4.2 Restorative Care, ROM & Rehabilitation

The Restorative Philosophy

Kentucky CHFS regulations require nursing facilities to operate restorative nursing programs, and the SRNA is an active participant under the direction of licensed nurses and physical, occupational, or speech therapists. The exam consistently tests the primary goal: restorative nursing aims to maintain or improve a resident's existing functional abilities and prevent further decline. It does NOT necessarily aim to return every resident to pre-illness function (unrealistic for many) and is NOT the same as intensive rehab-hospital therapy.

The guiding motto is "do with, not for." If a resident can wash their own face or button a shirt slowly, the SRNA encourages and allows the extra time rather than taking over. Promoting independence preserves muscle strength, joint mobility, dignity, and self-esteem, and it reduces complications of immobility such as pressure injuries, contractures, pneumonia, constipation, and depression.

Range of Motion (ROM): Active vs. Passive

Range of motion is the movement of a joint through its full normal arc. There are three types:

• Active ROM (AROM): the resident performs the movement independently. This maintains AND builds strength.
• Active-assistive ROM (AAROM): the resident moves the joint with the SRNA's partial help.
• Passive ROM (PROM): the SRNA moves the joint for a resident who cannot move it themselves.

A key exam distinction: PROM prevents contractures and maintains flexibility and circulation but does NOT build muscle strength — only active movement does that. A contracture is a permanent shortening and stiffening of a muscle or joint from lack of movement; once fully formed it is often irreversible, which is why prevention through daily ROM is so important.

Safe ROM Technique

ROM is ordered by a physician or therapist, and the SRNA follows the care-plan specification for each joint. Universal safe-technique rules:

1. Support the joint above and below the one being exercised (e.g., support the elbow and wrist when moving the forearm).
2. Move slowly and smoothly through the normal range.
3. Move only to the point of resistance or mild discomfort — never force through pain or resistance. Forcing can tear ligaments, rupture tendons, or fracture brittle osteoporotic bone.
4. Never let the limb drop; keep it supported throughout.
5. Typically repeat each motion 3-5 times per care plan.
6. Stop and report to the nurse if the resident reports pain, or if you feel new resistance, swelling, warmth, or redness.

For a resident with hand contractures, never force the fingers open — clean gently between them with a folded cloth and use a palm roll to prevent skin-on-skin maceration.

Ambulation After Bedrest

Prolonged bedrest causes orthostatic (postural) hypotension — a blood-pressure drop on standing that causes dizziness and falls. The tested progressive sequence is:

1. Raise the head of the bed.
2. Sit the resident up and dangle the legs at the bedside for several minutes to let the cardiovascular system adjust.
3. Apply a gait belt and assist to standing with support.
4. Walk a short distance as tolerated, monitoring for dizziness, pallor, or complaints.

Distance is based on the individual's tolerance, not a fixed goal. If the resident becomes faint and begins to fall, use the gait belt to ease them into a controlled slide to the floor — bend your knees, widen your stance, and protect the head. Never try to hold a falling resident upright (you risk both injuries), and never push them against a wall.

Assistive Devices

Proper device use is heavily tested. Study this table carefully:

For any device, height is set with the handgrip at wrist level when the resident stands upright with arms relaxed, giving 15-30 degrees of elbow flexion. Check the rubber tips (ferrules) for wear — worn tips slip and cause falls. Keep the device within easy reach at the bedside so the resident never walks without it, and report any damage to therapy.

Wheelchairs are also mobility devices: always lock both brakes before any transfer and raise or swing away the footrests so the resident does not trip or tip forward. A frequent exam trap is transferring a resident into or out of a wheelchair with the brakes unlocked — the chair rolls and the resident falls. Position the chair on the resident's strong side for a stand-pivot transfer, and never let a resident use another resident's chair (an infection-control and fit issue).

Common mistake to avoid: do not confuse the walker and cane sequences. The walker moves first (walker, weak leg, strong leg), but with a cane the cane and the WEAK leg move together while the cane is held on the STRONG side. Mixing these up is one of the most common wrong answers on assistive-device questions.

Prosthetics, Orthotics & Adaptive Equipment

A prosthetic replaces a missing body part (an artificial leg); an orthotic (brace or splint) supports or aligns a weak part. SRNA care: inspect the residual limb (stump) and skin daily for redness or breakdown, keep it clean and dry, apply the device as the care plan directs (usually before ambulation), ensure a proper stump sock, and report any skin change, poor fit, or device damage. Never adjust a brace's set positions yourself.

Bowel and bladder retraining are restorative programs that rebuild continence through scheduled toileting — offering the toilet or bedpan at set intervals (often every 2 hours) and after meals, and using prompted voiding. The SRNA documents times and successes and reports patterns. Adaptive equipment helps residents self-perform ADLs: plate guards, built-up-handle utensils, non-slip mats, reachers, sock aids, and Velcro-closure shoes. The SRNA sets up the equipment, encourages its use, and flags new needs to occupational therapy.