Assistive Devices: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of assistive devices in order to:
- Assess the client for actual/potential difficulty with communication and speech/vision/hearing problems
- Assess the client's use of assistive devices (e.g., prosthetic limbs, hearing aid)
- Assist client to compensate for a physical or sensory impairment (e.g., assistive devices, positioning, compensatory techniques)
- Manage the client who uses assistive devices or prostheses (e.g., eating utensils, telecommunication devices, dentures)
- Evaluate the correct use of assistive devices by the client
Assessing the Client for Actual/Potential Difficulty with Communication and a Speech, Vision and/or Hearing Problem
As previously mentioned and fully explored with the section entitled "The Techniques of Physical Assessment", nurses assess their clients in terms of any actual and potential difficulties and deficits in terms of speech, hearing and vision.
Clients are further evaluated and assessed by other members of the health care team when a need to do so arises. For example, the nurse may refer the client to an ophthalmologist or optician when an actual or potential visual deficit is present; an audiologist or hearing aid professional may be referred for the client when they have an actual or potential auditory deficit; and a speech and language therapist may be contacted in order to evaluate and assess clients with a speech and oral communication deficit.
Many clients may already have an assistive device to accommodate for their assessed speech, hearing and/or visual deficit; when this is the case, the nurse and other members of the health care team must provide these assistive devices to the client.
Some clients may be permanently visually impaired with complete blindness, some may have low vision and still others may have a temporary visual change. For example, a client may be completely blind at birth because of some genetic disorder, an elderly client may have low vision as the result of aging related macular degeneration, and a client can have blindness as the result of some trauma; some visual disturbances can result of taking a medication such as an antihistamine that can lead to glaucoma, antipsychotic medications like thorazine and antimalarial medications which can affect the retina, and corticosteroids which can lead to eye swelling and cataracts.
Clients who are blind use a number of assistive devices such as a walking cane, a service dog, and a Braille note taker like Vario Ultra for written communication. People with significant low vision may also use these same assistive devices and others may use communication assistive devices such a low vision reader and magnifier such as the Merlin, the Amigo and the Pebble and other devices such as corrective lenses and magnifying glasses. Nurses must accommodate for these deficits and losses.
Similar to blindness and low vision, some clients may be permanently impaired with complete auditory losses and others may have temporary auditory changes. For example, a client may be completely deaf at birth because of some genetic disorder, an elderly client may have a hearing loss as the result of the aging process, and a client can have a hearing loss as the result of some trauma, and some medication such as loop diuretics like furosemide, cancer chemotherapy agents like cisplatin, aspirin, nonsteroidal anti-inflammatory medications like ibuprofen, and some aminoglycoside antimicrobial medications like neomycin, gentamicin and streptomycin.
Drug related hearing losses have a typically abrupt and sudden onset when the medication is begun. The first signs of possible auditory impairments secondary to medication are usually tinnitus and vertigo as the result of cochlea damage. At times this damage is permanent and, at other times, the damage will be corrected when the medication is discontinued.
Clients who are deaf use a number of assistive devices such as sound amplifiers, alerting devices, closed captioned television, electronic communication devices such as a teletypewriter and other more advanced devices like a terminal emulator and Unix.
People with a partial hearing loss may also use these same assistive devices and others may simply use a hearing aid and take advantage of closed captioned television shows and an American Sign Language interpreter.
Speech deficits are quite common among our client's particularly when they have had a trauma like a cerebrovascular accident. Some of the assistive devices that can be used for this population in order to facilitate oral communication can include things like word boards, picture boards, and handheld speech generating electronic devices as well as the professional services of a speech and language therapist.
Assistive devices facilitate the clients' communication abilities, their performance of the activities of daily living, their highest possible level of independence, the prevention of the complications associated with immobility, and it also enhances the patient's feelings of self-esteem and self-worth. Nurses must assess and reassess the client's safe and appropriate use of all assistive devices, as discussed above and immediately below.
Some of the commonly used assistive devices relating to mobility and ambulation include canes, walkers, wheelchairs, crutches, and prosthetic limbs. In most health care facilities, a physical therapist, in collaboration with nurses and other health care professionals, assess the client for these assistive devices and the physical therapist and/or the nurse instructs the client about their proper use and maintenance.
Canes are typically used to facilitate the client's balance and to facilitate ambulation when the client is physically and cognitively able to use it rather than a walker. There are a variety of different canes including a standard one foot cane, a tripod cane with three feet, and the quad cane which has four feet. Some canes like a wooden cane are not adjustable to the client's height and others can be adjusted to meet the height needs of the client.
The proper length of the cane should be the length that only permits the client's elbow to be slightly flexed. The cane is held by the client in the hand opposite of where support is needed. For example, the client will hold the cane with their right hand when the left leg is weak and the client will hold and use the cane with their left and when the client is affected with weakness on their right leg. Canes support the affected limb, not the unaffected limb, when the client is ambulating.
Walkers are indicated when the patient needs more support with ambulation than a cane can safely offer them. Walkers can be with or without wheels, with or without brakes, and with or without a seat that the client can use when they need to rest during a long walk.
Walkers that do not have wheels require that the client is able to pick the walker up and then advance it forward at the appropriate distance so the client can proceed to that point; some clients may lack the coordination and strength to do this, so they may then get a walker with two or four wheels. Walkers with wheels, however, may not be suitable for a client who is not able to control it from inadvertently rolling forward which could lead to a client fall. Walkers should be fitted and adjusted to a height that is at the level of the client's wrist cease when they are standing upright and erect without any hunching over or leaning forward.
Battery powered and manual wheelchairs offer the client the most assistance in terms of their mobility and locomotion needs. Manual, mechanical wheelchairs require that the client has upper arm strength to propel the wheelchair forward or the client must have the assistance of another to push them in the chair. Battery powered wheelchairs and scooters require some manual dexterity and close attention to safety. Some facilities prohibit the use of these battery powered chairs because some clients have the tendency to go too fast in these chairs and they may, as a result, injure themselves and others. Regardless of the type of wheelchair that is used, the client should always keep their feet on the foot rests to prevent injury and also lock the brakes prior to getting into and out of the wheelchair.
Crutches are used most often for younger clients who have good upper arm strength who have been affected with an acute musculoskeletal injury such as a sprain, strain or fracture. A specific method of using crutches, referred to as gait, is ordered for a patient as based on their physical support needs. These gaits include the two point gait, the three point gait, the four point gait, the swing through gait, and the swing to gait. Properly fitting crutches should have the client's hands firmly placed on the grips. The client's elbows should be slightly bent when holding the handgrips and the handgrips should be even with the hip line.
The client's weight is sustained by the hands; there should not be any weight or pressure on the arm pits when the person is walking with their crutches. All the weight is on the hands which are on the hand grips.
As with all patient care equipment, assistive devices must be safe, maintained and not broken. For example, wheelchairs without good brakes and without foot rests must be immediately taken out of service and not used for the client. Additionally, the rubber tips on a walker, cane and crutches should be inspected often and immediately replaced if there is any sign of wear or bareness.
Some clients also have artificial limbs which are referred to as a prosthetic device. The need for an artificial limb can occur as the result of some congenital anomaly, as the result of an accidental traumatic amputation of a limb, and also as a planned process when the client has a limb that has to be amputated, as often occurs among clients with diabetes.
A prosthetist assesses the client for prostheses and they also measure, custom design and supply the client with any necessary prostheses. The client will usually get a trial temporary prosthesis before they are fitted with a permanent one. Once the client is educated about the use and care of their permanent prosthesis, the client should be educated about the need to have the prosthetic device checked by a prosthetist on at least an annual basis.
Assistive devices for physical impairments affecting mobility and ambulation were previously discussed under the section immediately above and assistive devices for sensory impairments in terms of speech, vision and hearing was also previously discussed under the section entitled "Assessing the Client for Actual/Potential Difficulty with Communication and a Speech, Vision and/or Hearing Problem".
In addition to these assistive devices, there are also assistive devices such as pillows, bolsters and wedges that are used to position clients into positions that promote and maintain correct bodily alignment. Alert, orientated, and physically able clients with full range of motion should be encouraged to frequently change their position in bed; and, those who are not able to do so, need the help of the nursing staff to turn and position them at least every two hours to minimize the risks of pressure ulcers and contractures, which are two of the many hazards associated with immobility.
Other assistive devices to compensate for physical impairments include braces and splints. Braces and splints are also fitted and customized for the client by a prosthetist. When used, the nurse must insure that it is applied correctly and they must also assess the skin and its temperature and color under these assistive devices on a regular basis to insure skin integrity and adequate circulation, respectively.
In addition to the assistive devices and prostheses discussed above, there are assistive devices to aid the client in terms of their communication, eating, dressing, grooming, dentition and many of the activities of daily living.
The section above entitled "Assessing the Client for Actual/Potential Difficulty with Communication and a Speech, Vision and/or Hearing Problem" explored a large number of assistive devices, including telecommunication devices that facilitate the client's ability to communicate despite a sensory impairment.
Some of the assistive devices that are used to promote and facilitate the client's independent self-care including those to promote and facilitate the client's independent activities of daily living are listed below:
- Grooming self care: Adaptive hair brushes and combs and special nail clippers
- Dressing self care: Long shoe horns, button hooks, oversized buttons, sock pulls, oversized loops, zipper pulls and Velcro closures for clothing
- Hygiene and bathing self care: Shower chairs, grab bars, nonskid tub and shower floors, spray nozzles, and long handled back brushes
- Eating self care: Weighted plates, scoop dishes, food guards around the plate, assistive utensils, weighted and tip proof drinking glasses and cups
- Oral self care: Special tooth paste holders, special tooth brushes and easy to use and manipulate dental floss.
Dentures, another prosthetic and assistive device, are cleaned with a soft tooth brush and a denture cleaner. When these dentures are removed they are then placed in a safe place, like a labeled denture cup, with an overnight denture cleaner. Despite the client's use of dentures, the gums and cheeks should be gently brushed and a mouth wash should be used in the same manner that other clients do.
The client's correct use of assistive devices is evaluated and monitored by observing the client using these devices and evaluating whether or not the client has remained without injury secondary to the improper use of these devices.
- Assistive Devices (Currently here)
- Non Pharmacological Comfort Interventions
- Nutrition and Oral Hydration
- Personal Hygiene
- Rest and Sleep