Section 7.3: Restorative Nursing, ROM Exercises, & Rehab Goals
Key Takeaways
- Restorative nursing aims to maintain functional independence and prevent decline, whereas rehabilitation seeks to restore lost functions.
- Promote resident autonomy using the 'doing with, not doing for' approach, verbal cues, and adaptive self-care devices.
- Perform Passive Range of Motion (PROM) slowly and smoothly, supporting joints above and below, and stopping immediately if pain occurs.
- Prevent immobility complications including contractures, muscle atrophy, pressure injuries, deep vein thrombosis, and hypostatic pneumonia.
Restorative Nursing, ROM Exercises, & Rehab Goals
Restorative nursing care and rehabilitative care are essential services provided in Iowa long-term care facilities to help residents achieve and maintain their highest possible level of physical function and independence. While these terms are closely related, they represent distinct programs and responsibilities within the interdisciplinary healthcare team.
Restorative Nursing vs. Rehabilitation
| Feature | Restorative Nursing Care | Rehabilitative Care |
|---|---|---|
| Primary Goal | Maintain current function, prevent decline, and reinforce therapy goals | Restore functions lost due to illness, injury, or surgery |
| Duration | Long-term, ongoing, integrated into daily nursing care | Short-term, intensive, and goal-directed |
| Led By | Licensed nursing staff and Certified Nursing Assistants (CNAs) | Licensed therapists (Physical, Occupational, Speech Therapists) |
| Target Population | All residents needing assistance to maintain functional status | Residents with a specific, acute rehab potential (e.g., post-hip fracture) |
The CNA's Role in Promoting Independence
A central philosophy of restorative care is "doing with, not doing for." To promote independence, CNAs must encourage residents to perform as much self-care as possible, even if the task takes a significant amount of time. CNAs should use verbal cues (step-by-step guidance) and positive reinforcement.
If a resident has hemiplegia (paralysis on one side) following a stroke, the CNA should assist with the weak side but encourage the resident to use their strong side to brush their teeth, wash their face, and feed themselves. CNAs also assist residents in using adaptive or assistive devices such as:
- Plate guards and scoop dishes to prevent food from falling off the plate.
- Built-up or weighted utensils for residents with arthritis or hand tremors.
- Long-handled shoehorns, sock aids, and button hooks to assist with dressing.
Complications of Immobility
Immobility poses severe physical and mental risks to residents. The CNA must understand these risks and perform restorative interventions to prevent:
- Contractures: The permanent shortening and tightening of muscles, tendons, or ligaments, which causes joint deformity and restricts movement (e.g., foot drop, clenched hand).
- Muscle Atrophy: The wasting away, thinning, and weakening of muscle tissue due to lack of physical activity.
- Pressure Injuries: Skin breakdown caused by prolonged pressure on bony prominences, which cuts off circulation.
- Deep Vein Thrombosis (DVT): Blood clots forming in deep veins, usually in the legs, due to slowed circulation.
- Hypostatic Pneumonia: Fluid pooling in the lungs when a resident remains in one position for long periods, leading to infection.
Range of Motion (ROM) Exercises
Range of motion (ROM) refers to the maximum movement possible for a joint. ROM exercises prevent contractures and muscle atrophy, improve circulation, and maintain joint flexibility.
- Passive Range of Motion (PROM): The nursing assistant moves the resident's joints through their range of motion without any assistance from the resident.
- Active Range of Motion (AROM): The resident performs the exercises independently, with the nursing assistant providing guidance and supervision.
- Active-Assistive Range of Motion (AAROM): The resident moves the joints as much as possible, and the nursing assistant assists to complete the movement.
Step-by-Step PROM Protocol
When performing PROM, the CNA must follow strict clinical standards to ensure resident safety:
- Preparation: Perform hand hygiene, explain the procedure to the resident, raise the bed to a comfortable working height, and lock the bed wheels.
- Support the Joint: Place one hand under the joint being exercised and the other hand supporting the distal portion of the limb (e.g., support under the elbow and under the wrist).
- Execution: Move the joint slowly, smoothly, and gently. Never force a joint past the point of resistance or pain.
- Communication: Ask the resident if they feel any pain during the movements. Watch their face for non-verbal signs of discomfort (grimacing, flinching).
- Repetitions: Repeat each specific joint exercise 3 to 5 times (or as specified in the care plan).
- Post-Procedure: Lower the bed to its lowest position, place the call light within reach, perform hand hygiene, and document the session.
Major Joint Movements for PROM
- Shoulder:
- Flexion and Extension: Raise the arm up above the head and lower it back down.
- Abduction and Adduction: Move the straight arm away from the side of the body and bring it back.
- Elbow:
- Flexion and Extension: Bend the elbow to touch the hand to the shoulder, then straighten the arm.
- Wrist:
- Flexion and Hyperextension: Bend the hand down at the wrist, then bend it backward.
- Hip and Knee:
- Flexion and Extension: Bend the knee and hip toward the chest, then straighten the leg.
- Abduction and Adduction: Move the straight leg away from the other leg, then bring it back.
- Ankle and Foot:
- Dorsiflexion and Plantar Flexion: Bend the foot upward toward the shin, then point the toes downward.
Iowa Regulatory Compliance
Under Iowa Admin. Code 441 Ch. 81, facilities are legally required to provide restorative nursing services to assist residents in achieving and maintaining their highest practicable physical, mental, and psychosocial well-being. Failure to document restorative services or show that residents are encouraged to maintain independence can result in state survey deficiencies.
Practice Scenarios and Exam Traps
- Clinical Scenario: A resident with Parkinson's disease is trying to button their shirt. They are moving very slowly, and it has taken them five minutes to do two buttons. The CNA has other residents to care for. The correct action is to allow the resident to continue, offering encouragement and assistance only when requested. Rushing the resident or doing it for them destroys their independence.
- Exam Trap: During PROM exercises, if a resident complains of mild pain, the CNA must stop the exercise immediately and report it to the nurse. Never choose options suggesting the CNA should "gently push through the pain" or "reduce the range but keep going."
When performing Passive Range of Motion (PROM) exercises on a resident's shoulder, how should the nursing assistant support the resident's arm?
Which of the following statements best describes the difference between restorative nursing care and rehabilitative care in an Iowa long-term care facility?
A resident has been confined to bed for several weeks following a stroke. The nursing assistant notes that the resident's fingers are tightly flexed into the palm and cannot be straightened. What complication of immobility does this represent?