Impaired Arm
Resident unable to support affected arm safely while in the wheelchair/chair as evidenced by hand swelling, pain/injury, and lack of awareness of R/L arm (e.g. bruising, cuts, scrapes) related to stroke.
Chapter 6, Section 6.2 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Resident will be seated so that the affected arm is properly supported.
Resident will have fewer affected arm injuries related to poor arm support/positioning while seated in the wheelchair.
Resident will increase awareness of the affected hand/arm.
Affected hand swelling will be decreased.
Skin integrity will be maintained.
Pain score for affected arm will decrease from ___ to ___. / Perform wheelchair seating assessment.
Follow seating recommendations (e.g., arm trough, lap tray, arm sling, pressure glove, wedge support for forearm, seat height cushion).
Perform assessment to identify painful areas using a pain assessment scale and monitor progress.
Handle affected arm and shoulder gently and support arm when moving resident. Never pull on the arm.
Request an order for analgesics if indicated and administer as prescribed.
Remind resident as needed to re-position affected arm.
Apply assistive devices (specify) as prescribed by an Occupational Therapist/Physiotherapist.
Educate resident/family on interventions to protect affected arm. / OT/PT
PSW/HCA/Registered Staff/Restorative Staff
Registered Staff
PSW/HCA/Restorative Staff
Registered Staff
PSW/HCA/Restorative Staff/Registered Staff
PSW/HCA/Registered Staff
PSW/HCA/Registered Staff
Decreased Ability to Transfer
Resident exhibits a decrease in ability to transfer (e.g. from bed to chair/chair to toilet/sit to stand) requiring assistance of (specify) due to weakness/ impaired balance/ inability to weight bear/cognitive decline related to stroke
Chapter 6, Section 6.2 and Section 6.3 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Resident will improve transfer ability (specify) (e.g. 2 person to one person transfer, mechanical lift to one person transfer)
Resident’s ADL mid-loss function (transfers & locomotion) will be maintained at ___or will improve from ___ to ____. / Assess transfer function and required assistive devices/transfer supports.
Perform transfers and use devices as recommended by PT/OT (specify).
Prepare environment before transferring (e.g. position equipment, remove clutter, set wheelchair brakes, swing away or remove wheelchair footrests).
Provide resident with short, clear and simple instructions.
Ensure affected arm is supported during transfers. Never pull on affected arm or under shoulders.
Educate resident/family on transfer technique. / PT/OT
PSW/HCA/Registered Staff/Restorative Staff
PSW/HCA/Restorative Staff
PSW/HCA/Restorative Staff
PSW/HCA/Restorative Staff
PSW/HCA/Registered Staff
Impaired Hand Function
Resident has (specify):
· increasing hand muscle tightness
· flaccid (limp) hand
· cramping and inability to open affected hand
· poor hand hygiene
· decreased active and PROM of fingers and wrist
· impaired skin condition on hand
related to stroke
Chapter 6, Section 6.2 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Resident will have sufficient flexibility/ROM in affected hand to allow proper hand hygiene and to maintain skin integrity.
Skin integrity on resident’s affected hand will be maintained.
Resident’s affected hand swelling will decrease.
Resident’s affected hand ROM will improve. / Perform a hand assessment and provide recommendations for exercise, splints and supports.
Follow the recommendations to improve positioning of the affected hand (specify) (e.g. hand splint, stroking back of hand and passive/active range of movement exercises).
Assist resident to perform hand hygiene on affected hand as required. / PT/OT
PSW/HCA/Registered Staff/Restorative Staff
PSW/HCA/Registered Staff
Impaired Foot/Leg Function
Resident unable to position and maintain affected foot on w/c footrest as evidenced by lower extremity swelling, pain/injury (e.g. bruising, scrapes, cuts) and ankle stiffness related to stroke.
Resident unable to maintain proper foot contact with the floor when standing/transferring/walking as a result of muscle weakness, tightness, ankle stiffness related to stroke.
Resident exhibits swelling in affected leg and foot due to immobility and sensory changes related to stroke
Chapter 6, Section 6.2 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Resident will achieve proper foot position supported on the footrest at all times.
Resident’s affected ankle/leg/foot swelling will decrease.
Resident’s affected ankle ROM will improve.
Resident’s pain score for the affected leg will improve from ___ to ___.
Resident will have a decreased incidence of injury to affected leg/foot related to wheelchair footrest positioning.
Resident will maintain skin integrity.
Resident will maintain proper foot contact with the floor when standing, transferring, and walking. / Perform leg and foot assessment on affected side, gait/weight bearing assessment and provide recommendations for exercises and assistive devices.
Perform wheelchair assessment and provide recommendations.
Follow the recommendations made by the PT/OT to improve positioning of the affected foot (specify) (e.g. ankle brace, proper footwear, passive range of movement, compression stockings, proper footwear, elevation of foot).
To prevent foot stiffness and deformity, include standing in resident’s daily routine. Weight should be evenly distributed over each leg, leg joints should be aligned and heels should be on the ground.
Follow recommendations for resident’s positioning in the wheelchair.
Perform assessment to identify painful areas using a pain assessment scale and monitor for changes.
Request an order for analgesics if indicated and administer as prescribed.
Educate resident/family on interventions to protect affected foot/ankle. / PT/OT
PT/OT
PSW/HCA/Registered Staff/Restorative Staff
PSW/HCA/Restorative Staff/Registered staff
PSW/HCA
Registered Staff/PSW/HCA
Registered Staff
PSW/HCA/Registered Staff
Decreased Bed Mobility
Resident has decreased bed mobility (e.g. sitting to lying; rolling side to side; moving up and down bed) as evidenced by inability to position self in bed or maintain position in bed related to stroke
Chapter 6, Section 6.2 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Resident will maintain/increase independence in bed mobility as evidenced by (specify):
a) improved ability to shift up or down the bed independently or with cueing/assistance
b) improved ability to rise from lying to sitting at the edge of the bed independently or with assistance (e.g. rope ladder, one assistant, pole)
c) maintaining a comfortable upright sitting position in the bed for increased periods of time / Assess resident’s bed mobility and provide recommendations.
Follow recommendations for bed mobility (specify).
Educate resident/family on interventions to assist with bed mobility. / OT/PT
PSW/HCA/Registered Staff/Restorative Staff
PSW/HCA/Registered Staff
Impaired Upright Positioning
Resident unable to maintain a comfortable upright position in the wheelchair/chair due to weakness/lack of awareness/ abnormal posture/incorrect cushion etc. related to stroke.
Chapter 6, Section 6.2 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Resident will increase sitting tolerance and maintain a comfortable upright position in the wheelchair/chair for increased periods of time (specify). / Perform wheelchair/chair assessment and provide recommendations for positioning devices.
Follow positioning recommendations (specify).
Check resident’s posture in the wheelchair (specify frequency) for:
§ comfort
§ a 90 degree angle at the hips, knees and ankles
§ affected arm and foot properly supported
§ shoulders level
§ proper cushion in place
or as per OT/PT recommendations
Educate resident/family on proper wheelchair positioning. / OT/PT
PSW/HCA/Restorative Staff
PSW/HCA, Restorative Staff
PSW/HCA/Registered Staff
Impaired Mobility
Resident exhibits decreased ability to walk safely due to:
a) poor balance/posture
b) impaired weight-bearing
c) inappropriate walking aid
d) perceptual impairments (e.g. limited sight on impaired side)
related to stroke
Chapter 6, Section 6.2 Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) / Locomotion self-performance will be maintained or will improve as demonstrated by (specify):
a) improving standing balance
b) improving weight bearing ability
c) correcting walking aid
d) increasing awareness of affected side / Perform a gait/weight bearing assessment and provide recommendations.
Follow OT/PT recommendations for assisting resident with mobility (specify).
Ensure all mobility aids are accessible and remind resident to use mobility aids.
Use mobility aids as instructed by PT/OT when helping resident to walk.
Ensure resident is wearing appropriate footwear with good support and grip.
Stand on resident’s affected side when helping resident to walk unless otherwise instructed by OT/PT.
Remind/cue resident to maintain upright posture with eyes forward (not looking at feet).
Ensure resident is balanced prior to walking. Remind resident to keep hip, knee and ankle of affected leg lined up and to share weight equally between right and left foot.
Remind resident to strike with heel first as they step forward.
Maintain a slow pace. Do not rush.
Cue resident to position walking aid at appropriate distance.
Cue resident to avoid leaning heavily on walking aid
Encourage participation in exercise and to balance activity and rest.
Educate resident, family and caregivers re walking recommendations / OT/PT
PSW/HCA
PSW/HCA Restorative Staff
PSW/HCA/ Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA Restorative Staff
PSW/HCA/Registered Staff/ Restorative Staff
PSW/HCA/Registered Staff/ Restorative Staff
Alignment with Best Practice
§ BP Blogger Myth Busting Stroke 2 Volume 5 Issue 4, December 2010 http://www.the-ria.ca/resources/bp-bloggers/
§ Quality-Based Procedures: Clinical Handbook for Stroke (Acute and Postacute) 2015, Module 9, Community Treatment – QBP Stroke
§ Canadian Best Practice Recommendations for Stroke Care – Mobility, Positioning & Transfers
January 2016 Page 1 of 6
Developed by the Ontario Stroke System in collaboration with Long Term Care Stakeholders and based on the best practice resource:
Taking Action for Optimal Community and Long Term Stroke Care, A Resource for Healthcare Providers (2015) - Heart and Stroke Foundation.