5.1 Restorative Care, Mobility, and Range of Motion

The Restorative Care Philosophy

Restorative care (also called rehabilitative or restorative nursing) is care aimed at helping a resident reach and keep the highest level of function and independence they are capable of. The California nurse assistant model curriculum frames the goal as helping each resident do as much for themselves as possible, rather than having tasks done to or for them. Doing things for a resident who can do them alone causes learned helplessness and physical decline.

The restorative approach focuses on ability, not disability. A CNA breaks a task into small steps, allows extra time, gives cues and encouragement, and praises effort. The aim is to prevent the predictable complications of immobility, which include muscle atrophy, joint contractures, pressure injuries, blood clots, pneumonia, constipation, and depression.

Range of Motion (ROM)

Range of motion is the full movement an joint can normally make. ROM exercises move each joint through its complete arc to keep it flexible and prevent contractures — the permanent, painful shortening and tightening of muscles and tendons that develops when a joint is not moved. There are three types tested on the CNA exam:

When giving PROM, the CNA supports the joint above and below, moves slowly and smoothly, and stops at the point of resistance — never to the point of pain. Each joint is typically exercised through its movements (flexion, extension, abduction, adduction, rotation) about three to five times. ROM is given to all joints unless a joint is contraindicated (for example, a recent fracture or a swollen, red, painful joint), which must be reported to the nurse.

Ambulation and Assistive Devices

A gait (transfer) belt is the primary safety device for ambulation and transfers. It is buckled snugly over the resident's clothing around the waist, with room for the CNA's fingers underneath. The CNA grasps the belt with an underhand grip and stands slightly behind and to the weak side. Non-skid footwear is required before standing.

The two most-tested ambulation devices have specific rules:

• Walker: The resident moves the walker forward about an arm's length, sets all four legs down, steps in with the weak leg first, then brings the strong leg. The resident should never carry or lift the walker while stepping.
• Cane: The cane is always held on the strong (unaffected) side. The resident moves the cane forward, then the weak leg, then the strong leg — remembered as "COAL: Cane, Opposite, Affected Leg." The cane tip should be about 6–10 inches to the side of the foot for a wide, stable base.

If a resident begins to fall during ambulation, the CNA does not try to hold them upright. Instead, the CNA eases the resident to the floor, protecting the head, by keeping a wide stance and sliding them down the CNA's leg.

Retraining, Prosthetics, and Adaptive Equipment

Bladder retraining uses a fixed toileting schedule — for example, offering the toilet every two hours and gradually lengthening the interval toward about four hours — to rebuild control over urge and overflow incontinence. Bowel retraining establishes a regular elimination time, often after a meal to use the body's natural reflex, and the CNA encourages the resident to respond promptly to the urge and never to ignore it. Both require patience, fluids, fiber, and consistency.

A prosthesis replaces a missing body part (such as an artificial leg or hand), while an orthosis (orthotic) is a brace, splint, or support that aligns, supports, or corrects a body part (such as an AFO foot brace or a hand splint that prevents contractures). The CNA applies these devices exactly as the therapist directs, checks the skin underneath for redness or breakdown, and keeps an artificial limb's residual limb (stump) and the device clean and dry.

Adaptive equipment promotes independence with activities of daily living: built-up utensil handles, plate guards, long-handled sponges and shoehorns, sock aids, button hooks, and non-slip mats. The CNA's role in rehabilitation is to carry over the therapy plan during daily care, encourage the resident's own effort, report progress or decline, and keep the resident safe.

Preventing the Complications of Immobility

Much of restorative nursing exists to prevent the harm that comes when a resident cannot or does not move. The CNA should be able to name these complications and the simple measures that prevent each:

• Contractures — prevented by ROM exercises, proper positioning, and supportive devices such as hand rolls, splints, and footboards that hold a joint in good alignment.
• Pressure injuries — prevented by repositioning at least every two hours, keeping skin clean and dry, and relieving pressure over bony areas.
• Muscle atrophy and weakness — prevented by activity, ROM, and encouraging the resident to do their own care.
• Blood clots and poor circulation — reduced by movement, ROM, and applying anti-embolism (TED) stockings as ordered.
• Pneumonia — reduced by repositioning, deep breathing, and getting the resident up when allowed.
• Constipation and urinary problems — reduced by activity, fluids, and fiber.

Good body alignment is the foundation of positioning: the body is kept straight and supported, with pillows used to support the back, between the knees, and under the arms. When a resident is positioned on the side, the upper leg is brought forward and supported on a pillow to prevent pressure and keep the hips aligned. Every restorative action is documented and any decline reported, because catching a problem early is far easier than reversing it.