# Situation: The public health nurse follows up a family in an urban barangay. The son, 9, has cerebral palsy and uses a wheelchair; the house has two steps at the entrance and raised door thresholds. The mother, 36, is his only caregiver and also looks after a 2-year-old daughter. The father, 40, will leave next month to work abroad for 2 years. The nurse identifies the family's inability to provide a home environment that supports the son's mobility and independence. Which intervention should the nurse suggest?

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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse follows up a family in an urban barangay. The son, 9, has cerebral palsy and uses a wheelchair; the house has two steps at the entrance and raised door thresholds. The mother, 36, is his only caregiver and also looks after a 2-year-old daughter. The father, 40, will leave next month to work abroad for 2 years.

The nurse identifies the family's inability to provide a home environment that supports the son's mobility and independence. Which intervention should the nurse suggest?

## 보기

1. Help the family plan an entrance ramp and remove the door thresholds **✔ 정답**
2. Teach the mother safe lifting to carry him and the chair up the steps
3. Keep the son in one ground-floor room to limit his need to move
4. Refer the son for admission to a residential rehabilitation center

**정답: 1**

## 해설

Ramps and removal of thresholds are direct changes to the physical environment that let a wheelchair user move about more independently. Community-based rehabilitation keeps the person in the home and community rather than in an institution. Carrying him up the steps keeps him dependent and strains the mother, and confining him to one room restricts his participation.

## 심화 해설

The priority intervention is to modify the physical environment so the home itself supports the son’s mobility and independence. A wheelchair user’s ability to move through doorways and between rooms is directly shaped by architectural features such as steps, raised thresholds, and narrow passages. When these barriers remain, the child stays dependent on being carried or pushed, which increases caregiver strain and reduces his opportunities for self-directed activity.

In this family, the entrance has two steps and the door thresholds are raised. Both are fixed structural obstacles that a wheelchair cannot cross without assistance. Removing the thresholds and adding a ramp changes the home environment itself, so the child can enter and exit without being lifted. This is the core reason option 1 is correct: it addresses the root cause of the mobility restriction rather than working around it.

The distinction between environmental modification and caregiver-dependent strategies matters for nursing licensure exams. Community-based rehabilitation emphasizes keeping the person in the home and community while adapting the surroundings to their needs. Housing studies consistently show that people with disabilities are more likely to live in inaccessible housing, and that physical barriers in the home are a form of environmental exclusion [2]. When a nurse identifies an inability to provide a supportive home environment, the expected nursing action is to help the family plan structural changes, not to teach them how to manage the barrier through physical effort.

Option 2, teaching the mother safe lifting to carry both the child and the wheelchair up the steps, keeps the son dependent and places repeated mechanical load on a single caregiver. The mother is already the only caregiver for a 9-year-old with cerebral palsy and a 2-year-old, and the father will be absent for 2 years. Watch out! Lifting a growing child plus a wheelchair up two steps is not a sustainable or safe long-term plan. It also reinforces the idea that the environment cannot be changed, when in fact ramps and threshold removal are feasible home modifications.

Option 3, confining the son to one ground-floor room, limits his participation in family life and restricts his developmental and social engagement. This approach reduces the need for mobility but does so by shrinking the child’s world. Restricting a child to one room treats the environment as fixed and the child as the problem, which is the opposite of a rehabilitation-oriented nursing approach. Research on people with neurological disabilities identifies environmental barriers as key factors that interrupt continued care and participation, and facilitators are often simple structural or organizational adjustments .

Option 4, referral to a residential rehabilitation center, removes the child from the home and community. That is inconsistent with community-based rehabilitation principles, which prioritize keeping individuals within their own homes and neighborhoods while building local support . Residential placement is a last-resort option for situations where home care is unsafe or impossible, not the first response to correctable architectural barriers.

A useful way to organize the options is by asking whether the intervention changes the environment or changes the person’s location or dependence.

| Intervention | Effect on environment | Effect on child’s independence | Caregiver burden |
| --- | --- | --- | --- |
| Ramp and threshold removal | Removes physical barriers | Increases independent mobility | Reduces lifting and carrying |
| Safe lifting and carrying | No change | Maintains dependence | Increases strain over time |
| Confine to one room | No change | Restricts participation | May reduce immediate effort but limits child’s world |
| Residential placement | Removes child from home | Separates from family and community | Shifts care to institution |

The home environment is a modifiable determinant of function. When a wheelchair user cannot cross a threshold, the clinical question is not how to lift them over it, but why the threshold is still there. Home healthcare providers frequently report that environmental barriers in the home complicate care delivery and that addressing these barriers requires planning and coordination rather than more physical effort from caregivers . The nurse’s role is to help the family identify practical modifications and connect them with resources for construction or funding.

Key point! For a wheelchair-using child, the correct nursing intervention is to modify the home so the child can move independently. Ramps and threshold removal are direct environmental changes that support mobility, reduce caregiver strain, and align with community-based rehabilitation.References (research sources)

- [2]Housing ableism in finding and maintaining housing among people with disabilities: A scoping review.Research articleLindsay S, Öncil G, Leo S. (2026) · DOI: 10.1371/journal.pone.0351309

## 임상 시나리오

Home Accessibility for a Wheelchair-Using ChildPrioritize structural change over caregiver-dependent lifting
When a family cannot provide a supportive home environment, the first nursing action is environmental modification. For a wheelchair user, entrance steps and raised door thresholds are fixed barriers that block independent movement.

Suggest a ramp at the entrance and threshold removal. These changes let the child enter, exit, and move between rooms without being lifted, reducing caregiver strain and supporting self-directed activity.

Use a community-based rehabilitation approach: keep the child in the home and community while adapting the surroundings. Avoid strategies that maintain dependence, such as carrying the child and wheelchair up steps.

CautionDo not confine the child to one room or refer for residential placement. Restricting space limits participation, and institutional referral contradicts home-based, family-centered care.

## 핵심 개념

- **Environmental modification** — Changing physical structures such as ramps and thresholds to remove barriers and support independent mobility.
- **Community-based rehabilitation** — An approach that keeps persons with disabilities in their home and community while adapting the environment to their needs.
- **Caregiver strain** — Physical and emotional burden on a family caregiver, worsened by dependent transfers such as lifting a wheelchair user.
- **Wheelchair accessibility** — The degree to which doorways, entrances, and passages allow a wheelchair user to move without assistance.
- **Participation restriction** — Reduced involvement in daily activities and social roles due to environmental or physical barriers.

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