occupational therapists role in toileting

Occupational Therapists’ Vital Role in Toileting

Everyone knows that occupational therapists assist with improving independence in activities of daily living (ADLs), but not everyone understands the large role that occupational therapists have in toileting.

I remember when I was first qualified, I knew that toileting was within the scope of occupational therapy, but incorrectly believed that it wasn’t as important as other activities of daily living. I think I was also a bit embarrassed to assist in such an intimate activity. After many years working as an OT, I am now a strong advocate for helping patients become independent in going to the toilet.  

A Quick Example of the Importance of Toileting: 

I remember assessing a patient after a stroke. This person had communication difficulties, cognitive difficulties, and was unable to walk or use his affected arm. When I asked him what his main goal was, he replied, “toilet.” Even though he has so many different areas that require intervention, he felt that being able to go to the toilet independently was his top priority.

Toileting is a very intimate activity, and it can be embarrassing for our patients to rely on a family member or a paid caregiver to assist in this activity. We need to maintain our patients’ dignity and help them achieve independence in this meaningful activity.

60% of injury-related ER visits are from falls, and 80% of those falls in the home occur in the bathroom. Occupational therapists are the primary health care practitioners to improve independence and safety with toileting. Read this article to gain greater insight into how we can do this. 

This article will highlight the following:

  • What does toileting entail?
  • The body functions involved in toileting
  • How to assess the environment
  • Interventions for toileting

What Does Toileting Entail?

Toileting is one of the basic activities of daily living. There are a few main tasks within this activity. 

  1. Clothing management
  2. Toilet transfer
  3. Toilet hygiene
  4. Hand hygiene

Going to the toilet is more complicated than having normal bowel or bladder sensation. There are many body functions involved in it, and we’ll include what’s needed in each task. 

occupational therapy toileting

Before even going to the bathroom, one needs:

  • Bladder and bowel sensation 
  • Memory of where the bathroom is
  • Planning of how to get there
  • Communication if they require the assistance from someone
  • Mobilizing to the toilet: either by walking or by self-propelling wheelchair or commode

Clothing management:

These are some of the skills we need to target:

  • Dynamic standing balance: to doff pants and underwear and pull them back up. 
  • Fine motor skills: to manage zips and buttons.
  • Sequencing: knowing how to manage clothes before sitting down on the toilet, and pulling up underwear before pants

Toilet transfer:

This can come in many shapes and forms. It might involve the patient walking to the toilet, or transferring from wheelchair to the toilet, or even transferring from bed onto a commode that is used over the toilet or on its own. 

These are some of the skills we need to target for toilet transfers:

  • Upper and lower limb muscle strength and range
  • Trunk strength 
  • Dynamic balance
  • Coordination

For some helpful tips on how to safely work on patient transfers, check out our article Transfer Training Tips for New Occupational Therapists.

Toilet hygiene:

This involves the process of cleaning yourself after using the toilet. Take note of cultural differences. This may involve wiping or making use of a vessel with water.

These are some of the skills we need to target for toileting hygiene:

  • Dynamic sitting balance (trunk rotation might be needed while reaching for toilet paper, and trunk flexion and rotation while wiping/cleaning.)
  • Hand function: maintaining grasp on the toilet paper
  • Hand strength and coordination to break toilet paper
  • Concrete judgment: to judge whether you are clean and no longer need to wipe/wash yourself. 
  • Upper and lower limb muscle strength and range
  • Trunk strength 
  • Vision/sensation: seeing where the toilet paper is or feeling where it is
  • Proprioception: correct amount of pressure applied when wiping self

Hand hygiene: 

These are some of the skills we need to target:

  • Bilateral hand coordination
  • Good sitting or standing balance while washing hands
  • Sequencing
  • Concrete judgment

Assessing the Environment

  • Does my patient have sufficient lighting?
  • How low is the toilet? Can they stand up from such a low surface? Practice these skills, or recommend a raised toilet seat and or grab bars.
  • Are there loose rugs that they can trip on in the bathroom? 
  • Is there enough space on the side of the toilet for them to position the wheelchair appropriately?
  • Do they have easy access items in the bathroom? Are they within reach? (access to toilet paper/bidet/shower and faucet for hand washing)
  • Is there enough space in the bathroom doorway to allow for a wheelchair or walker to fit through?

Toileting Interventions

Determine and target the underlying body function that is preventing them from being independent in toileting. Toileting interventions could involve targeting:

    • Sit to stands from low surfaces.
    • Target their grasp to be able to hold toilet paper.
    • Use sequencing cards to sequence the order of tasks in toileting.
    • Sticking a picture of a toilet on the toilet door to compensate for their memory.
    • Simulating toilet hygiene by making them reach for items behind their buttocks, which will target trunk rotation with shoulder extension and internal rotation needed for wiping/washing. 
    • Transfer training onto the toilet, with an emphasis on safety awareness.

Compensate for the underlying impairment, with the use of the following:

  • Assistive devices for difficulty with transfers and mobility include: raised toilet seat, grab bars, and a commode.
  • Assistive devices for difficulty with toilet hygiene: toilet aids (otherwise known as long reach wiping aid) and portable bidets.
  • Assistive devices for difficulty with hand washing: sink knobs that are easier to hold, extended length lever taps, and tap turners.
  • Assistive devices/alternative options for clothing management: choose loose pants that have elastic bands for easy donning and doffing, a button hook, a loop around a zipper for an easier grip, and using a long handled reacher to lift up the pants from the floor. 

adapted bathroom

Adapt the environment:

  • Ensure good lighting to prevent a fall in the bathroom.
  • Recommend height and placement for assistive devices, such as grab bars. 
  • Recommend loose rugs are removed, or swapped for non-slip mats.
  • Recommend, if possible, repositioning of toilet paper or toilet shower for easier access.
  • Recommend positioning of the wheelchair for the toilet transfer.
  • Assess all the bathrooms (if there are more than one) and select the bathroom with the most space available for the transfer.
  • Increase the bathroom doorway space with the use of a “swing clear offset hinge” that provides an extra inch of clearance in total.
  • Incorporate a “squatty potty” foot stool for foot support for short people sitting on the toilet. This will improve a patient’s safety while sitting on the toilet. Foot stools are also good for ultimate positioning for bowel movement. 

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Toileting is and should be a top priority for essentially all occupational therapists to target. We have the skill of activity analysis to determine what is the underlying impairment affecting our patient’s independence in toileting.

We also have the knowledge of what adaptations and assistive devices we can recommend in the bathroom to improve safety and independence.

We hope this article has provided you with greater insight into occupational therapists’ role in toileting and gave you the confidence to regularly address this very important ADL!

Reference:

Safety for seniors: preventing falls in the bathroom, belvedere health services, Belvedere Home Care, 2018, https://belvederehealthservices.com/belvedere-home-care/blog/safety-seniors-preventing-falls-bathroom, accessed on 28/02/2023. 

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