ROM, Restorative and Positioning

Principles and Foundations of Restorative Nursing

  • Definition of Restorative Nursing:

    • Nursing care specifically designed to restore and maintain a resident's previous level of health.
    • Focused on helping the patient regain their highest state of functioning across physical, mental, and psychosocial domains.

  • Initiation of Care:

    • Rehabilitation and restorative interventions should be initiated soon after admission or immediately upon detecting any functional decline in Activities of Daily Living (ADLs).

  • Core Principles:

    • Begin treatment early: Early intervention prevents secondary functional deterioration.
    • Activity strengthens and inactivity weakens: Ongoing physical activity maintains physiological function, while disuse leads to rapid decline.
    • Prevent further disability: Implement proactive care to protect remaining functional abilities.
    • Focus on ability not disability: Structure interventions around the tasks the resident is capable of performing rather than focusing solely on limitations.
    • Treat the whole person: Address physical, psychological, social, and emotional needs collectively.

Scope and Modalities of Restorative Nursing Activities

  • Core Restorative Program Activities:

    • Exercise:
    • Range of motion (ROM), both Active and Passive.
    • Balance training in a seated position.
    • Standing exercises.
    • Assisted ambulation.
    • Integration of exercise into self-care ADLs.
    • Promoting Fluid and Dietary Intake with Improved Independence:
    • Encouraging self-feeding.
    • Serving finger foods when appropriate.
    • Progressing dietary independence as indicated.
    • Utilizing adaptive eating utensils.
    • Positioning and Mobility Support:
    • Implementing proper body positioning.
    • Executing scheduled position changes.
    • Respiratory Care:
    • Deep breathing and coughing exercises.
    • Elimination Care:
    • Bowel and bladder retraining.
    • Pelvic and abdominal exercises to promote continence.

  • Misconceptions (What Restorative Nursing is NOT):

    • It is not busy work.
    • It is not specialized therapy (physical, occupational, or speech therapy).
    • It is not in competition with specialized therapy.
    • It is not administered merely to increase Medicare and Medicaid reimbursement rates.
    • It is not restricted solely to alert residents.
    • It does not require highly technical equipment or personnel with superior technical skills to administer.
    • It is not an optional service; it is an integral component of resident care.

Specialized Rehabilitation Services vs. Restorative Nursing Care

  • Specialized Rehabilitation Services:

    • Focus: Retraining, formal education, and teaching of new compensatory or restorative skills.
    • Origin: Flows directly from an acute injury or event, incorporating multidisciplinary input.
    • Structure: Highly task-oriented, directed toward specific aims to be accomplished within a defined time period.
    • Personnel: Provided exclusively by licensed, trained therapists according to their specialty discipline (Physical Therapy [PT], Occupational Therapy [OT], and Speech-Language Therapy [ST]).

  • Restorative Nursing Care:

    • Focus: Restoring or compensating for functional skills lost through disuse or altered physiology.
    • Model: Based primarily upon the nursing care model, requiring less ongoing, direct input from licensed therapists.
    • Goal: Seeks to maximize and prolong abilities that support the resident’s highest practicable level of independent functioning.
    • Continuity: Characterized by specific objectives carried out as an ongoing, continuous process.
    • Initiation: Can develop as an outgrowth of completed specialized therapy, or can be initiated directly by nursing staff.
    • Staffing: Administered across all tiers of nursing staff, ranging from Registered Nurses (RNs) down to Certified Nursing Assistants (CNAs).

Prevention of Immobility Complications

  • Restorative nursing care is directly aimed at mitigating the systemic complications that arise from immobility:
    • Integumentary System: Formation of pressure ulcers.
    • Musculoskeletal System: Development of permanent joint contractures.
    • Gastrointestinal System: Constipation, fecal impaction, and decreased bowel motility.
    • Respiratory System: Secretion pooling, lung congestion, and pneumonia.
    • Cardiovascular System: Circulatory problems, venous stasis, and orthostatic hypotension.

Principles and Guidelines of Body Mechanics

  • Guidelines for Proper Body Mechanics:

    • Bend at the hips and knees rather than bending at the waist.
    • Spread feet apart to establish a broad base and solid foundation of support.
    • Maintain strict alignment of the back, neck, pelvis, and feet during all turns and movements.

  • Clinical Importance of Body Mechanics:

    • Protects the healthcare worker from musculoskeletal injury.
    • Reduces muscle fatigue to avert strain on the spine.
    • Leverages spinal mechanics to maximize natural body strength.
    • Makes lifting, transferring, and moving objects significantly easier while reducing physical exhaustion.
    • Supplies foundational balance and stability during resident transfers.

  • Key Procedural Points for Body Mechanics:

    • Provide verbal cues to the resident before and during movement.
    • Know the resident's physical capabilities and review their individual care plan prior to moving.
    • Maintain feet firmly on the ground as the base of support.
    • Keep the body close to the resident or object being lifted to reduce the center-of-gravity load.
    • Keep the back straight while bending through the hips and knees.
    • Lift by straightening the legs and engaging arm muscles, rather than pulling with the back.
    • Execute all lifts smoothly without jerking movements.
    • Pivot by turning the feet; never twist at the torso or waist.
    • Push, pull, slide, or roll objects whenever possible instead of lifting them entirely off the surface.
    • Always ensure equipment brakes are locked prior to transfer.
    • Inspect the immediate path and room environment for tripping hazards before initiating transfers.

Resident Transfer Guidelines and Safety Measures

  • General Transfer Protocols:

    • Slow, deliberate, and steady movements provide the highest level of safety.
    • Always explain the entire procedure to the resident prior to beginning, maintaining strict privacy and dignity.
    • Adhere to proper body mechanics throughout all resident positioning procedures.
    • Utilize a lift sheet when the resident is physically unable to assist, handling the individual with utmost care.
    • Allow the resident sufficient time to adjust to sudden position changes to prevent dizziness.
    • Encourage and allow the resident to assist with movement to the greatest extent possible.
    • Synchronize all lifting and transfer movements when working alongside coworkers.
    • Never permit residents to place their arms around the caregiver's neck during transfers or repositioning.

  • Safety Measures and Contraindications:

    • Axillary Lifting Prohibition: Never transfer a resident by lifting underneath the arms or axillae. This action can induce severe brachial plexus nerve damage, skeletal fractures, and shoulder dislocations.
    • Equipment Inspection: Ensure all transfer equipment (wheelchairs, mechanical lifts, transfer boards) is fully assembled, functioning, and checked for safety before initiating care.
    • Unilateral Weakness Considerations: When transferring an individual with a weak side, always position the chair or wheelchair on the resident's strong side.
    • Torso and Hip Control: Ensure complete physical control of the resident's shoulders and hips throughout the transfer if weakness is present.
    • Weight-Bearing Restrictions: Do not attempt a single-person transfer on any resident who is entirely unable to bear weight.
    • Wheelchair Footrest Protocol: Ensure wheelchair (W/C) footrests are swung out of the way, raised, or detached completely from the chair to prevent tripping or skin tears.
    • Communication: Deliver clear, simplified instructions before initiating each movement.
    • Footwear and Stance: Ensure the resident wears non-slip footwear, positioning their feet approximately 12 inches12\,\text{inches} apart.
    • Hazard Avoidance: Be acutely mindful of hanging badges, name tags, stethoscopes, or jewelry that could cause injury or become entangled during physical contact.

Gait Belt Indications, Safety, and Contraindications

  • Definition and Function:

    • A gait belt is a specialized safety belt applied around the resident’s waist that equips the CNA with a secure handle to hold onto during transfers, ambulation, or chair repositioning.

  • Purpose and Benefits:

    • Ensures optimum safety during resident transport.
    • Minimizes the risk of musculoskeletal injury for both staff and resident.
    • Facilitates correct caregiver body mechanics.
    • Enhances control over resident movement during standing and pivot transfers.
    • Decreases potential shear or grip damage to delicate skin.

  • Application Guidelines:

    • Always apply the gait belt over clothing or an exterior gown; never apply directly to bare skin.
    • Secure the belt snugly around the natural waistline.
    • Consistently maintain proper body mechanics when gripping the belt and transferring the resident.

  • Clinical Exceptions (Contraindications to Gait Belt Use):

    • Presence of an abdominal colostomy.
    • Acute rib fracture or acute vertebral fracture.
    • Diagnosed abdominal aneurysm.
    • Presence of an abdominal gastrostomy feeding tube (G-tube).
    • Recent post-operative abdominal surgery.

Resident Ambulation: Physiology and CNA Responsibilities

  • Purposes and Clinical Benefits of Ambulation:

    • Keeps the resident physically active and engaged.
    • Improves muscle tone in the lower extremities and builds overall strength.
    • Instills a sense of personal accomplishment and emotional well-being.
    • Enables the resident to maintain a higher degree of daily independence.
    • Slows down the loss of bone mass and density associated with disuse and osteoporosis.
    • Enhances gastrointestinal motility and peristalsis, significantly lowering the risk of constipation.
    • Stimulates and improves systemic vascular circulation.

  • Etiologies of Ambulation Impairment (Why Residents Need Assistance):

    • Decreased skeletal muscle strength.
    • Alterations in posture and shifts in the body's center of gravity.
    • Diminished sensory perception (proprioceptive and tactile loss).
    • Impaired balance or visual acuity.
    • Cognitive impairment and confusion.
    • Pharmacological side effects from prescribed medications.
    • Environmental or situational distractions.
    • Documented history of frequent falls.

  • CNA Ambulation Protocols:

    • Maintain constant awareness of fall prevention and environmental safety considerations.
    • Consistently apply a gait belt prior to initiating walking.
    • Demonstrate and enforce good body mechanics for both the caregiver and the resident.
    • Dress the resident in appropriate clothing and non-skid, supportive footwear.
    • Continually assess the resident's ambulation status, observing gait pattern, balance, and endurance.
    • Identify designated resting points along the ambulation route in advance.
    • When an asymmetric weakness is present, position oneself slightly behind and on the weak side of the resident while firmly grasping the gait belt.
    • Avoid rapid position changes to prevent orthostatic hypotension and associated syncope.
    • Continually monitor for signs of physical fatigue, shortness of breath, or distress.
    • If a resident begins to collapse or fall, gently guide and assist them down to the floor along the caregiver's leg rather than attempting to hold them upright against gravity.

Range of Motion (ROM): Purpose, Guidelines, and Terminology

  • Definition:

    • Range of Motion (ROM) is defined as the total amount of movement possible for each individual joint.
    • ROM exercises are administered to preserve flexibility, maintain joint mobility, and prevent disuse deformities.

  • Clinical Purpose:

    • Aids the musculoskeletal system in maintaining or regaining physiological health.
    • Prevents functional immobility and irreversible joint contractures.
    • Prevents muscle weakness, deterioration, and atrophy.
    • Prevents mineral demineralization from skeletal structures (osteoporosis).
    • Stimulates peripheral blood flow and circulation.
    • Maximizes resident functional mobility and self-sufficiency.

  • CNA Protocols for Administering ROM:

    • Review the individual resident care plan to know their baseline capabilities and prescribed restrictions.
    • Seamlessly incorporate ROM exercises into daily care and ADL routines.
    • Never force a joint past the point of resistance or exercise to the point of pain; remain strictly within the range of comfortable movement.
    • Administer 3 to 53\text{ to }5 repetitions per joint exercise set.
    • Immediately halt the exercise if the resident reports pain or displays discomfort, and promptly alert the charge nurse.
    • Adequately support the limb by placing hands above and below the targeted joint.
    • Handle the resident's extremities gently, supporting limbs with broad, open palms rather than gripping tightly with fingertips.
    • Anatomical Restriction: Recognize that hyperflexion of the neck is physically impossible when a resident is in the supine position.
    • Actively encourage the resident to execute as much of the motion independently as possible (Active or Active-Assistive ROM).

  • Anatomical Movement Terminology:

    • Abduction: Movement of a limb laterally away from the midline of the body.
    • Adduction: Movement of a limb medially toward the midline of the body.
    • Flexion: Bending movement that decreases the angle between two body parts or bones at a joint.
    • Extension: Straightening movement that increases the angle between two body parts or bones at a joint.
    • Hyperextension: Extreme or abnormal extension of a joint beyond its normal anatomical resting limit.
    • Eversion: Turning the sole of the foot outward away from the median plane.
    • Inversion: Turning the sole of the foot inward toward the median plane.
    • Internal Rotation: Turning an extremity inward toward the central axis of the body.
    • External Rotation: Turning an extremity outward away from the central axis of the body.
    • Pronation: Turning the forearm and hand such that the palm faces downward or posteriorly.
    • Supination: Turning the forearm and hand such that the palm faces upward or anteriorly.
    • Lateral: Pertaining to, positioned at, or directed toward the side of the body.

Resident Positioning Classifications

  • Standard Clinical Body Positions:
    • Chair Positioning: Upright alignment in a chair or wheelchair with hips back and feet supported.
    • Bed Positioning: Correct anatomical alignment executed while lying in bed.
    • Supine Position: Resident lies completely flat on their back facing upward.
    • Prone Position: Resident lies flat on their abdomen facing downward.
    • Lateral Position: Resident lies on their side, supported with positioning pillows between bony prominences.
    • Fowler's Position Classifications:
    • Low Fowler's: Head of the bed elevated between 15∘15^{\circ} and 30∘30^{\circ}.
    • Semi-Fowler's: Head of the bed elevated between 30∘30^{\circ} and 45∘45^{\circ}.
    • High Fowler's: Head of the bed elevated between 60∘60^{\circ} and 90∘90^{\circ}, sitting nearly upright.
    • Trendelenburg's Position: The bed frame is tilted flat with the head of the bed lower than the foot of the bed.
    • Reverse Trendelenburg's Position: The bed frame is tilted flat with the head of the bed higher than the foot of the bed.
    • Orthopneic or Tripod Position: Resident sits upright and leans forward over an overbed table or knees, facilitating respiratory expansion.

Mobility, Positioning, and Seating Devices

  • Purpose of Assistive Positioning Devices:

    • Substantially improve structural body stability.
    • Deliver necessary trunk and head alignment and support.
    • Evenly distribute body weight to reduce pressure points on vulnerable skin.

  • Categories of Mobility and Seating Equipment:

    • Manual wheelchairs.
    • Electric / motorized wheelchairs.
    • Powered mobility scooters.
    • Canes (single-point and quad canes).
    • Crutches.
    • Walkers (standard and wheeled).

  • Specialized Wheelchair Seating Systems:

    • Pressure-relieving cushions (gel, foam, or air cell).
    • Custom-molded contour seating systems.
    • Tilt-in-space and recline features to facilitate pressure redistribution without shearing.
    • Supportive accessories including elevating leg rests, footplates, lateral trunk supports, and headrests.
    • Specific parameters for device utilization are documented within each resident's care plan.

Clinical Definition, Hazards, and Systemic Risks of Restraints

  • Verbatim Clinical Definition of Restraint:

    • Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the individual’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.

  • Direct Adverse Physical Outcomes and Accidents:

    • Severe soft tissue trauma, including hematomas, contusions, and lacerations.
    • Physical entrapment within bed rails or mechanical apparatuses.
    • Siderail-related strangulation, asphyxiation, and death.

  • Physiological Systemic Complications:

    • Circulation: Peripheral circulatory compromise and deep vein thrombosis.
    • Gastrointestinal: Severe constipation, fecal impaction, and altered metabolism.
    • Genitourinary: Incontinence and related skin breakdown.
    • Musculoskeletal: Rapid muscle wasting, weakness, loss of bone mineral density, and contractures.
    • Integumentary: Pressure sores and friction injuries.
    • Psychological/Behavioral: Increased agitation, restlessness, and combativeness.
    • Nutritional: Depressed appetite, dehydration, and malnutrition.
    • Systemic Decline: Elevated vulnerability to severe systemic infections and premature death.

  • Adverse Changes in Resident Quality of Life:

    • Profound reduction in social contact and conversational interaction.
    • Emotional withdrawal and social isolation.
    • Acute loss of personal autonomy and self-determination.
    • Development of severe situational depression.
    • Chronic sleep cycle disruptions.
    • Escalating agitation and fear.
    • Irreversible loss of functional physical mobility.