Environmental Modifications

Jennifer Thompson, MS, OTR/L

Evaluation

• Occupational profile
  • Home setup: apartment, condo, house, motor home, mobile home, housing insecure
    • How many steps to enter? How many steps inside of the home?
    • Bathroom: tub/ shower combo, stall shower (typically has 2-4” lip to step over), walk in shower; toilet height (handicapped height ~19”, standard toilet 17”
    • Any durable medical equipment already owned? Shower chair, grab bars,  hand held shower hose tub bench, stair lift, rolling walker, cane,  wheelchairs
    • Hallways and other living spaces: types of floors, lighting: adequate , are all traffic lanes (walking spaces between furniture) clear? 
  • Patient’s strengths and barriers that impact recovery (weightbearing / surgical precautions, bracing / splints, support at home, previous level of independence and baseline task performance, prior medical history, etc).
    • How did the patient perform their morning routine at home (seated shower in the morning, caregiver assisted with bathing at nighttime)?
• Common assessments used:
  • Gerontological Environmental Modifications (GEM)

Treatment 

• Intervention strategies/emphasis
  • Transfers training: progress as patient is able, progress to height of shower (stall, tub) with least restrictive device and durable medical equipment as the patient needs
    • Assess for durable medical equipment to be ordered for discharge (shower chair, commode, tub bench, toilet safety frame, raised toilet seat, grab bars).
  • Simulate home environment as much as possible: ask patient / family for measurements of shower, height of toilet, etc (photographs are helpful as well) and use tape on the floor to create a “mock up” of the patient’s space.
  • Safety awareness – patient and family education and hands on training for transfers before the patient discharges home.
  • Balance training: static and dynamic state/ standing 
  • Progression to IADLs: grade activity from simple (cold table top beverage prep, sorting and folding laundry while seated), to multistep complex tasks (baking a cake, ambulatory bed making, etc) and assess patients movement and problem solving in their environment.
  • Coordinate with other disciplines for least restrictive device use and PT equipment needed (ex: if the patient requires a wheelchair for mobility and is unable to access their bathroom in the wheelchair due to a narrow door frame, does the patient need a commode at their bedside? Can the door frame come off of the door? Etc)

Important safety information

• Any weightbearing precautions, other than weight bearing as tolerated (WBAT), require seated position for shower level bathing for safety. Patients with surgical precautions, hemiparesis, weakness, inattention, neglect, impaired balance, and decreased safety awareness may also require seated position with potential for hands on assist for showers.
  • Assess the level of assistance and willingness available from family or caregivers to help with bathing/ dressing tasks; consider private assistance if family is unable.
  • If unable, or bathroom inaccessible, consider sponge bathing.
• Patients may require a second set of cervical collar pads for bathing, or secondary cervical collar, or additional TLSO/LSO for showering as ordered by MD.
• Consider cast covers or use of plastic bags to cover splints or casts on extremities.
• Waterproof dressings for other areas of concern (PEG tube sites, IV sites, etc).
• Grab bars that are drilled into shower and/or bathroom walls are much safer than suction cup grab bars.

Additional Resources: see Environmental Modifications folder

References:

Brachtesende, A. (n.d.). Home modifications promote independent living. American Occupational Therapy Association. https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/Articles/HomeMod.aspx.