9.2 Care of the Physically Impaired Resident: Paralysis, Amputation & Adaptive Equipment
Key Takeaways
Hemiplegia is paralysis of one side of the body and hemiparesis is weakness of one side; the affected side is called the weak, involved, or affected side — never "the bad side."
Dress the weak or affected arm first and undress it last, and when transferring, position the chair and lead the movement toward the resident's strong side.
Never lift, pull, or reposition a resident by the affected shoulder; a flaccid hemiplegic shoulder subluxes easily and the injury is permanent and painful.
Support a residual limb after amputation with the prosthesis or positioning ordered in the care plan, inspect the limb and the socket liner daily for redness or breakdown, and report any change before the resident wears the prosthesis again.
Assistive devices belong within reach and in working order: a walker is advanced first then the weak leg then the strong leg, a cane is held on the strong side and moved with the weak leg, and wheelchair brakes are locked for every transfer.
Care of the Physically Impaired Resident: Paralysis, Amputation & Adaptive Equipment
The second half of the Care Impaired subject area deals with residents whose bodies, rather than their senses, limit how care can be delivered. The rule is unchanged: adapt the method, never lower the standard, and never do for a resident what the resident can do for themselves.
1. Vocabulary the Exam Uses Precisely
| Term | Meaning |
|---|---|
| Hemiplegia | Paralysis of one side of the body |
| Hemiparesis | Weakness (not full paralysis) of one side |
| Paraplegia | Paralysis of the lower body and both legs |
| Quadriplegia / tetraplegia | Paralysis of all four extremities and the trunk |
| Flaccid | Limp, without muscle tone |
| Spastic | Stiff, with involuntary increased tone and resistance |
| Contracture | Permanent shortening and tightening of a muscle, tendon, or joint from immobility |
| Atrophy | Wasting and shrinking of muscle from disuse |
| Prosthesis | An artificial replacement for a missing body part |
| Residual limb | The remaining portion of an amputated extremity (the preferred term over "stump") |
| Orthosis / brace | A device that supports or aligns a body part |
Important
Language matters and is scored. Say weak side, affected side, or involved side — never "the bad side," "the dead arm," or "the good side versus the bad side." The wording appears in dignity-focused exam items and in real complaints.
2. Hemiplegia and Hemiparesis After Stroke
A cerebrovascular accident damages one hemisphere and weakens the opposite side of the body. Right-hemisphere damage produces left-sided weakness, and vice versa.
The two rules that generate the most exam questions
+-----------------------------------------------------------------------------+
| THE TWO HEMIPLEGIA RULES YOU CANNOT AFFORD TO MIX |
| |
| [DRESSING] ---> Weak/affected arm goes IN FIRST when dressing. |
| Weak/affected arm comes OUT LAST when undressing. |
| (Strong limb can bend and stretch to meet the garment; |
| the weak limb cannot.) |
| |
| [TRANSFERS] ---> Move TOWARD the STRONG side. Place the chair on the |
| resident's strong side at a slight angle to the bed, |
| and pivot on the strong leg. |
+-----------------------------------------------------------------------------+
Positioning and protection
- Support the affected arm at all times — on a pillow, in a sling if ordered, on the wheelchair armrest or lap tray. Never allow it to dangle over the side of the chair or bed, where the weight of the arm drags the shoulder joint downward.
- Never pull, lift, or turn a resident by the affected arm or shoulder. A flaccid shoulder subluxes (partially dislocates) with startling ease, and the resulting pain is chronic.
- Keep the affected hand in a functional position with the ordered hand roll, splint, or palm protector; a fisted contracted hand macerates and breaks down in the palm.
- Prevent foot drop with a footboard, heel-suspension boots, or high-top shoes as ordered.
- Approach and place items on the resident's unaffected side when they have visual field loss on the affected side, unless a therapy program specifically directs otherwise.
One-sided neglect
Some residents after a right-hemisphere stroke ignore the entire left side of the body and the environment — shaving only one side of the face, eating only the right half of the plate, bumping the doorframe on the left. This is a perceptual deficit, not stubbornness. Cue the resident to turn the head and scan, and rotate the plate rather than assuming the meal is finished.
3. Preventing Contractures
Contractures are the classic preventable complication of paralysis, and once established they are largely permanent.
| Prevention measure | Detail |
|---|---|
| Range of motion | Passive ROM for joints the resident cannot move; active-assist or active ROM whenever the resident can participate. North Dakota publishes ROM tasks for the hip and knee and for the shoulder. |
| Correct body alignment | Reposition at least every 2 hours; use pillows, wedges, trochanter rolls, and hand rolls to hold neutral alignment. |
| Splints and braces | Applied and removed on the ordered schedule; skin under the device inspected at each application. |
| Early and frequent mobility | Up in the chair, ambulation, and restorative programs whenever tolerated. |
Warning
Never force a joint past the point of resistance or pain during range of motion. Move slowly and smoothly, support the limb above and below the joint, stop at resistance, and report any new pain, swelling, or reduced movement to the nurse. Forcing is how a fragile osteoporotic bone fractures during "routine" care.
4. Amputation and Prosthesis Care
Care of the residual limb
- Inspect daily and at every prosthesis application for redness that does not fade, blisters, open areas, drainage, or odor. Report any of them before the resident puts the prosthesis back on.
- Wash gently with mild soap and water, rinse well, and dry thoroughly, especially in skin folds. Do not apply lotion, powder, or oil to the residual limb unless the care plan orders it — residue changes how the socket fits and traps moisture.
- Apply the limb sock or liner smooth and wrinkle-free; a single fold becomes a pressure injury inside the socket where nobody can see it.
- Follow the ordered positioning program. Propping the residual limb on a pillow for long periods feels comfortable but encourages a hip or knee flexion contracture that can make the prosthesis unusable.
- Clean the socket interior as directed and report a prosthesis that has become loose, noisy, or painful — limb volume changes with fluid status and weight.
Phantom sensation and phantom pain
Phantom sensation — feeling that the missing limb is still present — is normal and extremely common. Phantom pain is real, physiological pain perceived in the missing limb. Neither is imaginary and neither is a psychiatric symptom. Never tell a resident the limb "isn't there anymore." Acknowledge the experience, provide comfort measures, and report the pain to the nurse for treatment.
5. Complications Specific to Spinal Cord Injury
Residents with paraplegia or quadriplegia carry risks that are easy to miss because sensation is absent:
- Pressure injuries develop silently, because the resident does not feel the ischemia. Weight shifts every 15 minutes in a chair, repositioning every 2 hours in bed, and pressure-redistributing surfaces are not optional.
- Orthostatic hypotension on sitting up; raise the head of the bed gradually and watch for pallor, dizziness, or a complaint of "graying out."
- Neurogenic bowel and bladder requiring scheduled programs; report any deviation.
- Autonomic dysreflexia in injuries at roughly T6 and above — a sudden pounding headache, flushing and sweating above the injury level, and a sharply rising blood pressure, most often triggered by a distended bladder, an obstructed catheter, impacted stool, or a skin irritant. This is a medical emergency. Do not leave the resident; call for the nurse immediately, and raise the head of the bed while help comes.
6. Assistive and Adaptive Equipment
Ambulation devices
| Device | Correct use |
|---|---|
| Standard walker | Resident stands inside the frame. Advance the walker first, then step with the weak leg, then the strong leg. All four legs on the floor before stepping. Never use a walker to pull to standing — push up from the chair arms. |
| Cane (single-point or quad) | Held on the strong side. Move cane and weak leg together, then the strong leg. Cane tip about 6 to 10 inches to the side of the foot; handle level with the hip so the elbow bends about 15 to 30 degrees. |
| Gait belt | Applied over clothing, snug around the waist with room for a flat hand underneath; buckle off-center and away from the spine. Grasp underhand from below. Contraindicated after recent abdominal, back, or chest surgery, or with a colostomy, feeding tube, or severe cardiac or respiratory disease — check the care plan. |
| Wheelchair | Brakes locked before every transfer and whenever stationary; footrests swung away or removed before standing; never let the resident step on a footplate. Push forward at a walking pace, and back down inclines and into elevators. |
Adaptive dining and dressing equipment
These devices exist to preserve independence, which is a resident right and a nursing-home quality measure — not merely a convenience:
- Built-up or weighted utensil handles for weak grip or tremor
- Plate guards and scoop dishes so food can be pushed against a wall rather than off the plate
- Non-slip mats under plates and cups
- Nosey / cut-out cups that let a resident drink without extending the neck backward
- Two-handled mugs, weighted cups, and straw holders
- Long-handled reachers, sock aids, long-handled shoehorns, and dressing sticks
- Button hooks and zipper pulls; elastic-waist clothing and hook-and-loop closures
- Long-handled sponges and grab bars for bathing
Tip
The exam's default answer for adaptive equipment is "let the resident do it." If one option performs the task for the resident and another provides the device and supervises while the resident performs it, choose the second. Doing for a resident what they can do with a device is a restraint on independence and accelerates functional decline.
A CNA is helping a resident with left-sided hemiplegia put on a cardigan and later transfer to a wheelchair. Which pair of actions is correct?
Place the right arm in the sleeve first, and position the wheelchair on the resident's left side.
Place the left arm in the sleeve first, and position the wheelchair on the resident's right side.
Place the left arm in the sleeve first, and position the wheelchair on the resident's left side.
Place the right arm in the sleeve first, and position the wheelchair on the resident's right side.
A resident with a below-knee amputation reports burning pain "in my left foot," which was amputated four months ago. What is the CNA's best response?
Gently remind the resident that the foot was removed, then redirect the conversation to a pleasant topic.
Reapply the prosthesis, since the sensation usually stops once the limb is bearing weight.
Document the comment as a sign of confusion and monitor for further disorientation.
Acknowledge that the pain is real, provide comfort measures within the CNA scope, and report it to the charge nurse.
A resident who uses a standard walker after right hip surgery is preparing to ambulate. What is the correct sequence?
Step forward with the strong leg first, then advance the walker, then bring the weak leg through.
Advance the walker and both legs simultaneously to maintain a steady rhythm.
Advance the walker first with all four legs on the floor, then step with the weak leg, then the strong leg.
Have the resident pull upward on the walker to rise from the chair, then move the strong leg first.
While providing morning care to a resident with a T4 spinal cord injury, the CNA notes that the resident suddenly has a pounding headache, a flushed and sweaty face, and appears anxious. What should the CNA do first?
Stay with the resident, call for the nurse immediately, and raise the head of the bed while waiting.
Lay the resident flat and elevate the legs to restore blood pressure.
Finish morning care quickly so the resident can rest, then report the symptoms at the end of the shift.
Offer fluids and a cool cloth, and recheck the resident in thirty minutes.
Sections you finish are checked off in the contents.