15.3 PROM, Independence, and Contracture/Pressure Prevention (Skills 15, 16; I.C)

15.3 PROM, Independence, and Contracture/Pressure Prevention (Skills 15, 16; I.C)

Quick Answer: Skill 15 (modified PROM, one knee and one ankle): explain, privacy, client supine, instruct the client to report pain. Critical elements: support the knee and ankle and perform flexion/extension at least 3 times unless pain; support the foot and ankle and perform dorsiflexion and plantar flexion at least 3 times unless pain. Skill 16 (one shoulder): instruct the client to report pain. Critical elements: support the elbow and wrist, flexion/extension to ear level ×3 unless pain; abduction/adduction to shoulder level ×3 unless pain. Motions are gentle, slow, and smooth. Stop if the client verbalizes pain. Call light, bed low, wash. Restorative care trains self-care to the client's ability. Do not do for the client what the client can do. Apply a prosthetic or orthotic only if trained and assigned, and report skin under a brace. Prevention of contractures, foot drop, and pressure injuries is the other half of this work; the Colorado outline prints prevention inside the I.B.2 Safety/Prevention/Emergency leaf name rather than as a numbered I.C sub-topic.

Why I.C is only four items — and still fails people

Self Care/Independence (I.C) is 7% of the 60 scored written items — about 4 questions. Candidates ignore a 7% leaf. Those four items are almost always the same ideas: do not take over an ADL the person can finish, stop PROM at pain, and prevent the frozen joint and the pressure injury. Skills 15 and 16 turn the same ideas into motor steps.

Colorado 3 CCR 716-1.11 requires basic restorative services and promoting independence in the 75-hour program; independence is also in the first 16 pre-clinical hours. Rule 3 CCR 716-1.10 keeps restorative work inside basic CNA scope when it is assigned.

/practice/co-cnaPractice questions with detailed explanations

Active versus passive — whose muscle works

• Active range of motion (AROM): the client moves the joint. You cue and guard.
• Active-assist: the client starts; you finish the arc they cannot complete.
• Passive range of motion (PROM): you move the joint because the client cannot. Skill 15 and Skill 16 are modified PROM. The client should still tell you about pain. They do not kick or lift to satisfy the card.

PROM is not a sports stretch. You do not bounce, you do not force past the point of resistance, and you do not continue after the person says it hurts.

Skill 15 — Modified PROM for One Knee and One Ankle

1. Explain, face to face when possible.
2. Provide privacy.
3. Ensure the client is supine in bed and instruct the client to tell you if pain is experienced.
4. Critical element: While supporting the leg at the knee and the ankle, bend the knee and then return the leg to the client's normal position (flexion/extension) at least 3 times unless pain is verbalized. Move gently, slowly, and smoothly. Discontinue if the client verbalizes pain.
5. Critical element: While supporting the foot and ankle close to the bed, push/pull the foot toward the head (dorsiflexion) and push/pull the foot down, toes pointing down (plantar flexion) at least 3 times unless pain is verbalized. Same gentle, slow, smooth rule. Stop if pain.
6. Signaling device in reach and bed in the low position.
7. Wash your hands.

Support means two hands on the limb — knee and ankle for the knee motions, foot and ankle close to the mattress for the ankle motions. Holding only the toes lets the foot twist. Three times is the minimum if there is no pain. One pretty arc does not meet the card. Ten forced arcs after the person said stop also fail the card.

Skill 16 — Modified PROM for One Shoulder

1. Explain.
2. Provide privacy.
3. Instruct the client to report pain.
4. Critical element: While supporting the arm at the elbow and at the wrist, raise the client's straightened arm from the side upward toward the head to ear level and return it to the side (flexion/extension) at least 3 times unless pain is verbalized. Gentle, slow, smooth. Stop if pain.
5. Critical element: While supporting the arm at the elbow and at the wrist, move the straightened arm away from the side to shoulder level and return it (abduction/adduction) at least 3 times unless pain is verbalized. Gentle, slow, smooth. Stop if pain.
6. Call signal in reach, bed low.
7. Wash.

Ear level is the flexion target — not up and over the pillow, not a full jumping-jack. Shoulder level is the abduction target — not straight up beside the head. A straightened arm means you do not bend the elbow and call it shoulder flexion.

Prevent contractures, foot drop, and pressure injuries

A contracture is a joint that has stiffened into a frozen position because it was not moved. Foot drop is a plantar-flexion contracture — the toes point down and the person can no longer place the foot flat. Pressure injuries are the skin version of the same neglect: one position, too long, over bone.

Prevention is daily work, not a special therapy hour:

• Assigned PROM (Skills 15 and 16) and encouragement of AROM when the person can move.
• Repositioning (Skill 17; commonly about q2h in bed as facility practice, following the care plan).
• Wrinkle-free, dry, crumb-free linen; no massage of red areas; report Stage-looking skin.
• Foot support as assigned (a footboard, a positioning boot, or an ankle-foot orthosis) so the foot does not hang in plantar flexion.
• Hands open around a washcloth roll only if the care plan says so — you do not invent gadgets.
• Nutrition and hydration support skin; you offer the assigned fluids. You do not diagnose malnutrition.

You do not work through a contracture with force. You report a new loss of range to the licensed nurse.

Train self-care to the client's ability

Restorative care means the person keeps or regains what they can still do. The CNA's default is assist, cue, and wait — not take over.

• ADLs: Let the person wash the face, hold the toothbrush, push the arm through the strong-side sleeve, and choose clothes (Skill 9 already requires a shirt choice).
• Assistive devices for walk, eat, and dress: walker, cane, gait belt, plate guard, built-up utensils, long-handled sponge, sock aid, reacher. Use the device on the care plan. Do not hand a walker to a person who is assigned a sit-to-stand lift.
• Bowel and bladder training: follow the scheduled toilet times. That is restorative elimination, not a convenience. You do not start a training program on your own.
• Time. A slow independent bite is better than a fast fed bite (Skill 10 still applies when the person truly cannot feed self).

Do not do for the client what the client can do. Rushing is how independence dies on a busy evening shift.

Prosthetics and orthotics

A prosthesis replaces a missing body part (a below-knee leg). An orthosis / brace supports a body part that is still there (an AFO, a knee immobilizer, a hand splint).

The CNA applies or removes a prosthetic or orthotic only if trained and assigned. Watching a video is not training. Finding a roommate's brace in the closet is not an assignment.

Before and after you apply an assigned device:

• Look at the skin under the brace — redness, blisters, open areas, swelling, or a tight mark that does not fade.
• Report those findings to the licensed nurse and do not force the device back on over broken skin unless the nurse directs the next step.
• The device should be clean and dry. You do not pad a broken buckle with gauze and hope.
• After a new residual-limb sock or a new wear-time, watch for pain and report it. You do not change wear-time on your own.

Colorado scenario

You are in an Aurora Credentia skills room. Skill 15 and Skill 16 are both in your set. You sit Ms. Patel on the edge of the bed so she can help, bounce her knee once, keep going after she says it hurts, then swing her arm in a fast circle past her ear. You never support the ankle. You wash later.

That fails both cards. Supine for the knee and ankle. Teach her to report pain. Support knee and ankle — flexion/extension at least three times unless pain. Support foot and ankle — dorsiflexion and plantar flexion at least three times unless pain. For the shoulder, support elbow and wrist, to ear level and to shoulder level, three times unless pain. Stop when she says it hurts. Gentle, slow, smooth. Call light, bed low, wash.

Back on the Fort Collins unit, Ms. Patel can brush her own teeth if you set the supplies up. You do not take the brush and finish for her because supper trays are late. She wears an AFO. You were checked off and assigned to apply it. This morning the skin over the lateral ankle is red and open. You do not snap the brace on. You report the skin to the licensed nurse.

Exam traps

• Doing each PROM motion only once, or doing twenty after the person reported pain.
• Supporting only the fingers or only the toes.
• Shoulder flexion past ear level or abduction above shoulder level as if higher is better.
• Calling active kicking passive.
• Doing the entire ADL because it is faster.
• Applying a brace you were never assigned.
• Ignoring red skin under an orthotic.
• Forcing a contracted joint.
• Treating I.C as too small to study.