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Journal of Nursing

RN's informed about skills of Occupational Therapist & Physical Therapists

Joan M Fenske RN,MS,PhD. [email protected]


Registered Nurses do not differentiate between the applied skills of the Occupational Therapist and Physical Therapist, nor do Registered Nurses realize it is the Occupational Therapist who is responsible for prescribing patients with developmental disabilities the type and configuration of an appropriate wheelchair.

The Occupational Therapist functions as an advocate for not only the patient, but also the family. Responding to multiple issues, the Occupational Therapist applies her expertise in multiple settings such as the school, clinics and referral physicians. Their expertise allows them to convey, in professional language, the need and rational for equipment needed for patients with developmental disabilities. Their skills are responsible for patients with developmental disabilities to fully function at home and at school. As they care for the patient, they educate the multi-disciplinary team responsible for the patient’s care.

Wheelchairs are carefully configured according to each patient’s needs and/or deformities. Occupational Therapists initiate a specific prescription to assure the patient’s wheelchair conforms to each patient’s dimensions. Wheelchairs are individualized and are not interchangeable patient to patient

Occupational Therapy differs from Physical Therapy. Each has a distinct scope of practice. Most RN’s are unaware of the differences until they, themselves, become patients and are referred for services. Occupational Therapists and Physical Therapist are state-licensed practitioners completing four years of professional curricula dictated by state law. For advanced and specialized practice, Master’s of Science degrees is necessary.

Physical Therapists are dedicated to developing, maintaining and healing the skeletal-muscular mechanisms of human anatomy. Whether rebuilding muscles withered within a cast, preventing contractures along neurologically disabled limbs, or healing muscle tears due to injuries such as whiplash, Physical Therapists evaluate patient needs, prescribe, teach then perform necessary individualized therapies.

Occupational Therapists are referred patients with given skeletal-muscular parameters, most often deficits. Strokes, accidents or birth defects may incapacitate patients. It is the professional responsibility of the Occupational Therapist to evaluate the patient’s deficit and determine the means to offset the deficit allowing the patient to again perform desired functions. To eat, the Occupational Therapist will design an appropriately configured self-feeding spoon and establish accompanying spoon-handling behaviors; to walk; the Occupational Therapist will evaluate the patient’s posture and select the type of braces for the patient’s use.

For a developmentally disabled child to function, the potential to find adaptable objects is unlimited. Every new idea becomes an immediate priority. To sort through the many ideas formulated by Special Education teachers, Vocational Trainers, Physical and Occupational Therapists, Psychiatric Technicians and mothers, all must be carefully reviewed. Assuming each developmentally disabled child is enrolled in their school’s Special Education Program, ideas are often discussed within the school district’s annual Individual Education Program (IEP) review.

Some examples include:
A) Adapting a television overhead pull switch, using a 30 second delay, allows a developmentally disabled child, lying in bed, to meet multiple IEP objectives. The pull switch expands the developmentally disabled child’s knowledge of switch work. Having mastered pushing large round red button switches, placed upon a wheelchair tray, the developmentally disabled child is able to keep favorite television shows on. If not continuously pushed, TV’s shut off.
B) Increasing skills from pushing round red buttons to pulling overhead switches increase the patient’s vocational potential. In addition, introducing the pull switch enlarges the patient’s leisure time activities by allowing them to interact with the television instead of passively viewing programs.
C) Developmentally disabled patients need “downtime”; it is essential to rest a patient’s deformities in bed and out of their wheelchair. The pull switch mechanism can be adapted to turn on many mechanisms including radios, fans, twirling mobiles of birds; even a moving and singing Santa Clause ornaments. Lying in bed with such mechanisms is a source of various acquired powers intriguing a patient for hours.

Finding and adapting mechanisms for developmentally disabled patients keep mothers, Occupational Therapists and Physical Therapists, searching a variety of catalogues. Knowing how mother’s are, Physical and Occupational Therapists listen to numerous ideas, agreeing only with those having merit. Physical and Occupational Therapists primarily focus on two developmentally disabled patients concerns, that of self-protection and mobility.

Often developmentally disabled patients need protection from self-mutilation. Registered Nurses may not comprehend patients’ with this affliction. However Occupational Therapists skillfully observe, assessing and interpreting patient’s needs. Multiple possibilities are tried. Designs must work to prevent patients from indiscriminate self-mutilation. Comprehending patients’ compulsion for self-mutilation among those with severe developmental disabilities is challenging for all professional staff.

Nursing those with developmental disabilities has never been included as an aspect of pediatric nursing. Such children have compelling issues with communication, self-mutilation, eating, swallowing, positioning, wheelchair modification and bowel care. If unskilled personnel attempt to feed developmentally disabled patients, the probability of pneumonia exists. Those patients at risk for self-mutilation, use of an adequate restraint is problematic even with physicians’ order.

An Occupational Therapist may design an arm protector designed with color-coded Velcro fasteners. Straps are fashioned to secure the padded protectors around the patient’s neck and chest. In this particular model, only two of the four straps need to be undone for bathing. To change clothes, protectors do not need to be removed completely unless to be exchanged for a clean protector.

Occupational Therapists create and post visual aids to assure color-coded protectors are correctly strapped in place. Even with color-coded fasteners, if one completely undoes all harness straps, it becomes critical to think carefully about which strap goes were. Because a patient’s potential for self-mutilation, and the complexity of correctly fastening arm protectors, caretakers readily learn how to correctly fasten protectors.

Children with developmental disabilities outgrow their wheelchairs requiring new and larger wheelchairs. Occupational Therapists consult with the Adaptive Engineering Firms and other similar agencies to design mobility systems; typically called wheelchairs. Non-ambulatory developmentally disabled individuals live their lives, wheelchair bound. They meet the world, daily, in a seated position. Wheelchairs support activities of daily living such as eating, learning, and training, interacting and playing.

Newer wheelchair models offer a “tilt in space” option providing wheelchair-confined patients multiple positioning options. Developmentally disabled patient are at risk for scoliosis, thus pelvic braces and secured strapping sustain each patient in correct positions. Goals of the Occupational Therapists’ include offsetting a patient’s pending curvature of the spine. This is especially true if the patient has not yet encountered their adolescent growth spurt.

Cerebral palsied patients are muscular and strong. They may slouch forward in their wheelchairs, pushing themselves out of alignment while exercising leg muscles. Occupational Therapists assess each patient for pending scoliosis. The patient’s pelvic position may become twisted by torque and determined muscular isometric thrusts. Most cerebral palsied patients require wheelchairs that accommodate muscular twisting and thrusting. Occupational Therapists often choose wheelchairs that “tilt in space” allowing a patient’s position to be readily changed. This reduces pressure on the patient’s skin, buttocks and back. Skin breakdown is always a danger when patients’ perspire. Newer wheelchairs are covered in stretchable fabrics that “breathe” preventing moisture from collecting between the fabric and where it contacts the patient’s body. Wheelchairs seats are made from memory foam assuring comfortable seating for the long spells.

Developmentally disabled children have corrective surgeries requiring careful assessment by the Occupational Therapist. Surgical interventions may result in one leg being shorter than the other leg. Occupational Therapists measure the difference between leg lengths and order appropriate wheelchair leg lengths to ensure each leg and foot is held in position. Often it is necessary to ensconce feet in footplates using welded metal footplates with Velcro straps. The patient with pronounced scoliosis requires a chair to accommodate the patient’s increasing deformity while keeping the patient in alignment. As patients age, surgical interventions to offset scoliosis become problematic and unadvisable.

Patient’s wheelchairs have headrests set to angles contributing to their overall alignment. Patients have ways of negating the influence of fixed headrests. Cerebral palsied patients are not weak and often use powerful muscles in their legs, chest and necks to force headrests into more comfortable positions they think best. Caretakers must watch and initiate re-securing the patient, if and when, their posture becomes contorted.

Maintaining a correct position is essential for those confined to a wheelchair and it is in this domain, Occupational Therapists apply their professional skills. As a cerebral palsied patient struggles to twist, the Occupational Therapist and caretakers pull. When cerebral palsied patient becomes contorted: the Occupational Therapist and caretakers push, lugs and disentangles, pushing patients back into alignment. This may necessitate wider Velcro straps and reworked welded footplate and hinges.

Occupational Therapists monitor the ongoing wear and tear on patients' wheelchairs as they travel to and from school and vocational training. When button switches need to be mounted onto tray tables, Occupational Therapists consult with computer specialists to assess each patient’s range of motion and finger dexterity. Finding the “sweet spot” on the wheelchairs’ tray table, the Occupational Therapist introduces the new button switch, centered, in front of the patient’s line of vision.

Pushed about in wheelchairs, patients eye their course of travel. They find openings in which to hook fingers. Door jams seem to offer enticing possibilities and openings. Teaching the command “arms down”, as patients pass through doorways, rarely modifies a patients’ behavior.

Whether or not such behavior might be considered a self-mutilation strategy, attracting attention by injuring themselves, is beside the point; patients still need protection for wily fingers. Occupational Therapists find weightlifter hand gloves to protect patient hands. With a black and chrome wheelchair plus silver weightlifter hand gloves, the patient is readily accepted into integrated and mainstreamed Special Education classrooms.

Occupational Therapists’ caseloads include many active young adults. Their experience and wise consul assist to keep families’ expectations realistic. Searching for assistive equipment, Occupational Therapists listen carefully. Needing bath chairs to bathe a severely developmentally disabled patient at home: resources from medical supply companies are reviewed. Purchasing less bulky, collapsible wheelchairs, Occupational Therapist support planned family outings. Occupational Therapists may devise seat inserts to assure alignment is correct and comfortable. Families with developmentally disabled family members frequently purchase recreational vehicles. Occupational Therapists are strong advocates for developmentally disabled patients and their families providing patients and parents the potential to explore the world together.

Children with developmental disabilities need multiple assistive devices, allowing then to function as normally as possible. The adapted wheelchair, arm protectors and gloves, and as well as unique spoons and cups allow children with developmental disabilities to participate in family outings. Because of the expertise of Physical and Occupational Therapists families are at ease with their family members with developmental disabilities and their public presentation of self. Families no longer need to hide family members away away or be limited by their disabilities. Similar families with kids with developmental disabilities are readily found shopping in places such as Costco, Wal-Mart and Target.

Physical and Occupational Therapists make it possible to integrate developmentally disabled patients, using there modified equipment, into the population at large. Instead of being greeted by contrary reactions, families and patients are accepted by sympathetic folk witnessing how diversity works in action.

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