Losses and Restorations in Basic Skills and Information
Loss of Mobility
Carroll’s Concept: To lose mobility means to be unable to get about with grace, ease, and safety. One of the first marks of infant development is the power to walk. Adults cheer and praise, independence begins. With loss of mobility comes the return to the creeping dependency of childhood or the forced slow, shuffling dependency of old age. People with visual impairment may become immobilized, fixed, fearful, rooted, and confined to a spot in which he stands. Challenges appear in moving in and around the home, outdoors, at work, and to recreation. Children’s toys, pebbles or broken glass, hydrants, animals, backing trucks, low awnings, and careless pedestrians might be in the way.
Cleary’s Observation: People with visual impairment and diabetes need to be able to move around safely and efficiently to locate self-managing tasks, supplies, and food. Accessibility to a favored form of safe exercise becomes limited. Complications of diabetes decrease time, skill, and opportunities for movement. Personal goals for independence can seem increasingly elusive.
Carroll’s Concept: Restoring mobility for those with visual impairment is needed for normal life, social adequacy, and meaningful work. Orientation and mobility (O&M) instructors teach movement around the home, and use of a human guide, and techniques to employ the long cane. Training consists in relying on the remaining senses and the travel tools which extend the senses.
Cleary’s Observation: People with diabetes develop an awareness of (a) the potential danger of injury; (b) solutions to neuropathies (nerve damage from diabetes); (c) balance problems; (d) ways to spare family and friends during the demand for increased medical appointments; and (e) the use of recommended mobility devices.
My Reflections: I met Jason in northern Maine and found that due to pains in his legs and feet he had stopped taking mobility lessons. As he was not ready for rehabilitation, a number of health referrals were made. With medication for neuropathy, a brace for foot drop, and updated diabetes education, he resumed mobility lessons with renewed energy.
Loss of Techniques of Daily Living
Carroll’s Concept: Daily living techniques mean the hundreds and hundreds of simple things that daily need doing. They usually include independently accessing food, eating, drinking, dressing, and undressing. The imposition of blindness makes thousands of routine tasks very difficult to perform, coming in with a sledgehammer blow. This major loss turns many inconveniences and nuisances into big obstacles.
Cleary’s Observation: Added duties occur in such diabetes self-managing tasks as measuring insulin, performing blood glucose self-management, securing food, managing time, locating equipment, doing paperwork, making appointments, counting money, ensuring cleanliness and neatness, shaving, and applying makeup.
Restoring Techniques of Daily Living
Carroll’s Concept: Hundreds and hundreds of activities that we take for granted each day become insurmountable when we are unable to see to do them. Once again, rehabilitation aims to train the other senses of the person with visual impairment. Indirectly this occurs through the restoration of psychosocial strengths, health techniques, communication skills, mobility, and personal self-care training.
Cleary’s Observation: People with diabetes and visual impairment learn with adaptive skills to measure insulin, perform blood glucose self-monitoring, select and prepare food, get adequate exercise, tend to personal hygiene, insert eye medications, prevent complications, resume homemaking activities, manage finances, and face work challenges.
My Reflections: What a mess it was! Patricia had to downsize and her new apartment was cramped and scattered. Lessons from her vision rehabilitation therapist resulted in organizational skills; items sorted into containers; clothing organized and labeled; controls marked; and her body anchored while measuring insulin. Gradually, order was restored.
Loss of Ease of Written Communication
Carroll’s Concept: This loss includes mainly reading and writing, but also takes in signs, cartoons, pictures, television, and graphics. Many people enjoy books, journals, magazines, trade publications, and newspapers. From making a grocery list to academic pursuits, this affects everyone to some degree. People who have visual impairment feel their privacy is violated when they are unable to read the mail, write checks or handle finances. They may also feel invaded when having to ask for someone’s help for name signing, letter writing, messages, as well as providing a telephone number or personal information. Many occupational tasks require written communication.
Cleary’s Observation: People with diabetes and visual impairment face frustrations when making an appointment, detailing a medical history, making a list of necessary supplies, ordering equipment, reporting monitoring results, interpreting instructions on new devices, obtaining recipes, and reading food content.
Restoring Ease of Written Communication
Carroll’s Concept: Many tools exist for a person with visual impairment to restore ordinary reading and written communication including the use of braille, the National Library Service (NLS) Talking Book Program, audio books, digital recording devices, radio information services, handwriting aids, raised-line drawing paper, mathematical devices, and a paid or volunteer reader.
Cleary’s Observation: People with diabetes and visual impairment benefit from teaching handouts available in large print, braille, pictograms, podcasts, CDs, and MP3 recordings. The National Library Service Talking Book players have a USB port so that diabetes education materials are accessible through MP3s on a flash drive.
My Reflections: Nutrition educator Kathleen had enjoyed reading professional and consumer magazines to keep her information updated. Upon investigation, she found several of her favorite magazines were online and others were available on CD and MP3 recordings. When she lost all her vision, she wanted updated and accessible information. She was referred to several resources.
Loss of Ease of Spoken Communication
Carroll’s Concept: We ordinarily communicate with extensive use of body language and inflection. This loss affects not only actual listening and speaking, but also gestures, posture, mannerisms, pantomime, and facial expressions. People with visual impairment may be cut off from the world of people. They often cannot identify the speaker among others, interpret silences, see expressions, or respond appropriately. They can’t even notice when others communicate sympathy among themselves over their “plight.” Oftentimes they are unaware to whom they speak, whether anyone is in the room, or what direction to face.
Cleary’s Observation: People with diabetes and visual impairment may miss much of what the healthcare provider or diabetes educator says. They may wonder, “Is that good news or bad news?” Sometimes these professionals seem to treat consumers as children, or may talk to an accompanying person instead.
Restoring Ease of Spoken Communication
Carroll’s Concept: People with visual impairment know that something has happened to disturb their communication with other people, but they do not know clearly what has happened or how much is missed. They may not know of the presence of others, and may need help to localize sound and direction.
Cleary’s Observation: People with diabetes and visual impairment learn to request that their rehabilitation professionals, healthcare providers, or diabetes educators position themselves with lighting that is helpful; seek appropriate materials to supplement what is being said; and refer to an appropriate professional to discuss the feelings and concerns about vision loss.
My Reflections: Dr. Alan manifested deep depression about the closing of his dental practice, but he loved to discuss oral prevention. Our rehabilitation team decided to utilize that enthusiasm and invite him to speak. He was asked and accepted. Armed with free toothbrushes and toothpaste, he presented a lively lesson on diabetic oral health and resources.
Loss of Informational Progress
Carroll’s Concept: This loss might be given various names: awareness of the social scene, of growth in information, of ability to keep up with the times, or of contact with the present day. It reflects lack of progress when other things are moving on, standing still while the world goes by, and moving backwards. The content of this loss varies considerably with the person who has visual impairment, depending upon the length and breadth of interests. New information may be obtained, but lack of visual input stunts the extent of the information. People with this loss may not realize that their fashions are old, former landmarks are gone, and news resources are outdated.
Cleary’s Observation: People with diabetes and visual impairment know that self-care instruction quickly becomes outdated. Attempts to update information may be restricted by the inability to have other opportunities to learn new ideas, to go to a class on foot care, and to be able to read informational resources.
Restoring Informational Progress
Carroll’s Concept: Restoring this loss prevents the person with visual impairment from becoming stagnant in the ways of the world. This occurs with mobility training, sensory development and adaptive equipment, as well as interactions with families, support groups, rehabilitation workers, and health care professionals.
Cleary’s Observation: People with diabetes and visual impairment realize that information, as well as technology, may be obsolete. This renewed interest challenges providers to give the updated information in understandable and accessible form; demonstrations with verbal descriptions; and audiovisual materials with descriptive language.
My Reflections: The concept of learning braille appears overwhelming to some individuals who have lost vision as adults, especially those with diabetic neuropathy. Jim, who had diabetic neuropathy, said he couldn’t feel the braille dots, but with creative instruction, he was able to do so to keep records and to label food packages.
Part 2 in a series of articles by Margaret E. Cleary, M.S., R.N., CVRT, based on principles from Thomas J. Carroll’s book Blindness.