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Healthcare Training Institute - Quality Education since 1979

Section 30
Key Slides and Commentary

Table of Contents | NCCAP/NCTRC CE Booklet

a. Tracing
Some residents have the mental ability to be involved in a simple craft but lack the hand movement to do the craft.  Thus they are unmotivated to be involved.  You might find an answer in Tracing.  Tracing is exactly what it sounds like, you cut a corrugated shape and have the resident trace around the outside of it, the thicker the shape, the easier it is for residents with stiff fingers to trace. If your resident has excellent hand-eye coordination, you can use the thinner poster board.  If the resident has poor hand-eye coordination, it might take two or three thicknesses of corrugated cardboard for the resident to be successful at tracing around a shape.

Before you implement Tracing with a resident, you need to assess their ability to hold some kind of a writing implement. Oftentimes when I give a resident a pencil, they have no grasping ability when their thumb and index finger get about one inch apart. Therefore, to provide them with a writing implement, you take a one or two inch Styrofoam ball and push a pencil through it. This helps overcome their limited grasping ability to acquire enough pressure to hold the pencil. Then assess your resident's ability to move the pencil or move the pencil and the Styrofoam ball. The use of a Styrofoam Ball and other writing adaptors are explained in detail in Volume Three of this series.

Stabilizing the Paper
Some activities you might have a resident do to assess their ability to do Tracing is to simply make marks on a paper, or to have them write their name.

A piece of typing paper taped with masking tape to the work surface works well. Most over-the-bed-tables are made out of the dark Formica so if a pencil should happen to stray, its not going to cause too much damage to the work surface. If you have a concern about stray marks on the work surface, however, you could put newspaper underneath the paper. However, the newspaper may act to distract the disoriented resident.  Of course the more success the resident experiences with Tracing the more motivated he or she will be to do the activity again.  For this reason it is important that you are aware of the relative difficultly level of various shapes.

Level of Difficulty in the Patterns
The forms I have in my set of Tracing materials are as follows:
1, The Circle, is the easiest Tracing pattern because it requires just one continuous directional move of the pencil
2. The bell shape is the second easiest because at the bottom of the bell there are two direction changes at either edge.  See illustration to the right.
3. The third level in difficulty is the pumpkin shape because of the direction change at the stem.
4. Next is the three leaf clover which as you can see requires several directions changes of the pencil.
5. The Christmas tree comes next.
6. The star is the most difficult because of the many direction changes the resident Tracing has to make with his or her pencil.

Observe and Adapt - Stabilizing the Form:  Adaptive "T" Handle
In addition to stabilizing the paper, a second challenge the resident has in doing this Tracing activity is stabilizing the tracing pattern itself. Here is what happens.  Many residents have very stiff fingers.  This stiffness is oftentimes in the second digit of their fingers.  When your resident comes to push down on the tracing pattern to stabilize it, to enable them to trace around, they end up sliding the pattern away from themselves.  Therefore, on most of my patterns, I attached what I call an "Adaptive T Handle," as in the letter T.  To make the Adaptive T Handles illustrated here above.
1. cut a rectangular piece of corrugated cardboard that is about two inches wide and about 7 or 8 inches long
2. fold it into a T shape by folding in half and then folding the two ends towards the middle again. It makes sort of a M and then you bring the middle of the M together to make a T shape.
3. Staple this to your pattern.  This makes a nice handle for the resident to grasp and put pressure down onto the form rather than pushing it away from themselves.   The staples poke through the other side.  So consider talking an identical pattern and pasting it to the bottom.  The added thickness makes the pattern easier for the resident to track.

Many residents can trace only part way around an object.  Here’s their challenge.  As they stabilize the form with their left hand and trace with their right hand, they get to the portion of the pattern where your own forearm is in their way.  So you might complete the rest of the Tracing for them if they are unable to learn to Trace completely around.   Below is a Goal related Tracing part of a pattern.

An Interdisciplinary Approach to Tracing
You might notice that Tracing is constructed at zero to little cost because the purpose is to leave the projects in the resident's room available for family, visitors, and staff to use with the resident. This clearly is an Interdisciplinary Culture Change approach to your Activity Program. To me the word Interdisciplinary means more than one department is involved .  This means nursing, dietary, housekeeping and not just activities is involved.  So if all the activity projects are kept in a box in your Activity Room, that really doesn’t provide very much of an opportunity for the other staff, family, visitors, volunteers, etc. to support you in your goal of involvement, for example, with the Tracing project, the Magazine Folding, described in a previous volume. So as outlined in Volume One of the series one way to encourage Interdisciplinary support is to leave the Activity in the resident's room.  A way to leave the activity in the resident's room is to take a brown paper bag cuffed or folded twice at the top, or plastic Ziploc bag and tape it to the night stand.  Place a label on the bag stating “Martha is tracing this pattern to exercise her hand, please feel free to help her with this project.” In the Activity Project bag, place the pencil and, if she needs it, a Styrofoam ball with the pencil poked through it, the Tracing Form, and paper.  See Activity Project Bag labels at the beginning of this Manual.

Residents with whom to try Tracing

Culture Change Implementation: Place Tracing in labeled Activity Project Bag left in resident’s room for CNA, volunteer, etc. use.

b. Exercise Wands
The Exercise Wand, illustrated in the slide on DVD Track 15 is made from a full sheet of newspaper rolled diagonally from corner to the opposite diagonal corner.  Then tape the newspaper corner that appears at the outside of the tube to keep the tube from unwinding.  The ribbon part of the Exercise Wand can actually be ribbon.  However, I used a roll of crepe paper because it was less expensive than ribbon and worked just as well.  You could also use strips of cloth, providing that the fabric is lightweight to facilitate the strip catching the air as it is waved. You can affix this strip with a staple or two, or a strip of tape. 
Observe and Adapt:  Music, of course, always adds to an exercise session.  Some movements residents might do with the Exercise Wands would be a circle, a figure-eight, a zigzag line, ocean wave, a halo over their head, etc.

Residents with whom to try Exercise Wand

Culture Change Implementation: Place Exercise Want in labeled Activity Project Bag left in resident’s room for CNA, volunteer, etc. use.

c. Seated Musical Chairs
Some residents are motivated by fun.  The next portion of this manual contains several “Fun” activities.  Clearly, most residents do not have the physical ability to do the rapid stand-up and sit-down motion required for Musical Chairs.  In Seated Musical Chairs, the residents do not move, but a sliding sheet does.  First tear a sheet lengthwise.  The drawing to the left and photos in Track 15 on the DVD illustrate an approximate diameter for the finished sheet.  Clearly, the diameter of the sheet needs to be small enough for residents to grasp.  Tie knots every two to three feet.  The idea is to space the knots at intervals corresponding to the approximate distance at which residents will be seated in the circle.  I found staff gets involved with this activity in trying to help residents to grab a knot once the music stops.  The elimination part of Musical Chairs with each round is changed somewhat to accommodate this slower pace.  Mainly, you try to help a resident to grab a knot with each round of music.  Usually what happens is, after a few rounds, residents start to lose interest in participating, and are content to just watch, and if alert enough, cheer on others who have still decided to play. 

Observe and Adapt:  As indicated in the Competition section of the DVD and this Manual, the key is to compare the resident with themselves, and not with others.  You might say, "Martha, great, you did a good job grabbing that knot!  Your fingers seem to be more flexible today."  Or you might say, "Harvey, you grabbed three knots today.  The other day, you only got two.  Good job!"  At the end, if two or possibly three residents are "battling it out" to grab a knot, consider declaring them the two or three winners of the Seated Musical Chairs Game.

Residents with whom to try Seated Musical Chairs

Culture Change CNA Inservice:  Brainstorm with CNAs residents they might assist with for a few minutes during “Seated Musical Chairs.”

d. Roll Across
Like Seated Musical Chairs, Roll Across is another activity aimed at those residents who may be motivated by having fun.  The game of Roll Across requires a sheet and a fairly large inflated ball, around nine inches in diameter.  The idea of the game is to roll the ball to a resident across from you.  Like Seated Musical Chairs, this is another group activity in which staff tend to get involved, as they try to help the resident lower the sheet on their side to be able to grab the ball; and roll it back across; and then helping them to raise the sheet to help the ball roll across to a resident on the other side.  Unlike Seated Musical Chairs, there is no goal to have a 'winner.' 

Observe and Adapt:  Words of encouragement might be:  "Let's see if you can grab the edge of the sheet?" Crumple up the edge of the sheet to give your residents a larger portion to grab onto, if needed.  Then, slide the edge of the sheet into his or her hand if the resident lacks the range of motion needed to grab the edge themselves.
For a resident that is unable to grab the ball you might state, "Here, I'll grab it for you, and let's roll the ball to Esther on the other side." "Good job!  Let's raise your hand up now to get it to the other side."  You might state this while gently grasping resident's wrist and forearm, if needed. "Here, let's lower your hand a little so we can get the ball to come to us.  Good job!"

 
Residents with whom to try Roll Across

Culture Change CNA Inservice:  Brainstorm with CNAs residents they might assist with for a few minutes during “Roll Across.”

e. Table Shuffle Board
The photos in Track 15 of the DVD clearly illustrate the construction of Table Shuffle Board.  Or perhaps you can buy a Table Shuffle Board game from the internet.  Here is a recap of those directions.
1.  Cut lengthwise along one corner of a large corrugated cardboard box in order to open it flat.
2.  Use a string and a pencil to make the circle; and a yardstick to divide the circle into eight sections.
3.  Use Tempera-Color to paint the sections and add the numbers.

Observe and Adapt:  For the Shuffle Board pucks use items that can easily be grasped by residents.  If a resident has flexible thumb and index finger dexterity, you might use poker chips, which are extremely thin and difficult for most residents to manipulate.  You might glue two gallon milk bottle caps together using a small vice and Elmer's Glue-all.  Or if you have a glue gun you might hot glue the gallon milk caps together.  Also most lids work well, like Gatorade bottle lids, juice bottle lids, etc.  Remember to compare the resident with him or herself, rather than with others.  In order to do this, consider keeping track of the resident's score from previous games, and providing physical and verbal assistance as needed to create a successful experience.  If you feel a reward or prize is needed or expected, provide what is probably dictated by the history of prizes or rewards in your facility, and the expectation level of the more alert residents participating.  In some facilities I consulted at, receiving a marshmallow or a single diabetic cookie was considered a great reward.  In other facilities in which the Activity Director had unwittingly "upped the ante," an entire bag of marshmallows or an entire box of diabetic cookies was expected.

Residents with whom to try Table Shuffle Board

Culture Change CNA Inservice:  Brainstorm with CNAs residents they might assist for a few minutes during “Shuffle Board.”

f. Horse Race
Like Table Shuffled Board, the Horse Race game is an activity that may motivate those residents that are alert enough who still have a concept of fun. The construction of the Horse Race game is illustrated in the photos on Track 15 of the DVD, or perhaps you can buy a Horse Race game from the internet.  Here is a review of it's construction. 
a. Three pieces of poster board are placed end to end and taped on the back side
b. Rectangles are drawn on them which are the same size as the base of the horses or other objects to be moved from space to space.  Actually, the horses don't have to be on a base, of course, if they will stand on their own. 
c. Some variations are you might substitute horses for the small beanie baby stuffed animals, and have a Beanie Baby race or small race cars.
 
The resident rolls one die, and their horse, beanie baby, jelly bean, marshmallow, plastic car, etc advances that many spaces.  As you are well aware, many residents do not have the hand coordination to hold dice and release it onto the table.  I found the use of a small frozen orange juice can be helpful.  You might use masking tape around the top edge of the can to cover the inside part which may have been left jagged from the can opener.  Soup cans are also a good size.  Plus, when using the can for the dice, the clattering sound of the dice against the metal seems to add to the fun.  Agree?

Observe and Adapt:  Regarding a prize or prizes for the winner or winners, a way to provide everyone with a feeling of success is to say, "Everybody gets a (you insert the item here) treat for racing today.  And Esther, Bill, and Mabel get an extra treat for being our big winners today!"  Regarding the treat or prize to be given, note what I said above in Table Shuffle Board regarding prizes becoming an ever-escalating trap depending on the alertness level of the residents involved and the previous history you have created regarding rewards or prizes.

Residents with whom to try a Horse Race game

Culture Change CNA Inservice:  Brainstorm with CNAs residents they might assist for a few minutes during  the “Horse Race.”

g. Grocery Bag Weaving
Grocery Bag Weaving is also depicted in Track 15 of the DVD.  This project requires brown paper grocery bags and Scotch tape that is extremely wide.  By extremely wide tape, I mean you need to purchase a special roll that is two inches wide.  The normal 3/4 inch Scotch tape will not be strong enough to hold the strips in place while they are being moved about in the weaving process.  Here's how the weaving is constructed.
a. Cut the narrow sides of the grocery bag into two strips.  They will be about three and a half inches in width. 
b. Then cut the wide sides of the grocery bag in half, and then in half again.  By cutting it this way, you don't have to measure.  You will end up with four strips for each wide side and two strips for each narrow side of the grocery bag.  Clearly, the width of the strips does not need to be precise. 
c. Then take your three to three and a half inch strips and fold them lengthwise in half, and then in half again. 
d. Take twelve of your strips and tape them across the top to the resident's work surface.  The reason why twelve is a good number is because that is about the length of the horizontal strips, leaving some left over for the edges.  Decrease the number from 12 to fit the physical and mental ability of your resident, of course.

One of the disadvantages of this activity is that the tape can leave a gummy residue on the table, if left down for a while.  A product called Goo Gone, which can be purchased at a hardware store, is an oily type substance that cuts through the adhesive residue left from the Scotch tape.  Also, some table surfaces are not made of Formica, but are actually contact paper placed over particle board.  Thus, you want to make sure that the Scotch tape will not pull the surface off of your table.

I have found it easiest for residents to weave across from left to right, or right to left, depending upon their preference.  Therefore, the strips that you tape to the table are the vertical strips.  The resident then weaves the remaining grocery bag strips horizontally.  However, as indicated in the slides some residents have an easier time weaving up and down the rows.

So, once the strips are woven, what do you do?  As you are aware, some residents are so disoriented they do not remember weaving the same pattern over and over again.  Therefore, once some horizontal strips are woven, and the resident is out of sight, you merely remove them, and they are rewoven again the next day.  However, as you are aware, other, more alert residents need the motivation to see a finished product.  To motivate these residents you can prevent the strips from slipping by folding over the ends and stapling them in place.  Scotch tape tends not to hold well to the fibrous grocery bag material.  So I like to staple the ends.  Then, use your imagination regarding a use for the woven mats, if the resident requires this "product-producing" facet as a motivator.  Maybe at holiday times you might mount a pumpkin, heart, shamrock, Christmas tree, egg, flag, etc on the woven mats.  Thus the woven mat becomes a background for the flat decoration.

Observe and Adapt!  Some residents will be overwhelmed with twelve vertical strips.  Provide them with five or seven vertical strips spaced further apart to make the weaving easier.  Consider shortening the horizontal strips, if cutting the strips to a shorter length will make it easier for the resident to weave.  Or perhaps the extra length may make it easier for the resident to grasp the strips to weave.

Residents with whom to try a Grocery Bag Weaving

Culture Change CNA Inservice:  Brainstorm with CNAs about residents who might be able to do “Grocery Bag Weaving.”