6.1 ADLs, Mobility, Nutrition & Elimination
Key Takeaways
- Reposition a bedbound, immobile client at least every 2 hours to prevent pressure injuries; use the Braden Scale to rate risk.
- For dysphagia, position the client upright at 90 degrees and use a chin-tuck while swallowing to reduce aspiration risk.
- A Stage 1 pressure injury is intact skin with localized non-blanchable erythema; Stage 2 shows partial-thickness loss with an open shallow ulcer or blister.
- First-line management of constipation is non-pharmacologic: increase fluids, dietary fibre, and physical activity before laxatives.
- Provide indwelling-catheter perineal care front-to-back, keep the drainage bag below bladder level, and maintain a closed system to prevent CAUTI.
Activities of Daily Living and the Basic Care Domain
On the REx-PN, Basic Care and Comfort makes up roughly 6-12% of scored items; on the CPNRE the same fundamentals live inside Physiological Integrity. Although the weighting looks modest, these questions reward candidates who understand safe, everyday, hands-on nursing. They centre on activities of daily living (ADLs) — bathing, dressing, grooming, toileting, transferring, and eating — and the instrumental ADLs (IADLs) such as cooking and managing medications.
The governing principle is promoting independence: the practical nurse (PN) assists only as much as the client needs. Over-helping fosters dependence and deconditioning, while doing nothing risks safety. The exam expects you to grade your support to the client's actual ability, preserve dignity and privacy, and document the level of assistance objectively (for example, 'ambulated 20 m with a one-person assist and a walker'), not with labels like 'uncooperative.'
Mobility, Positioning, Transfers, and Pressure Injuries
Immobility is dangerous. Complications include pressure injuries, deep-vein thrombosis, pneumonia, muscle atrophy, contractures, constipation, and orthostatic hypotension. The PN counters these with scheduled movement and body-mechanics safety.
Repositioning: turn and reposition a bedbound, immobile client at least every 2 hours (more often over bony prominences or if the skin reddens). Use pillows to offload the sacrum, heels, and trochanters, keep the head of bed at or below 30 degrees when possible to reduce shear, and avoid dragging the client (friction damages skin).
Range-of-motion (ROM) exercises — active or passive — maintain joint mobility and prevent contractures. Transfers demand good body mechanics: lock the bed and wheelchair, widen your base of support, bend the knees, keep the load close, and pivot rather than twist. Use a gait belt or mechanical lift for heavier or unsteady clients; protecting your own back is part of a 'safe environment.'
Braden Scale: a validated tool scoring six factors (sensory perception, moisture, activity, mobility, nutrition, friction/shear). A lower score means higher risk. Pressure injuries are staged by tissue depth:
| Stage | Key finding |
|---|---|
| Stage 1 | Intact skin, localized non-blanchable erythema (redness that does not fade) |
| Stage 2 | Partial-thickness loss; shallow open ulcer or intact/ruptured blister |
| Stage 3 | Full-thickness loss; subcutaneous fat visible, possible slough |
| Stage 4 | Full-thickness loss exposing muscle, tendon, or bone |
| Unstageable | Base obscured by slough/eschar |
| Deep tissue | Persistent non-blanchable deep red/maroon or purple discolouration |
Nutrition, Therapeutic Diets, and Enteral Feeding
Adequate nutrition and hydration support healing and skin integrity. The PN monitors intake and output, weights, albumin trends, and swallowing ability. Common therapeutic diets include clear-liquid (post-op or before procedures), full-liquid, diabetic/consistent-carbohydrate, low-sodium (heart failure, hypertension), renal (low potassium/phosphorus/protein), high-fibre (constipation), and texture-modified/thickened-fluid diets for dysphagia.
Dysphagia and aspiration precautions are heavily tested. Position the client upright at 90 degrees, have them tuck the chin while swallowing, offer small bites, allow unhurried time, avoid mixed textures and thin liquids if these are unsafe, and keep suction available. Watch for coughing, a wet/gurgly voice, or pocketing food.
Enteral (tube) feeding — nasogastric (NG) or gastrostomy (PEG) — is used when the gut works but oral intake is unsafe. Core safety steps: verify tube placement (pH of aspirate, and X-ray confirmation for a newly inserted NG tube — auscultation alone is not reliable), keep the head of bed elevated 30-45 degrees during and for 30-60 minutes after feeding to prevent aspiration, check residual volumes per policy, and flush with water to maintain patency.
Bowel and Bladder Elimination
Constipation: the first-line response is non-pharmacologic — increase fluids, dietary fibre, and physical activity, and honour the urge to defecate — before stool softeners or laxatives.
Urinary catheter care: for an indwelling (Foley) catheter, provide perineal care and clean front-to-back, away from the urethra; keep a closed drainage system, keep the bag below bladder level to prevent backflow, secure the tubing to avoid traction, and remove the catheter as early as clinically possible — duration is the biggest driver of catheter-associated urinary tract infection (CAUTI).
Ostomy care: for a colostomy or ileostomy, size the appliance so the opening fits snugly around the stoma without constricting it, protecting the peristomal skin. Empty the pouch when one-third to one-half full, assess stoma colour (a healthy stoma is pink/red and moist; dusky or dark suggests ischemia), and support the client psychologically — body-image concerns are common and appropriate to address.
Urinary incontinence and bladder training
The exam distinguishes incontinence types: stress (leakage with coughing, sneezing, or lifting — treated with pelvic-floor/Kegel exercises), urge (a sudden strong need — helped by timed voiding and bladder training), overflow (dribbling from an over-full, poorly emptying bladder), and functional (the client cannot reach the toilet in time due to mobility or cognition — helped by scheduled toileting and a clear, well-lit path). Non-invasive strategies precede catheterization, which is a last resort because of CAUTI risk.
Common-mistake callout
A frequent error is measuring urinary output only from what the client voids while an indwelling catheter is in place, or clamping a catheter bag above bladder level 'to keep it tidy.' Keep the bag dependent (below the bladder) and the tubing free of kinks and loops; a bag raised above the bladder allows contaminated urine to reflux and cause infection. Likewise, never disconnect a closed drainage system for convenience — each break in the system is an infection portal.
How often should a practical nurse reposition a bedbound, immobile client to help prevent pressure injuries?
A practical nurse is helping a client with dysphagia eat. Which action best reduces the risk of aspiration?
The nurse observes intact skin with a localized area of non-blanchable redness over a client's sacrum. This finding indicates which stage of pressure injury?