4.5 Restorative Care and Mobility

Restorative Care: Build Independence

Restorative Skills are about 5% of the Virginia NNAAP written exam, but they carry weight on the skills floor because Passive Range of Motion (PROM), ambulation with a transfer belt, and positioning on the side are all on the randomly assigned skills list. The guiding philosophy is restorative: help each resident regain and maintain the highest possible level of function and independence, rather than doing everything for them. Encouraging a resident to wash their own face or feed themselves is not neglect; it is restorative care and it is the scored answer.

Range of Motion and Contracture Prevention

When a joint is not moved, the muscles shorten and a permanent contracture (frozen, deformed joint) develops, along with muscle atrophy. Range-of-motion (ROM) exercises prevent this.

• Active ROM: the resident moves the joint themselves; the CNA encourages and supervises.
• Active-assistive ROM: the resident moves with some help from the CNA.
• Passive ROM (PROM): the CNA moves the joint for a resident who cannot; on the NNAAP this is tested for a knee and ankle, or for a shoulder.

The scored rules for PROM: support the joint above and below, move slowly and smoothly, exercise to the point of slight resistance but never to pain, and never force a joint. Repeat each movement the required number of times (commonly 3-5 per the checklist), and stop and report if the resident reports pain. Movements have specific names the exam may use: flexion (bending), extension (straightening), abduction (away from the body), adduction (toward the body), and rotation.

Repositioning and Body Positions

Reposition immobile residents at least every 2 hours to prevent pressure injuries and contractures, maintaining good body alignment with pillows and supports.

When side-lying, support the top arm and leg on pillows, keep the spine aligned, and use a pillow to keep knees from pressing together. Float the heels off the mattress with a pillow under the calves to prevent heel pressure injuries.

Pressure-Injury Prevention

Immobile residents develop skin breakdown over bony prominences — the sacrum, heels, hips, elbows, shoulder blades, and the back of the head. Prevention is heavily tested:

• Reposition at least every 2 hours and keep skin clean and dry.
• Keep linens smooth and wrinkle-free; friction and moisture accelerate breakdown.
• The earliest warning is non-blanchable redness (skin that stays red when pressed). Report it before it opens.
• Never massage a reddened bony prominence — it worsens the underlying tissue damage.

Ambulation and Adaptive Devices

For ambulation with a transfer/gait belt: apply the belt snugly over clothing, lock the wheelchair, help the resident to a standing position, grasp the belt from underneath at the back/side, and walk slightly behind and to the weak side, guarding. Walkers are advanced first, then the resident steps in; canes are held on the strong side and advanced with the weak leg. Adaptive equipment (built-up utensils, plate guards, sock aids, long-handled sponges) lets residents do more themselves and should be encouraged.

Bladder and Bowel Restorative Programs

Restorative care also includes bladder and bowel retraining. For a bladder program the CNA offers the toilet on a set schedule (often every 2 hours), answers call lights promptly, encourages fluids during the day, and records voiding patterns so continence can be rebuilt. For a bowel program the CNA offers toileting after meals to use the natural gastrocolic reflex, encourages fiber and fluids per the plan, and never rushes the resident. Success is measured by fewer episodes of incontinence and more independent toileting, which also protects skin.

The CNA reports new incontinence, constipation, diarrhea, or blood in stool or urine to the nurse rather than treating it.

Prosthetics, Casts, and Special Devices

Many restorative residents use a prosthesis (artificial limb), a cast, or a brace. Inspect the skin where a device meets the body for redness or breakdown, keep the stump or skin clean and dry, apply and remove devices exactly as the care plan directs, and report swelling, color change, numbness, foul odor, or complaints of pain or tightness. The CNA does not adjust or repair the device; that is reported to the nurse. With a cast, support it with pillows, keep it dry, and never insert anything inside to scratch an itch.

The Restorative Trap

The wrong answer on a restorative item usually does too much for the resident (feeding someone who can self-feed, dressing someone who can dress with setup) or forces a joint past pain. Fostering dependence is a failure of restorative care. The correct choice encourages the resident's own ability, uses adaptive aids, supports joints gently within a pain-free range, repositions and protects skin on schedule, and reports any new problem with a device, the skin, or elimination to the nurse rather than acting outside scope.