่วมกิจกรรมทางวัฒนธรรมและเข้าถึงบริการต่างๆ เช่น บริการด้านสุขภาพ การเคลื่อนที่เปิดโอกาสส าหรับผู้ใช้รถนั่งคนพิการในการศึกษา ท างาน และเข้าร่วมในกิจกรรมด้านสังคม และเข้าถึงบริการต่างๆ เป็นต้นว่า การดูแลสุขภาพ ความส าคัญของการเคลื่อนที่ได้ระบุไว้ในอนุสัญญาว่าด้วยสิทธิคนพิการขององค์การสหประชาชาติ (the United Nations Convention on the Rights of Persons with a Disability; UNCRPD) ซึ่งได้ สนับสนุน "มาตรการที่มีประสิทธิผลเพื่อให้แน่ใจว่าคนพิการสามารถเคลื่อนที่ได้โดยอิสระมากที่สุดเท่าที่ เป็นไปได้" เพื่อให้การเคลื่อนที่ที่มีประสิทธิผล ผู้ใช้งานต้องการรถนั่งคนพิการที่ขนาดพอดีและตรงกับความ ต้องการที่จ าเพาะเจาะจง ซึ่งต้องมีวิธีการตอบสนองความต้องการของผู้ใช้รถนั่งคนพิการ วิธีหนึ่งที่มีประสิทธิผลในการตอบสนองต่อความต้องการของผู้ใช้งาน นั่นคือการให้บริการผ่านบริการรถนั่ง คนพิการ อย่างไรก็ตาม จากข้อมูลทางสถิติแสดงให้เห็นว่ามีน้อยกว่าร้อยละ 5 ของผู้ที่มีความ ต้องการรถนั่งคนพิการที่ได้รับรถนั่งคนพิการที่เหมาะสม นอกจากนี้ยังมีบุคลากรผู้ให้บริการยังมีโอกาสใน การเพิ่มพูนทักษะที่จ าเป็นในการพิจารณารถนั่งคนพิการอย่างมีประสิทธิผล หลักสูตรการอบรมเรื่องการให้บริการรถนั่งคนพิการ – ระดับพื้นฐาน มีความตั้งใจเพื่อให้การสนับสนุน เพิ่มเติมความรู้แก่บุคลากรผู้เกี่ยวข้องทั้งในบทบาททางเทคนิคและทางคลินิกในการให้บริการรถนั่งคน พิการ (ดูแนวทางการให้บริการรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคนในพื้นที่ที่มีทรัพยากรจ ากัด ตาราง 4.2) ในระดับพื้นฐาน หลักสูตรนี้มีทั้งเนื้อหาด้านทฤษฎีและปฏิบัติที่จ าเป็นในการให้บริการแก่ผู้ใช้รถนั่ง คนพิการที่สามารถนั่งได้โดยไม่ต้องใช้อุปกรณ์ประคองท่าทาง หลักสูตร ประกอบด้วย วิธีการประเมิน ความต้องการรายบุคคล การช่วยเหลือเพื่อเลือกและปรับรถนั่งคนพิการที่เหมาะสมที่สุดที่มีอยู่ การฝึกใช้ งานและดูแลรถนั่งคนพิการแก่ผู้ใช้และผู้ดูแล ตลอดจนการติดตามผล 2 หลักสูตรการอบรมนี้ใช้เวลาประมาณ 35-40 ช่ัวโมง ซึ่งอาจปรับเพิ่มหรือลดเวลาได้ข้ึนอยู่กับความ ต้องการจเพาะเจาะจงและทรัพยากรที่มีในแต่ละบริบท ควรมีการฝกึปฏิบัติเพิ่มเติมกับที่ปรึกษาเพื่อสร้าง เสริมสมรรถนะและความสามารถในการปฏิบัติงานโดยอิสระ องค์การอนามัยโลกหวังว่าหลักสูตรนีจ้ะถูกน าไปใช้ทัง้เป็นการฝึกระยะสั้นส าหรับบุคลากรที่เกี่ยวข้อง และมี การบรูณาการสู่หลักสูตรการฝึกอบรมส าหรบับุคลากรด้านการฟื้นฟูด้วย กลุ่มเป้าหมายผู้เข้าอบรม หลักสูตรอบรมนี้ใช้ส าหรับบุคลากรหรืออาสาสมัครที่มีหน้าที่บริการรถนั่งคนพิการในที่ท างานของพวกเขา ซึ่งอาจได้แก่ บุคลากรด้านสาธารณสุข ด้านการฟื้นฟู หรือบุคลากรทาช่างเทคนิค เจ้าหน้าที่ด้านการฟื้นฟู สมรรถภาพในชุมชน (CBR) นักกิจกรรมบ าบัด นักกายภาพบ าบัด นักกายอุปกรณ์เสริม นักกายอุปกรณ์ เทียม ช่างฝีมือในท้องถ่ิน ช่างเทคนิค รวมทั้งผู้ใช้รถนั่งคนพิการ เป้าประสงค ์ หลักสูตรอบรมระดับพื้นฐานนีอ้อกแบบเพื่อสนับสนุนการอบรมบุคลากรหรืออาสาสมัครในหารใหบ้รกิารรถ นั่งคนพิการแบบขับเคลื่อนด้วยแรงคนและเบาะรองนั่งที่เหมาะสมส าหรับคนทุกเพศทุกวัยที่มีที่มีความ บกพร่องทางการเคลื่อนไหวที่สามารถนั่งตรงได้โดยไม่ต้องมีการรองรับท่าทางเพิ่มเติม เป้าประสงค์หลักของหลักสูตรการอบรมนี้คือการพฒันาความรู้และทักษะแกบุ่คลากรทีม่ีส่วนเกี่ยวกับการ ให้บรกิารรถนั่งคนพิการ โดยการให้การอบรมตามหลักสูตรนี้จะช่วยให ้  เพิ่มจ านวนผู้ใช้รถนั่งคนพิการที่ได้รบัรถนัง่คนพิการที่ตรงกบัความต้องการของเขาเหล่าน้ัน  เพิ่มจ านวนผู้ใช้รถนั่งคนพิการที่ได้รบัการสอนวิธีการใช้งานและดูแลรักษารถนั่งคนพกิาร รวมทั้งดูแลให้ มีสุขภาพดีเมือ่ใช้รถนั่งคนพิการ  เพิ่มจ านวนบุคลากรที่ได้ผ่านการฝึกอบรมการให้บริการรถนัง่คนพิการระดับพื้นฐาน  เพิ่มระดับความสามารถของบุคลากรผู้ใหบ้ริการรถนัง่คนพิการ  เพิ่มคุณภาพของการให้บริการรถนัง่คนพิการ  บรรลุถึงการบูรณาการของบริการรถนัง่คนพิการในงานฟื้นฟสูมรรถภาพมากข้ึน ขอบเขตของเนือ้หา หลักสูตรนีป้ระกอบด้วย 3  เนื้อหาโดยรวมของข้ันตอนในการใหบ้รกิารรถนั่งคนพิการ 8 ข้ันตอน ดังอธิบายใน แนวทางการ ให้บรกิารรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคนในพื้นที่ทีม่ีทรัพยากรจ ากัดขององค์การอนามัยโลก (ตาราง 1)  ร่วมกับผู้ใช้รถนั่งคนพิการเพื่อประเมินความต้องการในการเคลื่อนที่และระบุหนทางแกป้ัญหาที่ดีทีสุ่ด  การใหร้ถนั่งคนพิการที่เหมาะสมพร้อมด้วยเบาะรองนั่งทีเ่หมาะสม  แก้ไขปัญหาเพื่อดัดแปลงเบื้องต้นเพือ่ให้รถนัง่คนพิการมีขนาดพอดีกับผู้ใช้มากทีสุ่ด  การดแูลรักษาและซ่อมแซมรถนัง่คนพิการ  ฝึกการใช้งานแก่ผู้ใช้รถนัง่คนพิการให้ใช้งานได้อย่างดีทีสุ่ด  การผลิตเบาะรองนัง่ฟองน้ าแบบเข้ารูป การให้ความรู้ในการดัดแปลงรถนั่งคนพิการอย่างง่ายจะมีประโยชน์อย่างมากในพื้นที่ที่มีข้อจ ากัดในเรื่อง ของชนิดและขนาดของรถนั่งคนพิการ จึงมักจ าเป็นต้องดัดแปลงรถนั่งคนพิการง่ายๆเพื่อให้เหมาะสมกับ ผู้ใช้ การให้บริการรถโยกไม่รวมอยู่ในรายละเอียดของหลักสูตรนี้ แม้ว่ารถโยกจะมีประโยชน์กับผู้ใช้รถนั่งคน พิการที่ต้องการเดินทางในระยะไกลข้ึน ตารางท่ี 1 ขั้นตอนหลักในการให้บริการรถน่ังคนพิการ ขั้นตอนท่ี 1 การสง่ต่อและนัดหมาย (referral and appointment) ขั้นตอนท่ี 2 การประเมิน (assessment) ขั้นตอนท่ี 3 การพิจารณา/เลือก (prescription/selection) ขั้นตอนท่ี 4 การหางบประมาณและการสัง่ซื้อ (funding and ordering) ขั้นตอนท่ี 5 การจัดเตรียมผลิตภัณฑ์ (รถนั่งคนพิการ) (Product (wheelchair) preparation) ขั้นตอนท่ี 6 การลองอปุกรณ์(fitting) ขั้นตอนท่ี 7 การฝกึผู้ใช้รถนัง่คนพิการ (user training) ขั้นตอนท่ี 8 การดูแลรักษา ซ่อมแซม และติดตามผล (maintenance, repairs, and follow-up) ความรู้และทกัษะที่จ าเป็น การอบรมเรื่องการใหบ้รกิารรถนั่งคนพิการนี้ ผู้เข้าอบรมไม่จ าเป็นต้องมี ประสบการณ์มากอ่น อย่างไรก็ตามควรมีทักษะและความรูเ้บื้องต้น ต่อไปนี้  สามารถอ่านและเขียนภาษาที่ใช้ในการอบรมได ้  มีความรู้พื้นฐานเกี่ยวกับปัญหาสุขภาพทั่วไป หรือความบกพร่องด้านร่างกายต่างๆซึง่อาจสง่ผลใหผู้้คน ต้องใช้รถนั่งคนพิการ ได้แก่ ภาวะสมองพิการ การสูญเสียอวัยวะส่วนล่างของร่างกาย โรคโปลิโอ การ บาดเจบ็ไขสันหลงั และโรคหลอดเลือดสมอง 4 ในกรณีที่ผูเ้ข้าอบรมไมม่ีความรู้พื้นฐานเหล่าน้ี ผูส้อนควรเพิม่เติมเนื้อหาเหล่าน้ีในเนื้อหาของความรู้หลัก (core knowledge) ด้วย ขอบเขตเนื้อหา หลักสูตรการอบรมเรื่องการให้บริการรถนั่งคนพิการระดับพืน้ฐานถูกออกแบบเพือ่ให้ท าการฝึกอบรมโดย ผู้สอนที่มีทกัษะด้านการให้บริการรถนั่งคนพกิารระดับพื้นฐานและมสีมรรถนะในการสอน โดยมีวัสดุ อุปกรณ์ประกอบการอบรมดังนี ้  คู่มือและอปุกรณ์ส าหรับผูส้อน  คู่มือประกอบการอบรมส าหรบัผูเ้ข้าอบรม (ฉบับนี้)  ใบงานส าหรบัผูเ้ข้าอบรม  แบบฟอร์มการใหบ้รกิารรถนั่งคนพิการ  แบบบันทึกการตรวจสอบความพร้อมใช้งานของรถนัง่คนพิการ  สื่อต่างๆ ประกอบด้วย สไลด์น าเสนอ วีดีโอและโปสเตอร ์ กระบวนการพฒันา ภายหลังการเผยแพร่ แนวทางการให้บริการรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคนในพื้นที่ที่มีทรัพยากร จ ากัด (องค์การอนามัยโลก 2008) องค์การอนามัยโลกได้แต่งตั้งคณะท างานเพื่อพัฒนาหลักสูตรการอบรม เรื่องการให้บริการรถนั่งคนพิการข้ึน การประชุมครั้งแรกของคณะท างานจัดโดยองค์การอนามัยโลกในเดอืน ตุลาคม ปีค.ศ. 2008 เพื่อก าหนดขอบเขตและเนื้อหาของหลักสูตร หลังจากนั้นได้ส่งให้ผู้เช่ียวชาญที่ เกี่ยวข้องให้ความเห็นจ านวนกว่า 20 คน จากนั้นคณะท างานหลักจึงจัดท าหลักสูตรน าร่อง ในปีค.ศ. 2010 ได้เริ่มโครงการน าร่องในประเทศอินเดีย เกาะโซโลมอนและประเทศเคนย่า โครงการน าร่อง ดังกล่าวมีผู้สังเกตการณ์จากคณะท างานของคณะท างานพัฒนาหลักสูตร ความคิดเห็นจากผู้สอน ผู้เข้า อบรมและผู้ใช้รถนั่งคนพิการได้ถูกน ามาใช้ในการปรับปรุงหลักสูตรจนเป็นฉบับล่าสุด นอกจากนี้ หลักสูตรฉบับน าร่องนี้ได้ถูกส่งให้ผู้เช่ียวชาญที่เกี่ยวข้องเพื่ออ่านทบทวน (peer review) และให้ความ คิดเห็นที่มีคุณค่า ผู้แต่งทุกคนที่มสี่วนร่วมในการพัฒนาหลักสูตรได้ลงลายมือช่ือไว้ในประกาศยืนยันแหง่ผลประโยชน์ (Declaration of Interest; DOI) และไม่แสดงผลประโยชนท์ับซ้อนใดๆ 5 A. ความรู้หลัก 6 A.1: ผู้ใช้รถนั่งคนพิการ (wheelchair user) ผู้ใช้รถนั่งคนพิการคือบุคคลที่มรีถนั่งคนพิการอยู่แล้วหรือบคุคลจะได้รบัประโยชน์จากการใช้รถนัง่คนพิการ อันเนื่องมาจากมีข้อจ ากัดในการเดิน ผู้ใช้รถนั่งคนพิการ ประกอบด้วย  เด็ก ผู้ใหญ่ ผูสู้งอายุ ทั้งเพศชาย เพศหญิง เด็กผู้หญิงและเดก็ผู้ชาย  บุคคลที่มีความบกพร่องด้านการเคลื่อนทีรู่ปแบบต่างๆ ที่มีความแตกต่างของรปูแบบการด าเนินชีวิต และภูมิหลังของชีวิต  บุคคลผู้อาศัยและท างานในสิ่งแวดล้อมต่างๆ ประกอบด้วยชนบท กึ่งชนบทกึ่งเมือง และในสงัคมเมือง ถึงแม้ความต้องการของผู้ใช้รถนั่งคนพิการจะมีความแตกต่างกัน แต่ทุกคนล้วนแต่ต้องการรถนัง่คน พิการทีเ่หมาะสม ประโยชน์ของรถนั่งคนพกิารมีอะไรบ้าง?  การเคลื่อนท่ี : รถนั่งคนพิการช่วยให้ผู้คนไปไหนมาไหนได้โดยอิสระและท าสิ่งที่ต้องการได้  สุขภาพ : รถนั่งคนพิการสามารถส่งเสริมสุขภาพของผู้ใช้งานได้หลายด้าน รถนั่งคนพิการที่ขนาดพอดี พร้อมด้วยเบาะรองนั่งที่สามารถลดปัญหาต่างๆ เช่น แผลกดทับ หรือ การท่าทางที่ไม่ดีได้ รถนั่งคน พิการที่ใช้งานได้ดี มีขนาดพอดีและสามารถปั่นง่ายจะช่วยเพิ่มการท ากิจกรรมทางร่างกายของผู้ใช้รถ นั่งคนพิการได้จึงเป็นการส่งเสริมสุขภาพด้วย  ความเป็นอิสระ : ผู้ใช้รถนั่งคนพิการสามารถเป็นอิสระมากขึ้นและควบคุมชีวิตตนเองได้มากข้ึน  ความมั่นใจและความภาคภูมิใจในตนเอง : ผู้ใช้รถนั่งคนพิการจะมีความมั่นใจและความภาคภูมิใจ เพิ่มข้ึน เมื่อได้รับรถนั่งคนพิการที่เหมาะสม และสามารถใช้งานได้ดี  การเข้าสู่สังคม : รถนั่งคนพิการท าให้ผู้ใช้สามารถเข้าสู่สังคม เช่น ท าให้สามารถไปท างาน ไปโรงเรียน เยี่ยมเยียนเพื่อน และเข้าร่วมกิจกรรมทางสังคมอื่นๆได ้ 7 รถนั่งคนพิการที่เหมาะสมคืออะไร? รถนั่งคนพิการที่เหมาะสม คือ รถนั่งคนพิการที่มีคุณสมบัติ ดังนี้  ตรงกับความต้องการของผู้ใช้งาน  เหมาะสมกับสภาพแวดล้อมของผู้ใช้งาน  มีขนาดเหมาะสมกับผู้ใช้งาน  ช่วยรองรับท่าทาง (ช่วยให้ผู้ใช้งานนั่งในแนวตรง)  สามารถบ ารุงรักษาและซ่อมแซมได้ในท้องถ่ิน อนุสัญญาว่าด้วยสิทธิคนพิการขององค์การสหประชาชาติ อนุสัญญาว่าด้วยสิทธิคนพิการขององค์การสหประชาชาติ (the United Nations Convention on the Rights of Persons with a Disability; UNCRPD) ประกาศใช้เมื่อวันที่ 3 พฤษภาคม พ.ศ. 2551 (ค.ศ. 2008) มนุษย์ทุกคนมีสิทธิ อนุสัญญาฯฉบับนี้ได้เน้นให้ทุกๆคนเข ้าใจว่าคนพิการก็มีสิทธิต่างๆเท่าเทียมกับบุคคล ทั่วไปซึ่งในอนุสัญญานี้มี 50 หมวด หมวด 20 เกี่ยวกับ ‘การเคลื่อนที่ของบุคคล’ ซึ่งหมายถึง ความสามารถในการเคลื่อนที่ในรูปแบบและ เวลาที่บุคคลต้องการ ในหมวด 20 กล่าวไว้ว่า ‘ประเทศสมาชิกจะใช้มาตรการที่มีประสิทธิผลเพื่อให้ มั่นใจว่าคนพิการสามารถเคลื่อนที่ได้อย่างเป็นอิสระมากที่สุดเท่าที่จะเป็นไปได้’ รถนั่งคนพิการและบริการรถนั่งคนพิการมีความส าคัญในการช่วยผู้มีความบกพร่องด้านการเคลื่อนที่ ส่วน ใหญ่ให้สามารถเคลื่อนที่ได้ บุคลากรผู้ให้บริการรถนั่งคนพิการสามารถช่วยในการปรับใช้หมวด 20 ของ อนุสัญญาได้โดย  ให้บริการรถนั่งคนพิการที่เหมาะสมแก่ผู้มารับบริการ  ช่วยให้ผู้ใช้รถนั่งคนพิการเรียนรู้วิธีการเคลื่อนย้ายตัวเข้าและออกจากรถนั่งคนพิการด้วยตนเอง  สอนวิธีการปั่นรถนั่งคนพิการด้วยตนเอง  กระตุ้นสมาชิกในครอบครัวให้ช่วยเหลือและส่งเสริมให้ผู้ใช้รถนั่งคนพิการเป็นอิสระเท่าที่เป็นไปได้ นอกจากนี้ยังมีหลักสิทธิมนุษยชนอีกหลายข้อที่ระบุว่าบุคคลที่มีความยากล าบากในการเคลื่อนที่สามารถมี ความสุขในการด าเนินชีวิตได้มากข้ึน หากได้รับรถนั่งคนพิการที่เหมาะสม ได้แก่  ด ารงชีวิตอย่างเป็นอิสระและเป็นส่วนหนึ่งของชุมชน (หมวด 19)  สิทธิในการศึกษา (หมวด 24)  สิทธิในการมีสุขภาพในระดบัมาตรฐานสงูสุดที่บรรลุได้ (หมวด 25)  สทิธิในการท างานและการจ้างงาน (หมวด 27) 8  สิทธิในการมีส่วนร่วมทางการเมืองและการใช้ชีวิตในที่สาธารณะ (หมวด 29)  สิทธิในการมีส่วนร่วมในกิจกรรมทางวัฒนธรรม กิจกรรมสันทนาการ กิจกรรมยามว่างและกีฬา (หมวด 30) อนุสัญญาฯ (หมวด 20 – การเคลื่อนท่ีส่วนบุคคล ) ประเทศสมาชิกจะใช้มาตรการที่มีประสิทธิผล เพื่อให้มั่นใจว่าคนพิการสามารถเคลื่อนที่ได้อย่าง เป็นอิสระมากที่ สุด เท่ าที่ จะ เป็นไปได้ อัน ประกอบด้วย a) ส่งเสริมความสามารถในการเคลื่อนที่ของคน พิการให้เหมาะสมกับเวลาและรูปแบบที่คน พิการเลือกและด้วยค่าใช้จ่ายที่เหมาะสม b) ส่งเสริมการเข้าถึงอุปกรณ์ช่วยในการเคลื่อนที่ อุปกรณ์ช่วยเหลือ เทคโนโลยีสิ่งอ านวยความ สะดวกมีคุณภาพ และรูปแบบของสื่อกลางและ การช่วยเหลือในการด าเนินชีวิต และในราคาที่ สามารถเข้าถึงได้ c) ให้การฝึกทักษะการเคลื่อนที่แก่คนพิการและ บุคลากรที่ท างานร่วมกับคนพิการอุปกรณ์ ช่วยเหลือ และเทคโนโลยีสิ่ งอ านวยความ สะดวก d) ส่งเสริมให้ภาคส่วนต่างๆผลิตอุปกรณ์ช่วยใน การเคลื่อนที่ อุปกรณ์เครื่องช่วย ตลอดจน เทคโนโลยีสิ่งอ านวยความสะดวกโดยค านึงถึง ทุกด้านของการเคลื่อนที่ของคนพิการ หมายถึง ประเทศต่างๆ ควรส่งเสริมให้คนพิการมีความเป็น อิสระให้มากที่สุดเท่าที่จะท าได้ โดย  ช่วยให้ผู้คนเข้าใจประเด็นนี้  ช่วยเหลือให้ได้รับรถนั่งคนพิการที่มีคุณภาพใน ราคาที่เหมาะสม  ให้การฝึกวิธีการใช้งาน  กระตุ้นให้ภาคส่วน/บริษัทต่างๆค านึงถึงความ ต้องการที่แตกต่างๆกันทุกด้านของคนพิการ A.2: บริการรถนั่งคนพิการ (wheelchair services) บริการรถนั่งคนพิการเป็นการช่วยให้ผู้ใช้งานได้รับรถนั่งคนพิการที่เหมาะสมที่สุดเท่าที่มีให้บริการ แนว ทางการให้บริการรถนั่งคนพิการแบบขับเคลื่อนด้วยแรงคนในพื้นที่ที่มีทรัพยากรจ ากัดขององค์การอนามัย โลกได้กล่างถึงข้ันตอนหลักของการให้บริการรถนั่งคนพิการ 8 ข้ันตอน โดยได้สรุปไว้ในหน้าถัดไป และ รายละเอียดของแต่ละข้ึนตอนอยู่ในหมวด B ของคู่มือนี้ 9 ขั้นตอนท่ี สรุป 1.การสง่ต่อและนัดหมาย การส่งต่อผู้ใช้รถนั่งคนพิการเพื่อรับบริการมี หลายวิธี อาจเป็นการมารับบริการด้วยตนเอง หรือส่งต่อจากเครือข่าย จากบุคลากรด้าน สุขภาพและสาธารณสุข ทั้ งจากหน่วยงาน รัฐบาลและเอกชนหรืออาสาสมัครในชุมชน อ าเภอหรือระดับภูมิภาค ในบางหน่วยงานอาจ ต้องระบุศักยภาพของผู้ใช้รถนั่งคนพิการด้วยว่า เขาเคยได้รับบริการทางสุขภาพหรือทางสังคม การเข้าร่วมในโรงเรียน ท างานหรือกิจกรรม ทางสังคม 2. การประเมิน ผู้ใช้รถนั่งคนพิการจ าเป็นต้องได้รับการประเมนิ รายบุคคล เกี่ยวกับวิถีชีวิต การท างาน และ สภาวะร่างกายและสภาพแวดล้อม 3. การพิจารณา (เลอืก) การพิจารณารถนั่งคนพิการ โดยใช้ข้อมูลจาก การประเมินและเป็นการด าเนินการร่วมกับผูใ้ช้ รถนั่งคนพิการ ครอบครัวหรือผู้ดูแล การ พิจารณา (เลือก) เป็นก าหนดรายละอียดชนิด และขนาด ลักษณะและการดัดแปลงรถนั่งคน พิการที่เลือก ตลอดจนทักษะที่ผู้ใช้งานต้องฝึก เพื่อให้สามารถใช้งานและดูแลรถนั่งคนพิการ ได้อย่างเหมาะสม 4. งบประมาณและการ สั่งซือ้ การระบุแหล่งงบประมาณ และรถนั่งคนพิการ จะเบิกจากจ านวนที่มีอยู่ในคลังหรือสั่งซื้อจาก ผู้ผลิต 5. การเตรียมผลิตภัณฑ์ (รถนั่งคนพิการ) บุคลากรที่ผ่านการอบรมท าการเตรียมรถนัง่คน พิการเพื่อปรับเบื้องต้น ซึ่งข้ึนอยู่กับผลิตภัณฑ์ ที่มีอยู่และเครื่องมืออุปกรณ์ต่างๆ อาจเป็นการ ประกอบรถนั่งคนพิการและดัดแปลงที่สามารถ ท าได้ หรือผลิตภัณฑ์สั่งจากโรงงานผลิต หรือ ผลิตภัณฑ์ที่ผลิตในห้องปฏิบัติงาน 10 ขั้นตอนท่ี สรุป 6. การปรบัใหเ้หมาะสม เป็นข้ันตอนที่ผู้ใช้ลองใช้รถนั่งคนพิการ และ ตัดสินใจว่ารถนั่งคนพิการเหมาะสมหรือไม่ กรณีที่ต้องดัดแปลงหรือจัดหาอุปกรณ์ประคอง ท่าทางอาจจ าเป็นต้องมีการลองและปรับให้ เหมาะสมอีกครั้ง 7.การฝกึทักษะการใช้งาน ผู้ใช้รถนั่งคนพิการและผู้ดูแลได้รับการสอน วิธีการใช้งานและการดูแลรถนั่งคนพิการอย่าง ปลอดภัยและมีประสิทธิผล 8.การดูแลรักษา ซ่อมแซม และติดตามผล หน่วยบริการรถนั่งคนพิการให้บริการดูแล รักษา ซ่อมแซมปัญหาทางเทคนิคที่ไม่สามารถ แก้ไขได้ภายในชุมชน กาติดตามผลควร ด าเนินการภายในชุมชนให้มากที่สุดเท่าที่ เป็นไปได้ การนัดติดตามผลเป็นโอภาสที่จะได้ ตรวจสอบความพอดีของรถนั่งคนพิการและ การฝึกและสนับสนุนเพิ่มเติม ระยะเวลาใน การติดตามผล ข้ึนอยู่ กับความจ าเป็นของ ผู้ใช้งานและบริการอื่นๆที่มี หากพบว่ารถนั่ง คนพิการไม่เหมาะสมแล้วควรพิจารณารถนั่ง คนพิการคันใหม่ โดยเริ่มจากข้ันตอนการ ให้บริการที่ 1 อีกครั้ง ที่มา : World Health Organization. Guidelines on the provision of manual wheelchairs in less resourced settings, Table 3.2. Geneva, 2008:76. A.3: การใช้รถนั่งคนพิการ (wheelchair mobility) ผู้ใช้รถนั่งคนพิการจ านวนมากอาศัยและท างานในพื้นที่ที่เคลื่อนที่ได้ยากล าบาก เช่น พื้นขรุขระ พื้นทราย หรือโคลน มีข้ันบันได ขอบทาง หรือพื้นที่แคบ การฝึกทักษะการใช้รถนั่งคนพิการจะช่วยให้ผู้ใช้งานสามารถเอาเคลื่อนที่ผ่านอุปสรรคต่างๆได้ไม่ว่าจะท า ด้วยตนเองและโดยการช่วยเหลือจากผู้อื่น 11 ทักษะต่างๆ ใน การใช้รถน่ังคนพิการ ดังอธิบายต่อไปน้ี ทักษะการใช้รถน่ังคนพิการ: การเข็น  การเข็นที่ถูกตอ้งจะใช้แรงน้อย  เข็นจากต าแหนง่ 10 นาฬิกา ไปยัง 2 นาฬิกา  ใช้การเข็นแบบนุม่นวลยาวๆบ การเลี้ยว  จับวงปั่นข้างหนึง่ดันไปด้านหน้าและอีกข้างหนึง่ดงึไป ด้านหลัง  ดึงมือที่อยู่ด้านหน้ามาด้านหลังและดันข้างที่อยู่ ด้านหลังไปด้านหน้าพร้อมๆกัน การขึ้นทาง ลาด  โน้มตัวไปด้านหน้า-เพื่อป้องกันการหงายหลงั  ในขณะที่ฝึกปฏิบัติ ต้องมผีู้ช่วยเหลืออยู่ด้านหลังด้วย  หากต้องการหยุดหรือพัก-ให้จอดรถนั่งคนพิการ ขวางทางลาด การลงทาง ลาด  เอนตัวไปด้านหลัง  ปล่อยให้วงปั่นหมุนผ่านมือช้าๆ  ผู้ใช้รถนั่งคนพิการที่มีประสบการณ์ที่สามารถท ายกล้อ หน้าได้ (เป็นการทรงตัวของรถนั่งคนพิการบนล้อหลัง อย่างเดียว) สามารถใช้เทคนิคนี้ในการลงทางลาดได้โดย การใช้ล้อหลัง วิธีนี้มีประสิทธิภาพมาก การขึ้นบันได โดยการ ช่วยเหลือ  ข้ึนด้านหลัง  เอนรถนั่งคนพกิารไปทางด้านหลงั เลื่อนให้ลอ้หลังชิด ข้ันบันได  ผู้ช่วยเหลือดึงรถนั่งคนพิการไปทางด้านหลังและยกข้ึน ตามขั้นบันได  ผู้ใช้รถนั่งคนพิการอาจช่วยเโดยดงึวงปั่นไปด้านหลงั  ผู้ช่วยเหลือคนทีส่องสามารถช่วยเหลือโดยจบัที่โครง ด้านหน้ารถนั่งคนพิการ (ห้ามจบับริเวณที่พักเท้า) 12 การลงบันได โดยการ ช่วยเหลือ  ลงด้านหน้า  เอนรถนั่งคนพิการไปทางด้านหลังให้ล้อหน้ายกลอยข้ึน  ผู้ช่วยเหลือค่อยๆ ปล่อยให้ล้อหลังของรถเลื่อนลงตาม ข้ันบันไดที่ละข้ัน  ผู้ใช้รถนั่งคนพิการสามารถช่วยโดยควบคุมรถด้วยการ จับวง  ผู้ช่วยเหลือคนที่สองช่วยในการประคองรถนั่งคนพิการ ด้านหน้าโดยจับบริเวณโครงรถ (ห้ามจับที่พักเท้า) การยกล้อ หน้าชั่วครู่  การยกล้อหน้าช่ัวครู่ได้มีประโยชน์ต่อผู้ใช้รถนั่งคนพิการ อย่างมาก  ผู้ใช้รถนั่งคนพิการสามารถยกล้อหน้าเพื่อข้ามสิ่งกีด ขวางต่างๆ เช่น ขอบถนน ก้อนหินและเนิน  หมุนล้อไปทางด้านหลังจนกระทั่งมืออยู่ที่ต าแหน่ง 10 นาฬิกา จากนั้นดันไปด้านหน้าอย่างรวดเร็ว  ล้อหน้าของรถนั่งคนพิการจะยกลอยข้ึน  ถ้าฝึกบ่อยๆจะสามารถยกล้อหน้าได้ถูกจังหวะเพื่อข้าม สิ่งกีดขวาง  ต้องแน่ใจว่ามีผู้ช่วยเหลืออยู่ด้านหลังตลอดเวลาที่ฝึกใน ข้ันตอนน้ี วิธีฝึกใช้รถนั่งคนพกิารอย่างปลอดภัย  ห้ามยืนบนที่พักเท้าขณะเข้าและออกจากรถนั่งคนพิการ  ระวังอย่างให้นิ้วมือเข้าซี่ล้อและเบรก  ขณะฝึกข้ึนหรือลงทางลาด ต้องมีผู้ช่วยเหลอือยู่ด้านหลังเสมอ เพื่อป้องกันการหงายหลัง  อย่าให้การช่วยเหลือในการเข็นรถนั่งคนพิการข้ึนและลง จนกว่าจะมั่นใจว่าสามารถควบคุม 13 A.4: การนั่งตัวตรง (sitting upright) ผู้ใช้รถนั่งคนพิการส่วนใหญ่ใช้เวลาหลายช่ัวโมงในท่านั่ง ดังนั้นรถนั่งคนพิการจึงไม่เป็นเพียงแค่อุปกรณ์ช่วย ในการเคลือ่นที่แต่ยังช่วยประคองให้พวกเขาน่ังตัวตรงอย่างสบายด้วย การนั่งตัวตรง/ท่านั่งแบบธรรมชาติ ท่าทางหมายถึงอะไร? ท่าทาง หมายถึง รูแบบการจัดวางส่วนต่างๆของร่างกาย รถนั่งคนพิการที่มีขนาดเหมาะสมควรช่วยรองรับ ร่างกายของผู้ใช้รถนั่งคนพิการให้อยู่ในท่านั่งตัวตรง บางครั้งการนั่งตัวตรงอาจเรียกว่า ท่านั่งแบบธรรมชาติ เพราะอะไรการน่ังตัวตรงจึงมีความส าคัญ ? การนั่งตัวตรงมีประโยชน์ต่อผู้ใช้รถนั่งคนพิการในหลายด้าน ดังนี้ :  สุขภาพ: ท่านั่งตัวตรงช่วยในการย่อยอาหารและการหายใจ  ความมั่นคง: ท่านั่งตัวตรงช่วยให้มีความมั่นคงมากข้ึน  การกระจายน้ าหนัก: ขณะนั่งตัวตรงน้ าหนักของร่างกายกระจายอย่างทั่วถึง-ซึ่งจะช่วยลดความเสี่ยง ต่อการเกิดแผลกดทับ  ความสบาย: เมื่อร่างกายมีการกระจายน้ าหนักอย่างทั่วถึงจะท าให้เกิดความสบายมากขึ้นแก่ผู้นั่ง  ป้องกันปัญหาด้านท่าทาง: การนั่งตัวตรงจะช่วยลดโอกาสในการผิดรูปของกระดูกสันหลังในอนาคต  ความมั่นใจและความภาคภูมิใจในตนเอง: การนั่งตัวตรงจะช่วยให้ผู้ใช้รถนั่งคนพิการเกิดความรู้สึกดี กับตนเอง แม้ว่าการนั่งตัวตรงจะมีประโยชน์มากมาย แตห่ากไม่มีการรองรับท่าทางอาจเป็นเรื่องยากที่จะคงท่านั่งนี้ ไดท้ั้งวัน นั่นเป็นเหตุผลที่คนที่ไม่พิการต้องมีการเปลี่ยนท่าทางตลอดทั้งวัน ดังนั้นผู้ที่ต้องนั่งบนรถนั่ง คนพิการตลอดทั้งวัน จ าเป็นต้องได้รับการรองรับท่าทางอย่างเพียงพอเพื่อให้สามารถนั่งตัวตรงได้อย่าง สบาย 14 วิธีการพิจารณาว่าบุคคลน้ันน่ังตัวตรง มองจากด้านข้างและตรวจสอบ:  เชิงกรานตัง้ตรง  หลงัอยู่ในแนวโค้งตามแนวปกติ 3 ส่วน  ข้อสะโพกงอใกล้เคียง 90 องศา  ข้อเข่าและข้อเท้างอใกล้เคียง 90 องศา  ส้นเท้าอยู่ในแนวเดียวกับข้อเข่าหรืออยู่ด้านหน้าหรือ ด้านหลังเลก็น้อย  เท้าวางราบบนพื้น มองจากด้านข้างและตรวจสอบ:  เชิงกรานเสมอกัน  ไหล่เสมอกัน แขนสามารเคลื่อนไหวได้อย่างอิสระ  ขากางออกเล็กนอ้ย  ศีรษะตั้งตรงและสมดลุเหนือร่างกาย เชิงกรานมีผลตอ่ท่านั่งอย่างไร เชิงกรานเป็นฐานส าหรับท่านั่งตัวตรง ตึกที่ต้องการความแข็งแรงและมั่นคง ย่อมต้องการรากฐานที่ แข็งแรง เช่นเดียวกันกับการนั่งที่ต้องการความมั่นคง เชิงกรานต้องแข็งแรงและมั่นคง เมื่อผู้ใช้รถนั่งคนพิการนั่งตัวตรง เชิงกรานจะ  อยู่ในระดับเดียวกัน (มองจากด้านหน้า) และ  อยู่ในแนวตั้งตรง หรือเอียงไปทางด้านหน้าเล็กนอ้ย (มองจากด้านข้าง) มองจากด้านหน้า มองจากด้านข้าง การเปลี่ยนแปลงใดๆที่เกิดต่อเชิงกรานจะส่งผลให้เกิดการปลี่ยนแปลงที่ส่วนอื่นๆของร่างกาย หากเชิง กรานไม่อยู่ในท่าต้ังตรงย่อมเป็นการยากที่จะนั่งตัวตรง 15 เชิงการมีการเคลื่อนไหวได้หลายทิศทาง ตารางต่อไปนี้แสดงการเคลื่อนไหวของเชิงกรานใน 4 ทิศทาง และ อธิบายการเปลี่ยนแปลงของร่างกายตอ่การเคลื่อนไหวแต่ละทิศทาง การเคลื่อนไหว ภาพแสดง การเปลี่ยนแปลงของร่างกาย เอียงไปด้านหน้า ภาพด้านข้างของเชิงกราน  ล าตัวเหยียดแอ่นออกขณะที่ข้อไหล่ถูกดึง ไปด้านหลงั  ส่วนโค้งของกระดูกสันหลังเหนอืกเชิงกราน ข้ึนไปมีความโค้งแอ่นมากขึ้น เอียงไปด้านหลงั ภาพด้านข้างของเชิงกราน  ล าตัวงอไปด้านหน้ามากขึ้นและข้อไหลห่่อ ไปด้านหน้า เอียงไปด้านข้าง ภาพด้านหลังของเชิงกราน  ล าตัวเอียงไปทางด้านข้าง หมุน ภาพด้านบนของเชิงกราน  ล าตัวส่วนที่เหลอืมีการหมุน 16 A.5: แผลกดทับ (pressure sores) แผลกดทับ คือบริเวณผิวหนังและกล้ามเนื้อที่เกิดความเสียหาย สามารถเกิดข้ึนได้ในเวลาไม่กี่ช่ัวโมงแต่ ส่งผลกระทบเป็นระยะเวลานานหลายเดือนและอาจเป็นสาเหตุการเสียชีวิตได้ สาเหตุของแผลกดทับ สาเหตุหลักของการเกิดแผลกดทบัมี 3 ประการ ดังนี ้ แรงกดทับ (pressure): แผลกดทับอาจเกิดจากแรงกดทับบนผิวหนังจากการนั่ง หรือนอนในท่าเดิมเป็นเวลานานเกินไปโดยไม่มีการเคลื่อนไหว ผู้ใช้รถนั่งคนพิการเป็นกลุ่มที่มีความเสี่ยงเนื่องจากใช้เวลาน่ังบนรถนั่งคนพิการแต่ ละวันเป็นเวลานาน หากไม่มีการลดแรงกดทับ แผลกดทับจะเกิดข้ึนง่ายมาก การเสียดสี (friction): การเสียดสี เป็นการถูไปมาบนผิวหนัง ตัวอย่างเช่น แขน ถูไปมากับล้อ/ที่พักแขนในขณะที่รถนั่งคนพิการเคลื่อนอาจเกิดแผลกดทับได ้ แรงเฉือน (shear): เกิดจากการที่ผิวหนังอยู่น่ิงถูกยืดหรือบีบเนื่องจากกล้ามเนื้อ หรือกระดูกเคลื่อนที่ ตัวอย่างในผู้ใช้รถนั่งคนพิการที่นั่ง “ตัวงอโค้งไปด้านหน้า” ผิวหนังจะเกิดอันตราย จากการฉีกขาดที่เกิดข้ึนบริเวณปุ่มกระดูกรองนั่ง เนื่องจากเชิงกรานจะหมุนไป ทางด้านหลัง หรือเกิดจากปุ่มกระดูกสันหลังถูกับพนักพิง ปัจจัยเสี่ยงของการเกดิแผลกดทับ นอกเหนือจากสาเหตุส าคัญ 3 ประการที่ท าให้เกิดแผลกดทับแล้ว ยังมีอีกหลายสิ่งที่เพิ่มโอกาสการเกิดแผล กดทับได้ง่ายข้ึน ซึ่งเรียกว่า “ปัจจัยเสี่ยงต่อการเกิดแผลกดทับ” (pressure sore risk factors” 17  บุคคลท่ีสุญเสียการรับความรู้สึก : บุคคลที่สูญเสียหรือไม่สามารถรับรู้ความรู้สึกสัมผัสบริเวณก้น (โดยเฉพาะในผู้ป่วยอัมพาตครึ่งท่อนและผู้ป่วยอัมพาตทั้งตัว) มีโอกาสเกิดแผลกดทับบริเวณก้นและขา  บุคคลท่ีไม่สามารถเคลื่อนไหวได้ : ผู้ที่ไม่สามารถเคลื่อนไหวได้จะไม่สามารถลดแรงกดได้  ความชื้นจากเหง่ือ น้ าหรือปัสสาวะ/อุจจาระเล็ดราด : ความช้ืนท าให้ผิวหนังนุ่มและท าให้เกิด อันตรายได้ง่าย ถ้าผู้ป่วยไม่ทราบวิธีจัดการกับปัสสาวะ/อุจจาระที่เหมาะสม ปัสสาวะและอุจจาระจะ ระคายเคืองต่อผิวหนัง  การอยู่ในท่าทางท่ีไม่ดี : การไม่น่ังตัวตรงจะท าให้เกิดแรงกดในบริเวณใดบริเวณหน่ึงมากกว่าปกต ิ  เคยมีหรือก าลังมีแผลกดทับ  โภชนาการไม่ดีและดื่มน้ าน้อย : การได้รับสารอาหารครบถ้วนและดื่มน้ าอย่างพอเพียงจะท าให้ผิวหนัง มีสุขภาพดีและท าให้ขบวนการหายของแผลเป็นไปได้ด้วยดี  ผู้สูงอายุ : ผู้สูงอายุมักผอมและมีผิวหนังที่เปราะบางซึ่งท าให้เกิดอันตรายได้ง่าย  น้ าหนัก (น้ าหนักท่ีมากเกินหรือน้อยเกินไป) : ผู้ที่อ้วนจะมีการไหลเวียนโลหิตบริเวณผิวหนังไม่ดีท าให้เกิด อันตรายได้ง่ายและบาดแผลจะหายยาก ผู้ใช้รถน่ังคนพิการที่มีน้ าหนักน้อยจะมีโอกาสเสี่ยงต่อการเกิดแผลกดทับ เพราะผิวหนังจะอยู่ติดกับกระดูก ท าให้ผิวหนังบริเวณนั้นเกิดอันตรายได้รวดเร็ว บริเวณที่พบแผลกดทับได้บ่อย: มุมมองด้านข้าง มุมมองด้านหลัง ระยะของแผลกดทับ 4 ระยะ3 การแก้ไข 1 เป็นจุดสีแดงหรือสีเข้มบนผิวหนัง และเม่ือไม่ มีแรงกดทับบริเวณน้ันแล้ว สีแดงหรือสีเข้า ดังกล่าวยังไม่หายไปภายใน 30 นาที  ขจัดแรงกดในบริเวณน้ันทันที  ไม่กดทับบนผิวหนังที่มีปัญหาจนกว่าผิวหนังจะกลับ คืนสู่ สภาพปกติ  หาสาเหตุและจัดการกับปัญหาเหล่าน้ัน  สอนผู้ใช้รถน่ังคนพิการใหท้ราบถึงการเกิดแผลกดทับและ การป้องกันแผลกดทับไม่ให้เกิดขึ้นอีกในอนาคต 18 ระยะของแผลกดทับ 4 ระยะ3 การแก้ไข 2 เป็นแผลตื้นและเริ่มมกีารหลุดลอกของ ผิวหนังช้ันบนหรอืมรีอยช้ า  ปฏิบัติตามค าแนะน าส าหรบัแผลกดทบัระยะที่ 1  ส่งต่อเพื่อการรกัษาแผลกดทับโดยผูเ้ช่ียวชาญ  แผลกดทับทีเ่ป็นแผลเปิดต้องได้รบัการล้างท าความ สะอาดแผล และต้องได้รับการดูแลอย่างใกล้ชิด เพื่อให้แน่ใจว่าแผลหายและไม่ติดเช้ือ  แผลกดทับระยะที่ 4 อาจต้องได้รับการผ่าตัด 3 เป็นแผลลึก ช้ันของผิวหนงัทัง้หมด หายไป 4 เป็นแผลลึกมาก แผลลามลึกลงไปถึงช้ัน กล้ามเนื้อและอาจลึกถึงกระดูก การปอ้งกันแผลกดทบั ใช้เบาะรองน่ังลดแรงกดทับ: เบาะรองนัง่ลดแรงกดทบัจะช่วยลดแรงกด ผู้ที่เสี่ยงตอ่การเกิดแผลกดทับควรได้รบัเบาะรองนั่งลดแรงกดทับ น่ังตัวตรง: การนั่งตัวตรงช่วยกระจายแรงกดให้สม่ าเสมอ ซึง่ช่วยลดแรง กดทับต่อปุ่มกระดูกและช่วยลดการเกิดแผลกดทับที่มสีาเหตุมาจากแรง กดทับได ้ การนั่งตัวตรงสามารถยังช่วยลดการเกิดแผลกดทับที่มสีาเหตุ จากแรงเฉือน (shear) ผู้ให้บริการสามารถช่วยผู้ใช้รถนั่งคนพิการให้นั่งตัวตรงได้โดยตรวจสอบ ความพอดีของขนาดของรถนั่งคนพิการซึ่งจะช่วยให้ผู้ใช้รถนั่งคนพิการ สามารถนั่งตัวตรงได้ดีข้ึน และอธิบายถึงความส าคัญของการนั่งตัวตรง ใช้เทคนิคลดแรงกด: การลดแรงกดอย่างสม่ าเสมอเป็นการป้องกันแผล กดทับทีม่ีประสิทธิผล รายละเอียดเกี่ยวกบัวิธีลดแรงกดทบัจะได้กล่าว ต่อไป 19 รับประทานอาหารท่ีมีประโยชน์และดื่มน้ ามากๆ: การรับประทานอาหาร ให้ครบถ้วนทั้งผัก ผลไม้และเนือ้สัตว์สามารถช่วยป้องกันแผลกดทบัได ้ การดื่มน้ าในปริมาณมากจะช่วยใหผ้ิวหนังไม่แห้งและป้องกนัแผลกดทับได ้ หากท่านกงัวลเกี่ยวกับภาวะโภชนาการของผู้ใช้รถนั่งคนพิการ – พิจารณา ส่งต่อไปยงัหน่วยงานที่สามารถช่วยเหลือได ้ หลีกเลี่ยงการเสียดส:ี ตรวจสอบให้แน่ใจว่ารถนั่งคนพิการขนาดพอดีและ ไม่มีขอบแหลมคม สอนผู้ใช้รถนัง่คนพิการที่สญูเสียการรบัความรูส้ึกให้หมั่นตรวจสอบส่วน ต่างๆของร่างกายไม่ให้เกิดการเสียดสีกับรถนั่งคนพิการ สอนใหผู้้ใช้รถนั่งคนพิการใหร้ะมัดระวังขณะเคลื่อนย้ายตัวเข้าและออกจาก รถนั่งคนพิการ หลีกเลี่ยงความชื้น: ผู้ใช้รถนั่งคนพิการตอ้งได้รบัค าแนะน าให้เปลี่ยนเสื้อผ้า ที่เปียกช้ืนหรอืเปือ้นดินทันที และห้ามใช้เบาะรองนัง่ที่เปียก การฝึกการดูแลปัสสาวะและอุจจาระช่วยลดปัญหาเกี่ยวกับความช้ืนได้ ส่ง ผู้ใช้รถนั่งคนพิการที่มีปัญหาการควบคุมปัสสาวะ/อุจจาระไปหน่วยงานที่ สามารถช่วยเหลือได้ ตรวจสอบผิวหนังทุกวัน: แผลกดทับสามารถเกิดข้ึนได้อย่างรวดเร็ว ดังนั้นจึงจ าเป็นต้องตรวจสอบให้พบแผลกดทับและใหก้ารดแูลอย่างรวดเร็ว กระตุ้นให้ผู้ใช้รถนั่งคนพิการที่เสี่ยงต่อเกิดแผลกดทับตรวจสอบผิวหนังของ ตัวเองทุกวันโดยใช้กระจกส่องหรือให้สมาชิกในครอบครัวช่วยตรวจสอบ ให้ผู้นั่งรถคนพิการลดแรงกดบริเวณผิวหนังทันทีที่ตรวจพบว่าผิวหนังมีสี แดงหรือสีเข้ม (ระยะที่ 1) ขณะท่ีนอนหรือน่ัง ให้เปลี่ยนท่าอย่างสม่ าเสมอ: การเปลี่ยนท่าอย่าง สม่ าเสมอจะช่วยลดแรงกด ตัวอย่างเช่นการเปลี่ยนท่านัง่ไปเป็นท่านอน การเปลี่ยนท่าบ่อยๆจะมีความประโยชน์อย่างมากในผู้ใช้รถนั่งคนพิการที่ มีปัจจัยเสี่ยงตอ่การเกิดแผลกดทับสูงหรือในผู้ที่แผลกดทับพึ่งหาย ผู้ที่ไมส่ามารถเปลี่ยนท่าได้ด้วยตนเองจะมปีัจจัยเสี่ยงตอ่การเกิดแผลกด ทับสงู 20 เทคนคิลดแรงกดทบั ผู้ใช้รถนั่งคนพิการสามารถลดแรงกดบริเวณปุ่มกระดูกรองนั่งด้วยตัวเอง ขณะอยู่ในนรถนั่งคนพิการวิธีการ ลดแรงกดสามารถกระท าได้หลายวิธี โดยข้ึนอยู่กับความแข็งแรงและความสามารถในการนั่งทรงตัวของเขา เหล่าน้ัน ผู้ให้บริการรถนั่งคนพิการควรสอนวิธีการลดแรงกดอย่างน้อย 1 วิธีให้ผู้ใช้รถนั่งคนพิการที่เสี่ยงต่อการเกิด แผลกดทับ การโน้มตัวไปด้านหน้า (Bending forward): เทคนิค นี้เหมาะสมกับผู้ใช้รถนั่งคน พิการทกุคน ท าได้ด้วยตัวเอง (independence) : ส าหรบัผู้ใช้ รถนั่งคนพิการที่ก าลังกล้ามเนื้อ แข็งแรงและการทรงตัวที่ดี มีผู้ช่วยเหลือ (with assistance) : ส าหรับผู้ใช้รถนั่งคนพิการที่ก าลัง กล้ามเนื้อไม่แข็งแรงและการทรงตัวที่ ไม่ด ี การ เ อีย งตั ว ไปด้ านข้ า ง (side to side leaning): เทคนิคนี้เหมาะส าหรับผู้ใช้รถ นั่ ง คนพิ กา ร ที่ มี ข้ อ จ า กั ด ทางด้านความแข็งแรงและ ความสามารถในการทรงตัว คล้องแขนกับที่จบัเข็นเพื่อช่วยในการ ประคองตัว 21 A. 6: รถนั่งคนพิการท่ีเหมาะสม (appropriate wheelchair) ส่วนประกอบของรถนัง่คนพิการ ค าจ ากัดความของ “รถนั่งคนพกิารที่เหมาะสม” ดูเนื้อหาในบท A.1 ผู้ใช้รถนั่งคนพิการ ตรงกับความต้องการของผู้ใช้งาน รถนั่งคนพิการที่เหมาะสมควรช่วยให้ผู้ใช้งานสามารถท าสิ่งต่างๆ ที่ต้องการได้ง่ายข้ึน ผู้ใช้รถนั่งคนพิการ ควรสามารถเข้าและออกจากรถนั่งคนพิการ ปั่นและพับรถนั่งคนพิการเพื่อเก็บ เดินทาง และท ากิจกรรม ต่างๆ ในแต่ละวัน ประเภทของรถนั่งคนพิการที่เหมาะสม สามารถท าให้ผู้ใช้รถนั่งคนพิการท ากิจกรรมต่างๆ ได้สะดวก ดังตัวอย่างข้างล่าง พนักพิง ท่ีพักแขน ด้ามจับเข็น ล้อหลัง เบาะรองน่ัง ท่ีรองน่ัง ผ้ารองน่อง ท่ีพักเท้า ล้อหน้า วงป่ัน แกนรองน่ัง แกนท่ีพักเท้า 22 การเคลือ่นย้ายตัว การเคลื่อนย้ายตัวเข้าและออกจากรถน่ังคนพิการ การเข้าและออกจากรถนั่งคนพิการท าได้หลายวิธี ข้ึนอยู่กับความสามารถทางร่างกาย ลักษณะต่างๆของ รถนั่งคนพิการท าให้การเคลื่อนย้ายตัวท าได้ง่ายข้ึน ส่วนประกอบของรถนั่งคนพิการที่ส่งผลต่อวิธีการ เคลื่อนย้ายตัว 3 ส่วน ได้แก่ ที่พักแขน ที่พักเท้า และเบรก ที่พักแขนที่ถอดออกได้หรือที่พักแขนที่โค้งตามรูปวงล้อหลังจะช่วย ให้การเคลื่อนย้ายตัวด้านข้างท าได้ง่ายข้ึน ผู้ใช้รถนั่งคนพิการที่ใช้วิธีการเคลื่อนย้ายตัวในท่ายืนอาจต้องการที่ พักแขนเพื่อช่วยในการลุกขึ้นยืน ที่พักเท้าทีส่ามารถถอดได้จะช่วยให้การเคลื่อนย้ายตัวแบบการยืน ท าได้ง่ายข้ึน ผู้ใช้รถนั่งคนพิการที่ต้องการเคลื่อนย้ายข้ึน/ลงระหว่างรถนั่งกับพื้น ควรใช้รถนั่งคนพิการทีส่ามารถถอดที่วางเท้าได้ เบรคของรถนั่งคนพกิารมีความส าคัญเป็นอย่างยิ่งในการตรึงเพื่อ ไม่ให้รถนั่งขยับไปมาขณะที่ท าการเคลื่อนย้ายตัว การปัน่รถนั่งคนพกิาร การขับเคลื่อนรถนั่งคนพิการท าได้หลายวิธี ผู้ใช้จ านวนมากขับเคลื่อนโดยใช้แขน 2 ข้าง ผู้ใช้รถนั่งคนพิการ บางกลุ่มขับเคลื่อนโดยการใช้เท้า 2 ข้าง - หรือใช้เท้า 1 ข้างและมือ 1 ข้าง ผู้ใช้บางรายต้องมีบุคคลอื่นเข็น รถนั่งคนพิการให้เป็นบางครั้งหรือตลอดเวลา การปั่นรถนั่งคนพิการด้วยมือจะท าได้ง่าย ถ้าพนักพิงและทีพ่ักแขนมีความสูงในระดับที่เหมาะสม 23 พนักพิงที่สูงเกินไป ผู้ใช้ ร ถ นั่ ง ค น พิ ก า ร ไ ม่ สามารถเคลื่อนไหวไหล่ และแขนเพื่อปั่นรถได ้ ที่พั กแขนที่ สู ง เ กิน ไป ผู้ใช้รถนั่งคนพิการ ไม่ สามารถเอื้อมไปที่ล้อ เพื่อปั่นได ้ หากพนกัพิงต่ าลง ผู้ใช้รถนั่งคนพิการสามารถเคลื่อนไหวหัวไหล่เพื่อปั่นรถได ้ ส าหรับผู้ใช้รถนั่งคนพิการที่ทรงตัวดี ระดับนีเ้ป็นความสูงของพนักพงิที่ เหมาะสม การปั่นรถนั่งคนพิการจะท าได้ง่ายข้ึน หากผู้ใช้สามารถเอื้อมมาจับวงปั่นได้สะดวก ต าแหน่งล้อหลังที่ เหมาะสมคือ ต าแหน่งที่เมื่อผู้ใช้รถนั่งคนพิการ วางมือบนขอบบนสุดของวงปั่น แล้วข้อศอกจะงอ 90 องศา นี่คือต าแหน่งที่ดสี าหรับการปั่น หากลอ้หลังเลื่อนไปข้างหลังมาก เกินไป จะท าใหผู้้ใช้รถนั่งคนพิการ เหนื่อยมากขึ้นเมือ่ปั่นรถ รถนั่งคนพิการบางรุ่นสามารถปรับต าแหน่งของล้อหลังได้ ต าแหน่งของล้อหลังส่งผลต่อความยากง่ายใน การยกล้อหน้า การยกล้อหน้ามีประโยชน์เมื่ อ เคลื่อนที่บนพื้นผิวขรุขระหรือข้ึน/ ลงพื้นต่างระดับ ถ้าต าแหน่งของล้อหลังที่ เลื่อนมา ข้างหน้าจะท าให้ง่ายต่อการยกล้อ หน้า ถ้าต าแหน่งของล้อหลังเลื่อนอยู่ไปขา้ง หลังจะมีความมั่นคงมากกว่าแต่จะยก ล้อหน้ายากกว่า 24 การปั่นรถนั่งคนพิการโดยใช้ เท้าจะท าได้ง่ายหากผู้ ใ ช้มี ก าลังขาเพียงพอและสามารถ นั่งโดยเชิงกรานชิดพนักพิงได้ ดีและเท้าต้องสามารถวาง ราบกับพื้นได้ ในกรณีนี้ ความสูงของที่รองนั่งถึงพื้น (รวม เบาะรองนั่งแล้ว) มีความส าคัญอย่างมาก ที่วางเท้าที่สามารถถอดออกได้มีความจ าเป็น เช่นกัน ผู้ใช้รถนั่งคนพิการบางรายทีป่ั่นด้วยวิธีนี้ อาจ ต้องการถาดหรือที่พักแขนเพือ่โน้มตัวไป ข้างหน้าขณะปั่น รถนั่งคนพิการที่มีน้ าหนักมาก จะใช้แรงในการปั่นมากกว่า – ไม่ว่าจะปั่นโดยมอื เท้า หรือ ผู้อื่นช่วยเข็นให ้ อย่างไรก็ตาม หากรถนั่งคน พิการมีการออกแบบและมี สมดุลที่ดี ปัจจัยด้านน้ าหนัก ของรถอาจไม่มีผลมากนัก ปัจจัยด้านน้ าหนักของรถนั่งคนพิการจะมีผล อย่างมากในผู้ใช้ที่เป็นเด็ก รถนั่งคนพิการที่มี น้ าหนักมากอาจท าให้ผู้ ใ ช้งานที่ เป็นเด็ก ควบคุมได้ยาก การพับรถนั่งคนพกิาร การพับรถนั่งคนพิการมปีระโยชน์ต่อการเก็บหรือการขนย้าย รถนั่งคนพิการสามารถพบัเก็บได้ 2 วิธี รถนั่งคนพิการที่มีโครงพับกากบาท (cross-folding frame) สามารถพับ ได้โดยดึงให้โครงทั้งสองด้านพับเข้าหากัน บางครั้งอาจถอดล้อหลังออกได้ ด้วย รถนั่งคนพิการที่โครงพับกากบาท มีประโยชน์ในการพับให้แคบลงเมื่อ เคลื่อนที่ผ่านเข้าประตูแคบ ผู้ใช้รถนั่งคนพิการที่เดินทางบ่อยอาจชอบรถนั่งคนพิการที่โครงพับ กากบาท ตัวอย่างเช่น อาจมีขนาดเล็กขึ้นรถเมล์ได้ ข้อด้อยของรถนั่งคนพกิารแบบนี้คือกลไกลการพบัไม่แข็งแรง ท าให้รูส้ึก ว่ารถนั่งคนพิการไมม่ั่นคง และเป็นผลให้ปั่นยากข้ึน 25 รถนั่งคนพิการที่โครงแบบแข็ง (rigid frame) สามารถพับเก็บได้โดยการพับที่พนักพิงลงมา หาที่รองนั่งและล้อหลังสามารถถอดออกได้ ข้อดขีองโครงแข็งคือมีความคงทนมากกว่า เนื่องจากมสี่วนประกอบที่มกีารเคลื่อนเข้า ออกน้อยกว่า การท ากิจกรรมต่างๆ ลักษณะหลายอย่างของรถนั่งคนพิการที่ส่งผลต่อความง่ายในการท ากิจกรรมต่างๆ ตัวอย่างเช่น ลักษณะที่ ช่วยให้ผู้ใช้รถนั่งคนพิการปั่นรถ (ดังอธิบายไว้ข้างบน) ส่งผลต่อความสะดวกในการท ากิจกรรมต่างๆ ดัง ตัวอย่างต่อไปนี้ ความยาวของโครงรถน่ังคนพิการ (frame length): ความยาวของ โครงรถนั่งคนพิการมีผลต่อการใช้งานในพื้นที่แคบ ส าหรับผู้ใช้เวลาส่วน ใหญ่ภายในอาคาร รถนั่งคนพิการที่มีความยาวไม่มากถือเป็นทางเลือกที่ ดีที่สุด ความยาวนี้วัดจากต าแหน่งหลังสุดไปยังต าแหนง่หน้าสุดของรถนั่งคน พิการ ท่ีพักแขน: ที่พักแขนสูงจะท าให้ยากล าบากในการเข้าชิดโต๊ะ ข้อควรจ า: รถนั่งคนพิการที่เหมาะสมจะตอบสนองความต้องการของผู้ใช้งาน รวมถึงท าให้พวกเขาสามารถ ท าสิ่งต่างๆทีจ่ าเป็นและที่ต้องการท าได้ง่ายข้ึน 26 เหมาะสมกบัสภาพแวดลอ้มของผู้ใช้รถนั่งคนพกิาร รถนั่งคนพิการชนิดต่างๆ มีความเหมาะสมกบัสภาพแวดล้อมที่แตกต่างกัน ลักษณะของรถนั่งคนพิการที่ ส่งผลต่อการใช้งานในสภาพแวดลอ้มที่ต่างกันคือ  ระยะระหว่างล้อหน้าและล้อหลงั (ระยะฐานล้อ/wheelbase)  ขนาดความกว้างของล้อ ระยะระหว่างล้อหน้าและล้อหลัง (wheelbase) ระยะระหว่างล้อหน้ากับล้อหลงัมีความส าคัญ ถ้าล้อหน้ากบัลอ้หลังอยูห่่างกัน เรียกว่า ระยะฐานล้อยาว (long wheelbase) หากอยู่ใกล้กัน เรียกว่า ระยะฐานล้อสั้น (short wheelbase) รถนั่งคนพิการที่มีระยะฐานล้อยาว จะมีความมั่นคงมากกว่าและมีการ คว่ าไปข้างหน้าน้อยกว่า ซึ่งเหมาะส าหรับบุคคลที่ใช้เวลาส่วนใหญ่ กลางแจ้งและใช้งานบนพื้นขรุขระหรือพื้นที่ไม่เรียบ รถนั่งคนพิการที่มรีะยะฐานล้อยาวนีม้ีทัง้แบบ 3 ล้อ และ 4 ล้อ รถนั่งคนพิการแบบสาม ล้อ เป็นตัวอย่างของรถ นั่งคนพิการที่มีระยะฐาน ล้อยาว ซึ่งมีความมั่นคง สูงเหมาะส าหรบัใช้ กลางแจ้งและพื้นขรุขระ รถนั่งคนพิการแบบสี่ล้อ ที่มี ล้อหน้ าอยู่ ใต้ที่ พัก เท้าจะท าให้มีระยะฐาน ล้อยาวข้ึน รถนั่งคนพิการที่มีระยะฐานล้อสั้นเหมาะสมส าหรับการใช้งานบนพื้นเรียบหรือพื้นที่แคบ เช่น ในอาคาร รถนั่งคนพิการที่มีระยะฐานล้อสั้นมีแนวโน้มที่จะล้มไปทางด้านหน้าในขณะที่ลงเนินหรือเมื่อล้อหน้าชนสิ่ง กีดขวาง 27 ตั วอย่ า ง ขอ ง รถนั่ ง คน พิ ก า ร แ บ บ ธ ร ร ม ด า (orthopaedic wheelchair) ที่มีระยะ ฐานล้อสั้น รถนั่งคนพิการชนิดนี้ ใ ช้ ง าน ในพื้ นที ข รุ ข ร ะ ได้ ล าบาก ผู้ ใ ช้ร ถนั่ ง คนพิการที่ มี ทักษะดีอาจใช้รถนั่งคน พิการที่มีระยะฐานล้อสั้น ภายนอกอาคารโดยการ ยกล้อหน้าขณะลงเนิน หรือขณะใช้งานบนพื้น ขรุขระ ขนาดและความกว้างของล้อ ล้อที่ใหญ่กว่าจะท าใหก้ารเคลื่อนทีผ่่านพื้นที่ไม่ราบเรียบ ล้อหลังขนาดใหญ่และล้อหน้าทีห่น้ายางกว้างและใหญ่จะช่วยป้องกัน ไม่ให้รถนัง่คนพกิารจมลงไปในพื้นทรายหรือโคลน ข้อควรจ า : รถนั่งคนพิการที่เหมาะสมต้องเหมาะกับสภาพแวดล้อมของผู้งาน – ซึ่งหมายถึงพื้นที่ผู้ใช้รถนั่ง คนพิการใช้เวลาส่วนใหญ่อยู ่ มีขนาดและรองรับร่างกายอย่างเหมาะสม ผู้ใช้รถนั่งคนพิการแต่ละคนมีขนาดร่างกายแตกต่างกัน รถนั่งคนพิการต้องขนาดพอดีกับขนาดของผู้ใช้งาน เพื่อให้รองรับร่างกายอย่างเหมาะสม รถนั่งคนพิการหลายชนิดที่ผลิตมาหลายขนาดหรือสามารถปรบัขนาด ได้ ซึ่งจะช่วยให้ปรับให้เหมาะสมกับผู้ใช้งานได้ง่ายกว่ารถนั่งคนพิการที่มีเพียงขนาดเดียว ลักษณะหรือ ส่วนประกอบของรถนั่งคนพิการที่จะกล่าวต่อไปนี้จะส่งผลต่อขนาดเหมาะสมกับผู้ใช้งานและช่วยให้นั่งตัว ตรงได้ 28 ที่รองน่ัง ท่ีรองน่ัง: ที่รองนั่งอาจเป็นแบบยืดหยุ่นหรือแบบแข็ง ในภาพน้ีแสดงที่รองนั่งแบบแข็ง ซึ่งอาจท าด้วยไม้หรือพลาสติก ที่รองนั่ง ที่แข็งจะต้องมีเบาะรองนั่งด้านบนเสมอ ที่รองนั่งแบบยืดหยุ่นมักจะท าจากผ้าใบ ที่รองนัง่แบบยืดหยุ่นที่ท าจากผ้าใบและยึดกบัโครงรถนั่งคนพิการแต่ละ ข้าง ผ้าใบที่ด้อยคุณภาพจะหย่อนง่ายเมือ่ใช้งาน ซึ่งจะท าให้นั่งใน ท่าทางไม่ด ี ผู้ชายในภาพทางซ้ายมือนี้น่ังบนรถนั่งคนพิการที่มทีี่รองนั่ง หลวมและหยอ่น ซึ่งไม่ช่วยรองรบัร่างกายของเขา ท าให้เขาไม่สมารถนัง่ ตัวตรงได ้ พนักพิง: พนักพิงอาจเป็นแบบยืดหยุ่นหรือแบบแข็ง พนักพิง แบบแข็งทุกช้ินต้องมีแผ่นรองหรือเบาะหุ้มไว้ รถนั่งคนพิการมีความสูงของพนักพิงแตกต่างกัน รถนั่งคน พิการบางชนิดสามารถปรับความสูงของพนักพิงได้ ความสูง ของพนักพิงที่เหมาะสมขึ้นอยู่กับผู้ใช้รถนั่งคนพิการแต่ละคน ท่ีพักแขน: ที่พักแขนยังช่วยในการรองรับร่างกาย ที่พักแขนบางแบบสามารถปรับสูงต่ าได้ หากไม่สามารถปรับ ได้ อาจดัดแปลงให้ช่วยเพิ่มการประคองส าหรับผู้ใช้งานที่ จ าเป็น เบาะรองน่ัง: เบาะรองนั่งช่วยให้นั่งสบายข้ึน ช่วยลดแรงกด ทับ และยังช่วยรองรับร่างกายและป้องกันการเลื่อนตัวไป ข้างหน้า ท่ีพักเท้า: ที่พักเท้าช่วยรองรับผู้ใช้รถนั่งคนพิการ ต้องปรับ ความสูงต่ าของที่พักเท้าให้มีความสูงเหมาะสมซึ่งส าคัญมาก ด้วยเหตุผลนี้ โดยทั่วไปที่พักเท้าจะสามารถปรับได้ ที่พักเท้าบางแบบยังสามารถปรับองศาการเอียงและระยะห่าง จากรถนั่งคนพิการได้อีกด้วย ข้อควรจ า : รถนั่งคนพิการที่เหมาะสมต้องมีขนาดพอดี และรองรับร่างกายผู้ใช้ 29 A.7: เบาะรองนั่ง (cushions) เบาะรองนั่งมีไว้เพื่ออะไร? เบาะรองนัง่เป็นส่วนทีส่ าคัญมากในรถนั่งคนพิการทุกคัน เบาะรองนั่งช่วยให:้  ให้ความสบาย  รองรับท่าทาง (ช่วยให้นั่งตัวตรงข้ึน)  ลดแรงกด ผู้ใช้รถนั่งคนพิการทุกรายควรรู้สึกสบายขณะนั่งในรถนั่งคนพิการ และเบาะรองนั่งที่ดีจะช่วยให้ให้นั่ง ตัวตรงได้ง่ายและสบายข้ึน จึงเป็นเหตุผลที่รถนั่งคนพิการทุกคันควรมีเบาะรองนั่ง แต่ไม่จ าเป็นที่ผู้ใช้รถ นั่งคนพิการทุกคนต้องมีเบาะรองนั่งลดแรงกดทับ ชนิดของเบาะรองนั่ง เบาะรองนัง่มหีลายแบบ ซึ่งสามารถจ าแนกได้หลายวิธี ได้แก่  ตามวัสดุที่ท า เช่น ฟองน้ า ใยมะพร้าว  ตามวัสดุที่บรรจุข้างใน เช่น อากาศ ของเหลวหรือเจล  ตามหน้าที่หลักของเบาะ เช่น ลดแรงกด ความสบาย จัดท่าทาง  ตามรูปร่าง เช่น แบนหรือโค้งเข้ารูป  ตามวิธีการท า เช่น เบาะฟองน้ าอาจท าโดยการหล่อข้ึนรปูเป็นช้ินเดียวหรอืท าจากการตัดฟองน้ าเป็น แผ่นแล้วน ามาติดกันเป็นช้ันๆ เบาะรองนัง่ฟองน้ าเป็นชนิดทีห่าได้ทั่วไปและราคาถูกทีสุ่ด สามารถผลิตได้ง่ายในที่ที่มีฟองน้ าและสามารถ ดัดแปลงให้เหมาะกบัผู้ใช้แต่ละคนได ้ ใครบ้างท่ีต้องใช้เบาะรองน่ัง? ผู้ใช้รถนั่งคนพิการทุกคนควรมเีบาะรองนั่ง กรณีทีผู่้ใช้มีความเสี่ยงต่อการเกิดแผลกดทับควรไดร้ับเบาะรองนัง่ลด แรงกด 30 เบาะรองน่ังลดแรงกดทับ ลักษณะส าคัญของเบาะฟองน้ าลดแรงกดทับ ได้แก่ ฐานแน่นมั่นคง: ฐานของเบาะรองนั่งลดแรงกดทับต้องเป็นฐานที่ แน่น ซึ่งจะท าให้เบาะรองนั่งช่วยรองรับร่างกายของผู้ใช้รถนั่งคน พิการและเบาะจะไม่เคลื่อนที่เมื่อผู้ใช้รถนั่งคนพิการมีการเคลื่อนไหว ชั้นบนสุด: บนฐานของเบาะควรมีช้ันเพื่อความสบาย (comfort layer) ช้ันนี้ควรเป็นฟองน้ านุ่ม (อาจมีมากกว่า 1 ช้ัน) ฟองน้ าช้ัน บนสุดควรมีความนุม่เพียงพอที่ท าให้ปุ่มกระดูกรองนั่งจมลงไปได้ แต่ ไม่ควรนิ่มเกินไปจนกระทั่งปุ่มกระดูกรองนั่งจมลงไปจนถึงฐานของ เบาะที่แข็งหรือถึงที่รองนั่งของรถนั่งคนพิการ เบาะรองนั่งลดแรงกดทับจะช่วยลดแรงกดโดย  กระจายน้ าหนักของผู้ใช้รถนั่งคนพิการให้เท่ากันบนพื้นผิวของที่ รองนั่ง  ลดแรงกดทับในจุดที่มีความเสี่ยงสูงต่อการเกิดแผลกดทับ (ปุ่ม กระดูกรองนั่ง กระดูกสะโพก กระดูกก้นกบ)  ลดแรงเฉือน (shear) โดยการช่วยให้ผู้ใช้รถนัง่คนพิการนัง่ตวัตรง การรูปทรงบนเบาะรองน่ังลดแรงกดทับ เบาะรองนัง่ลดแรงกดทับมหีลากหลาย รูปทรงที่เห็นบนเบาะรองนัง่ลด แรงกดทบัอาจมีดังนี:้  มีแอ่ง (well) ใต้ปุ่มกระดูกรองนัง่ เพื่อลดแรงกดทบั  รองรับบรเิวณกระดูกสะโพก เพื่อช่วยกระจายน้ าหนัก  เนินด้านหน้าของปุ่มกระดูกรองนัง่ช่วยให้เชิงกรานตั้งตรงและ ป้องกันการเลื่อนไปข้างหน้า  ร่องรองรับกระดกูต้นขาส่วนบน 31 เบาะรองนั่งลดแรงกดทบัชนดิลม/ของเหลว/เจล  เบาะรองนัง่แบบขยายตัว (flotation cushion) ได้แก่เบาะที่บรรจุ ด้วยลม ของเหลวหรือเจล  เบาะรองนัง่แบบเจลควรมฐีานที่ท าด้วยฟองน้ าแน่นคล้ายกบัเบาะ รองนัง่แบบโค้งเข้ารูป  ด้านบนของฐานจะมีถุงทีบ่รรจุด้วยเจลหรือของเหลว  ถุงที่บรรจุด้วยเจลจะเข้ารปูกบัผู้ใช้รถนั่งคนพกิารโดยอัตโนมตัิ ซึ่งจะ ช่วยให้เกิดการกระจายน้ าหนักของผู้ใช้รถนั่งคนพิการอย่างสม่ าเสมอ และช่วยลดแรงกดทับบรเิวณปุ่มกระดูกต่างๆ เบาะรองนั่งชนดิใดที่ควรใช้? ทั้งเบาะรองนั่งชนิดฟองน้ าเข้ารปูและแบบบรรจุด้วยลม/เจล/ของเหลวมีทัง้ข้อดีและข้อดอ้ย ข้อด ี ข้อด้อย เบาะฟองน้ า โค้งเข้ารูป  สามารถผลิตได้ในท้อง ถ่ิน (ในที่ที่มี ฟองน้ าคุณภาพดี)  สามารถดัดแปลงได้ในท้องถ่ินเพื่อให้ เหมาะกับความต้องการที่ต่างกัน  เบาะไม่แบนแฟบแบบทันทีทันใด (เบาะลม/เจลที่รั่ว ท าให้เกิดการแบน ของเบาะอย่างทันทีทันใด และไม่ช่วย ลดแรงกดทับ)  ช้ันบนสุดของเบาะสามารถเปลี่ยนได้ ง่ายและสามารถใช้วัสดุราคาถูกได ้ (แทนที่จะเปลี่ยนเบาะใหม่ทั้งช้ิน)  ฟองน้ าจะแบนลงและแข็งข้ึนเมื่อใช้งาน ตามระยะเวลาที่ผ่านไป ดั งนั้นควร ตรวจสอบเบาะรองนั่งอย่างสม่ าเสมอ และเปลี่ยนช้ินใหม่ทุกๆ 1-2 ป ี  ใช้เวลาในการผึ่ง ให้แห้ง (เป็นปัญหา ส าหรับผู้ที่มีปัญหาปัสสาวะ/อุจจาระเลด็ ราด)  การระบายอากาศไม่ดีท าให้เนื้อเยื่อมี อุณหภูมิสูงข้ึน เบาะลม/เจล  แรงกดจะกระจายอย่างสม่ าเสมอบนที่ รองนั่ง  แผ่นรองที่เป็นเจลจะเปลี่ยนรูปให้เข้า กับส่วนของร่างกายโดยอัตโนมัติใน ขณะที่มีการเคลื่อนไหวหรือเมื่อเปลี่ยน ท่า  เบาะลม/เจล/ของเหลวมีราคาแพงและ หายาก เมื่อเทียบกับเบาะแบบฟองน้ า โค้งเข้ารูป  ผู้ใช้รถนั่งคนพิการบางรายจะรู้สึกไม่ มั่นคงเมื่อนั่งบนเบาะลม/ของเหลว/เจล  อาจเกิดการแบนแฟบทันทีทันใดได ้หาก ผู้ใช้รถนั่งคนพิการที่ไม่สามารถหาเบาะ รองนั่งอันใหม่มาทดแทนไดอ้ย่างรวดเร็ว อาจเกิดปัญหาตามมาได้ 32 ผ้าหุ้มเบาะรองนัง่ เบาะรองนั่งลดแรงกดทับควรมีผ้าหุ้มซึ่งสามารถถอดซักได้และกันน้ าได้ วัสดุที่น ามาหุ้มเบาะรองนั่งลดแรง กดควรยืดและหลวมพอที่จะปล่อยให้ปุ่มกระดูกรองนั่งจมลงในฟองน้ าได้ ถ้าผ้าที่หุ้มไม่สามารถยืดได้ การใช้ผ้าบางเป็นวิธีที่ดีเนื่องจากรอยพับของผ้าบางมีแนวโน้มจะท าให้เกิดรอยที่ผิวหนังน้อยและก่อให้เกิด แผลกดทับน้อยด้วย กรณีที่มีพลาสติกบางรองใต้ผ้าคลุมควรหลวมพอที่ปุ่มกระดูกรองนั่งจะจมลงในฟองน้ า ได ้ ควรแนะน าผู้ใช้รถนั่งคนพิการว่าหากเบาะรองนั่งหรือผ้าหุ้มเบาะเปียก ควรท าให้แห้งและน ามาใช้เมื่อแห้ง แล้วเท่านั้น ส าหรับผู้ใช้รถนั่งคนพิการที่มีปัญหาในการควบคุมปัสสาวะ/อุจจาระและมีความเสี่ยงต่อการ เกิดแผลกดทับ ควรมีเบาะรองนั่ง 2 อัน เพื่อใช้สลับกัน กรณีที่ไมส่ามารถหาผ้าหุ้มเบาะทีก่ันน้ า(water proof/water resistant) ได ้ หากเป็นไปได้ ผู้ใช้รถนั่งคนพิการที่ที่มีปัญหาในการควบคุมปัสสาวะ/อุจจาระ ควรได้รับผ้าหุ้มเบาะรองนั่ง ชนิดกันน้ าและกันของเหลวไม่ให้สัมผัสกับผิวหนังของผู้ใช้ หากไม่มีผ้าหุ้มเบาะรองนั่งชนิดกันน้ า:  หาวิธีการช่วยเหลือส าหรับปัญหาการกลั้นปัสสาวะ/อุจจาระ  ให้เบาะรองนั่ง 2 ช้ิน เพื่อสลับใช้งานเมื่ออีกช้ินหนึ่งเปียก  ปกป้องเบาะรองนั่งด้วยการหุ้มด้วยพลาสติกแบบบางไว้ด้านใน ในกรณีที่ใช้แผ่นพลาสติกหุ้ม  ตรวจสอบให้แน่ใจว่าแผ่นพลาสติกไม่ท าให้ผู้ใช้รถนั่งคนพิการมีการ “ตัวไหลเลื่อน” เมื่อนั่งบนเบาะ  ผู้ใช้รถนั่งคนพิการต้องแน่ใจว่าไม่มี “ของเหลวต่างๆ” ขังอยู่บนแผ่นพลาสติก ซึ่งมีความเสี่ยงต่อการ เกิดแผลกดทับมากขึ้น  ผู้ใช้รถนั่งคนพิการต้องแน่ใจว่าผ้าหุ้มเบาะแห้งสนิทและพลาสติกที่หุ้มต้องสะอาดหรือเปลี่ยนใหม่ วิธีตรวจสอบว่าเบาะรองนัง่ลดแรงกดทับสามารถลดแรงกดได้หรือไม่ ทุกครั้งมีการพิจารณาเบาะรองนั่งลดแรงกดทับแก่ผู้ใช้รถนั่งคนพิการ ควรมีการทดสอบแรงกดทบัด้วยมือ อย่างง่ายเพื่อตรวจสอบว่าเบาะรองนั่งช่วยลดแรงกดทบัใต้ปุม่กระดกูร่องนั่งหรือไม่ ในการทดสอบผู้ทดสอบต้องใช้มือสอดใต้ปุ่มกระดกูรองนั่งของผู้ใช้รถนัง่คนพิการโดยตอ้งมกีารอธิบายสิ่งที่ จะท าและประโยชน์ของการท าดงักล่าวแกผู่้ใช้รถนั่งคนพิการก่อนทกุครั้ง ท าการทดสอบเช่นน้ีกับเบาะรองนั่งอันเดิมและรถนั่งคนพิการให้บริการแก่ผู้ใช้ 33 การทดสอบแรงกดทับด้วยมือ A  อธิบายต่อผู้ใช้รถน่ังคนพิการว่าจะประเมินอะไร ท าอย่างไรและมี ความส าคัญอย่างไร โดยใชค้ าอธิบายงา่ยๆ B  ให้ผู้ใช้รถน่ังคนพิการยกตวัขึ้นหรือโน้มตัวไปข้างหน้าเพื่อให้ปลาย น้ิวของผู้ประเมินอยู่ใต้ปุ่มกระดูกรองน่ัง (หงายมือขึ้น)  ท าประเมินโดยการสอดมือจากด้านหลงั C  ให้ผู้ใช้รถน่ังคนพิการเอนตัวกลับไปน่ังทับบนมือของผู้ประเมิน  ให้ผู้ใช้รถน่ังคนพิการน่ังตัวตรงและวางมือลงบนหน้าขา เพื่อให้ ม่ันใจว่าผู้ใช้รถน่ังคนพิการจะน่ังในท่าเดิมขณะที่ท าการประเมิน อีกด้านหน่ึง  ในกรณีที่ปลายน้ิวของผู้ประเมินไม่อยู่ในต าแหน่งทีถู่กต้องและไม่ สามารถรับรู้แรงกดทบัไดด้ี ใหผู้้ใช้รถน่ังคนพิการยกตัวขึ้นและผู้ ประเมินเปลี่ยนต าแหน่งของน้ิวใหม ่ D ระบุระดับของแรงกดทับใตปุ้่มกระดูกรองน่ังข้างที่หน่ึง โดยใหเ้ป็น 3 ระดับ ระดับที่ 1 = ปลอดภัย: ปลายน้ิวสามารถกระดิกขึ้นลงได้ไม่น้อยกว่า 5 มม. ระดับที่ 2 = เตือน: ไม่สามารถกระดิกปลายน้ิวขึ้นลงได้ แต่สามารถเลื่อนมือออกได้ง่าย ระดับที่ 3 = ไม่ปลอดภัย: ปลายน้ิวถูกกดแน่น เลื่อนมือออกได้ยาก E ท าการประเมินซ้ าที่ปุ่มกระดูกรองน่ังอีกข้างหน่ึง วิธีลดแรงกดทับระดับ “เตือน” และ “ ไม่ปลอดภัย” เมื่อพบแรงกดทับปุ่มกระดูกรองนั่ง ระดับที่ 2 (เตือน) และระดับที่ 3 (ไม่ปลอดภัย) จ าเป็นต้องลดแรงกด ทับ วิธีแก้ไขง่ายๆ คือ การเพิ่มช้ันฟองน้ า ซึ่งเรียกว่า “แผ่นฟองน้ าเสริม” ส่วนที่น ามารองนี้ควรหนา ประมาณ 20 มิลลิเมตร และตัดร่องบริเวณใต้ปุ่มกระดูกรองนั่ง แผ่นฟองน้ าเสริมนี้จะเสริมระหว่างช้ัน ฟองน้ าส่วนฐานและช้ันฟองน้ านุ่มของเบาะรองนั่ง ในบางครั้งอาจต้องการช้ันแผ่นฟองน้ าเสริมนี้มากกว่า 1 ช้ัน ผู้ให้บริการควรเพิ่มช้ันแผ่นฟองน้ าเสริมนี้ทีละช้ันแล้วท าการประเมินแรงกดทับ ถ้าแรงกดทับยังอยู่ใน ระดับ 2 หรือ 3 ให้เพิ่มแผ่นฟองน้ าเสริมเข้าไปอีก 34 A.8: การเคลื่อนย้ายตัว (transfers) การเขา้และออกจากรถน่ังคนพิการ ความสามารถเข้าและออกจากรถนั่งคนพิการได้ง่ายและปลอดภัยทั้งด้วยตนเองและโดยการช่วยเหลือจาก ผู้อื่นจะช่วยผู้ใช้รถนั่งคนพิการในการใช้ชีวิตประจ าวัน ซึ่งเรียกว่า “การเคลื่อนย้ายตัว” เพราะอะไรผู้ใช้รถน่ังคนพิการต้องเรียนรู้วิธีเคลื่อนย้ายตัว? ผู้ใช้รถนั่งคนพิการอาจต้องเข้าและออกจากรถนั่งคนพิการวันละหลายครั้ง พวกเขาจ าเป็นต้องมีวิธีการที่ ปลอดภัย รวดเร็วและใช้พลังงานน้อย ผู้ใช้รถนั่งคนพิการใช้วิธีต่างกันข้ึนอยู่กับระดับความสามารถของแต่ ละคน ผู้ใช้รถนั่งคนพิการบางรายสามารถเข้าและออกจากรถนั่งคนพิการด้วยตนเอง ในขณะที่บางคนอาจ ต้องการความช่วยเหลือ บางคนใช้วิธีการเคลื่อนย้ายตัวแบบยืน ในขณะที่บางคนไม่สามารถใช้วิธีนี้ได้ วิธีการเขา้และออกจากรถน่ังคนพิการ 3 วิธี ก่อนให้ค าแนะน าหรือฝึกผู้ใช้รถนั่งคนพิการในการเคลื่อนย้ายตัว ผู้ให้บริการควรทราบก่อนว่าผู้ใช้รถนั่งคน พิการรายนั้นสามารถเคลื่อนย้ายตัวได้ด้วยตัวเองหรือต้องการความช่วยเหลือ  การเคลื่อนย้ายตัวด้วยตนเองในท่านั่ง ต้องตรวจสอบว่าผู้ใช้รถนั่งคนพิการสามารถยกตัวเองได้โดยใช้ ก าลังแขนของตนเอง ในกรณีที่ไม่สามารถท าได้ ต้องให้ความช่วยเหลือในขณะเคลื่อนย้ายตัว  การเคลื่อนย้ายตัวด้วยตัวเองในท่ายืน ต้องตรวจสอบว่าผู้ใช้รถนั่งคนพิการสามารถยืนและลงน้ าหนัก ด้วยขาของตนเองได้ ในกรณีที่ไม่สามารถท าได้เองต้องให้ความช่วยเหลือในขณะเคลื่อนย้ายตัว วิธีการเคลื่อนย้ายตัวอื่นๆ มีดงัต่อไปนี ้ การเคลื่อนย้ายตัวในท่าน่ังด้วยตนเอง (จากรถน่ังคนพิการไปเตียง) 35  เลื่อนรถนั่งคนพิการให้ชิดกบัเตียง และกดเบรค  ยกเท้าออกและเหว่ียง(หรือถอด)ที่พักเท้าออก (แล้วแต่กรณีตามความเหมาะสม)  ถอดที่พักแขนด้านที่ชิดเตียงออก  ยกตัวข้ึนและเลือ่นตัวมาด้านหน้าของรถนั่งคนพิการ  วางมือข้างหนึง่บนเตียง มืออกีข้างวางทีร่ถนั่งคนพิการ ยกตัวข้ึนแล้วย้ายตัวมายังเตียง  ในกรณีที่ผู้ใช้รถนั่งคนพิการมีการทรงตัวไม่ดีหรือไม่สามารถยกตัวได้สูงหรือไมส่ามารถเหว่ียงตัวมา ทางด้านข้างได้ไกลพอ ให้ใช้กระดานเคลื่อนย้ายตัว (transfer board) ช่วย อธิบาย :  การเคลื่อนย้ายตัวไปที่เตียง ผู้ใช้รถนั่งคนพิการบางรายอาจ ชอบใช้วิธียกขาไปวางขาบนเตียงก่อน แล้วจงึเคลื่อนย้ายตัว ไป การเคลื่อนย้ายตัวในท่าน่ังแบบมีผู้ช่วยเหลือและใช้กระดานเคลื่อนย้ายตัว (จากรถน่ังคนพิการไปเตียง)  เลื่อนรถนั่งคนพิการให้ชิดกบัเตียง กดเบรค  น าเท้าออกและเหว่ียง(หรือถอด)ทีพ่ักเท้าออก (แล้วแต่ กรณีตามความเหมาะสม)  ถอดที่พักแขนด้านที่ชิดเตียงออก  ช่วยผู้ใช้รถนั่งคนพิการเคลื่อนตัวมาด้านหน้า  สอดกระดานเคลื่อนย้ายตัวไว้ใต้ก้นและวางพาดจากรถ นั่งคนพิการกบัเตียง  ผู้ใช้รถนั่งคนพิการออกแรงมากทีสุ่ดเท่าที่จะท าได้เพื่อ เคลื่อนย้ายตัวเองจากรถนั่งคนพกิารไปยงัเตียง  ผู้ให้การช่วยเหลือยืนด้านหลังของผู้ใช้รถนัง่คนพิการ และจบัสะโพกของผู้ใช้รถนั่งคนพกิารเคลื่อนไปยังเตียง การเคลื่อนย้ายตัวในท่ายืนแบบมีผู้ช่วยเหลือ (จากเตียงไปรถน่ังคนพิการ)  เลื่อนรถนั่งคนพิการให้ชิดกบัเตียง กดเบรค  น าเท้าออกและเหว่ียง(หรือถอด)ทีพ่ักเท้าออก (แล้วแต่ 36 กรณีตามความเหมาะสม)  ถอดที่พักแขนด้านที่ชิดเตียงออก  ช่วยผู้ใช้รถนั่งคนพิการเคลื่อนตัวมาด้านหน้าและวาง เท้าบนพื้น  ผู้ช่วยเหลืออยู่ด้านหน้าและใช้ขาประคองขาผู้ใช้รถนัง่ คนพิการจากด้านข้างของหัวเข่า (ห้ามดันหัวเข่าจาก ด้านหน้า)  โน้มตัวของผู้ใช้รถนั่งคนพกิารมาด้านหน้าและดึงล าตัว ข้ึนโดยให้การช่วยเหลือบรเิวณสะบัก  บิดล าตัวผู้ใช้รถนั่งคนพกิารออกจากรถนั่งคนพกิารและ ให้นั่งลงบนเตียงอย่างนุ่มนวล กระดานเคลื่อนย้ายตัวคืออะไร? กระดานเคลื่อนย้ายตัวคือแผ่นกระดานที่บางและแข็งแรง ซึ่งช่วยปิดช่องว่างระหว่างรถนั่งคนพิการและ พื้นผิวที่ผู้ใช้รถนั่งคนพิการจะเคลื่อย้ายตัวไป กระดานเคลื่อนย้ายตัวมีประโยชน์ส าหรับผู้ที่ฝึกเคลื่อนย้ายตัวด้วยตนเอง หรือผู้ความแข็งแรงของแขนมี น้อย ผู้ใช้รถนั่งคนพิการสามารถเคลื่อนย้ายตัวโดยการยกตัวที่ละน้อยเป็นช่วงๆแทนการยกตัวสูงๆครั้ง เดียว กระดานเคลื่อนย้ายยังช่วยลดการช่วยเหลือจากผู้อื่นด้วย กระดานเคลื่อนย้ายตัวอาจผลิตเองในท้องถ่ินโดยท าจากไม้หรือไม้อัด กระดานควรบาง แข็งแรง และเรียบ มากๆ ลบขอบให้บาง ขนาดที่แนะน าคือ 300 x 600 มิลลิเมตร ความหนาของกระดานข้ึนอยู่กับความ แข็งแรงของวัสดุ โดยความหนาทั่วไปอยูร่ะว่าง 20- 25 มิลลิเมตร 37 การเคลื่อนย้ายตัวด้วยตนเองจากพ้ืนไปรถน่ังคนพิการ  การเคลื่อนย้ายตัวแบบนี้ผู้ใช้รถนั่งคนพิการต้องมีแขนที่แข็งแรงมีการทรงตัวที่ดี  ผู้ใช้รถนั่งคนพิการที่มีความเสี่ยงต่อการเกิดแผลกดทับควรนั่งบนเบาะรองนั่งลดแรงกดทับตลอดเวลา ขณะนั่งบนพื้น  นั่งด้านหน้าของรถนั่งคนพิการและงอเข่าต้ังข้ึนให้ชิดตัวมากที่สุด  ก้มหน้าไว้ตลอดเวลาที่ยกตัว  วางมือข้างหนึง่บนพื้น อีกข้างวางบนด้านหน้าของที่นัร่องนัง่รถนั่งคนพิการ  ดันตัวเองโดยการออกแรงหัวไหล่และแขนเพื่อให้ยกก้นลอยจากพื้นและยกตัวข้ึนมายังด้านหน้าของที่ รองนัง่รถนั่งคนพกิาร  นั่งลงบนทีร่องนัง่แล้วเลื่อนตัวไปด้านหลัง เอื้อมมือหยบิเบาะรองนัง่  เอียงตัวไปทางด้านใดด้านหนึ่งเพื่อสอดเบาะรองนั่งให้เข้าที่ เมื่อเคลื่อนย้ายตัวจากรถน่ังคนพิการไปพ้ืน  นั่งด้านหน้าของรถนั่งคนพิการ  ยกเท้าออกจากที่วางเท้าแล้ววางไขว้ไปด้านข้าง (ในทิศทางที่ตรงข้ามกับทิศทางที่จะเคลื่อนย้ายตัว)  วางเบาะรองนั่งลงบนพื้น  วางมือข้างหนึ่งบนที่รองนั่งของรถนั่งคนพิการ เอื้อมมืออีกข้างเพื่อวางลงบนพื้น  ใช้ก าลังจากไหล่และแขนเพื่อควบคุมให้ก้นวางลงบนเบาะรองนั่งที่วางบนพื้นอย่างนุ่มนวล วิธีการเขา้และออกจากรถน่ังคนพิการอย่างปลอดภัย ส าหรับผู้ใช้รถนั่งคนพิการ  กดเบรคทุกครัง้เมื่อย้ายตัวเข้าและออกจากรถนั่งคนพกิาร  ตรวจสอบบริเวณทีจ่ะย้ายตัวไป ให้แน่ใจว่าไม่มสีิ่งกีดขวาง  ให้ยกตัว ห้ามลากตัว เนื่องจากจะท าใหผ้ิวหนังเป็นแผลและน าไปสู่แผลกดทบั ส าหรับผู้ให้การช่วยเหลือ  ก่อนให้การช่วยเหลือ ต้องมั่นใจว่าท่านสามารถช่วยรับน้ าหนักผู้ใช้รถนั่งคนพิการ  อธิบายต่อผู้ใช้รถนั่งคนพกิารว่าจะท าอะไร  ใช้วิธีการยกตัวที่ปลอดภัย  ห้ามให้การช่วยเหลือ หากท่านก าลังตั้งครรภ์หรือมปีัญหาเกีย่วกับหลัง 38 B. ขั้นตอนการให้บริการรถน่ังคนพิการ 39 ข้ันตอนท่ี 1 การส่งต่อและนัดหมาย (referral and appointment) การส่งต่อ การส่งต่อ หมายถึง การส่งหรือแนะน าให้บุคคลไปรับการรักษาหรือขอความช่วยเหลือในสถานที่ที่ถูกต้อง การส่งต่อผู้ใช้รถนั่งคนพิการเพื่อรับบริการท าได้หลายวิธี ตัวอย่างเช่น ผู้ใช้รถนั่งคนพิการอาจ  ได้รับฟังข้อมูลเกี่ยวกับบริการรถนั่งคนพิการและเดินทางมารับบริการด้วยตนเอง  ได้รับการแนะน าจากโรงพยาบาลในท้องถ่ิน ศูนย์บริการสุขภาพในชุมชน บริการฟื้นฟูสมรรถภาพ ในชุมชน ผู้น าหมู่บ้าน/ผู้น าชุมชน/วัด องค์กรด้านคนพิการ หรือผู้ใช้รถนั่งคนพิการด้วยกัน หน่วยบริการรถนั่งคนพิการสามารถช่วยเพิ่มจ านวนของผู้ใช้รถนั่งคนพิการที่ได้รับการส่งต่อมายัง หน่วย บริการของตนเอง โดยการท าให้แหล่งส่งต่อที่เป็นไปได้เหล่าน้ีรับทราบข้อมูลเกี่ยวกับการเข้ารับบริการรถ นั่งคนพิการ หน่วยบริการรถนั่งคนพิการแต่ละแห่งต้องออกแบบแบบฟอร์มส่งต่อ มีข้อมูลใดบ้างที่ต้องมีในแบบฟอร์ม และจะใช้แบบฟอร์มนั้นอย่างไร เช่น ส่งแบบฟอร์มทางไปรษณีย์ไปให้หน่วยบริการรถนั่งคนพิการ หรือให้ ผู้ใช้รถนั่งคนพิการน าไปติดต่อหน่อวยบริการ) ตัวอย่างแบบฟอร์มส่งต่อ อยู่ในหน้าถัดไป การนัดหมาย เมื่อผู้ใช้รถนั่งคนพิการได้รับการส่งต่อไปที่หน่วยบริการรถนั่งคนพิการ ผู้ใช้รถนั่งคนพิการดังกล่าวควรได้รับ การนัดหมายเพื่อตรวจประเมิน ซึ่งการนัดอาจเป็นได้ทั้งให้ผู้ใช้รถนั่งคนพิการไปพบเจ้าหน้าที่ในหน่วย บริการ หรือให้เจ้าหน้าที่ออกไปพบผู้ใช้รถนั่งคนพิการ ระบบการนัดช่วยให้ผู้ให้บริการสามารถบริหารจัดการเวลาของตนเองได้ นอกจากนี้ยังช่วยให้ผู้ใช้รถนั่งคน พิการหลีกเลี่ยงการรอคอยเพื่อรับบริการ วิธีนัดหมายข้ึนอยู่กับความสะดวกในการส่งข่าวสารให้กับผู้ใช้รถนั่งคนพิการได้รับทราบ ในบางกรณีผู้ใช้รถนั่งคนพิการอาจเดินทางมาโดยไม่ได้นัดหมาย ถ้าผู้ใช้รถนั่งคนพิการดังกล่าวเดินทางมา ไกลจ าเป็นอย่างยิ่งที่ต้องพยายามหาเวลาเพื่อพบและให้บริการกับบุคคลเหล่าน้ัน 40 การส่งต่อและการนัดหมายท่ีดี  จัดท าแฟ้มประวัตผิู้ใช้รถนั่งคนพิการแต่ละรายเมื่อถูกสง่ต่อมารับบรกิาร  ให้ข้อมูลเกี่ยวกบับริการรถนั่งคนพิการและวิธีการสง่ต่อแก่แหลง่สง่ต่อ  ให้แบบฟอรม์สง่ต่อแก่แหล่งส่งต่อ  กรณีที่มผีู้ใช้รถนั่งคนพิการหลายราย หน่วยบรกิารควรจัดล าดับผู้ทีจ่ะได้รบับริการก่อน โดยพิจารณา จากความจ าเป็นของเด็กและผูท้ี่มีภาวะที่เป็นอันตรายตอ่ชีวิต เช่น มีแผลกดทบั กรุณากรอกแบบฟอร์มและสง่ไปที่: ช่ือหน่วยบริการรถนัง่คนพิการและทีอ่ยู:่ ช่ือของผู้สง่ต่อ: . หน่วยงานของผู้สง่ต่อ: . ที่อยู่ส าหรบัการติดต่อผูส้่งต่อ (วิธีที่ดีที่สุดในการติดต่อท่าน): . . . ช่ือผู้ใช้รถนั่งคนพิการ: . วันเกิด: . ผู้ปกครอง/ผู้ดูแล: . ที่อยู:่ . . จะติดต่อผู้ใช้รถนัง่คนพิการได้อย่างไร? . ทางไปรษณีย ์ โทรศัพท์ของเขาเอง  โทรศัพท์ของเพื่อน/เพือ่นบ้าน  กรณีโดยโทรศัพท์ เบอรโ์ทร: . ความพิการของผู้ป่วย หากทราบ: . เหตผุลทีส่ง่ต่อ:  ไม่มีรถนั่งคนพิการ  รถนั่งคนพิการช ารุด  มีรถนั่งคนพิการแต่ไม่ตรงกับความต้องการ    กรุณาให้ข้อมลูเพิ่มเตมิเกี่ยวกบัผูป้่วยที่ท่านคิดว่าส าคัญที่หน่วยบริการรถนั่งคนพิการควรทราบ: . . . ผู้ป่วยเห็นด้วยกับการสง่ต่อน้ีแล้วหรือยงั? เห็นด้วย  ไม่เห็นด้วย  ลายมือช่ือของผูส้่งต่อ: . วันที่: . แบบฟอร์มการส่งต่อควรมีข้อมูลให้ติดต่อที่ชัดเจนเพ่ือ การบริการ ได้แก่ ชื่อหน่วยบริการ ที่อยู่และเบอร์ โทรศัพท์ จากแบบฟอร์มการส่งต่อนี้ หน่วยบริการจะติดต่อ ผู้ใช้รถนั่งคนพิการเพ่ือนัดหมายมารับบริการ ซ่ึงหาก ไม่มีที่อยู่ข้อมูลนี้ หน่วยบริการอาจยอมรับแบบฟอร์ม นี้โดยไม่ได้นัดหมาย ผู้ใช้รถนั่งคนพิการควรได้รับข้อมูลเก่ียวบริการรถนั่ง คนพิการอย่างครบถ้วนและเห็นด้วยกับการส่งต่อนี ้ 41 ข้ันตอนท่ี 2: การประเมิน (assessment) ใครคือผู้ท่ีต้องใช้รถน่ังคนพิการ? เมื่อมีผู้มารับบริการที่หน่วยบริการรถนั่งคนพิการ สิ่งส าคัญคือต้องแน่ใจว่า บุคคลนั้นจ าเป็นต้องใช้รถนั่งคน พิการอย่างแท้จริง บุคคลต้องใช้รถนั่งคนพิการถ้าซ  ไม่สามารถเดินได้  เดินได้ แต่ด้วยความยากล าบาก หรือเดินได้เพียงระยะทางสั้นๆ ท าไมต้องท าการประเมิน? การประเมินเป็นการรวบรวมข้อมูลเพื่อ:  เลือกรถนั่งคนพิการที่เหมาะสมที่สุดส าหรับผู้ใช้งานจากจ านวนรถนั่งคนพิการที่มีอยู่  เลือกส่วนประกอบรถนั่งคนพิการที่เหมาะสมที่สุดจากจ านวนที่มีอยู่  ค้นหาว่าผู้ใช้รถนั่งคนพิการ และ/หรือครอบครัวต้องได้รับการฝึกสอนด้านใดบ้างเพื่อให้สามารถใช้รถ นั่งคนพิการได้ดีที่สุด ควรท าการประเมินท่ีไหน การประเมินควรด าเนินการในสถานที่ที่ เงียบและสะอาด อาจเป็นพื้นที่ ในหน่วยบริการรถนั่งคน พิการ หรือที่หน่วยบริการด้านสุขภาพหรือ หน่วยงานในชุมชน รวมถึงบ้านของผู้ใช้รถ นั่งคนพิการ หากจ าเป็นต้องตรวจสอบว่าบุคคลนั้นมี แผลกดทับหรือไม่ - ให้ตรวจสอบในที่ มิดชิด เคารพศักดิ์สรีและความเป็นส่วนตัวของ ผู้ใช้รถนั่งคนพิการ โดยไม่แบ่งแยกอายุ เพศ ศาสนาหรือสถานะทางสังคม 42 การประเมิน 2 ส่วน:  การสัมภาษณ์  การประเมินทางร่างกาย 1. การสัมภาษณ์ วิธีการที่ดีที่สุดในการรวบรวมข้อมูลเกี่ยวกับผู้ใช้รถนั่งคนพิการ คือการถามค าถาม แบบประเมินเพื่อพิจารณารถนัง่คนพิการจะช่วยให้ผู้ให้บริการสามารถถามค าถามที่ส าคัญเพื่อการพิจารณา รถนั่งคนพิการได้ หัวข้อค าถามหลัก 4 ข้อ ได้แก่  ข้อมูลเกี่ยวกับผู้ใช้รถนั่งคนพิการ  สภาวะทางร่างกาย  วิถีชีวิตและสภาพแวดล้อม  รถนั่งคนพิการที่มีอยู่ ข้อมูลเกี่ยวกับผู้ใช้รถนัง่คนพิการ: ช่ือผู้รับบรกิาร . หมายเลข .. อายุ . เพศ  ชาย  หญิง โทรศัพท ์ . ที่อยู ่ . . เป้าหมาย: . . ค าถามเหล่าน้ีมีความส าคัญ ในการติดต่อกับผู้ใช้รถนั่งคนพิการในอนาคต และยังเป็นข้อมลูทางสถิติ เกี่ยวกับผู้รบับริการในหน่วยบริการ ในหัวข้อ “เป้าหมาย” ให้เขียนว่าเหตุใดผู้ใช้รถนั่งคนพกิารจึงต้องการรถนั่งคนพิการ และต้องการท าอะไร ได้บ้างในการใช้รถนั่งคนพกิาร 43 ข้อควรจ าในการถามค าถาม:  อธิบายแก่ผู้ใช้รถนั่งคนพิการเข้าใจถึงความส าคัญของข้อมูลเหล่าน้ีทุกครั้ง  ถามค าถามกับผู้ใช้รถนั่งคนพิการโดยตรง (ไม่ใช่กับผู้ช่วยเหลือ/สมาชิกในครอบครัว) ยกเว้นกรณีเป็น เด็กเล็กหรือเป็นผู้ที่ไม่สามารถเข้าใจหรือตอบค าถามได้  ใช้วิธีการสื่อสารที่ดี  ข้อมูลที่ได้ อาจไม่เรียงล าดับตามแบบประเมิน ท่านต้องสร้างความคุ้นเคยกับแบบประเมินเพื่อให้ สามารถบันทึกได้ถูกที่ สภาวะทางร่างกาย ข้อมูลส่วนน้ีมีความส าคัญ เนื่องจากสภาวะสุขภาพสามารถส่งผลกระทบต่อการเลือกรถนั่งคนพกิาร ตัวอย่างเช่น สภาวะทางรา่งกาย  สมองพิการ โปลโิอ  บาดเจ็บไขสันหลัง  โรคหลอดเลอืดสมอง  กล้ามเนื้ออ่อนแรว  กล้ามเนือ้เกร็ง/มีการเคลื่อนไหวที่ควบคุมไม่ได้  ขาขาดเหนือเข่าขวา  ขาขาดใต้เข่าขวา  ขาขาดเหนือเข่าซ้าย  ขาขาดใต้เข่าซ้าย  มีปัญหาการขับถ่ายปสัสาวะ  มีปัญหาการขับถ่ายอจุจาระ ถ้ามีปัญหาการขับถ่ายปัสสาวะ/อุจจาระ คนพิการได้รับการจัดการทีเ่หมาะสม?  ใช่  ไม่ใช่ อื่นๆ: __________________________________________________________________ 44 ภาวะต่างๆที่ส่งผลต่อการพิจารณา (เลือก)รถนั่งคนพกิาร สิ่งที่ต้องรู ้ ข้อควรจ า สมองพิการ(Cerebral palsy) ภาวะสมองพิการ ส่งผลต่อบุคคลแตกต่าง กันมาก บุคคลที่มีภาวะสมองพิการที่สามารถน่ังตัว ตรงได้ พึงระลึกไว้เสมอว่าพวกเขาอาจมี ความยากล าบากในการทรงท่าในท่าน่ังได้ นานๆเน่ืองจากความเหน่ือย ซ่ึงจะท าให้ ท ากิจกรรมต่างๆได้ยากขึ้นและเหน่ือยง่าย การรองรับร่างกายทีด่ีมีความ ส าคัญมาก บุคคลที่ มีภาวะสมองพิการอาจ จ า เป็ นต้อ ง ได้ รับ อุปกรณ์ช่ วย ประคองท่าทางในรถน่ังคนพิการ ซ่ึงผู้เข้าอบรมจ าเป็นต้องผ่านการ ฝึกอบรมในระดับกลางก่อน โปลิโอ (Poliomyelitis) ผู้ที่มีภาวะโปลิโอ อาจมีปัญหาการอ่อนแรง หรืออ่อนปวกเปียกตามส่วนต่างๆของ ร่างกาย ภาวะโปลิโอสามารถส่งผลต่อขา แขน และหลัง แต่ส่วนใหญ่จะเกิดกับส่วน ของขา กล้ามเน้ือและกระดูกของผู้ที่มีภาวะโปลิโอ มักลีบลง และส่วนของระยางค์ไม่ค่อยมีการ เจริญเติบโตมากนัก ส่งผลให้แขนขาสั้น หากเกิดผลกระทบที่ล าตัว จะท าใหล้ าตวั สั้นลง แม้ว่าผู้มีภาวะโปลิโอจะมีการรับ ความรู้สึกปกติ แต่เบาะรองน่ังยังมี ความส าคัญเพื่อให้เกิดความสบาย เบาะรองน่ังที่สูงกว่า หรือหนากว่า จะท าให้รู้สึกสบายในขณะปั่นรถ มากกว่า บาดเจบ็ไขสันหลงั (Spinal cord injury) ผู้ที่มีภาวะบาดเจ็บไขสันหลัง มักเสี่ยงต่อ การเกิดแผลกดทับ ทั้งน้ีเน่ืองมาจากบุคคลเหล่าน้ีไม่สามารถรับ ความรู้สึกตั้งแต่ระดับที่ต่ ากว่ารอยโรคลงไป ควรพิจารณาเบาะรองน่ังลดแรงกด ทับแก่บุคคลเหล่าน้ีเสมอ โรคหลอดเลือดสมอง (Stroke) ผู้มีภาวะโรคหลอดเลือดสมอง มักมีปัญหา อ่อนแรงซีกหน่ึงของร่างกาย ซ่ึงหมายความ ว่าผู้ป่วยอาจล้มไปด้านใดด้านหน่ึงในขณะที่ น่ังอยู่บนรถน่ังคนพิการ ผู้มีภาวะโรคหลอดเลือดสมองอาจมีการรับ ความรู้สึกที่ผิดปกติในซีกร่างกายด้านที่ อ่อนแรง ผู้มีภาวะโรคหลอดเลือดสมองอาจเข้าและ ออกจากรถน่ังคนพิการได้โดยการยืน การรองรับร่างกายเป็นสิ่งส าคัญ ตรวจสอบการรับความรู้สึกว่าปกติ หรือไม่ – เขา/เธออาจจ าเป็นต้อง ใช้เบาะรองน่ังลดแรงกดทับ ผู้มีภาวะโรคหลอดเลือดสมองมัก ชอบรถน่ังคนพิการที่สามารถพับที่ พั ก เ ท้ า ไ ด้ เ พื่ อ ใ ห้ ส า ม า ร ถ เคลื่อนย้ายตัวในท่ายืนได้ 45 ต่อ สิ่งท่ีต้องรู้ ข้อควรจ า ขาขาด (Lower limb amputation) ผู้ที่ตัดขาทั้งสองข้าง จะไม่มีน้ าหนักของขา เพื่อป้องกันการหงายไปด้านหลังของรถน่ัง คนพิการ การให้บุคคลตัดขาทดลองใช้รถน่ังคนพิการเป็น ครั้งแรกต้องระมัดระวังเป็นอย่างมาก ตรวจสอบสมดุลของรถน่ังคนพิการ ล้อหลัง อาจต้องเลื่อนไปด้านหลังมากขึ้นเพื่อเพิ่มความ ม่ันคงให้กับรถน่ังคนพิการ ภาวะอ่อนแรง (Frail) ผู้สูงอายุอาจต้องการใช้รถน่ังคนพิการด้วย เหตุผลที่แตกต่างกัน โดยทั่วไปมักเกิด จากมีความยากล าบากในการเดิน รถน่ัง คนพิการจะช่วยให้สามารถท ากิจกรรม ต่างๆร่วมกับครอบครัวและใช้ชี วิตใน ชุมชนได้ง่ายขึ้น ผู้สูงอายุอาจเคลื่อนย้ายตัวในท่ายืนได้ จึง อาจต้องการที่พักเท้าที่ เป็นพับได้หรือ เหว่ียงไปด้านข้างได้ ผู้สูงอายุควรได้รับรถน่ังคนพิการที่มีการรองรับ ร่างกายที่ดีและน่ังสบาย เพื่อช่วยให้น่ังได้ดีและ หลีกเลี่ยงปัญหาจากการน่ังในท่าทางไม่ดี ที่พักเท้าที่พับขึ้นหรือเหว่ียงไปด้านข้างได้อาจ เป็นทางเลือกที่ดีที่สุดส าหรับผู้ใช้รถน่ังคนพิการ กลุ่มน้ี ภาวะเกร็งหรือกระตุก (Spasms or jerky movements) ผู้รับบริการบางคนอาจมีปัญหาเรื่องการ เคลื่อนไหวของร่างกายแบบกระตุกที่ไม่ สามารถควบคุมได้ ภาวะเหล่าน้ีจะท าให้น้ าหนักตัวเคลื่อนไป ด้านหลังซ่ึงอาจท าให้รถน่ังคนพิการหงาย ไปข้างหลังได้ การเคลื่อนไหวเหล่าน้ีอาจท าให้เท้าเลื่อน ออกจากที่พักเท้าได้ ซ่ึงอาจก่อให้ เกิด อันตรายในขณะที่ปั่นรถน่ังคนพิการ เลือกรถน่ังคนพิการล้อหลังอยู่ในต าแหน่งเลื่อน ไปข้างหลังเพื่อเพิ่มความม่ันคง อาจใช้สายรัดเพื่อจัดต าแหน่งเท้า หมายเหตุ : สายรัดควรเป็นแบบตีนตุ๊กแก เพื่อให้สามารถปลดออกได้ หากผู้ใช้รถน่ังคน พิการตกจากรถ ปัญหาการขับถา่ยปสัสาวะ หรืออุจจาระ (Bowel or bladder problems) ผู้ รับบริการบางรายอาจมีปัญหาการ ควบคุมการขับถ่ายอุจจาระ/ปัสสาวะ ปัญหาเหล่าน้ีสามารถแก้ไขได้หากได้รับ อุปกรณ์ ยา หรือการฝึกที่ถูกต้อง ผู้รับบริการกลุ่มน้ีต้องไม่น่ังบนเบาะรองน่ัง ที่อับชื้นหรือสกปรก เน่ืองจากผิวหนังจะ เกิดแผลได้ง่าย นอกจากน้ีสิ่งสกปรกต่างๆ ที่อยู่ ในอุจจาระอาจเข้าไปในแผลและ น าไปสู่การติดเชื้ออย่างรวดเร็วได้ ระบุผู้เชี่ยวชาญที่อยู่ในพื้นที่เช่น แพทย์และ พยาบาลเฉพาะทาง ที่สามารถให้ค าแนะน า หรือให้โปรแกรมการฝึกต่างๆเหล่าน้ีได้ ให้เบาะรองน่ังที่หุ้มด้วยวัสดุที่สามารถกันน้ าได้ สอนวิธีท าความสะอาดและการท าให้เบาะแห้ง แก่ผู้ใช้งาน การให้เบาะรองน่ังอันที่สองอาจช่วยให้ผู้ใช้รถ น่ังคนพิการมีเบาะส ารองใช้ขณะที่รอเบาะอีก หน่ึงอันแห้ง 46 วิถีชีวิตและสภาพแวดล้อมทีอ่ยู ่ ค าถามเหล่าน้ีเป็นการรวบรวมข้อมูลเก่ียวกับที่สถานที่ที่ผู้ใช้รถน่ังคนพิการใช้ชีวิตอยู่ และต้องการท าอะไรได้บ้างในการใช้ รถน่ังคนพิการ วิถีชีวิตและสภาพแวดล้อมท่ีอยู่ อธิบายสภาพแวดล้อมที่คนพิการจะใช้รถนั่งคนพกิาร _____________________________________________________________________________ ระยะทางที่ใช้รถนั่งคนพกิารในแต่ละวัน:  ประมาณ1ก.ม.  1-5 ก.ม.  มากกว่า 5 ก.ม. ระยะเวลาที่นั่งในรถนั่งคนพิการในแต่ละวัน?  น้อยกว่า1ช.ม. 1-3ช.ม.  3-5ช.ม.  5-8 ช.ม.  มากกว่า 8 ช.ม. ขณะที่ไม่ได้นั่งในรถนั่งคนพิการ คนพิการนอน/นั่งอยูอ่ย่างไร (ท่าทาง และลักษณะพื้นผิวที่นั่ง/นอน) _____________________________________________________________________________ การเคลื่อนย้ายตัว ท าได้เอง  ต้องมีผู้ช่วยเหลือ  ท่ายืน  ท่านั่ง อุ้ม อื่นๆ ลักษณะส้วม  แบบนั่งยอง  แบบชักโครก  ดัดแปลง คนพิการเดินทางโดยรถสาธารณะบ่อยหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ ชนิดไหน:  รถยนต์  แท็กซี่  อื่นๆ __________________________________ รถนั่งคนพกิารที่ใช้อยู ่ ค าถามเหล่าน้ีช่วยใหรู้้ว่ารถนั่งคนพิการที่มอียู่ตอบสนองความต้องการของผู้ใช้หรือไม่ ถ้าไม่เป็นเพราะอะไร รถน่ังคนพิการท่ีใช้อยู่ (กรณีเคยได้รับรถน่ังคนพิการแล้ว) รถนั่งคนพิการตรงตามความต้องการของคนพิการหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการตรงกับสภาพแวดล้อมที่อยู่อาศัยของคนพิการหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการมีขนาดเหมาะสมและช่วยให้คนพิการอยู่ในทา่ทางที่ดีหรือไม่?  ใช่  ไม่ใช่ รถนั่งคนพิการปลอดภัยและคงทนหรือไม?่  ใช่  ไม่ใช่ เบาะรองนัง่ที่ใช้ช่วยป้องกันแผลกดทับไดห้รือไม่? (กรณีคนพิการรายนี้มีความเสี่ยงตอ่การเกิดแผล)?  ใช่  ไม่ใช่ ความเห็น: _____________________________________________________________________ ถ้าตอบ “ใช่” ทุกข้อ หมายความว่า คนพิการรายนี้ไมจ่ าเปน็ต้องเปลี่ยนรถนั่งคนพิการ ถ้าตอบ “ไม่ใช่” ข้อใดข้อหนึ่ง หมายความว่า คนพิการรายนี้สมควรได้รบัการพิจารณาเปลี่ยนรถนัง่คน พิการหรือเบาะรองนัง่ หรือพิจารณาซ่อมแซมรถนัง่คนพิการ 47 2: การประเมินทางร่างกาย หัวข้อค าถามหลัก 3 ประเด็น ได้แก ่ ภาวะแผลกดทบัทั้งในปัจจุบัน และอดีต และความเสี่ยงต่อการเกิดแผลกดทับ  วิธีการปั่นรถนั่งคนพกิาร  การวัดขนาดร่างกาย แผลกดทับ /// = ไม่รู้สึก O = เคยมีแผลกดทับ  = ก าลังเป็นแผลกดทับ การรับความรู้สึกปกติหรือไม่?  ใช่  ไม่ใช่ เคยมีแผลกดทับหรือไม่?  ใช่  ไม่ใช่ ก าลังเป็นแผลกดทับหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ อยู่ในระยะ1 – 4 หรือไม่?  ใช่  ไม่ใช่ ระยะเวลาที่เป็นแผลและสาเหตุของการเกิดแผลครั้งน้ี: ___ ____________________________________________ มคีวามเสี่ยง*ต่อการเกิดแผลกดทับหรอืไม?่ (A)* …สูญเสียการรับความรู้สึก หรือ (B) มีอย่างน้อย 3 ปัจจัยเสี่ยงต่อไปน้ี …เคลื่อนไหวไม่ได้…ความอับชื้น …อยู่ในท่าไม่ดี …มีประวัติเป็นแผลกดทับ …โภชนาการไม่ดี …สูงอายุ …น้ าหนักมาก/น้อยเกินไป  ใช่  ไม่ใช่ ท าเครื่องหมายบนร่างกาย:  ต าแหน่งที่ผู้ใช้รถน่ังคนพิการไม่สามารถรับความรู้สึกได้ ให้ท าเครื่องหมาย ///  ต าแหน่งที่ผู้ใช้รถน่ังคนพิการเคยมีแผลกดทับในอดีต ให้ท าเครื่องหมาย  ต าแหน่งที่ผู้ใช้รถน่ังคนพิการเคยมีแผลกดทับในปัจจุบัน ให้ท าเครื่องหมาย กรณีผู้ใช้รถน่ังคนพิการมีแผลกดทับ ให้ขอดูแผลดังกล่าว โดยท าในพื้นที่มิดชิดเป็นส่วนตัว ผู้ใช้รถน่ังคนพิการที่มีความเสี่ยงต่อการเกิดแผลกดทับ จากการไม่สามารถรับความรู้สึกได้หรือมีปัจจัยเสี่ยงดังต่อไปน้ี  บกพร่องหรือสูญเสียการรับความรู้สึก  ไม่สามารถเคลื่อนไหวได้  ความชื้นจากเหงื่อ น้ าหรือปัสสาวะ/อุจจาระเล็ดราด  อยู่ในท่าทางไม่ดี  เคยมีหรือก าลังมีแผลกดทับ  โภชนาการไม่ดี หรือดื่มน้ าน้อย  สูงอายุ  น้ าหนักร่างกาย มากหรือน้อยเกินไป ข้อควรจ า: ผู้ใช้รถน่ังคนพิการที่มีความเสี่ยงต่อการเกิดแผลกดทับ จ าเป็นต้องได้รับเบาะรองน่ังลดแรงกดทับและได้รับการ สอนวิธีป้องกันแผลกดทับ 48 วิธีการป่ันรถ คนพิการเข็นรถด้วยวิธีไหน?  ใช้แขนสองข้าง  ใช้แขนซ้าย  ใช้แขนขวา  ใช้ขาสองข้าง  ใช้ขาซ้าย  ใช้ขาขวา  มีผู้อื่นเข็นให ้ ความเห็น: _____________________________________________________________________ การค้นหาวิธีการที่ใช้ขับเคลื่อนรถนั่งคนพิการมีความส าคัญ เพราะมีผลต่อการเลือกและการประกอบรถนัง่ คนพิการ (ดูรายละเอียดใน บทที่ A.6: รถนั่งคนพิการที่เหมาะสม หัวข้อย่อย “วิธีการปั่นรถนั่งคนพกิาร”) การวัดร่างกาย การวัดร่างกายผู้ใช้รถนั่งคนพกิาร 4 ข้อต่อไปนี้ มีความจ าเปน็ต่อการเลือกขนาดรถนั่งคนพิการที่ดีทีสุ่ดที่มี อยู่ส าหรับบุคคลนั้น การวัดขนาดร่างกายแต่ละข้อมีความสมัพันธ์กับขนาดของรถนั่งคนพิการ การวัดขนาดร่างกาย ขนาด ร่างกาย (มม.) การค านวณขนาดร่างกายไปสู ่ ขนาดของรถน่ังคนพิการที่เหมาะสม ขนาดของ รถน่ังคน พิการ A ความกว้างของสะโพก ความกว้างของสะโพก= ความกว้างของที่รองน่ัง B ความลึกของที่น่ัง ซ้าย B ลบออก 30 – 50 มม. = ความลึกของที่รองน่ัง ขวา C ความยาวของน่อง ซ้าย = จากขอบบนของเบาะรองนั่งถึงขอบหลงัของที่ วางเท้า หรือ = จากขอบบนของเบาะรองนั่งถึงพ้ืน กรณีคน พิการใช้เท้าเข็นรถ ขวา D ระยะจากที่น่ังถงึชายโครง = ระยะจากขอบบนของเบาะรองน่ังถึงขอบบน ของพนักพิง (วัดระยะ D หรือ E – ขึ้นอยู่กับความต้องการของ คนพิการ) E ระยะจากที่น่ังถงึฐานสะบัก *การวัดระยะ C, D และ E ให้ค านึงถึงความหนาของเบาะรองนั่งที่คนพิการใช้ดว้ย อุปกรณ์วัด  ใช้ตลับเมตร (ภาพขวา)  กระดาษแข็ง/หนังสือสามารถใช้เพื่อให้วัดได้แม่นย า (ดูหัวข้อ การวัดขนาดร่างกาย)  คาลิปเปอร์ (caliper) ขนาดใหญ่ เป็นเครื่องมืออีกชิ้นที่มี ประโยชน์มาก สามารถท าเองในท้องถิ่นโดยท าจากไม้  ฐานวางเท้า ใช้เพื่อจัดต าแหน่งเท้าของผู้ใช้รถน่ังคนพิการให้อยู่ ในระดับความสูงที่เหมาะสม 49 วิธีการวัดขนาดร่างกาย ให้ผู้ใช้รถน่ังคนพิการน่ังในท่าตั้งตรงที่สุดเท่าที่จะท าได้ เท้าของผู้ใช้รถน่ังคนพิการควรวางาบกับพื้นหรือวางบนฐานวางเท้า หากเท้าไม่ สามารถวางถึงพื้นได้พอดี ในการวัดทุกครั้ง ต้องแน่ใจว่า ดึงสายวัดตรงและผู้ใช้รถน่ังคนพิการน่ังในท่าตั้ง ตรง การวางกระดาษแข็ง/หนังสือที่ด้านข้างของผู้ใช้รถน่ังคนพิการ จะช่วยให้วัด ได้แม่นย าขึ้น ก้มตัวลงดูเพื่อให้ม่ันใจว่าท่านเห็นสายวัดในมุมที่ถูกต้อง A ตรวจสอบว่าไม่มีสิ่งใดอยู่ในกระเป๋ากางเกงของผู้ใช้รถนั่งคนพิการก่อนท าการวัด วัดสะโพกหรือส่วนที่ กว้างที่สุดของต้นขา จับใช้แผ่นกระดานหรือหนังสือตั้งทาบไว้ด้านข้างทั้งสองข้างของผู้ใช้รถนั่งคน พิการจะช่วยให้ตัวเลขที่ได้มีความแม่นย าข้ึน B วางแผ่นกระดาน/หนังสือที่ด้านหลังของผู้ใช้รถนั่งคนพิการเพื่อช่วยให้วัดแม่นย า วัดจากด้านหลังของ เชิงกรานถึงด้านหลังของเข่าในแนวเส้นตรง วัดขาทั้ง 2 ข้างเสมอ หากมีความแตกต่างกันระหว่างขาทั้งสองข้าง ตรวจสอบให้แน่ใจว่าผู้ใช้รถนั่งคน พิการนั่งตัวตรง เชิงกรานทั้งสองข้างอยู่ในระดับเดียวกัน หากยังได้ความยาวที่แตกต่างอยู่ให้บันทึก ความยาวของขาข้างที่สั้นกว่า C วัดจากด้านหลังของเข่าไปถึงส้นเท้า ตรวจดูให้ข้อเท้าของผู้ใช้รถนั่งคนพิการอยู่ในท่างอ 90 องศา (หาก เป็นไปได)้ วัดขาทั้งสองข้าง ถ้าผู้ใช้รถนั่งคนพิการใส่รองเท้า ให้วัดในขณะที่ใส่รองเท้าคู่ที่ใส่เป็นประจ า D วัดจากที่รองนั่งข้ึนไปยังกระดูกชายโครง (rib cage) การหาต าแหน่งของชายโครงท าได้โดยการ วางมือลงบนกระดูกเชิงกรานทั้งสองข้าง บีบมือเบาๆแล้วเลื่อนข้ึน ส่วนล่างสุดของชายโครงอยู่เหนือ ระดับเอวที่จับนั้น E วัดจากที่รองนั่งไปยังส่วนล่างสุดของกระดูกสะบักในแนวตั้ง การหาต าแหน่างล่างสุดของกระดูกสะบัก ท าได้โดยให้ผู้ใช้รถนั่งคนพิการยักไหล่ข้ึน ข้อมูลเพ่ิมเติมเกีย่วกับขนาดท่ีเหมาะสมของรถน่ังคนพิการ อยู่ในหัวข้อขั้นตอนท่ี 6: การลองอุปกรณ์ 50 ขั้นตอนที่ 3: การพิจารณา (การเลอืก) (Prescription (selection)) การพิจารณา(เลือก)คืออะไร? การพิจารณา (เลือก) หมายถึง หมายถึง การเลือกรถนั่งคนพิการที่ดทีี่สุดทีม่ีอยู ่ที่ตรงกบัความต้องการของ ผู้ใช้งานมากทีสุ่ด การพิจารณา (เลือก)รถนั่งคนพกิาร ควรเป็นการตัดสินใจร่วมกับผู้ใช้รถนั่งคนพิการ รวมทัง้สมาชิกใน ครอบครัว หรือผู้ดูแล การพิจารณา (เลือก) รถนั่งคนพิการ ประกอบด้วย  การเลือกขนาดของรถนั่งคนพิการและเบาะรองนั่งที่ถูกต้อง  การเลือกชนิดของรถนั่งคนพิการ เบาะรองนั่ง และส่วนประกอบที่ถูกต้อง  ท าความตกลงกับผู้ใช้รถนั่งคนพิการเกี่ยวกบัการฝึกที่จ าเป็นที่จะช่วยให้พวกเขาสามารถใช้งานและ ดูแลรักษารถนั่งคนพิการและเบาะรองนัง่ได้รถนั่งคนพิการ และเบาะรองนั่งที่มีในท้องถ่ิน การคัดเลือกรถนั่งคนพิการที่มีขนาดเหมาะสมมีความส าคัญมาก เพราะขนาดที่เหมาะสมจะช่วยให้เกิด ความสบาย รองรับร่างกายขณะนั่ง และง่ายต่อการใช้งาน ข้อมูลเพิ่มเติมเกี่ยวกับขนาดที่เหมาะสมของรถ นั่งคนพิการ อยู่ในข้ันตอนที่ 6: การลองอุปกรณ์  โครงสร้าง - เช่น เป็นแบบที่มีระยะฐานล้อและความยาวของโครงยาวหรือสั้น โครงพับได้หรือพับไม่ได้  ลักษณะส าคัญ – ได้แก่ รวมถึงชนิดของที่นั่ง พนักพิง ที่พักเท้า ที่พักแขน ล้อหน้า ล้อหลัง  ขนาดของรถนั่งคนพิการ ซึ่งโดยทั่วไปจะบอกด้วยความกว้างของที่รองนั่ง บางครั้งอาจบอกความลึก ด้วย นอกจากนี้หากทราบระดับความสูงของที่รองนั่งซึ่งวัดจากพื้นจะเกิดประโยชน์ด้วย  ทางเลือกในการปรับ : ส่วนประกอบใดบ้างที่สามารถปรับได้ และปรับได้มากน้อยเพียงใด ซึ่งส่วนใหญ่ จะสามารถปรับได้ต้ังแต่ 2 ต าแหน่งขึ้นไป เช่น รถนั่งคนพิการส่วนใหญ่จะสามาถปรับความสูงของที่พัก ได้ ระยะของการปรับจะเริ่มจากน้อยที่สุดไปถึงมากที่สุด  เบาะรองนั่ง: เบาะรองนั่งที่มากับรถนั่งคนพิการเป็นแบบใด (ถ้ามี) หรือมีเบาะรองนั่งที่ให้แยกต่างหาก บริษัทผู้ผลิตรถนั่งคนพิการบางราย อาจให้  แผ่นพับหรือสรุปข้อมูลผลิตภัณฑ์  ข้อมูลลักษณะเฉพาะของผลิตภัณฑ์ (รถนั่งคนพิการ) ข้อมูลเหล่านี้ มักประกอบไปด้วย ขนาด น้ าหนัก ลักษณะของรถนั่งคนพิการ และบางครั้งอาจรวมถึง ส่วนประกอบเพิ่มเติมของรถนั่งคนพิการด้วย ควรมีการตรวจสอบเสมอว่ารถนั่งคนพิการที่เราพิจารณา (เลือก) มีข้อมูลต่างๆอยู่หรือไม่ ควรอ่านข้อมูล เหล่าน้ีเพื่อให้คุ้นเคยกับผลิตภัณฑ์ ถ้าผู้ผลิตไม่ได้ให้ข้อมลูเหล่าน้ีไว้ – ควรขอข้อมูลนี้ด้วย 51 บันทึกการพิจารณา (เลือก)รถน่ังคนพิการ ควรมีการบันทึกข้อมูลการพิจารณา(เลือก)รถนั่งคนพิการ ดังตัวอย่างแบบฟอร์มด้านล่าง ซึ่งสามารถ ดัดแปลงส าหรับหน่วยบริการในท้องถ่ินได้ โดยการระบุชนิดรถนั่งคนพิการ เบาะรองนั่งและขนาดที่มี ให้บริการ แบบฟอร์มการพิจารณารถนั่งคนพิการ 1. ข้อมูลเกี่ยวกับผู้ใช้รถนั่งคนพิการ ชื่อผู้รับบริการ หมายเลข .. วันที่ประเมิน วันที่นัดลอง . ชื่อผู้ประเมิน 2. ชนิดของรถนั่งคนพิการและขนาดท่ีเลือก การเลือกชนิดของรถน่ังคนพิการ  พูดคุยกับผู้ใช้รถน่ังคนพิการ  พูดคุยเก่ียวกับความต้องการที่ส าคัญที่สุดของผู้ใช้รถน่ังคนพิการ  ตรวจสอบ: โครงรถ ล้อหน้าและล้อหลัง ที่พักเท้า ที่พักแขน ความสูงของพนักพิง (หรือปรับได้หรือไม่) ต าแหน่งล้อ หลัง การรองรับร่างกายและความสบาย ชนิดของรถน่ังคนพิการ ขนาด      3. เบาะรองนั่ง ชนิดของเบาะรองนั่ง ขนาด เช่น เบาะรองนั่งลดแรงกดทับ  เช่น เบาะฟองน้ าแบบเรียบ   4. ลงชื่อเห็นด้วย ลายมือชื่อของผู้ใช้รถน่ังคนพิการ: . ลายมือชื่อของผู้ประเมิน: . ลายมือชื่อของผู้จัดการ: . ระบุชนิดรถนั่งคนพิการที่มีให้บริการในหน่วย บริการของท่าน ระบุชนิดและขนาดเบาะรองนั่งที่มีให้บริการ 52 ขั้นตอนที่ 4: งบประมาณและการสัง่ซื้อ (funding and ordering) งบประมาณ เมื่อได้พิจารณารถนั่งคนพิการแล้ว ควรสามารถประมาณราคาของรถนั่งคนพิการที่เลือกอย่างแม่นย า เราต้องรู้ว่าใครจะเป็นผู้รับผิดชอบค่าใช้จ่าย ซึ่งอาจเป็นผู้ใช้รถนั่งคนพิการออกค่าใช้จ่ายทั้งหมดเอง ออก ค่าใช้จ่ายโดยรัฐ องค์กรเอกชน ได้บริจาค หรือบริษัทประกันภัยเป็นผู้ออกค่าใช้จ่ายให้ ในประเทศที่ ก าลังพัฒนา ประชาชนที่จ าเป็นต้องใช้รถนั่งคนพิการจ านวนมากไม่สามารถซื้อรถนั่งคนพิการเองได้ อย่างไรก็ตาม บุคคลใดที่มีความจ าเป็นต้องใช้รถนั่งคนพิการควรได้รับสิทธิในการได้รับรถนั่งคนพิการตาม ก าลังในการจ่ายที่ตนมี ดังนั้นการหาแหล่งทุนจึงมีความจ าเป็นส าหรับผู้ใช้รถนั่งคนพิการที่ต้องการความ ช่วยเหลือเรื่องค่าใช้จ่าย การให้บริการโดยส่วนใหญ่จ าเป็นต้องการระบุแหล่งงบประมาณก่อนการสั่งซื้อรถ นั่งคนพิการ การสั่งซื้อรถนั่งคนพิการมักเป็นหน้าที่ของบุคลากรฝ่ายอ านวยการหรือผู้จัดการ ไม่ใช่บุคลากรทางคลิกนิก หรือช่าง หากบทบาทนี้ผู้ให้บริการต้องรับผิดชอบด้วย ควรจัดระบบการเบิกจ่ายค่าใช้จ่ายเกี่ยวกับรถนั่ง คนพิการด้วย การสั่งซื้อ เมื่อได้เลือกรถนั่งคนพิการที่ดีที่สุดให้กับผู้ใช้ และมีการพิจารณาให้รถนั่งคนพิการแล้ว จ าเป็นต้องมีการ สั่งซื้อรถนั่งคนพิการให้กับผู้ใช้ หากบริการมีรถนั่งคนพิการอยู่ในคลังแล้ว ข้ันตอนนี้อาจหมายถึงการกรอกแบบฟอร์มเพื่อขออนุมัติจาก ผู้จัดการของหน่วยบริการ หลังจากนั้นเจ้าหน้าที่ผ็รับผิดชอบจะท าการเตรียมรถนั่งคนพิการ หากหน่วยบริการไม่มีรถนั่งคนพิการอยู่ในคลัง ข้ันตอนน้ีอาจหมายถึงการสั่งซื้อจากบริษัทผู้ขาย ระบบการสั่งซื้อรถนั่งคนพิการมีความแตกต่างกันไปในแต่ละหน่วยบริการ ให้ผู้สอนบันทึกสิ่งจ าเป็นที่ควร จ าในการสั่งซื้อรถนั่งคนพิการในหน่วยบริการในท้องถ่ิน 53 วิธีการสั่งซื้อรถน่ังคนพิการในหน่วยบริการในท้องถิ่นของฉัน วิธีการสั่งที่ด ี  การมรีถนั่งคนพิการในคลัง จะช่วยลดเวลาการรอคอยของผูใ้ช้รถนั่งคนพิการ  การออกใบสัง่ซื้อตอ้งท าให้เร็วที่สุดเพื่อป้องกันความล่าช้า  แจ้งแกผู่้ใช้รถนั่งคนพิการให้ทราบถงึก าหนดเวลาทีจ่ะได้รบัรถนั่งคนพิการเสมอ 54 ขั้นตอนที่ 5: การเตรียมผลติภณัฑ์ (รถนั่งคนพกิาร) (product (wheelchair) preparation) การเตรียมรถน่ังคนพิการคืออะไร? การเตรียมรถนั่งคนพิการประกอบด้วย:  การเตรียมรถนั่งคนพิการที่ได้รบัการประกอบแล้วให้ตรงกบัรถนั่งคนพิการที่พจิารณาให้กบัผู้ใช้  ตรวจสอบความปลอดภัยและพร้อมใช้ของรถนั่งคนพกิาร เพื่อให้มั่นใจว่ามีความปลอดภัย พร้อมใช้ และส่วนประกอบต่างๆท างานไดเ้ป็นปกต ิ การเตรียมรถน่ังคนพิการ 1. ตรวจสอบความกว้างและความลึกของที่รองนั่งของรถนั่งคนพิการว่าถูกต้องตามที่ได้พิจารณา ไว้ หรือไม่ 2. ตรวจสอบความกว้างและความลึกของเบาะรองนั่งว่าเท่ากับที่รองนั่งหรือไม่ 3. ปรับ (ถ้าเป็นไปได้):  ความสูงของพนักพิง  ความสูงของที่พักแขน  ต าแหน่งของล้อหลัง  ต าแหน่งของเบรค  ความสูงของที่พักเท้า  ความสูงของด้ามจับเข็น  การปรับอื่นๆที่สามารถท าได้ 4. ตรวจสอบ “ความปลอดภัยและพร้อมใช้ของรถนั่งคนพกิาร” วิธีท่ีดีในการเตรียมรถน่ังคนพิการ  ติดช่ือผู้ใช้รถนั่งคนพิการไว้ทีร่ถนั่งคนพิการที่เตรียมไว้  การดัดแปลงรถนั่งคนพิการต่างๆ ควรท าโดยผู้มีความรู้และทักษะที่เหมาะสม เนือ่งจากการ ดัดแปลงจะส่งผลต่อความแข็งแรงและการใช้งานของรถนั่งคนพิการ  ตรวจสอบความปลอดภัยและพร้อมใช้ของรถนั่งคนพกิารกอ่นให้ผู้ใช้งานทดลองใช้ การตรวจสอบความปลอดภัยและพร้อมใช้ของรถน่ังคนพิการ ใช้แบบตรวจสอบต่อไปนี้เพื่อตรวจสอบความปลอดภัยและความพร้อมใช้ของแต่ละส่วนส่วนประกอบ โดย ตรวจสอบก่อนให้ผู้ใช้รถนั่งคนพิการทดลองใช้เสมอ 55 แบบตรวจสอบ: รถน่ังคนพิการปลอดภัยและพร้อมใช้งานหรอืไม่? รถน่ังคนพิการท้ังคัน วิธีตรวจสอบ ไม่มีขอบคม  ตรวจสอบรถนั่งคนพิการทั้งคัน ทั้งด้วยการ มองดูและการสัมผัส ไม่มีส่วนใดฉีกขาดหรอืช ารุด  รถนั่งคนพิการเคลือ่นที่ในแนวตรง  ผลักให้รถนัง่คนพิการเคลื่อนที่ไปข้างหน้า ตรวจสอบว่าล้อหน้าอยู่ในต าแหนง่ที่ถูกต้อง ก่อนเรมิผลัก ล้อหน้า หมุนโดยอสิระ  หงายรถนัง่คนพิการข้ึน แล้วหมุนลอ้หน้า หมุนโดยไมส่ัมผัสตะเกียบ  น๊อตขันแน่น  ตรวจสอบว่าขันแน่น แต่ไม่แน่นเกินไป ลูกปืนล้อหน้า ตะเกียบหมุนโดยอิสระ  หงายรถนัง่คนพิการข้ึน แล้วหมุนลอ้หน้า รอบๆ ล้อหลัง หมุนโดยอสิระ  เอียงรถนั่งคนพิการไปด้านข้างใหล้้อหลงัข้าง หนึ่งลอยข้ึน แล้วหมุนล้อทีล่อยเพื่อตรวจสอบ น๊อตยึดแกนล้อขันแน่น  ตรวจสอบว่าหมุนแน่น แต่ไม่แน่นเกินไป ยางมีลมพอเหมาะ (ใช้นิ้วหัวแม่มือกด แล้วยางยุบลงน้อยกว่า 5 มม.)  ใช้นิ้วหัวแม่มือกดยาง ยางควรถูกกดลงไป เล็กนอ้ยแต่ไม่เกิน 5 มม. วงปั่นมีความมั่นคง  ตรวจสอบ เบรค ท าหน้าที่อย่างเหมาะสม  กดเบรค แล้วตรวจสอบว่ารถนัง่คนพิการยงั เคลื่อนที่ไดห้รือไม ่ ท่ีพักเท้า ที่พักเท้ายึดอย่างมั่นคง  ตรวจสอบ 56 โครงรถ ส าหรับรถนั่งคนพิการแบบพับได ้– สามารถพบัและกางได้โดยง่าย  พับรถนั่งคนพกิารเพื่อตรวจสอบว่ากลไกต่างๆ ท างานได้ดี ส าหรับรถนั่งคนพิการแบบพับพนกัพิง ลง – สามารถพับและกางได้โดยง่าย  เบาะรองน่ัง เบาะรองนัง่อยู่ในผ้าหุ้มอย่างถูกต้อง  ปกติขอบผ้าหุ้มเบาะ จะอยู่ด้านหลังของเบาะ รองนั่ง โดยอยู่ใต้เบาะ เบาะรองนัง่วางบนทีร่องนั่งอย่าง ถูกต้อง  กรณีเป็นเบาะชนิดโค้งเข้ารูป แอ่งรองรับปุ่ม กระดูกรองนั่งจะอยู่ทางด้านหลังของที่นั่ง ผ้าหุ้มเบาะรองนั่งตึงแต่ไม่ตงึเกินไป  ผ้าหุ้มเบาะรองนั่งบริเวณส่วนโค้งของเบาะ ต้องไม่ตึงเกินไป ถ้ารถนั่งคนพิการเป็นแบบทีร่องนัง่แข็ง: เบาะรองนัง่คลุมทั่วที่รองนั่งแข็ง  ตรวจสอบให้แน่ใจว่าไม่มีส่วนใดของที่นั่ง ที่เกินออกมาจากเบาะรองนั่ง ข้อนี้ส าคัญมาก ส าหรับที่นั่งชนิดแข็ง การผลิตเบาะรองนั่ง กรณีที่มีฟองน้ า ผู้ให้บริการสามารถจัดท าเบาะฟองน้ าลดแรงกดทับได้จากเครื่องมือเพียงไม่กี่ช้ิน เจ้าหน้าที่ต้องรู้ว่าจะใช้ฟองน้ าชนิดใดและรู้จักมิติที่ส าคัญในการท าเบาะรองนั่ง ซักถามจากผู้สอนของท่าน เกี่ยวกับฟองน้ าที่มีในพื้นที่เพื่อค้นหาฟองน้ าที่เหมาะกับการท าเบาะลดแรงกดทับ ข้ันตอนต่อไปนีจ้ะแสดงวิธีการจัดท าเบาะฟองน้ าลดแรงกดอย่างง่าย ที่มีส่วนโค้ง 2 ส่วน และมีแอ่งรองรับ ใต้ปุ่มกระดูกรองนั่ง และมีขอบด้านหน้าปุ่มกระดูกรองนั่ง ลักษณะและมิติของเบาะรองนั่ง ลักษณะส าคัญของเบาะฟองน้ าลดแรงกดทับอย่างง่าย ประกอบด้วย ชั้นฐาน ท าจากฟองน้ าแน่น (เช่น ฟองน้ าอัด) 57 แอ่งรองรับปุ่มกระดูก  ลดแรงกดทับใต้ปุ่มกระดูกรองนั่งและกระดกูกน้ กบ  ช่วยประคองให้กระดูกเชิงกรานตั้งตรงอยู่ส่วน หลังของเบาะรองนั่ง ฐานเบาะส าหรับที่รองนั่งหย่อน  ถ้าเบาะรองนั่งนั้นต้องใช้กับที่รองนั่งแบบหย่อน ขอบล่างของเบาะรองนั่งจะตัดให้มีเอียง  การตัดขอบล่างให้เอียงนี้จะช่วยให้เข้ากับรูปร่าง ของที่รองนั่งที่หย่อน โดยส่วนบนของเบาะรอง นั่งยังคงความตรงราบ ไม่ห่อตามที่รองนั่ง ชั้นบน ท าจากฟองน้ าท่ีมีความนุ่มสบาย ฟองน้ าช้ันบนสุด:  ช่วยให้นั่งสบาย วิธีท าฐานเบาะลดแรงกดทับ แนวทางต่อไปนี้เป็นวิธีท าเบาะขนาดกว้าง 400 มม. x ลึก 400มม. x สูง 50 มม. โดยมีแอ่งรองรับปุ่ม กระดูกรองนั่ง ขนาดกว้าง 200 มม. x ลึก 200 มม. x สูง 35 มม. เบาะรองนั่งนี้เหมาะสมส าหรับผู้ใช้รถนั่ง คนพิการที่มีขนาดความกว้างของที่รองนั่ง 400 มม. ดัดแปลงมิติต่างๆให้เหมาะกับผู้ใช้แต่ละราย ดังอธิบายในตารางด้านล่าง 58 1. ขีดเส้นท่ีจะตัดลงบนแผ่นฟองน้ าแน่น  ใช้ฟองน้ าชนิดเนื้อแน่น ขนาด 400 มม. x 400 มม. x 50 มม.  จุดกึ่งกลางของแอ่งรองรับปุ่มกระดูกรองนั่งต้องอยู่กึ่งกลางของเบาะรองนั่ง  แอ่งรองรับปุ่มกระดูกรองนั่งควรมีขนาด 200 มม. x 200 มม. x 35 มม.  วาดเส้นที่จะตัดด้วยหมึกสีด าบนฟองน้ าทั้ง 6 ด้าน แอ่งรองรับปุ่มกระดูกรองน่ัง ปรับขนาดของเบาะและแอง่รองรบัปุม่กระดูกรองนัง่ให้เหมาะ กับผู้ใช้แต่ละราย โดย  แอ่งรองรบัปุ่มกระดกูรองนั่งกว้าง = ½ ของความกว้าง ของที่นั่ง หรือ 200 มม [a]  ความลึกของทีร่องรบัปุ่มกระดกูรองนั่ง (จากหน้าไปหลัง) = ½ ของความกว้างของที่นัง่ หรอื 200 มม [b]  ความสูงของที่รองรบัปุ่มกระดกูรองนั่ง = 35 มม ส าหรบั ผู้ใหญ่และ 20-25 มม ส าหรบัเด็ก [c] 59 2. ตัดส่วนแอ่งรองรับปุ่มกระดูกรองน่ัง: ใช้เลื่อยหรือมีดยาวที่คมตัดช้าๆเป็นแถบยาว การดึงแล้วตัดจะ ท าให้ควบคุมการตัดได้ดี เริ่มจากตัดผ่านด้านหลังของเบาะไปถึงส่วนลึกของ แอ่งรองรบัปุ่มกระดกูรองนั่ง จากนั้นตัดขอบด้านข้างของแอ่งรองรับปุ่มกระดูก รองนัง่ออก ทากาวที่ขอบฟองน้ าแน่นด้านข้างแอ่งทัง้ 2 ข้าง ปล่อยให้กาวเกอืบแหง้สนทิแล้วกดฟองน้ าเข้าหากัน 3. ตัดส่วนลาดเอียงท่ีมุมด้านในของแอ่งรองรับปุ่ม กระดูกรองน่ัง 4. ส าหรับท่ีรองน่ังแบบหย่อน: ตัดเป็นมุมลาด เอียงท่ีฐาน(ด้านล่าง)ท้ัง 2 ข้าง  ท าเครื่องหมายดังตัวอย่าง แล้วตัด  การตัดส่วนน้ีจะช่วยให้เข้ากับรูปร่างของทีร่อง นั่งที่หย่อน 60 5. วางฟองน้ าชั้นบนสุดทับลงบนเบาะรองน่ัง  วางส่วนฐานและส่วนบนของเบาะรองนั่งเข้าด้วยกัน  ไม่จ าเป็นต้องติดกาวระหว่างฟองน้ าทั้งสองช้ัน  หากช้ันบนสุดเปื้อนหรือขาด สามารถซัก ตากให้แห้งหรือเปลี่ยนใหม่ได้  อาจเพิ่มแผ่นฟองน้ าเสริมในผ้าหุ้มเพื่อเพิ่มความลึกของที่รองรับปุ่มกระดูกรองนั่งได้ ค าถามท่ีพบบ่อยเกี่ยวกับเบาะฟองน้ าลดแรงกดทับ ควรใช้ผ้าแบบใดมาท าเป็นผ้าหุ้มเบาะรองนั่ง?  เลือกผ้าที่ยืดได้ และกันน้ า กรณีเป็นผ้ากันน้ าไดไ้ม่ควรหนาเกินไป เพราะรอยพับอาจท าให้ผิวหนังเป็น รอยและเกิดแผลกดทับได้  การเลือกข้ึนอยู่กับผ้าที่สามารถหาได้ ซึ่งบางครั้งอาจมีข้อจ ากัด  กรณีมีผ้าให้เลือกแต่ไม่แน่ใจ ควรให้ผู้ใช้รถนั่งคนพิการทดลองหลายๆชนิด  ผู้ให้บริการรถนั่งคนพิการจะมีประสบการณ์เพิ่มข้ึน จากการลองใช้ผ้าหลายชนิด เบาะรองนั่งชนิดนีเ้หมาะกับผู้ใช้ทุกรายหรือไม่?  ไม่-เบาะรองนั่งนี้ไม่ได้เหมาะสมกับผู้ใช้ทุกราย  อย่างไรก็ตาม ข้อดีประการหนึ่งของเบาะรองนั่งชนิดนี ้คือสามารถดัดแปลงได้ง่าย เบาะรองนั่งชนิดนีร้้อนหรือท าให้เหงื่อออกหรือไม่?  เบาะรองนั่งชนิดฟองน้ านี้อาจท าให้ร้อนหรือเหงื่อออกได้  อย่างไรก็ตาม เบาะรองนั่งนี้มีประโยชน์หลายอย่าง ข้อเสียน้ีจึงพอยอมรับได้ ผู้ใช้รถนั่งคนพิการทุกรายต้องใช้เบาะรองนั่งลดแรงกดทับหรือไม่?  ไม่ – ไม่ใช่ผู้ใช้รถนั่งคนพิการทุกรายที่ต้องใช้เบาะรองนั่งลดแรงกดทับ  พิจารณาปัจจัยเสี่ยงต่อการเกิดแผลกดทับตามที่ได้เรียนมา เพื่อตัดสินใจว่าผู้ใช้รถนั่งคนพิการมีความ เสี่ยงต่อการเกิดแผลกดทับหรือไม่  แม้ว่าบางครั้งไม่จ าเป็นต้องใช้เบาะรองนั่งเพื่อลดแรงกดทับ แต่เบาะรองนั่งยังสามารถช่วยประคอง ร่างกายและท าให้เกิดความสบาย แม้ในผู้ที่ไม่มีความเสี่ยงต่อการเกิดแผลกดทับ 61 จะเกิดอะไรข้ึน หากใช้เบาะรองนั่งโดยวางกลับด้านหน้า-หลัง หรือสลับบน-ล่าง?  เบาะจะใช้งานได้ไม่ดี และอาจเพิ่มความเสี่ยงในการเกิดแผลกดทับ  ควรแน่ใจว่าผู้ใช้รถนั่งคนพิการตลอดจนสมาชิกในครอบครัวเข้าใจวิธีการใช้และการดูแลเบาะรองนั่ง อย่างถูกต้อง  กรณีจ าเป็น อาจท าเครื่องหมายระบุด้านหน้า-หลัง ด้านบน-ล่างไว้ที่เบาะรองนั่ง เบาะรองนั่ง สามารถใช้กับเด็กได้หรือไม่?  ได้ เบาะรองนั่งสามารถใช้กับเด็กได้ แต่แอ่งรองรับปุ่มกระดูกรองนั่งควรมีขนาดเล็กลง ดูวิธีการวัด ขนาดส าหรับเด็กในเนื้อหาด้านบน  เด็กที่ใช้รถนั่งคนพิการจ านวนมาก ต้องการการรองรับท่าทางเพิ่มเติม เบาะรองนั่งนี้อาจไม่รองรับ ท่าทางอย่างเพียงพอ เบาะรองน่ังท่ีพอดี ตรวจสอบทกุครั้งว่าปุม่กระดูกรองนัง่อยู่ในแอ่งอย่าง ถูกต้อง ไม่ใช่อยู่บนขอบหรือส่วนทีสู่งของเบาะรองนั่ง ขณะลองอปุกรณ์ให้ตรวจสอบเสมอว่า  แรงกดทบับริเวณใต้ปุ่มกระดกูรองนั่งอยู่ในระดับ "ปลอดภัย" (ดหูัวข้อ วิธีทดสอบว่าเบาะรองนั่งช่วยลด แรงกดทบัหรือไม)่ และ  ปุ่มกระดูกรองนัง่อยู่ในแอ่ง ไม่ใช่อยูบ่นขอบหรือช้ันบน ของเบาะรองนั่ง 62 ขั้นตอนที่ 6: การลองอปุกรณ ์ การลองอุปกรณ์ประกอบด้วยอะไรบ้าง? ในระหว่างการลองอุปกรณ์ ผู้ใช้รถนั่งคนพิการและผู้ให้บริการจะตรวจสอบดังหัวข้อต่อไปนี้  รถนั่งคนพิการมีขนาดถูกต้องและได้รับการลองอุปกรณ์แล้ว  รถนั่งคนพิการและเบาะรองนั่งช่วยรองรับผู้ใช้รถนั่งคนพิการให้นั่งตัวตรง หากมีการพิจารณาเบาะรองนั่งลดแรงกดทับด้วย – ตรวจสอบว่าเบาะรองนั่งนั้นช่วยลดแรงกดทับ การปฏิบัติท่ีดีในการลองอุปกรณ์  ถ้าเป็นไปได้ ผู้ประเมินและผู้ให้ลองรถนั่งคนพิการควรเป็นคนเดียวกัน  ตรวจสอบทั้งขณะรถนั่งคนพิการอยู่นิ่งและขณัขบเคลื่อนรถนั่งคนพิการหรือขณะที่บุคคลอื่นเข็นให้  ให้การลองอุปกรณ์ตามล าดับดังนี้  ตรวจสอบขนาดและการปรับส่วนต่างๆ  ตรวจสอบท่าทาง  ตรวจสอบแรงกดทับ  ตรวจสอบความพอดขีองรถนั่งคนพิการขณะที่ผู้ใช้รถนั่งคนพิการมีการเคลื่อนไหว  แบบตรวจสอบการลองอุปกรณ์เพื่อใหจ้ าข้ันตอนต่างๆได ้ ตรวจสอบขนาดและการปรับส่วนต่างๆ ความกว้างของท่ีรองน่ัง ขนาดที่พอดี: ควรพอดีกับร่างกาย วิธีตรวจสอบ  เลื่อนปลายนิ้วผ่านระหว่างด้านข้างของต้นขาผู้ใช้รถนั่งคนพิการกับขอบ ข้างของรถนั่งคนพิการ นิ้วควรผ่านได้พอดีไม่แน่น ตรวจสอบให้แน่ใจว่าด้านข้างของรถนั่งคนพิการไม่กดขาของผู้ใช้ ข้อนี้ส าคัญ มากส าหรับผู้ที่ไม่สามารถรับรู้แรงกดใต้ต้นขา (การรับความรู้สึกผิดปกติ) เพราะ แรงกดที่ต้นขาจากด้านข้างของรถนั่งคนพิการนี้ท าให้เกิดแผลกดทับได้ ความลึกของท่ีน่ัง ขนาดที่พอดี: วางนิ้วมือสองนิ้ว (30 มม.) ระหว่างด้านหลังของเข่ากับเบาะรองนั่ง ต่อ... 63 วิธีตรวจสอบ  ตรวจสอบว่าผู้ใช้รถน่ังคนพิการอยู่ในท่าน่ังตัวตรง  เลื่อนมือระหว่างด้านหน้าของเบาะรองน่ังกับด้านหลังของเข่าของผู้ใช้รถน่ังคนพิการ แล้วนับว่าสอดน้ิวได้ก่ีน้ิว – ปกติควรมีช่องว่างประมาณ 2 น้ิวมือ (30 มม.) ส าหรับ ผู้ใช้รถน่ังคนพิการที่ขายาว อาจมีช่องว่างขนาดใหญ่ถึง 60 มม.  เลื่อนมือลงตามแนวด้านหลังน่องและตรวจสอบให้แน่ใจว่าน้ิวไม่สัมผัสที่รองน่ังหรือ เบาะรองน่ัง  ตรวจสอบทั้งสองข้าง ขนาดที่พอดี จะช่วยรองรับต้นขา และลดแรงกดใต้ปุ่มกระดูกรองน่ังป้องกันแผลกดทับ ถ้า ที่รองน่ังยาวเกินไป ผู้ใช้จะไม่สามารถน่ังตัวตรงได้ ถ้ามีความแตกต่างระหว่างข้างซ้ายกับข้างขวา ให้ใช้ค่าการวัดขาที่สั้นกว่า ความสูงของที่พักเท้า ขนาดที่พอดี: ต้นขาได้รับการรองรับเต็มที่บนเบาะรองน่ังโดยไม่มีช่องว่าง และเท้าได้รับการรองรับเต็มที่ บนที่พักเท้าโดยไม่มีช่องว่างเช่นกัน วิธีตรวจสอบ  เลื่อนมือเข้าระหว่างต้นขากับเบาะรองน่ังควรมีแรงกดทับอย่างสม่ าเสมอและไม่มี ช่องว่างระหว่างต้นขากับเบาะ  ดูที่เท้าบนที่พักเท้า เท้าวางราบเต็มฝ่าเท้าบนที่พักเท้าโดยไม่มีช่องว่าง หากมีช่องว่างใต้ต้นขาอาจเป็นเพราะที่พักเท้าสูงเกินไป หากมีช่องว่างใต้ฝ่าเท้าอาจเป็น เพราะที่พักเท้าต่ าเกินไป ความสูงของพนักพิง ขนาดที่พอดี: ขนาดที่พอดีควรให้การรองรับแก่ผู้ใช้รถน่ังคนพิการตามที่ต้องการ และสามารถเคลื่อนไหว หัวไหล่เพื่อปั่นรถได้อย่างอิสระ วิธีตรวจสอบ  สอบถามผู้ใช้รถน่ังคนพิการว่าพนักพิงให้ความสบายหรือไม่  สังเกตว่าล าตัวมีความสมดุลกับสะโพกหรือไม่  ผู้ใช้รถน่ังคนพิการสามารถปั่นรถได้โดยพนักพิงไม่เป็นอุปสรรคหรือไม่ ความสูงของพนักพิงขึ้นอยู่กับความต้องการของผู้ใช้ ผู้ใช้รถน่ังคนพิการที่ปั่นรถด้วยตนเองต้องการพนักพิงที่ท าให้สามารถ เคลื่อนไหวหัวไหล่ได้อย่างอิสระ ขณะที่ผู้ใช้ที่มีความยากล าบากในการทรงท่าต้องการพนักพิงสูง ซ่ึงให้การรองรับกระดูก สันหลังได้มากกว่า ในแบบประเมินเพื่อพิจารณารถน่ังคนพิการ มีการวัดความสูงของพนักพิง 2 ระดับ (ดูขั้นตอนที่ 2: การประเมิน หัวข้อ "การวัดขนาด") ควรวัดทั้ง 2 ระดับ เน่ืองจากบางครั้งผลอาจไม่ชัดเจนว่าพนักพิงสูงระดับใดจะให้ความสบายแก่ผู้ใช้มาก ที่สุด 64 พนักพิงที่ให้การรองรบัไปถึงบรเิวณฐานซี่โครงของผู้ใช้รถนั่งคนพิการ เป็นระดับ ความสูงทีเ่หมาะสมในกรณีทีผู่้ใช้รถนั่งคนพกิาร  แข็งแรงและคล่องแคล่ว  สามารถนัง่ตัวตรงไดแ้ละการทรงตัวด ี  สามารถปั่นรถได้เอง และต้องการอิสระในการเคลือ่นไหว ความสูงของพนกัพิง D (ฐานซี่โครง) พนักพิงที่ให้การรองรบัไปถึงบรเิวณฐานสะบกัของผู้ใช้รถนั่งคนพิการ เป็นความ สูงทีเ่หมาะสมในผู้ใช้รถนัง่คนพิการที ่  มีแนวโน้มเหนือ่ยง่าย เช่น สูงอายุ หรือมีโรคความเสื่อมต่างๆ  มีความยากล าบากในการนัง่ตัวตรง พนักพิงทีสู่งระดบันี้ ยังให้อสิระในการเคลื่อนไหวหัวไหล่ไดบ้างส่วน ส าหรบัผู้ใช้ รถนั่งคนพิการที่ปั่นรถด้วยมือ ความสูงของพนกัพิง E (ฐานสะบกั) ต าแหน่งของล้อหลัง – ส าหรับการป่ันรถด้วยมือ ขนาดที่พอดี: เมื่อจับที่วงปั่น ข้อศอกของผู้ใช้รถนั่งคนพิการควรงอในมุมทีเ่หมาะสม วิธีตรวจสอบ  ให้ผู้ใช้รถนั่งคนพกิารจับทีส่่วนบนสุดของวงปั่น ข้อศอกควรงอ 90 องศา  ตรวจสอบว่าล้อหลังอยู่ในต าแหนง่ทีเ่หมาะสมเพื่อให้ทรงตัวได้ดี (อยู่ ด้านหน้าเพื่อคล่องแคล่ว (active) อยู่ด้านหลงัเพือ่ความปลอดภัย (safe)) กรณีทีผู่้ใช้รถนั่งคนพิการต้องการใหล้้อหลงัอยู่ในต าแหน่ง "ปลอดภัย" (อยู่ ด้านหลัง) คือแขนย่ืนมาด้านหลงัเพือ่การปั่น ให้อธิบายสิ่งเหล่าน้ีต่อผู้ใช้งาน หากมีการปรับใดๆต่อต าแหน่งล้อหลงั เบรคควรได้รับการปรับและการ ตรวจสอบซ้ าเช่นกัน ความสูงของท่ีน่ัง- ส าหรับการป่ันรถด้วยเท้า ขนาดที่พอดี:  เมื่อนั่งตัวตรงและเชิงกรานชิดพนักพงิแล้ว เท้าของผู้ใช้รถนัง่คนพิการควร วางราบกบัพื้นได ้ 65 วิธีตรวจสอบ ให้ผู้ใช้รถนั่งคนพิการนั่งโดยเชิงกรานชิดพนักพิงโดยเท้าข้างที่ใช้เข็นวางราบกับ พื้น ตรวจสอบว่าเท้ามาสามารถวางราบกับพื้นได้หรือไม่ กรณีที่รองนั่งมีระดับสูงเกินไป ผู้ให้บริการอาจ  ลดความสูงของเบาะรองนั่ง  ติดที่รองนั่งแบบแข็งให้มีระดับต่ ากว่าที่รองนั่งเดิม (ควรขอค าแนะน าหรือ การช่วยเหลือทางเทคนิค) ส าหรับผู้ใช้รถนั่งคนพิการที่ปั่นรถด้วยเท้าหนี่งข้าง และเท้าอีกข้างวางบนที่พัก เท้า ให้ตรวจสอบแรงกดใต้ปุ่มกระดูกรองนั่งด้านที่วางเท้าบนที่พักเท้า (ดูในบทที่ A 7: การเลือกเบาะรองนั่ง หัวข้อ “วิธีทดสอบว่าเบาะรองนั่งลดแรงกดทับ หรือไม่”) ตรวจสอบท่าทาง ขณะผู้ใช้นั่งบนรถนั่งคนพิการ ให้ตรวจสอบว่าผู้ใช้นั่งในท่าตั้ง ตรงหรือไม่ โดยตรวจสอบทั้งจากด้านหน้าและด้านข้าง ผู้ใช้รถนั่งคนพิการบางรายชอบสอดเท้าไว้ด้านใน ซึ่งสามารถท าได้ในรถนั่งคน พิการบางชนิด หากผู้ใช้รถนั่งคนพิการรู้สึกสบายและทรงตัวดีก็สามารถท าได้ ตรวจสอบแรงกด ผู้ใช้รถนั่งคนพิการทุกรายที่มีความเสี่ยงต่อการเกิดแผลกดทับ – ควรตรวจสอบ ว่าแรงกดใต้ปุ่มกระดูกรองนั่งอยู่ในระดับปลอดภัย 66 ตรวจสอบความพอดีของรถน่ังคนพิการในขณะท่ีผู้ใช้รถน่ังคนพิการมีการเคลื่อนไหว ข้ันตอนสุดท้ายของการลองอุปกรณ์คือการตรวจสอบความพอดีขณะรถนั่งคนพิการก าลังเคลื่อนที่ กรณีที่ ผู้ใช้งานไม่สามารถปั่นรถได้อง ให้สมาชิกในครอบครัวหรือผู้ดูแลช่วยเข็นรถให้ สิ่งที่ต้องตรวจสอบ ได้แก่:  พนักพิงท าให้ผู้ใช้รถนัง่คนพิการมีอสิระในการเคลื่อนไหว หัวไหล่ในการปั่นรถได้หรือไม?่  พนักพิงสามารถช่วยรองรบัส่วนของร่างกายได้เพียงพอ หรือไม?่  ต าแหน่งของล้อหลังเหมาะสมกบัผู้ใช้งานหรือไม?่ แบบตรวจสอบการลองอุปกรณ ์ 1. รถน่ังคนพิการพร้อมใช้งานหรือไม่? รถนั่งคนพิการได้รับการตรวจสอบเพื่อให้แน่ใจว่ามีความปลอดภัยและส่วนต่างๆใช้งานไดห้รือไม่?  2. ตรวจสอบขนาดและการปรับส่วนต่างๆ ความกว้างของท่ี รองน่ัง: ควรมีขนาดพอดี  ความลึกของท่ีรองน่ัง: มีช่องว่างระหว่างหลัง เข่ากับขอบที่รองนั่ง หรือเบาะรองนั่ง ประมาณ 2 นิ้วมือ  ความสูงของท่ีพักเท้า: ต้นขาวางราบบนเบาะรองนัง่โดยไม่มีช่องว่าง เท้าทั้งสองข้างวางราบบน ที่พักเท้าโดยไม่มีช่องว่าง  67 ความสูงของพนักพิง: ผู้ใช้รถนั่งคนพิการได้รับการประคองเท่าที่ต้องการและมีอสิระในการ เคลื่อนทีห่ัวไหล่ในการปั่นรถ (กรณีปั่นด้วยตนเอง)  ต าแหน่งของล้อหลัง (ส าหรับการป่ันด้วยมือ): เมื่อเหยียดแขนลงด้านข้าง แขนของผู้ใช้รถนั่งคนพิการอยู่ในแนว เดียวกับแกนล้อหลัง เมื่อวางมอืที่ขอบบนสุดของวงปั่น ข้อศอกของผู้ใช้รถนั่งคนพิการควรงอ ประมาณ 90 องศา  เบรค: เบรคท าหน้าที่ได้อยู่หรือไม?่  ความสูงของท่ีรองน่ัง (ส าหรับการป่ันด้วยเท้า): เมื่อผู้ใช้รถนั่งคนพิการนั่งตัวตรง หลงัชิดพนักพิง และเท้าควรวางราบ บนพื้น  3. ตรวจสอบท่าทาง ผู้ใช้รถนั่งคนพิการสามารถนั่งตัวตรงได้อย่างสบายหรือไม?่  ตรวจสอบท่าทางจากด้านข้าง  ตรวจสอบท่าทางจากด้านหน้า/ด้านหลัง  4. ตรวจสอบแรงกดทับ ตรวจสอบแรงกดทับใต้ปุ่มกระดูกรองน่ังในผู้ใช้รถน่ังคนพิการทุกรายท่ีมีความเสี่ยงต่อการเกิด แผลกดทับ A อธิบายการทดสอนแกผู่้ใช้รถนั่งคนพิการ B บอกใหผู้้ใช้รถนั่งคนพกิารยกตัวข้ึนหรือโนม้ตัวไปข้างหน้า สอดปลายนิ้วของผูป้ระเมินเข้าใต้ปุ่มกระดกูรองนั่ง 68 C บอกใหผู้้ใช้รถนั่งคนพกิารเอนตัวกลบัไปนั่งทับบนมือของผูป้ระเมิน ตรวจสอบให้แน่ใจว่าผู้ใช้รถนั่งคนพิการนั่งตัวตรงและวางมือลงบนต้น ขา D ระบรุะดับของแรงกดทบั: ระดับท่ี 1 = ปลอดภัย: ปลายนิ้วสามารถกระดิกข้ึนลงได้ไมน่้อยกว่า 5 มม. ระดับท่ี 2 = เตือน: ไม่สามารถกระดิกปลายนิ้วข้ึนลงได้ แต่สามารถเลื่อนมือออกได้ง่าย ระดับท่ี 3 = ไม่ปลอดภัย: ปลายนิ้วถูกกดแน่น เลือ่นมือออกได้ยาก E ท าการประเมินซ้ าที่ปุม่กระดูกรองนั่งอีกข้างหนึง่ 5. ตรวจสอบความพอดีขณะรถน่ังคนพิการเคลื่อนท่ี พนักพิงช่วยให้ผู้ใช้รถนั่งคนพิการมีอสิระในการเคลื่อนไหวหวัไหล่ไปปั่นรถหรือไม่?  พนักพิงช่วยรองรบัร่างกายของผู้ใช้รถนั่งคนพิการอย่างเพียงพอหรอืไม่?  เท้าของผู้ใช้รถนั่งคนพิการวางบนที่พักเท้าหรือไม่?  ต าแหน่งของล้อหลังเหมาะสมส าหรับผู้ใช้งานหรือไม่?  6. การปฏิบัติ? จ าเป็นต้องมกีารด าเนินการใดเพิ่มเตมิหรือไม่? เขียนสิ่งที่ตอ้งด าเนินการลงในแฟ้มประวัติของผู้ใช้ รถนั่งคนพิการ  การแก้ไขปัญหา ในบางครั้งผู้ให้บริการอาจพบปัญหาในการท ารถนั่งคนพิการที่มีอยู่ให้เหมาะสมกับผู้ใช้รถนั่งคนพิการ ปัญหาดังกล่าวอาจเกิดจาก  ความจ ากัดในเรื่องประเภทและขนาดของรถนั่งคนพิการ  ผู้ใช้รถนั่งคนพิการต้องการส่วนที่รองรับเป็นพิเศษเพื่อให้ร่างกายสามารถอยู่ในท่าต้ังตรงได้และมีความ สบาย ต่อไปนี้เป็นการแก้ไขปัญหาเบื้องต้นส าหรับปัญหาพื้นฐานที่พบบ่อย การดัดแปลงและการการประคอง ท่าทางจะมีเนื้อหามากข้ึนในการฝึกอบรมระดับกลาง (intermediate - level training) การแก้ไขปัญหาทั้งหมดในบทนี้ เป็นการสมมติว่าได้เลือกรถนั่งคนพิการที่ขนาดใกล้เคียงที่สุดเท่าที่ มีอยู่ ส าหรับผู้ใช้งานแล้ว ตรวจสอบให้แน่ใจทุกครั้งก่อนท าการดัดแปลงรถนั่งคนพิการ 69 ปัญหา: ที่รองนั่งสั้นเกินไป หากความลึกของที่รองนั่ง (วัดจากขอบด้านหลัง) สั้นกว่าความลึกของที่รองนั่งที่เหมาะกับผู้ใช้งานเกินกว่า 100 มม. ถือว่าเป็นปัญหา เนื่องจากผู้ใช้งานจะไม่ได้รับการรองรับเพียงพอให้นั่งได้อย่างสบาย และการลด แรงกดทับจะท าได้น้อยลง จึงจ าเป็นต้องเพิ่มความลึกของที่รองนั่ง การแก้ไขปัญหา: มีวิธีแก้ไข 3 วิธีดังน้ี วิธีแก้ไข ข้อควรระวัง 1.เพิ่มความลกึของทีร่องนั่งให้ยาวข้ึนโดยขยายโครงทีร่องนัง่และเปลี่ยนผ้าใบรองนัง่ใหม ่  ถ้ารถนั่งคนพิการเป็นแบบที่โครงพับได้ ให้ตรวจสอบว่าโครงที่รองนั่งยึดติดกับ โครงรถหรือไม่ ซึ่งหมายถึงโครงที่รองนั่ง อาจแยกส่วนจากโครงสร้างรถ  ในกรณีนี้ จะสามารถเพิ่มความยาวของ โครงที่รองนั่งและผ้าใบรองนั่งได ้ 2. เพิ่มความลึกของทีร่องนัง่โดยเปลี่ยนผ้าใบรองนัง่  ถ้าโครงสร้างของรถนั่งคนพกิารเป็นแบบ โครงแข็ง ไม่สามารถพบัได้ ให้ ตรวจสอบว่าโครงที่รองนั่งยื่นเลยผ้าใบ รองนัง่หรือไม ่  ในกรณีนี ้อาจเปลี่ยนเฉพาะผ้าใบรองนั่ง โดยให้ผ้าใบมีความยาวที่ถูกต้องและยึด ติดกับโครงเดิมที่มีอยู่แล้ว 3. เพิ่มความลึกของทีร่องนัง่โดยเสรมิแผ่นกระดานแข็งพร้อมเบาะรองนั่ง  แผ่นกระดานแข็งนีอ้าจท าจากไม้ พลาสตกิ หรือ วัสดุอื่นๆทีม่ีความแข็ง ที่ไม่หักงอหรือแตก  สามารถน าไปยึดติดด้านบนของโครงที่ รองนัง่  เพิ่มเบาะรองนัง่ที่มีขนาดเดียวกันกับ ขนาดของแผ่นรองทีเ่สริมด้วย  ตรวจสอบให้แน่ใจว่าที่รองนั่งมีความแข็งแรงพอที่จะ รองรับน้ าหนักของผู้ใช้รถนั่งคนพกิารตรวจสอบว่าที่ รองนัง่นั้นไม่งอหรอืแตกบริเวณที่ขยายออกไป  ถ้าใช้ที่รองนั่งแบบแข็ง ใหเ้บาะรองนัง่แก่ผู้ใช้รถนั่ง คนพิการทุกรายเสมอ  ตรวจสอบระหว่างลองอุปกรณ์ว่าความสูงของพนัก พิงและที่พักเท้าว่ามีความสงูอยู่ในระดบัที่ถูกต้อง เนื่องจากแผ่นเสริมแบบแข็งและเบาะรองนั่งที่ใหจ้ะ ท าให้ตัวผู้ใช้รถนั่งคนพิการสูงข้ึนอีกขณะนั่ง 70 ปัญหา: ที่รองนั่งลึกเกินไป ถ้าที่รองนั่งที่สั้นที่สุดก็ยังมีขนาดลึกเกินไปส าหรับผู้ใช้รถนั่งคนพิการ ผู้ใช้รถนั่งคนพิการจะไม่สามารถนั่ง ตัวตรงได้ ต้องท าที่รองนั่งให้สั้นลง การแก้ไขปัญหา: มีวิธีแก้ไขดังน้ี วิธีแก้ไข ข้อควรระวัง 1. ลดความลึกของที่นั่ง  ท าเครื่องหมายที่ระยะที่รองนั่งที่ต้องการและ ลดความลึกของที่รองนั่งลง  ถ้าที่ รองนั่ง เป็นแบบผ้าใบรอง- ให้น าผ้าใบ ออกมาตัดให้สั้น (ใช้จักรอุตสาหกรรม) และใส่ ใหม่  ถ้าที่รองนั่งเป็นแผ่นแข็งให้แกะออกมาท าให้สั้น แล้วใส่กลับเข้าไปใหม่  ท าเบาะรองนั่งให้สั้นลงเพื่อให้ได้ขนาดเดียวกัน กับขนาดของที่รองนั่ง  หากเป็นการตัดที่รองนั่งที่เป็นแผ่นแข็ง ต้อง ตรวจสอบเสมอว่าส่วนของขอบเรียบ ไม่มีคม  ในการตัดเบาะรองนั่ง ต้องตัดส่วนด้านหน้า เสมอ เพื่อให้ส่วนด้านหลังที่ท าหน้าที่ลดแรงกด ทับยังเหมือนเดิม ปัญหา : ที่พักเท้าต่ าเกินไป ถ้าที่พักเท้าอยู่ต่ าเกินไป ผู้ใช้รถนั่งคนพิการจะเกิดความไม่สบายในขณะที่วางเท้า และยงัเป็นสาเหตุให้ตัว ผู้ใช้อาจเลื่อนไปด้านหน้า หรอือาจมีความรู้สกึว่าน่ังไม่มั่นคง ผู้ใช้รถนั่งคนพิการจะไม่ได้รบัการประคองให้ นั่งตัวตรงอย่างสบาย จึงควรปรับเพิ่มความสงูของที่พักเท้า การแก้ไขปัญหา: มีวิธีแก้ไข 2 วิธีดังน้ี วิธีแก้ไข ข้อควรระวัง 1. ยกที่พักเท้าข้ึน - โดยตัดแกนที่พักเท้าให้สั้นลง  รถนั่งคนพิการแบบสี่ล้อส่วนใหญ่แกนที่พักเท้า สามารถตัดให้สั้นลงได ้ ตรวจสอบเสมอว่ากลไกการท างานยังคงเหมือนเดิม 2. เพิ่มความสูงของที่พักเท้า - โดยการเสริมแผ่นที่พักเท้า  ใช้ไม้หรือวัสดุทีม่ีความแข็งแรงในการเพิ่มความ สูงใหก้ับทีพ่ักเท้า ตรวจสอบว่าส่วนที่เสริมขึ้นมาไม่ไปขัดขวางการพับ ข้ึนของแผ่นที่พักเท้า เพิ่มความสงูของที่พักเท้าโดยการเสรมิแผ่นพกัเท้า (ตามรูปเป็นการเพิ่มความ สูงของแผ่นพักเท้าเพียงข้างเดียวเพื่อให้รองรบัขาข้างทีส่ั้นกว่า) 71 ปัญหา: ที่พักเท้าสูงเกินไป ถ้าที่พักเท้าสูงเกินไป ต้นขาของผู้ใช้รถนั่งคนพิการจะไม่สามารถวางที่รองนั่งได้อย่างสบาย ที่พักเท้าที่สูง เกินไปยังอาจส่งผลให้เกิดแรงกดที่ปุ่มกระดูกรองนั่งเพิ่มข้ึนด้วย จึงจ าเป็นต้องปรับให้ต่ าลง การแก้ไขปัญหา: มีวิธีแก้ไข 2 วิธีดังน้ี วิธีแก้ไข ข้อควรระวัง 1. ปรับความสูงของที่พักเท้าให้ต่ าลง - โดยการเพิ่มความยาวของท่อในของแกนที่พักเท้า  ตรวจสอบว่าท่อในสามารถเปลี่ยนเป็น ท่อที่ยาวกว่าได้หรือไม่  ถ้าได้-สามารถเปลี่ยนท่อดังกล่าวกับ วัสดุที่ใกล้เคียงกันทั้งขนาดและความ แข็งแรง หากปรับที่พักเท้าให้ต่ าลง -ตรวจสอบให้แน่ใจว่าไม่ต่ าเกินไปจนสัมผัสพื้น ถ้าหากมีการสัมผัสกับพื้นให้ใช้วิธีการที่สองในการเพิ่มความสูงแทน และถ้า ยังไม่ได้ระดับแสดงว่ารถน่ังคนพิการน้ันไม่เหมาะสมกับผู้ใช้รถน่ังคนพิการ น้ัน 2. เพิ่มความสูงของเบาะรองน่ัง  เพิ่มความสูงของเบาะรองน่ังหรือยกที่ รองน่ังให้สูงขึ้นโดยการเสริมวัสดุที่มี ความแข็งเข้าไปใต้เบาะ ไม่ควรใช้ฟองน้ าน่ิมในการเพิ่มความสูงของเบาะรองน่ัง เน่ืองจากตัวฟองน้ า น่ิมจะยุบตัวและจะรู้สึกไม่ม่ันคงด้วย ตรวจสอบว่าพนักพิงและที่พักแขนอยู่ในระดับความสูงที่ถูกต้อง เบาะรอง น่ังที่สูงขึ้นจะยกตัวของผู้ใช้ให้สูงขึ้นด้วย ตรวจสอบว่าการเพิ่มความสูงของเบาะรองน่ังไม่ท าให้การท าทักษะต่างๆ เปลี่ยนไป ยกตัวอย่างเช่น หลังจากเสริมเบาะรองน่ังแล้วผู้ใช้รถน่ังคนพิการ อาจไม่สามารถปั่นรถน่ังคนพิการเข้าไปใต้โต๊ะได้ ปัญหา: ขาหมุนเข้าด้านในหรือหมุนออกด้านนอก บางครั้งขาของผู้ใช้รถนั่งคนพิการอาจมีการหมุนเข้าด้านในหรือออกด้านนอก ซึ่งอาจมีสาเหตุมาจากความ เคยชินในการนั่งของแต่ละคน หรือ เป็นเพราะปัญหาทางด้านร่างกาย (เช่นกล้ามเนื้ออ่อนแรง ) การปรับเปลี่ยนที่รองนั่งหรือเบาะรองนั่งแบบพื้นฐานสามารถช่วยลดปัญหาเหล่าน้ีได้ การแก้ไขปัญหา: มีวิธีแก้ไข 3 วิธีดังน้ี วิธีแก้ไข 1. ตรวจสอบความสูงของที่พักเท้าอีกครั้ง ตรวจสอบให้แน่ใจว่าความสูงของที่พักเท้าช่วยในรองรับผู้ใช้รถน่ังคนพิการได้อย่างถูกต้อง (ระดับแรงกดต่อเท้าและต่อใต้ ขาควรเท่ากัน) 2. ตรวจสอบความตึงของที่รองน่ังว่ามีความพอดี  ถ้ารถน่ังคนพิการน้ันมีที่รองน่ังท าจากผ้าใบ ให้ตรวจสอบความตึงให้อยู่ในระดับที่พอดี  ถ้ารถน่ังคนพิการน้ันมีที่รองน่ังที่หย่อนห้อยลงจะท าให้ขาของผู้ใช้รถน่ังคนพิการหมุนเข้าด้านใน 3. เสริมลิ่มเข้าไปในเบาะรองน่ังเพื่อจัดขาให้อยู่ในท่าที่ปกติ (ดังที่แสดงไว้ใน DVD และภาพตัวอย่างประกอบ) หรือให้เบาะ รองน่ังที่แบบโค้งเข้ารูปหรือปรับเบาะรองน่ังถ้าจ าเป็น 72  เบาะลดแรงกดแบบโคง้เข้ารูปบางชิ้นจะมีส่วนที่สงูขึ้นระหวง่ต้นขาทั้งสอง ซ่ึงช่วยใหข้าแยกจากกัน ส่วน ดังกลา่วน้ีสามารถปรับให้สงูขึ้นได้อีกเพื่อเพิ่มการรองรับ  เบาะลดแรงกดแบบโคง้เข้ารูปบางชิ้นจะมีร่องรองรับขา ร่องน้ีสามารถเพิ่มขึ้นได้เพื่อป้องกันไม่ให้ขาหมุนออก ดา้นนอก เสริมฟองน้ ารปูลิม่ที่กึง่กลางบริเวณด้านหน้าของเบาะรองนัง่จะช่วยให้ขา ของผู้ใช้รถนั่งคนพกิารแยกจากกัน เสริมฟองน้ ารปูลิม่ที่ขอบข้างส่วนหน้าของเบาะรองนั่งเพื่อช่วยให้ต้นขาของ ผู้ใช้รถนั่งคนพิการไม่กางออกเกินไป ปัญหา: เท้าเลือ่นหลดุออกจากทีพ่กัเท้าได้ง่าย บางครั้งเท้าของผู้ใช้รถนั่งคนพิการอาจมีการเลื่อนหลุดออกจากที่พักเท้า ซึ่งสาเหตุส่วนใหญ่มาจากปัญหา ทางร่างกาย (เช่น กล้ามเนื้ออ่อนแรง หรือกล้ามเนื้อที่มีการเกร็ง) การแก้ไขปัญหา: มีวิธีแก้ไข 3 วิธีดังน้ี วิธีแก้ไข ข้อควรระวัง 1. ตรวจสอบความสงูของทีพ่ักเท้าอีกครั้ง  ต้องให้แน่ใจว่าความสูงของที่พักเท้าช่วยรองรับ ร่างกายของผู้ใช้รถนั่งคนพิการได้อย่างถูกต้อง (แรงกดทับใต้ขาและใต้ฝ่าเท้าเท่ากัน) 2. ปรับมุมของที่พักเท้า (ถ้าเป็นไปได้)  ตรวจสอบดูว่ามุมของที่พักเท้าสามารถปรับได้ หรือไม่  ถ้าสามารถท าได้ ให้เพิ่มมุมของที่พักเท้า ซึ่งจะ สามารถช่วยให้เท้าอยู่กับที่ ไม่เลื่อนไหลตกจากที่ พักเท้า ตรวจสอบว่ามีแรงกดอย่างสม่ าเสมอบริเวณใต้ เท้าและใต้ต้นขา ต่อ 73 3. ติดสายรัด  ติดสายรัดตรงต าแหน่งข้อเท้า  ถ้าเท้าเลื่อนหลุดไปด้านหลัง สายรัดควรอ้อมไป ด้านหลังของขาด้วย  ถ้าเท้าเลื่อนหลุดไปด้านหน้า สายรัดควรอยู่ ด้านหน้าของขา ต้องให้แน่ใจว่าสายรัดสามารถแกะออกได้ง่าย เพื่อให้ผู้ใช้รถนั่งคนพิการสามารถเคลื่อนย้าย ตัวเข้าและออกรถนั่งคนพิการได้โดยไม่ยาก มาก ตรวจสอบว่าผู้ใช้รถนั่งคนพิการสามารถเอื้อม มือถึงสายรัดได้โดยไม่ต้องช่วยและสามารถติด สายรัดได้ง่าย สายรัดน่องช่วยให้ขาของผู้ใช้รถนั่งคนพกิารอยูก่ับที่ สายรัดด้านหลังของเท้าจะให้การรองรบัมากขึ้น ช่วยป้องกันไม่ให้เท้าของ ผู้ใช้รถนั่งคนพิการเลื่อนหล่นทางด้านหลังของที่พักเท้า ปัญหา: รถนั่งคนพกิารกว้างเกนิไป บางครั้งรถนั่งคนพิการขนาดเล็กที่สุดที่มียังมีขนาดที่กว้างเกินไปส าหรับผู้ใช้รถนั่งคนพิการบางคน ถ้าที่รอง นั่งกว้างเกินไป ผู้ใช้รถนั่งคนพิการจะนั่งตั้งตรงได้ยากและล าตัวจะเอียงไปด้านใดด้านหนึ่ง การเสริมฟองน้ า อย่างง่ายสามารถช่วยประคองให้ผู้ใช้รถนั่งคนพิการนั่งตัวตรงข้ึนได้ การแก้ไขปัญหา: มีวิธีแก้ไข 1 วิธีดังน้ี วิธีแก้ไข ข้อควรระวัง 1. เสริมฟองน้ าที่ด้านข้างของเชิงกรานทัง้สองด้าน  วัดช่องว่างระหว่างตัวผู้ใช้รถนั่งคนพิการกับด้านข้างของ ที่พักแขน (ในขณะที่นั่งอยู่ตรงกลางรถนั่งคนพิการ หลัง ชิดกับพนักพิง)  ตัดแผ่นฟองน้ าและใส่ลงไปตรงช่องว่างด้านข้างระหว่าง ผู้ใช้รถนั่งคนพิการกับด้านข้างของรถนั่งคนพิการ  ตรวจสอบความพอดี  หุ้มผ้าและติดฟองน้ ากับรถ ถ้าที่พักแขนเป็นวัสดุแข็งอาจ ติดฟองน้ าเข้ากับที่พักแขน หรืออาจติดกับด้านบนของ เบาะรองนั่ง แผ่นฟองน้ าควรอยู่ห่างจากล าตัวผู้ใช้รถนั่งคนพิการ ท าเบาะรองนั่งให้มีขนาดพอดีกับที่รองนั่ง หากที่รองนั่งกว้างมาก จะท าให้ผู้ใช้รถนั่งคนพิการ เอื้อมไปจับวงปั่นอย่างยากล าบากด้วย การต้องเอื้อมแขนอย่างมากเพื่อไปจับวงปั่น จะท าให้ เกิดการบาดเจ็บของหัวไหล่ได้ จึงควรพิจารณาอย่าง ระมัดระวังว่ารถนั่งคนพิการนั้นปลอดภัยส าหรับผู้ใช้ หรือไม่ก่อนพิจารณาให้เขา 74 การเสริมฟองน้ าจะลดความกว้างภายในรถน่ังคนพิการลง ขั้นตอนที่ 7: การฝึกผู้ใช้รถนั่งคนพิการ (user training) ข้อมูลและการฝึกเกี่ยวกับรถนั่งคน พิการสามารถช่วยให้ผู้ใช้งานได้ประโยชน์สูงสุดจากรถนั่งคนพิกาของตนเอง ถ้าปราศจากข้ันตอนนี้ อาจ เป็นไปได้ว่ารถนั่งคนพิการที่ได้รับจะไม่สามารถช่วย/เกิดประโยชน์กับผู้ใช้รถนั่งคนพิการได้เท่าที่ควรจะเป็น ทักษะที่เป็นประโยชน์ส าหรับผู้ใช้รถนั่งคนพิการ สิ่งส าคัญที่ต้องสอน 6 ข้อ ประกอบด้วย  การพับ-กางรถนั่งคนพกิาร  การเคลื่อนย้ายตัวเข้า-ออกจากรถนั่งคนพกิาร  การขับเคลื่อนรถนั่งคนพิการ-ให้เหมาะกบัความต้องการของผู้ใช้งาน  การป้องกันแผลกดทับและการดูแลกรณีมีแผลกดทับ  การดูแลรถนั่งคนพิการและเบาะรองนั่งทีบ่้าน  สิ่งที่ต้องปฏิบัติหากเกิดปญัหา ในแบบตรวจสอบการฝึกผู้ใช้รถนั่งคนพิการจะมีรายการทักษะต่างๆที่อาจเป็นประโยขน์ต่อผู้ใช้รถนั่งคน พิการที่ต้องเรียนรู้ ซึ่งผู้ใช้รถนั่งคนพิการบางคนอาจได้เรียนรู้เกี่ยวกับทักษะเหล่าน้ีแล้ว และผู้ใช้รถนั่งคน พิการทุกคนไม่จ าเป็นที่จะต้องฝึกทุกทักษะ หน่วยบริการรถนั่งคนพิการบางแห่งอาจใช้แบบตรวจสอบนี้เป็นแบบฟอร์มหลักที่เก็บไว้ในแฟ้มประวัติ ของผู้ใช้รถนั่งคนพิการ ผู้ให้บริการสามารถบันทึกเกี่ยวกับสิ่งที่ผู้ใช้รถนั่งคนพิการจ าเป็นต้องไดร้บัการสอน ในแบบฟอร์มนี้ ซึ่งข้อมูลดังกล่าวจะมาจากการประเมินและการสอบถามจากผู้ใช้รถนั่งคนพิการ นอกจากนี้ผู้ให้บริการยังสามารถบันทึกสิ่งที่ได้สอนไปแล้วลงในแบบฟอร์มด้วย ถามผู้ใช้รถนั่งคนพิการว่าต้องการให้สอนผู้ดูแลด้วยหรือไม่ ผู้ใช้รถนั่งคนพิการจ านวนมากที่ยังต้องได้รับ ความช่วยเหลือจากครอบครัวหรือผู้ดูแลอยู่ ซึ่งหากทุกคนได้มีส่วนร่วมและเรียนรู้เกี่ยวกับทักษะในการใช้ งานและการดูแลรักษารถนั่งคนพิการไปพร้อมกันย่อมจะเป็นประโยชน์อย่างมาก การฝึกผู้ใช้รถนั่งคนพิการให้ประสบผลส าเร็จ  ค้นหาว่าสิ่งใดที่ผู้ใช้รถน่ังคนพิการรู้อยู่แล้ว  อธิบาย สาธิตให้ดู จากน้ันให้โอกาสผู้ใช้รถน่ังคนพิการได้ทดลองปฏิบัติ  ใช้ภาษาที่ทุกคนสามารถเข้าใจได้  ให้ผู้ใช้รถน่ังคนพิการสอนผู้ใช้รถน่ังคนพิการด้วยกันเอง  ใช้ทักษะการสื่อสารที่ดี  ให้ก าลังใจ 75 แบบตรวจสอบการฝกึผู้ใช้รถนั่งคนพกิาร ทักษะ ที่ต้องสอน ทักษะ ที่สอนแลว้ การใชร้ถน่ังคนพิการ การพับและกางรถ   การยกรถ   การถอดใสล่้อหลัง   การใช้เบรค   การใช้เบาะรองน่ัง รวมถึงการวางเบาะอย่างถูกต้อง   การวางเบาะรองน่ังบนรถ   การเคลื่อนย้ายตัว แบบท าด้วยตนเอง   แบบมผีู้อ่ืนช่วยเหลือ   ด้วยวิธีอ่ืน   การใชร้ถน่ังคนพิการ การปั่นอยา่งถูกวิธ ี   การขึ้นและลงทางลาดชัน   การขึ้นและลงพื้นต่างระดับ   การเคลื่อนที่ผ่านพื้นขรุขระ   การยกล้อหน้าชั่วครู่   การปอ้งกันแผลกดทับ การตรวจสอบแผลกดทบั   เทคนิคการลดแรงกดทบั   การรับประทานอาหารที่ดแีละดื่มน้ ามากๆ   สิง่ทีต่้องท าเม่ือมีแผลกดทับ   การดูแลรักษารถน่ังคนพิการที่บ้าน ท าความสะอาดรถน่ังคนพิการ ซักและผึง่เบาะรองน่ังและผา้หุ้มให้แหง้   หยอดน้ ามันส่วนที่ท าให้รถน่ังคนพิการเคลื่อนที่   เติมลมยาง   ขันน๊อตและสลักตา่งๆให้แน่น (หากหลวม)   ขันซ่ีล้อใหแ้น่น (หากหลวม)   ตรวจสอบผ้าใบ   ตรวจสอบสนิม   ตรวจสอบเบาะรองน่ัง   จะท าอย่างไรหากเกิดปัญหา หากรถน่ังคนพิการจ าเป็นต้องซ่อมแซม   หากรถน่ังคนพิการขนาดไม่พอดีหรือน่ังไม่สบาย   76 ขั้นตอนที่ 8: การดูแลรักษาและซ่อมแซม (maintenance, repairs and follow up) การดูแลรักษารถนั่งคนพิการและเบาะรองนั่งอย่างสม่ าเสมอจะช่วยประหยัดค่าใช้จ่ายและป้องกันการ บาดเจ็บและปัญหาระยะยาวต่อร่างกายของผู้ใช้รถนั่งคนพิการ รถนั่งคนพิการที่ได้รับการดูแลรักษาจะท า ให้รู้สึกสบายและใช้งานง่ายข้ึน เบาะรองนั่งที่ได้รับการดูแลจะยังคงท าหน้าที่ลดแรงกดทับและรองรับ ร่างกาย ผู้ให้บริการรถนั่งคนพิการต้องสอนผู้ใช้รถนั่งคนพิการถึงวิธีการดูแลรักษารถนั่งคนพิการและเบาะรองนั่ง ด้วย ป้องกันการซ่อมแซม : การดูแลรักษา มีสิ่งที่ควรท าเพื่อดูแลรักษารถนั่งคนพิการและเบาะรองนั่ง 6 อย่าง ควรสาธิตวิธีการดูแลรักษารถนั่งคน พิการแก่ผู้ใช้งาน พร้อมอธิบายถึงความส าคัญของการดูแลรักษา ตารางในหน้าถัดไปเป็นการอธิบายสิ่งที่ ควรท า ความส าคัญและวิธีการท า ทรัพยากรในท้องถิ่นส าหรับการซ่อมแซมรถน่ังคนพิการ ค้นหาว่ามีใครในท้องถ่ินที่อาจซ่อมแซมรถนั่งคนพิการได้บ้าง ซึ่งอาจได้แก่  ช่างซ่อมจักรยาน  ช่างซ่อมรถยนต์ หรือจักรยานยนต์  ห้องปฎิบัติงาน – ช่างเช่ือม ช่างประปา (ส่วนที่เป็นโลหะ) ช่างไม้ ช่างเฟอร์นิเจอร์ (ส่วนที่เป็นไม้)  ผู้ใช้รถนั่งคนพิการ ครอบครัวของผู้ใช้รถนั่งคนพิการ ญาติ หรือเพื่อนบ้าน  ช่างตัดเสื้อส าหรับการซ่อมแซมผ้าใบ  หน่วยบริการรถนั่งคนพิการ 77 การดูแลรักษารถน่ังคนพิการที่บ้าน ความส าคัญ วิธีการ 1.ท าความสะอาดรถนั่งคน พิการและเบาะรองนั่ง ไม่ให้ส่วนทีเ่ป็นโลหะเกิดสนิม ไม่ให้ส่วนทีเ่ป็นไมห้รือผ้าเปื่อย ไม่ให้เกิดความเสียหายจากเศษ ดินเข้าไปอัดในส่วนที่ท าให้รถ เคลื่อนที ่ ใช้น้ าอุ่นและสบู ่ เช็ดและผึง่ให้แห้ง ควรให้ความสนใจส่วนที่เคลื่อนที่และ จุดที่ผ้าใบยึดติดกับโครงรถ ถอดเบาะรองนัง่จากผ้าหุม้และแยก ท าควมสะอาด เบาะรองนัง่ควรผึง่ในร่มเสมอ -ห้าม ตากแดด 2.หยอดน้ ามันในจุดที่ท าใหร้ถ นั่งคนพิการเคลื่อนที ่ ช่วยให้ส่วนต่างๆใหส้่วนต่างๆ เคลื่อนทีอ่ย่างนุ่มนวล ป้องกันการเกิดสนมิ ท าความสะอาดรถนัง่คนพิการและผึ่ง ให้แห้งกอ่น ใช้น้ ามันหล่อลื่น เช่น น้ ามันหล่อลื่น หยอดจุดทีท่ าใหร้ถนั่งคนพิการ เคลื่อนทีทุ่กจุด 3.เติมลมยาง (กรณีเป็นยางลม) ยางมีอายุการใช้งานนานข้ึน เข็นง่าย ใช้แรงน้อยลง เบรคท างานได้ดี ใช้นิ้วหัวแม่มือกดที่ยางเพื่อตรวจสอบ ลมยาง โดยควรมรีอยกดลงเลก็น้อย (5มม) ลมยางควรเท่ากันทุกล้อ เติมลมโดยใช้ที่เติมลมจักรยานหรือสิ่ง อื่นที่ใกลเ้คียง การลดลมยางท าโดย ปล่อยลมออกจากจุกปิดลมยาง 4. ขันน๊อตและสลักต่างๆให้ แน่น (หากหลวม) น๊อตที่หลวมจะท าให้ช้ินส่วน ต่างๆเคลื่อนจากที ่ ส่งผลให้เกิดความไมส่ะดวกใน การใช้งาน และช้ินส่วนต่างๆ หลุดและสญูหาย ตรวจสอบรถนั่งคนพิการว่าแกนต่างๆ หลวมหรือไม่ ขันให้แน่นด้วยประแจ อย่าขันแน่นจนเกินไป 78 ความส าคัญ วิธีการ 5. ขันซี่ล้อให้แน่น (หากหลวม) ซี่ล้อที่หลวมท าใหล้้อโคง้งอ และแตก ได ้ บีบซีล่้อทลีะ 2 ซี่เข้าหากัน หากดึง เบาๆแล้วซี่ลอ้หลุดออก อาจ เนื่องจากซีล่้อหลวมเกินไป ให้ขันให้ แน่นด้วยประแจ ซี่ล้ออาจแน่นเกินไป หากรูส้ึกว่าซี่ ล้อแข็งมาก อาจเป็นเพราะขันแน่น เกินไป ควรคลายใหห้ลวม 6. ตรวจสอบอย่างสม่ าเสมอ ตรวจสอบสนิมและผ้าใบ สนิมท าให้วัสดุต่างๆ ไม่ทนทาน ท าให้ส่วนต่างๆแตกหกัและเป็น อันตรายต่อผู้ใช้ ผ้าใบควรอยู่ในสภาพที่ดีเพือ่ให้ สามารถรองรับร่างกายและท าให้เกิด ความสบาย ถ้าผ้าใบฉีกขาดทันทีทันใด ผู้ใช้อาจ ได้รับบาดเจบ็ ตรวจสอบส่วนที่เป็นโลหะทีท่าสีว่า ผุกรอ่นหรือมสีนิมหรือไม ่ ถ้าพบสนิม ให้ใช้กระดาษทรายหรือ แปรงขัดเหล็กขัดสนมิออก ท าความสะอาดด้วยทินเนอร์ ผ้า และทาสีใหม ่ ส ารวจส่วนทีส่ึก ขาด สกปรก หรือ ส่วนที่ หลุดห้อยออกมา ตรวจสอบความตึงของที่นั่งและ พนักพิงว่าเหมาะสมหรือไม ่ ถ้าผ้าใบ ขาด ตึงหรือหย่อน ให้ ซ่อมแซม ตรวจสอบเบาะรองนัง่ เบาะรองนั่งควรสะอาดและแห้ง เพื่อ ปกป้องผิวหนังได้ เบาะรองนั่งจะมีอายุการใช้งานน้อย กว่ารถนั่งคนพิการ การตรวจสอบอย่างสม่ าเสมอจะท า ให้รู้เวลาที่ควรเปลี่ยนเบาะรองนั่ง ถอดผ้าหุ้มเบาะ ตรวจสอบส่วนที่ฉีกขาด สกปรก และรทูั้งในผ้าหุ้มและฟองน้ า ถ้าเบาะรองนั่งขาด ควรได้รับการ ตรวจสอบโดยผู้ใหบ้ริการรถนัง่คน พิการ บางทีอาจตอ้งเปลี่ยนใหม ่ การซ่อมรถน่ังคนพิการและเบาะรองน่ังโดยท่ัวไป บางกรณีอาจจ าเป็นต้องซอ่มแซมรถนั่งคนพกิารและเบาะรองนั่ง ผู้ให้บริการรถนั่งคนพิการต้องสามารถ ซ่อมหรือแนะน าผู้ใช้งานเกี่ยวกบัสถานที่ทีส่ามารถไปขอความช่วยเหลอื ผู้ใช้บางรายสามารถซอ่มได้เองใน ขณะที่บางรายต้องการความช่วยเหลอื อย่างไรก็ตามผู้ใช้งานรถนั่งคนพิการทุกรายควรได้รับข้อมูลเกี่ยวกับ แหล่งที่ซ่อมรถนั่งคนพกิารได ้ 79 การติดตามผลคืออะไร? และมีวิธีการอย่างไร? การติดตามผลเกิดหลังจากผู้ใช้ได้รับและใช้รถนั่งคนพิการสกัระยะ การนัดหมายติดตามผล เป็นโอกาสที่จะ  รวบรวมข้อมูลจากผู้ใช้รถนั่งคนพิการ  ตรวจสอบว่ารถนั่งคนพกิารใช้งานได้ดีหรือไม่  ตรวจสอบว่ารถนั่งคนพกิารมีขนาดพอดีหรือไม่ ผู้ใช้ทุกรายล้วนแต่ได้ประโยชนจ์ากการเยี่ยมติดตาม และส าคัญมากส าหรบั  เด็กเด็ก  ผู้ใช้รถนั่งคนพิการที่มีความเสี่ยงต่อการเกิดแผลกดทับ  ผู้ใช้รถนั่งคนพิการที่มีภาวะโรคแบบเสื่อม (progressive conditions)  ผู้ใช้รถนั่งคนพิการที่ยังไมส่ามารถท าทกัษะต่างๆที่เคยได้รบัฝึก ไม่มีกฏเกณฑ์ว่าเมื่อใดควรท าการติดตามผลในแต่ละครั้ง แต่มักพบว่าการติดตามผลภายในระยะเวลา 6 สัปดาห์หลังการให้บริการเป็นช่วงที่มีประโยชน์ ทั้งนี้ข้ึนอยู่กับความจ าเป็นของผู้ใช้รถนั่งคนพิการ อย่างไร ก็ตาม ส าหรับเด็ก ควรติดตามผลทุก 6 เดือน เนื่องจากเด็กมีการเปลี่ยนแปลงอย่างรวดเร็วจากการ เจริญเติบโตของร่างกาย การนัดติดตามผลอาจท าที่บ้านของผู้ใช้รถนั่งคนพิการ หน่วยบริการรถนั่งคนพิการ หรือสถานที่ใดๆที่ สะดวกส าหรับผู้ใช้รถนั่งคนพิการและผู้ให้บริการ สิ่งท่ีต้องท าในกาติดตามผล โดยท่ัวไปได้แก ่  ตรวจสอบว่ารถนั่งคนพกิารอยู่ในสภาพดีหรือไม่  ให้ค าแนะน าหรือการฝึกเพิ่มเติม  กรณีจ าเป็น o ปรับรถน่ังคนพิการใหม่ o ให้การดูแลและซ่อมแซมเบื้องต้น o พิจารณาแนวทางการซ่อมใหญ่หรือช่วยผู้ใช้งานในการติดต่อด้านการซ่อม แบบฟอร์มในหน้าถัดไปสามารถใช้เป็นแนวทางในการติดตามผล ผู้ใหบ้ริการควรบันทึกว่าควรท าอะไรต่อ หลงัจากติดตามผลไปแล้ว วิธีด าเนินการนัดหมายเพ่ือติดตามผล  นัดหมายการติดตามผล เมื่อผู้ใช้รถนั่งคนพิการได้รับรถนั่งคนพิการ  ไปเยี่ยมบ้านผู้ใช้รถนั่งคนพิการเพื่อติดตามผล (ถ้าเป็นไปได้)  ติดตามผลผ่านการเยี่ยมบ้านตามปกติของเจ้าหน้าที่ฟื้นฟูสมรรถภาพในชุมชนซึ่งผ่านการอบรม เกี่ยวกับการติดตามผลแล้ว  ติดตามผลทางโทรศัพท์ ส าหรบัพื้นทีท่ี่เดินทางล าบาก และผู้ใช้รถนั่งคนพิการมีโทรศัพท ์ 80 แบบฟอร์มติดตามผล แบบฟอร์มนีใ้ช้บันทึกข้อมูลที่ได้จากการติดตามผล 1. ข้อมูลเกี่ยวกับผู้ใช้รถน่ังคนพิการ ชื่อผู้ใช้รถน่ังคนพิการ หมายเลข .. วันที่ลองอุปกรณ์ วันที่ติดตามผล . ชื่อผู้ติดตามผล การติดตามผลด าเนินการที่:  บ้านของผู้ใช้รถน่ังคนพิการ  หน่วยบริการรถน่ังคนพิการ  อ่ืนๆ 2. การสัมภาษณ์ คุณได้ใช้รถน่ังคนพิการมากเท่าที่คุณต้องการหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่- เพราะอะไร? คุณมีปัญหาจากการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช่ – มีปัญหาอะไร? คุณมีค าถามเก่ียวกับการใช้งานรถน่ังคนพิการหรือไม่?  ใช่  ไม่ใช่ ถ้าใช้ – ค าถามเก่ียวกับอะไร? จ าเป็นต้องฝึกเพิ่มเติมหรือไม่? ผู้ใช้รถน่ังคนพิการทีแผลกดทับหรือมไม่?  ใช่  ไม่ใช่ บรรยาย (ต าแหน่งและระยะของแผล) คุณจะให้คะแนนความพึงพอใจต่อรถน่ังคนพิการของคุณก่ีคะแนน จาก 1-5? (1 =ไม่พึงพอใจ และ 5 = พึงพอใจมาก) คะแนน: ความเห็น: 3. ตรวจสอบรถน่ังคนพิการและเบาะรองน่ัง รถน่ังคนพิการอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ เบาะรองน่ังอยู่ในสภาพดีและปลอดภัยในการใช้งานหรือไม่?  ใช่  ไม่ใช่ ถ้าข้อใดข้อหน่ึงตอบไม่ใช่ – มีปัญหาอะไร? 4. ตรวจสอบความพอดี รถน่ังคนพิการขนาดพอดีหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? การทดสอบแรงกดทับ (1=ปลอดภัย 2=เตือนภัย 3=ไม่ปลอดภัย) (กรณีที่ผู้ใช้รถน่ังคนพิการมีความเสี่ยงต่อการเกิดแผลกดทับ) ซ้าย: ขวา: ผู้ใช้รถน่ังคนพิการน่ังตัวตรงทั้งขณะอยู่น่ิง ขณะเคลื่อนที่และ ระหว่างวันหรือไม่?  ใช่  ไม่ใช่ ถ้าไม่ใช่ – มีปัญหาอะไร? 81 Sirindhorn National Medical Rehabilitation Centre, Department of Medical Services, Ministry of Public Health, 88/26, Bumratnaradul, Tiwanon road, Meuang, Nonthaburi, Thailand 11000 www.snmrc.go.th

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 31 décembre 2012

Source Organisation mondiale de la santé