Prevention is one of the most important approaches you use with residents. The steps you take to help prevent complications of immobility, for example, are critical for the resident. Other skills you perform include observing changes in the resident’s status and reporting your findings so that immediate interventions can be made to ward off infection or infirmity. Restorative skills are those nursing duties you perform to help the resident function as normally as possible that goes beyond rehabilitation, a process of therapeutic treatments or approaches to restore and maintain the highest possible level of functioning a resident can possess. For example, physical therapists might assist the resident to walk, but the resident chooses to sit in a wheelchair all day and not ambulate, even though he or she is able; refusing to ambulate can result in a setback in his or her rehabilitation progress. Your encouragement and assistance to help motivate the resident to walk is preventive in nature because you are committed to maintain the resident’s restored function. It is also considered restorative because it involves more than physical therapy but emotional and psychological support. Feeding, assisting with toileting, and turning immobile residents are examples of preventive measures you take every day to prevent complications that can exist by inactivity, failure to maintain adequate nutrition, and skin breakdown from toileting problems.
Self-Care and Independence
The Omnibus Budget and Reconciliation Act (OBRA) of 1987 requires all long-term facilities to use every resource to help residents reach or maintain their highest level of physical, psychological, and mental functioning. The act requires that all residents have a right to make as many choices about their lives, their care, and their life style routines as possible. It is not only a legal requirement determined by OBRA but an ethical principle as well. Care guidelines discussed thus far have included self-care and independence. Adhering to residents’ rights helps meet the letter of the law as well as the spirit of the law, that is, to protect residents’ rights of a comfortable and caring environment in which they can live as safely and happily as possible.
The principles covered in the sections that follow apply to restorative skills.
Mobility is being able to move by one’s self, to walk, and to exercise to help maintain muscle function and improve a sense of independence and self-worth. Moving, ambulating, and exercising help improve blood circulation and proper musculoskeletal functioning. Immobility, the opposite of being mobile, affects the total well-being of the resident, that is, by exposing the resident to alterations in almost every body system.
- In the circulatory system—an increased risk of blood clots (thrombi) and edema in the lower extremities, causing undue stress on the heart.
- Respiratory complications like pneumonia, other infections of the respiratory tree, or failure to expand the lungs.
- In the digestive system, anorexia, or decreased appetite, and constipation.
- The musculoskeletal system suffers due to loss of calcium in the bones (called osteopenia), atrophy, or muscle wasting and contractures (deformities of the limbs due to immobility). The inability to walk also adds to an increased thinning and weakening of the bones, leading to osteoporosis, a chronic condition putting the resident at risk for fractures.
- Pressure ulcers on the skin.
Mentally and emotionally, the immobile resident might feel frustrated, isolated, depressed, and hopeless due to loss of autonomy and the need to rely on others. Socially, the resident loses self-esteem, has poor body image, and feels separated from social interaction.
Assisting the resident to maintain normal functional movement might include range of motion (ROM), which means freely moving all limbs and joints. If the resident cannot perform range of motion independently, you must perform passive range or motion exercises (PROM), which move the joints to protect the muscles from atrophy, increase circulation, and joint motion.
Range of motion includes abduction (moving the extremity away from the body), adduction (moving the extremity toward the body), flexion (bending the extremity), and extension (opposite of flexion). Report and record the PROM procedure and the resident’s response to the exercises. Physical therapists or massage therapists might also provide exercises for the residents as part of the rehabilitation plan. Your care helps to restore the resident to normal functioning and support the plan.
When you assist the immobile resident with lifting, moving, or transferring, remember to:
- Use proper body mechanics.
- Explain what you are going to do.
- Ask for the resident’s help as much as possible.
- Face the resident.
- Place your feet apart in line with your shoulders.
- Bend your knees.
- Keep your back straight.
- Reach close to the resident, protecting your balance, posture, and internal girdle (contract abdominal muscles and buttocks to protect the spine).
- Use both hands when lifting.
- Avoid twisting at the waist.
- When moving the resident’s entire body, move the top first, the middle (torso) second, and then the legs; in certain situations, logrolling might be necessary, which is moving the body from side to side as one unit.
- Ask for assistance from another nursing assistant as needed to keep you and the resident safe.
- Use a mechanical lift, lift sheet, or other device as needed to promote safe lifting.
Positioning the immobile resident requires using the previous principles to keep the body in proper alignment. For immobile residents, use positioning devices (hand rolls, wedges, splints, shoes, or boots) to provide dorsiflexion (pointing toes of the foot toward the knee) and to prevent contractures, pressure ulcers, and discomfort. Review body positioning, for example, prone, supine, Sim’s position, and fowler’s position as well as using a mechanical lift discussed in Chapter 6.
Transferring, or moving the resident from bed to chair, from bed to wheelchair, and from bed to stretcher requires proper body mechanics and the use of a gait belt or other assistance to prevent falling. Assisting the resident to walk is another important skill involved in ADLs. These skills are outlined in Chapter 6.
Health Maintenance and Restoration
Health maintenance and restoration includes measuring vital signs, height, and weight. Vital signs include the temperature, pulse, respiration, and blood pressure—all essential elements of life, thus the term vital. Accurate measurement and recording are important skills in determining the overall health of the resident.
Careful attention to vital signs can save a life. Age-related factors that affect vital signs include age, sex, time of day in which vital signs are measured, illness, emotions, activity and exercise, food intake, and medications. Often, a change in one vital sign will affect the other vital signs. For example, when the resident has a fever (temperature over 101 degrees), the pulse rate and respirations will also increase.
It is important to weigh residents carefully as ordered. Consider clothing, shoes, and other articles when weighing the resident because weight can be affected by clothing. Report any dramatic changes in weight because these changes might indicate a nutritional deficiency, fluid retention, or a serious illness.
Determining resident height is an important measure when admitting a resident; record subsequent measurements at least annually or as required by facility protocols. Changes in posture due to problems in the musculoskeletal system can be determined by monitoring resident height.
General guidelines that apply to measuring vital signs are as follows:
- Explain the procedure to the resident.
- Delay measuring the oral (PO) temperature at least 15 minutes for residents who have recently smoked or who have had a hot liquid.
- Arrange the steps of measuring vital signs, height, and weight to conserve energy and increase efficiency.
- If taking an axillary temperature, make sure the axilla is dry; record the reading with an A, indicating the method used; and follow other facility guidelines for use of approved medical abbreviations or terms.
- If unsure of any reading, repeat the procedure and report your findings.
- The radial pulse (pulse felt at the wrist) should be measured for at least one minute if the resident has heart disease. When taking the apical pulse (listening to the heart beat at the apex, or tip of the heart), listen for at least one minute and record the reading. Review the apical-radial pulse procedure in Chapter 6. Report an irregular pulse (heart beat), because the resident might be experiencing an abnormal heart condition.
- Respirations (includes inspiration and expiration) should be counted for one minute, noting any difficulty in breathing (dyspnea) or pauses in the rhythm of the respirations or the pulse.
- Review the facility’s procedure for using a wheelchair scale or other equipment for immobile residents who cannot stand on a scale.
Record and report vital signs, height, and weight promptly.
- Clean all vital sign equipment after each use, especially stethescope heads, to prevent cross-contamination.