2.2 ADLs, Mobility & Self-Care Management
Key Takeaways
- Basic activities of daily living (ADLs) include bathing, dressing, grooming, toileting, transferring, and feeding; rehabilitation retrains these using adaptive techniques and equipment.
- Safe transfers and progressive mobility preserve function and prevent injury; use gait belts, proper body mechanics, and the principle of moving toward the patient's stronger side.
- Neurogenic bowel and bladder programs rely on scheduled, consistent routines; intermittent catheterization is generally preferred over indwelling catheters to lower infection risk.
- Pressure injury prevention uses the Braden Scale for risk, repositioning schedules, pressure-redistribution surfaces, and skin inspection over bony prominences.
- Dysphagia screening, proper positioning (upright, chin-tuck when indicated), and texture-modified diets reduce aspiration risk in rehabilitation patients.
Why This Matters for the CRRN Exam
The bulk of rehabilitation nursing happens through daily self-care management. CRRN questions in this domain test whether you can promote independence safely — retraining activities of daily living (ADLs), mobilizing patients without injury, and running effective bowel, bladder, skin, and nutrition programs.
ADL Retraining
Basic ADLs are the fundamental self-maintenance tasks: bathing, dressing, grooming, toileting, transferring, and feeding. Instrumental ADLs (IADLs) are more complex community tasks such as cooking, managing medications, and handling finances.
Key rehabilitation nursing principles for ADL retraining:
- Promote maximum independence: allow the patient to do everything they can, even when it is slower; doing tasks for the patient fosters dependence.
- Energy conservation and work simplification: sit to dress, gather supplies first, alternate hard and easy tasks.
- Adaptive equipment: long-handled reachers, sock aids, button hooks, plate guards, and built-up utensils support independence.
- Hemiplegia dressing rule: dress the affected (weaker) side first and undress the unaffected side first.
Mobility and Safe Transfers
Progressive mobility maintains strength, prevents deconditioning, and protects skin and joints. Safe transfer principles tested on the CRRN exam:
- Use a gait/transfer belt and lock all wheels and brakes before moving.
- Apply correct body mechanics: wide base of support, bend at the knees, keep the load close, avoid twisting.
- For hemiplegia, generally transfer toward the patient’s stronger (unaffected) side so the strong limbs lead.
- Match equipment to ability: stand-pivot transfer, sit-to-stand lift, or full mechanical (Hoyer-type) lift for dependent patients.
- Safe patient handling and mobility (SPHM) programs and mechanical lifts reduce caregiver and patient injury — manual lifting of dependent patients is discouraged.
Neurogenic Bowel and Bladder Programs
Neurologic injury frequently disrupts elimination. Effective programs depend on consistency, scheduling, and the right technique.
| Program | Core Strategy |
|---|---|
| Neurogenic bladder | Scheduled voiding or clean intermittent catheterization (CIC); CIC is generally preferred over an indwelling catheter to reduce catheter-associated urinary tract infection (CAUTI) and preserve bladder health |
| Neurogenic bowel | Consistent timing (often after a meal to use the gastrocolic reflex), adequate fiber and fluid, scheduled stimulation/suppository, and activity to establish predictable, complete evacuation |
Goals are continence, predictability, and prevention of complications (urinary tract infection, distension, autonomic dysreflexia, constipation, and skin breakdown).
Skin Integrity and Pressure Injury Prevention
Pressure injuries are a high-yield CRRN topic because they are largely preventable and signal nursing quality.
Braden Scale
The Braden Scale predicts pressure injury risk across six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Total scores range from 6 to 23 — a lower score means higher risk. Lower scores trigger more aggressive prevention.
Pressure Injury Staging (NPIAP)
| Stage | Key Feature |
|---|---|
| Stage 1 | Intact skin with non-blanchable erythema over a bony prominence |
| Stage 2 | Partial-thickness loss of dermis; shallow open ulcer or intact/ruptured blister |
| Stage 3 | Full-thickness loss; subcutaneous fat may be visible; no exposed bone, tendon, or muscle |
| Stage 4 | Full-thickness loss with exposed bone, tendon, or muscle |
| Unstageable | Base obscured by slough or eschar |
| Deep Tissue Pressure Injury | Persistent non-blanchable deep red, maroon, or purple discoloration |
Prevention Bundle
- Repositioning on an individualized schedule; reduce shear by limiting head-of-bed elevation when feasible.
- Pressure-redistribution support surfaces for bed and chair.
- Skin inspection of bony prominences (sacrum, heels, ischium, trochanters) at least daily.
- Moisture management and protection from incontinence-associated dermatitis.
- Optimize nutrition and hydration, including adequate protein.
Nutrition and Dysphagia
Malnutrition slows wound healing and rehabilitation progress, and dysphagia (impaired swallowing) raises aspiration and pneumonia risk after stroke, traumatic brain injury, and other conditions.
Nursing priorities:
- Screen for dysphagia before the first oral intake in at-risk patients (e.g., after stroke); refer to the speech-language pathologist for formal evaluation.
- Position upright at 90 degrees for meals and for at least 30–60 minutes afterward; use a chin-tuck maneuver when recommended.
- Provide texture-modified diets and thickened liquids as ordered; minimize distractions and avoid rushing.
- Monitor for silent aspiration — coughing, wet/gurgly voice, or pocketing food are warning signs; ensure good oral care.
- Support adequate protein and calorie intake to promote healing and counter catabolism.
Bowel Program Mechanics
A reliable neurogenic bowel program is built around physiology, not luck. Schedule evacuation at the same time each day, ideally 20–40 minutes after a meal to harness the gastrocolic reflex. Use digital stimulation (for reflexic/upper-motor-neuron bowel) or a suppository/mini-enema as ordered, with the patient upright on a commode when possible to use gravity. Support the program with adequate fiber and fluid and as much activity as tolerated. Manual disimpaction may be needed for a lower-motor-neuron (areflexic) bowel.
The goals are continence, predictable complete evacuation, and prevention of impaction, which is itself a leading trigger of autonomic dysreflexia in high spinal cord injury.
Energy Conservation and IADLs
Fatigue limits participation, so the rehabilitation nurse teaches energy conservation and work simplification as a skill in its own right: sit rather than stand for tasks, gather all supplies first, alternate heavy and light activities, use both hands and gravity-assisted motions, and schedule demanding tasks for peak-energy times. Instrumental activities of daily living (IADLs) — cooking, medication management, finances, transportation, housekeeping — are higher-order tasks assessed before community discharge; a patient may be independent in basic ADLs yet unsafe in IADLs, which still blocks living alone.
Connecting to Exam Scenarios
CRRN vignettes commonly ask for the priority action: choosing CIC over an indwelling catheter, identifying the correct hemiplegia dressing sequence, recognizing a Stage 1 versus deep tissue injury, scheduling a bowel program after a meal to use the gastrocolic reflex, or positioning a dysphagic patient before feeding.
A rehabilitation nurse is helping a patient with left-sided hemiplegia get dressed. Which technique is correct?
Why is clean intermittent catheterization (CIC) generally preferred over an indwelling urinary catheter in a neurogenic bladder program?
On the Braden Scale, what does a lower total score indicate, and which subscale is NOT part of the tool?
A patient who had a stroke is about to receive the first oral intake. Which nursing action is the PRIORITY to reduce aspiration risk?