6.3 Restorative Care: Ambulation Aids and Bladder & Bowel Retraining

Restorative Care: Ambulation Aids and Bladder & Bowel Retraining

NCCT's test plan asks PCTs to assist patients with restorative rehabilitation activities (for example, bladder and bowel retraining, ambulation, feeding). Restorative care means helping a patient regain or keep the highest possible level of function after illness, injury, or surgery. Physical therapists (PTs), occupational therapists (OTs), and nurses write the plan; the PCT carries it out many times a day. That repetition decides whether the patient goes home walking and continent or goes home dependent.

Principles of Restorative Care

• Follow the care plan exactly: distance, assistive device, weight-bearing status, and schedules.
• Encourage independence. Do not do for patients what they can safely do for themselves, even when doing it yourself is faster.
• Break tasks into small steps, give clear cues, and praise effort and progress.
• Watch for fatigue, pain, dizziness, and shortness of breath, and report both progress and setbacks.
• Document distance walked, assistance needed, continence episodes, and the patient's response.

Safe Ambulation Basics

1. Check the activity order and weight-bearing status (for example, non-weight-bearing on the left leg).
2. Put on non-skid footwear and apply a gait belt (Section 2.2).
3. Have the patient sit on the edge of the bed (dangle) first and watch for dizziness from orthostatic hypotension.
4. Walk slightly behind and to the weak side, holding the gait belt with an underhand grip.
5. Stop and seat the patient if they become dizzy, pale, short of breath, or report chest pain, and notify the nurse.

Canes

• Fit: with the patient standing and arms relaxed, the top of the cane should reach the wrist crease (about the level of the hip bone), so the elbow bends about 15 to 30 degrees when holding it.
• Hold the cane in the hand on the strong (unaffected) side.
• Walking sequence: move the cane and the weak leg forward together, then step through with the strong leg.
• Stairs: going up, step up with the strong leg first, then bring up the cane and weak leg. Going down, lower the cane and weak leg first, then the strong leg. "Up with the good, down with the bad."
• Quad canes (four small feet) give more stability for patients with poor balance.

Walkers

• Fit: the handgrips reach the wrist crease, with the elbows bent about 15 to 30 degrees.
• Standard walker: lift the walker and set it down a short distance ahead (about one step), then step forward with the weak leg into the walker, then the strong leg. Do not step all the way to the front bar.
• Rolling walker: push it forward smoothly without lifting it.
• Never use a walker on stairs, and do not hang heavy bags on it, which can tip it over.
• Remind patients to push up from the bed or chair armrests to stand, not to pull up on the walker.

Crutches

• Fit: the crutch pad sits about 2 to 3 finger widths (roughly 1.5 to 2 inches) below the armpit, and the handgrips reach the wrist crease with the elbows slightly bent.
• Weight goes through the hands, not the armpits. Leaning on the pads can compress nerves in the armpit and cause "crutch palsy," with weakness or numbness in the arm.
• Common gaits:
  • Three-point gait (one leg cannot bear weight): move both crutches and the injured leg forward together, then step through with the good leg.
  • Two-point and four-point gaits: crutches and legs move in alternating patterns for patients who can bear some weight on both legs.
  • Swing-to and swing-through gaits: both crutches move forward, then the body swings to or past them; used when both legs are weak or braced.
• Stairs: going up, step up with the good leg first, then bring up the crutches and injured leg. Going down, lower the crutches and injured leg first, then the good leg.

Bladder Retraining

The goal is to restore a normal voiding pattern and reduce incontinence.

• Scheduled (timed) toileting: take the patient to the toilet or offer the bedpan or urinal on a fixed schedule, often every 2 hours at first, whether or not they feel the urge.
• Gradually lengthen the interval (for example, by 15 to 30 minutes at a time) as the patient stays dry.
• Prompted voiding for patients with cognitive impairment: check whether they are dry, ask whether they need to void, help them to the toilet, and give praise for success.
• Do not restrict fluids to prevent accidents unless ordered. Concentrated urine irritates the bladder and raises the risk of urinary tract infection. The care plan may shift fluids earlier in the day and limit caffeine.
• Help the patient into a natural position (women sitting, men standing if able), give privacy and time, and use cues such as running water.
• Encourage pelvic floor (Kegel) exercises if they are part of the plan.
• Keep a voiding diary: times, amounts, and any incontinence episodes.

Bowel Retraining

• Set a consistent daily time for a bowel movement, often 20 to 30 minutes after breakfast, when the gastrocolic reflex increases bowel activity.
• Support a normal sitting position on the toilet or commode rather than a bedpan when possible, with the feet supported and the patient leaning slightly forward.
• Provide privacy and enough time, and follow the plan for fluids, fiber, and activity.
• Record each bowel movement (the Bristol Stool Form Scale helps; see Section 4.3), and report no bowel movement for about 3 days, hard stools, straining, or liquid stool seeping around hard stool, which can signal an impaction.

Restorative Feeding and Adaptive Equipment

OTs provide devices that let patients do more themselves:

Set up the tray (open containers, cut food if needed), place items where the patient can reach them, and use hand-over-hand guidance only as much as needed. Section 4.1 covers dysphagia precautions.