2.4 Restorative Care, Mobility & Range of Motion (ROM)
Key Takeaways
- Restorative nursing care focuses on maintaining and regaining the resident's highest practical level of physical, mental, and psychosocial functioning, preventing learned helplessness and secondary immobility complications.
- Range of Motion (ROM) exercises maintain joint mobility and circulation: Active ROM (resident independent), Active-Assistive ROM (partial assistance), and Passive ROM (CNA performs all motions).
- During Passive ROM, the CNA must support the extremity above and below the joint, execute movements smoothly 3 to 5 times, and stop immediately if the resident experiences pain or if resistance is encountered.
- Canes are always held on the resident's stronger (unaffected) side (COAL: Cane Opposite Affected Leg); walkers are moved 6 to 10 inches forward before the resident steps into the frame with the weaker leg first.
- Complications of prolonged immobility—such as contractures, disuse muscle atrophy, foot drop, and deep vein thrombosis—are prevented through ROM, positioning devices (footboards, trochanter rolls), and anti-embolism (TED) stockings applied in the morning before rising.
Last updated: August 2026
Restorative Care, Mobility & Range of Motion (ROM)
Human physiology is engineered for continuous movement. When chronic disease, stroke, orthopedic surgery, or advanced age limits mobility, physical deterioration begins within 24 to 48 hours. Under the federal Omnibus Budget Reconciliation Act (OBRA) and North Dakota Department of Health and Human Services (ND HHS) long-term care regulations, nursing facilities are legally required to provide restorative care programs that ensure residents maintain their highest practical level of physical independence, mobility, and dignity.
1. Restorative Care Philosophy vs. Rehabilitation
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| REHABILITATION VS. RESTORATIVE CARE CONTINUUM |
| |
| [ACUTE EVENT / INJURY] (Stroke, Hip Fracture, Joint Replacement) |
| | |
| v |
| [REHABILITATIVE THERAPY] (Skilled Physical / Occupational / Speech Therapy)|
| - Directed by licensed therapists (PT, OT, SLP) |
| - Short-term, intensive clinical intervention |
| - Goal: Regain newly lost functional abilities |
| | |
| v |
| [RESTORATIVE NURSING CARE] (Long-Term Maintenance & Independence) |
| - Executed daily by Certified Nursing Assistants |
| - Integrated into routine Activities of Daily Living (ADLs) |
| - Goal: Maintain existing capabilities, prevent decline & contractures |
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Core Principles of Restorative Nursing:
- Promote Maximum Independence: Allow residents to perform as much self-care as safely possible (e.g., dressing, brushing teeth, eating with adaptive utensils), even if tasks require significantly more time.
- Prevent Learned Helplessness: Performing tasks for residents that they are physically capable of doing themselves fosters dependency, accelerates muscle atrophy, and damages self-esteem.
- Consistency and Encouragement: Restorative goals must be reinforced across every shift through positive verbal praise, patience, and clear step-by-step cueing.
2. Range of Motion (ROM) Classifications & Principles
Range of motion is the complete extent of movement of which a healthy synovial joint is normally capable.
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| ROM EXERCISE CATEGORIES |
| |
| [ACTIVE ROM (AROM)] ---> Performed INDEPENDENTLY by the resident |
| without physical assistance. |
| [ACTIVE-ASSISTIVE (AAROM)] ---> Resident performs motion with PARTIAL |
| support/guidance from the CNA. |
| [PASSIVE ROM (PROM)] ---> Performed ENTIRELY by the CNA for a |
| completely dependent resident. |
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Essential Rules for Performing Passive ROM (Headmaster Exam Protocol):
- Check Care Plan: Verify specific joint limitations, post-surgical restrictions (e.g., hip precautions), or ordered repetitions.
- Support Proximal and Distal to Joint: Always cradle the limb from underneath with both hands—one hand supporting above the joint (proximal) and one hand supporting below the joint (distal). Never grip muscle bellies or pull on fingers/toes.
- Smooth, Gentle Execution: Move joints slowly and smoothly. Never jerk, bounce, or force a joint.
- Repetition Standard: Move each joint through its full range 3 to 5 times (or as ordered).
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| THE MANDATORY ROM STOP RULE |
| |
| NEVER FORCE A JOINT PAST THE POINT OF RESISTANCE OR PAIN! |
| |
| If the resident: |
| - Verbalizes pain or discomfort |
| - Winces, grimaces, or groans |
| - Demonstrates muscle spasm or joint resistance |
| |
| ACTION: STOP THE EXERCISE IMMEDIATELY, return the joint to a comfortable |
| resting anatomical position, and report to the charge nurse. |
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3. Anatomical Movements & Terminology
Certified nursing assistants must know the exact medical terminology for all physiological joint actions.
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| ANATOMICAL JOINT MOVEMENT REFERENCE |
| |
| [FLEXION] ---> Bending a joint (decreasing the angle between bones) |
| [EXTENSION] ---> Straightening a joint (increasing angle / returning) |
| [HYPEREXTENSION]---> Bending a joint backward beyond normal anatomical line|
| [ABDUCTION] ---> Moving a limb AWAY from the midline of the body |
| [ADDUCTION] ---> Moving a limb TOWARD the midline of the body |
| [PRONATION] ---> Turning forearm/palm DOWNWARD |
| [SUPINATION] ---> Turning forearm/palm UPWARD ("holding a bowl of soup")|
| [DORSIFLEXION] ---> Bending foot backward at ankle (pointing toes UP/shin)|
| [PLANTAR FLEX] ---> Bending foot downward at ankle (pointing toes DOWN) |
| [INTERNAL ROT] ---> Turning a joint INWARD toward body center |
| [EXTERNAL ROT] ---> Turning a joint OUTWARD away from body center |
| [OPPOSITION] ---> Touching thumb tip to the tip of each finger |
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Joint-Specific ROM Protocol Table
| Joint / Body Part | Anatomical Actions | Proper CNA Hand Support & Technique |
|---|---|---|
| Neck (Cervical) | Flexion / Extension / Hyperextension / Lateral Flexion / Rotation | Performed only if specifically ordered. Support base of skull and chin. Gently move chin toward chest, upright, tilt toward each shoulder, and turn head left/right. |
| Shoulder | Flexion / Extension<br>Abduction / Adduction<br>Internal / External Rotation | Support under elbow and wrist. Raise straight arm upward overhead (flexion) and down to side (extension). Move arm laterally away from body (abduction) and back across chest (adduction). |
| Elbow & Forearm | Flexion / Extension<br>Pronation / Supination | Support upper arm and wrist. Bend forearm toward shoulder (flexion), straighten flat (extension). Rotate forearm so palm faces downward (pronation), then rotate palm upward (supination). |
| Wrist | Flexion / Extension / Hyperextension<br>Radial / Ulnar Deviation | Support forearm and palm. Bend hand forward toward inner wrist (flexion), straighten level (extension), tilt backward (hyperextension). Move hand sideways toward thumb (radial) and pinky (ulnar). |
| Fingers & Thumb | Flexion / Extension<br>Abduction / Adduction<br>Opposition | Support wrist and fingers. Gently curl fingers into a fist (flexion), straighten open (extension). Spread fingers wide (abduction), close together (adduction). Touch thumb tip to each fingertip (opposition). |
| Hip & Knee | Flexion / Extension<br>Abduction / Adduction<br>Internal / External Rotation | Support under knee and under heel. Bend knee and bring thigh upward toward abdomen (flexion), straighten back down (extension). Move straight leg outward away from body (abduction) and back to center (adduction). (Caution: Post-hip replacement THA precautions!) |
| Ankle & Toes | Dorsiflexion / Plantar Flexion<br>Inversion / Eversion<br>Toe Flexion / Extension | Support lower leg and heel. Push foot upward toward shin (dorsiflexion), point toes downward toward floor (plantar flexion). Turn sole of foot inward (inversion) and outward (eversion). Gently curl toes down (flexion) and straighten (extension). |
4. Assistive Ambulation Devices & Gait Mechanics
Assistive devices compensate for lower extremity weakness, neurological deficits, poor balance, or altered weight-bearing status.
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| ASSISTIVE AMBULATION DEVICE RULES |
| |
| [CANES] |
| - Held on STRONGER (unaffected) side (COAL: Cane Opposite Affected Leg). |
| - Top of handle level with greater trochanter; elbow flexed 15° to 30°. |
| - Sequence: Cane moves 6-12" forward -> WEAK leg steps forward to cane |
| -> STRONG leg steps forward past cane. |
| |
| [WALKERS] |
| - Handgrips level with wrist crease; elbow flexed 15° to 30°. |
| - Standard (No Wheels): Lift & move 6-10" forward, set all 4 tips flat, |
| step WEAK leg in, step STRONG leg forward. |
| - Resident must NEVER pull up on walker to stand; push from chair first! |
| |
| [STAIR NAVIGATION MNEMONIC] |
| "UP WITH THE GOOD, DOWN WITH THE BAD" |
| - Ascending (Going Up): Lead with STRONG leg -> follow with weak leg/cane |
| - Descending (Going Down): Lead with CANE & WEAK leg -> follow with strong|
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| CANE GAIT SEQUENCE DIAGRAM (COAL) |
| |
| STEP 1: Advance Cane 6-12 inches forward on STRONG SIDE. |
| STEP 2: Advance WEAK (Affected) Leg forward level with cane. |
| STEP 3: Advance STRONG (Unaffected) Leg forward PAST the cane. |
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5. Prevention of Systemic Complications of Immobility
Prolonged bed rest and lack of weight-bearing activity trigger severe multi-organ deterioration. The CNA must deploy specific preventative interventions.
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| HAZARDS OF IMMOBILITY & INTERVENTIONS |
| |
| [CONTRACTURES] ---> Daily ROM exercises, proper anatomical alignment|
| [MUSCLE ATROPHY] ---> Active exercise, ambulation, resistance training|
| [FOOT DROP] ---> Footboards, multi-podus boots, dorsiflexion ROM |
| [ORTHO HYPOTENSION] ---> Dangling at bedside 1-2 minutes before standing |
| [DEEP VEIN THROMBOSIS]---> Anti-embolism (TED) hose, sequential pumps (SCD)|
| [PRESSURE INJURIES] ---> Repositioning q2h in bed, q1h in chair |
| [CONSTIPATION / UTI] ---> Hydration (2,000-2,500 mL/day), upright voiding |
| [PNEUMONIA] ---> Coughing, deep breathing, High-Fowler's position|
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Clinical Deep Dive: Foot Drop & Prevention
- Foot Drop (Equinus Deformity): A permanent plantar flexion contracture where the calf muscles and Achilles tendon shorten, causing the toes to point permanently downward. A resident with foot drop cannot place their heel flat on the floor, destroying ambulation capability.
- Preventative Equipment:
- Footboards: Padded boards placed at a 90-degree angle at the foot of the bed firmly against the resident's soles to keep feet in dorsiflexion.
- Multi-Podus / Heel-Protector Boots: Rigid splints that hold the ankle at 90 degrees while suspending the heel off the mattress.
- High-Top Sneakers: Sturdy canvas shoes used in restorative programs to maintain ankle alignment.
- Bed Cradles: Metal frames placed over the lower bed to suspend heavy blankets off the toes, eliminating downward mechanical pressure.
Clinical Deep Dive: Anti-Embolism Stockings (TED Hose)
Anti-embolism elastic stockings apply graduated compression to the lower extremities, promoting venous blood return to the heart and preventing venous stasis, deep vein thrombosis (DVT), and pulmonary embolism (PE).
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| TED HOSE APPLICATION PROTOCOL (HEADMASTER) |
| |
| 1. APPLICATION TIMING: Apply in the MORNING BEFORE resident gets out |
| of bed (while legs are elevated & least swollen). |
| 2. POSITIONING: Resident resting comfortably in supine position in bed. |
| 3. TECHNIQUE: Turn stocking inside-out to the heel pocket. Place over toes|
| and heel, then gently roll/slide upward over calf/thigh. |
| 4. WRINKLE-FREE RULE: Stocking must be COMPLETELY SMOOTH with NO wrinkles |
| or bunched fabric (bunches act as tourniquets!). |
| 5. TOE OPENING: Position inspection hole under or over toes correctly. |
| 6. CIRCULATION CHECKS: Inspect toes for warmth, pink color, sensation, |
| and capillary refill (<3 seconds). |
| 7. REMOVAL: Remove at least once daily (or per care plan) to wash, dry, |
| and inspect underlying skin integrity. |
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Test Your Knowledge
A certified nursing assistant is performing passive range of motion (PROM) exercises on a resident's shoulder. During the third repetition of shoulder flexion, the resident winces and states, 'That really hurts my shoulder.' What is the immediate correct action for the CNA?
A
B
C
D
Test Your Knowledge
A resident recovering from a left cerebral vascular accident (stroke) has mild right-sided weakness and is prescribed a single-point cane for ambulation. How should the nursing assistant instruct the resident to use the cane?
A
B
C
D
Test Your Knowledge
Which complication of prolonged immobility is characterized by the permanent shortening and tightening of a muscle or tendon around a joint, resulting in severe deformity and loss of motion?
A
B
C
D
Test Your Knowledge
A nursing assistant is assigned to apply anti-embolism elastic stockings (TED hose) for a resident. When is the optimal time to apply these stockings to achieve maximum clinical efficacy?
A
B
C
D