1 he Iowa Veterans Home (IVH)in Marshalltown, Iowa is an 834-bed stateowned long-term care facility for veterans and their spouses. Each resident at IVH is assigned to a primary registered nurse who is responsible and accountable for that individual's nursing care.
Ages of residents range from 27 to 103 years. Many of these residents have multiple chronic illnesses that require a variety of interventions. Each nurse selects an area of special interest defined by nursing diagnosis terminology. The nurse develops this specialty in many ways, such as literature review, conference attendance, and independent study. Interest areas are published annually as a resource directory. Nurses consult with each other about their identified specialty areas, share resources, and present inservice education.
A number of clinics evolved from this framework to address special problem areas that were common to many residents. These clinics include dysphagia, wheelchair, and continence clinics. Scheduling is based on need, generally no more than 1 to 4 hours once a week. Clinics are staffed by a nurse with identified expertise in that area in conjunction with other disciplines that share that specialty. Clinic team members also prepare and present inservice education from their areas.
One of the most successful and sustained clinics at G?? is the Wheelchair Clinic. Approximately 80% (409) of the residents in the nursing home level of care are in wheelchairs. The goal is to ensure individual fit, assist with learning to use the chair, and provide wheelchair maintenance. In the past 2 years, G?? has been moving toward a restraint proper environment. Wheelchair modifications have minimized the conditions that seem to warrant the use of restraints.
The Wheelchair Clinic is held weekly. Team members include a physical therapist, certified occupational therapy assistant, registered nurse, and wheelchair services staff. A Veterans Affairs physiatrist consults two to three times a year to aid in assessment and intervention strategies. Alternate funding resources are explored for individuals who are unable to pay or who do not qualify for VA assistance for the purchase of chairs.
Consultations to the Wheelchair Clinic are initiated by written requests by primary nurses and care planning teams, verbally by families, or by residents themselves. After the initial screening at the clinic and determination of need, a wheelchair is issued. If it is an electric wheelchair, the resident attends a driving school. A driving test for competent residents is required annually thereafter. The wheelchair fit is also evaluated annually. The primary nurse attends the initial clinic visit and each annual evaluation along with the resident in the wheelchair. The primary nurse submits a short assessment of current status.
Besides the standard wheelchair, the Wheelchair Clinic identifies specific needs for electric wheelchairs, threewheelers, and one-armed drive (Poiret) wheelchairs, all designed to enhance the remaining abilities of the resident. Necessary adaptations are made to wheelchairs to ensure proper body alignment. Trays, positioning devices, or splints to prevent contractures are applied to support the resident. The weight of the wheelchair is considered in relation to the resident's strengths. Adaptations are made in the length and height of the seats. Movable arm and leg rests are adjusted to functional positions for each individual.
Many wheelchair seats are changed from the classic "hammock" to firm cushions that ensure proper posture. Special cushions may be prescribed to aid circulation and decrease pressure. The wheelchair seat and back may be tilted to minimize sliding and to prevent shearing. The work of the wheelchair team has assisted many residents to be more comfortable and to reach their optimal functioning level.