9.2 Care of the Physically Impaired Resident: Paralysis, Amputation & Adaptive Equipment

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

[!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.

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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.

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3. Preventing Contractures

Contractures are the classic preventable complication of paralysis, and once established they are largely permanent.

[!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.

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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.

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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.

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6. Assistive and Adaptive Equipment

Ambulation devices

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.