Restorative Care
Training for the Certified Nursing Assistant

Trainer Manual

TABLE OF CONTENTS
Introduction Making the Most of the Training Making the Most of the Lesson Plans Making the Most of the Activities Trainer Preparation Welcome Module Activity T1 Welcome to the training Activity T2 Common Rules to Follow Activity T3 Successful Completion Activity T4 You will learn Trainer Preparation Module one Module one Trainer Preparation Module two Module two Trainer Preparation Module three Module three Trainer Preparation Module four Module four Appendix A Feeding Assistance Appendix B Fall Prevention Page T3 Page T3 Page T3 Page T4 Page T5 Page T7 Page T7 Page T8 Page T8 Page 7a Page 8 Page 27a Page 28 Page 35a Page 37 Page 104a Page 105 Page 114 Page 123

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Introduction
Welcome to the program Restorative Care. This is the trainer manual used by trainers to teach nurse assistants and home health aides about caring for the person with Restorative issues. This manual accompanies the student manual, Restorative Care. This training is activity based. Participants are encouraged to share in the training process, to talk about relevant experiences if they choose and to ask questions.

Making the Most of the Training Program
Use this training manual as a guide for training individually or in groups. If you train on an individual basis it will be more effective to brainstorm with them than to use the activities as written. Individual learners will find brain storming less threatening than having to answer questions or carry a discussion without the support of other participants. It can be taught in small blocks of time or over a series of days. The Restorative Care student and trainer materials cover all the content to advance a nurse assistant or home health aide’s knowledge on this particular subject matter. You also have the option to use any of the lesson plans as part of an orientation for employment or as in-service education tools. The manual is designed to provide you with opportunities for creating facility-specific content, which will make the transfer of knowledge from the classroom to the facility floors, units or to a person’s home easier. You can add any facility specific protocol, policies or procedures that are important for the nurse assistant or home health aide to know that relates to your facility or agency. Be sure to take advantage of the learning feature of “Consider this” and/or exercise at the end of a major heading in the student manual. The student can apply what they just learned and validate their knowledge in that section to a practical clinical situation or a case study relevant to the content and the fictional characters built into the manual. The exercises are a valuable tool for reinforcing the important information in each module and validating whether the student truly understands what was learned. Making the Most of the Lesson Plans Objectives for activities are provided on both the Trainer Preparation Page and at the beginning of each activity. Approximate time frames are given for the entire lesson plan on the trainer preparation page and for individual activities. Preparation for activities is described both on the trainer preparation page and at the beginning of each activity. You are also told what equipment and supplies are needed and what advanced preparation you need to make. You are given instructions to create and use flip charts and markers as part of the student interaction. When using the flip chart you will build the student content necessary as you train. *Note: Any medium, flip chart, overhead or Power Point can be used. Directions for you to train by are provided in the margins of the trainer manual surrounding each relevant page of the student content. Answers to the exercises are included in the trainer manual.

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Making the Most of the Activities Guide the learning process by implementing the activities provided in each lesson plan. The most commonly used activities include the following. Content Review The entire content of the 4 modules of the student text, and the Appendix A, B is contained within the lesson plans. You should cover the key content completely to ensure that students understand all the information. Brainstorming Stimulate thought and encourage participation when leading off an activity with a brief brainstorming session. Throw out a question and encourage students to answer without thinking whether the answer is right or wrong. Write the exact students responses on the flip chart. Use their thoughts as a starting point when reviewing key points from the student content. Discussion Similar to brainstorming, discussion encourages students to volunteer and talk about experiences they’ve heard of or had themselves. To maintain confidentiality, explain that students do not need to mention names when sharing their experiences. These discussions are great to lead into a review of content. Small Group Presentations The instructions for small group presentations are outlined within the lesson plans. Most instructions include dividing the students into two or more smaller groups. Assign specific sections of content for each group to review, and ask them to choose a spokesperson to present the key points to the entire group of students. You can also choose a recorder to write key points from the presentation onto the flip chart as the spokesperson is reviewing. This type of activity helps keep the students engaged in the learning process.

Consider this
These scenarios or case studies can be found throughout the module. These are real life situations that challenge the student to use critical thinking and apply knowledge just learned. The trainer is instructed to review the information on the fictional character then, pose the issue. Students are instructed to write in their solution(s) then, open the discussion to the group.

EXERCISES
A variety of exercises can be found throughout the module. The trainer is instructed to have students answer the questions then review and discuss the answers.

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Restorative Care; Training for the Certified Nursing Assistant

Introduction to the Training
Lesson Summary Lesson Plan Plan Summary
Time: 2 hours Number of Activities: 4 Number of skills: 0

At the completion of this introduction students will be able to: State your name and at least one classmate’s name State the class rules List the criteria for successful completion State general information about the course calendar Explain the purpose of the training program Describe the student manual Describe the two characters Rosemarie and Jean Note to the trainer: This introductory module is about creating a positive beginning. If students are unfamiliar with you and each other it is important to create a supportive friendly environment for learning. This is a good time for you to communicate the goals of the training and criteria for successful completion. Using repetition allows students to hear key points over and over. Using role modeling for some activities allows students to use other senses during the learning process. The flip charts are numbered according to module. For example, in flip chart 1-1, the first number indicates module 1, the second number 1 refers to the first flip chart for the module. When asking for a student response to record on a flip chart always use the word(s) the student chooses. Do not change their words, by changing someone’s words you are saying their words are not good enough. Remember as trainers we are always trying to build self esteem. Always applaud and thank students after completing work or doing a presentation even if you need to add key points they did not mention. After every activity ask the students if they have any questions.

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Learning Objectives

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Trainer Preparation

Obtain the following equipment and supplies

Activity T-1 Welcome

Activity T-1

Create a Flip chart T-1 labeled Welcome, My name is ____________ Marker One piece of paper for each student, pens or pencils

Activity T-2 Class Rules Create a Flip chart T-2 labeled Class Rules Add all the rules you would like to communicate to the students such as class time, eating and drinking in class, break times and smoking rules. Marker(s)

Activity T-2

ActivityT-3
Create a Flip chart labeled Successful Completion Add your criteria for successful completion. You may want to include your attendance policy and passing grade. Marker

Activity T-4
Create a Training calendar Make one copy for each student One student manual for each student

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Restorative Care
Introduction

Activity T-1
Objective: At the completion of this activity students will know you and at least one classmate’s name Supplies needed: Flip chart T-1 labeled Welcome My name is _________________ Marker One piece of paper for each student, pens or pencils Time: 1 hour 1. Begin this activity by displaying the flip chart labeled Welcome, My name is _____________and greeting each student as they come into the classroom. 2. Introduce yourself and tell the class about your background as a trainer. If you feel comfortable share some personal information about yourself such as marital status, children, pets etc. 3. Divide the group into pairs and instruct each person to conduct an interview with the other. Give each student a piece of paper and pen/pencil if needed. Tell the students to interview their partner by asking for their name, where they were born, one personal fact they would like to share and why they are taking this course. Tell the person conducting the interview to write the answers on the piece of paper you have provided. Explain to the group that they do not have to share personal information if it makes them feel uncomfortable. Allow 5 minutes for the interviewing, and then ask each student to introduce the person they interviewed, sharing the information gathered. 5. Optional: You may have your own ice breaking exercise you prefer to use.

Activity T-2
Class Rules Objective: At the completion of this activity students will be able to state the class rules Supplies needed: Flip chart T-2 labeled Class Rules with your added rules Marker(s) Time: 10 minutes 1. Begin this activity by displaying the flip chart labeled Class Rules and explain to the class in order for the training to be successful class rules must be established. Review your rules with the students. Be sure to cover information such as class times, breaks, rest rooms, smoking, drinking and eating, your expectation on class participation or not participating, respecting the opinions of others. This is also a good time for you to discuss behavior you find bothersome such as calling out answers without raising a hand or being rude to others. 2. Ask the students if there is anything they would like to add or negotiate. Be sure everyone is in agreement with all the rules. 3. Be sure to tell the students they are not required to share any personal information in this training.

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Activity T-3
Successful Completion Objective: At the completion of this activity students will be able to list the criteria for successful completion. Supplies needed: Flip chart T-3 labeled Successful Completion Marker Time: 10 minutes 1. Begin this activity by displaying the flip chart labeled Successful Completion with your added criteria for successful completion. You may want to include your attendance policy and passing grade. 2. Review the criteria you have established with the class.

Activity T-4
Training/ student Manual Objective: At the completion of this activity students will be able to: State general information about the Course calendar Explain the purpose of the training program Describe the student manual Describe the two characters Rosemarie and Jean Supplies needed: Course calendar, one for each student Student manual, one for each student Time: 40 minutes 1. Begin this activity by distributing copies of the course calendar to each student. Explain the schedule and answer any questions they may have. 2. Distribute copies of the Restorative Care student manual to each student and ask them to open to page 1. Read the section “To the student”, the purpose of this course, the note on the language used in the manual and the Introduction, or ask for a volunteer to read. Ask the students if they have any questions. Be sure the students understand the purpose of the training and the importance of knowing as much information as possible to be able to help the person needing restorative nursing care and their family members through this process. 3. Review the modules and briefly explain what they will be learning in each. 4. Explain there are various exercises and special learning aids that will help the students in the learning process. 5. Read the information about the two fictional characters the students will meet throughout the student manual. Explain that they will be presented with different scenarios or case studies based on Rosemarie and Jean. These scenarios will help the student think about how the information they learn can be applied to real life situations that may occur when a person is receiving restorative care.

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Restorative Care Training for the Certified Nursing Assistant
Second Edition Authors, Margaret Casey-Mederios and Kathleen Masucci Copy Design Matthew Ross Masucci CC&R Health Care Solutions Winthrop, MA Copy Edit Tom Lochhaas Independent Consultant Newburyport, MA

Cover Design Rick Michaud Graphic Group Burlington, MA

Content Support Janice Young CC&R Health Care Solutions Winthrop, MA

Photos and Illustrations Robert Cavanaugh American Health Care Association Washington, D.C.

Commonwealth Corporation Contributors Pat Caron Carol Kapolka Caroline Kirton Gregg McCutcheon Betsy McIntrye Karen Shack

Content Copyright 2008 by Commonwealth Corporation Commonwealth Corporation The Schrafft Center 529 Main Street. Suite 1M8 Boston, MA 02129

Format Design Copyright 2005 CC&R Health Care Solutions CC&R Heath Care Solutions P.O. Box 520086 Winthrop, MA 02152 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without permission in writing from Commonwealth Corporation.

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Restorative Care Training for the Certified Nursing Assistant
Second Edition

Acknowledgment:
Commonwealth Corporation would like to acknowledge those who reviewed the second edition and provided great feedback to enhance the quality of these materials. Donna Howie, SunBridge Care and Rehabilitation Lauri Toohey

In addition Commonwealth Corporation would like to thank all the contributors to the first edition of these materials. We acknowledge:

Kenneth O. Bean Margaret Sullivan Linda McLinden Lutheran Home of Worcester Mary Jane Cavallo Cheryl Trimby Notre Dame Long Term Care Margaret Macksey Oakdale Skilled Nursing and Rehabilitation Center

Virginia L’Bassi Consultant

Lena L. Deter, Educational Services and Consulting

Alfred Gray, Jr. Greenberg & Traurig David Siddle Assumption College

We wish to also acknowledge the Commonwealth of Massachusetts and the Executive Office of Labor and Workforce Development for the ongoing financial support of the Extended Care Career Ladder initiative, which has made this publication possible.

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Restorative Care
As you grow in your career, you have the unique opportunity to develop special sets of skills that allow you to advance your knowledge. This growth further enhances your ability to be more involved with the person* you are caring for, their family, and other team members. In this course you will learn about restorative care. Although in your daily caregiving you already practice many of these skills, this program focuses primarily on mobility issues as well as on you taking on the role of teacher and coach. To help the person you care for maintain or restore their optimum level of functioning, these roles are necessary to ensure the person’s mobility. In the appendices of this manual you will learn additional knowledge needed to prevent falls, assist with feeding, and provide bowel bladder training. Remember, as in all caregiving, you must maintain the person's privacy, dignity, and confidentiality. *Note: This manual throughout refers to the resident, client, or patient as the “person” you care for. This Restorative Care course is organized in four modules. Following is an overview of the main topics in each: Module One The Influence of Movement on the Body Module Two Key Elements in Restorative Care Module Three Mobility Activities: For Maintenance and Restoration Module Four Additional Knowledge and Skills Appendices A Preventing Falls B Feeding Assistance

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Learning Aids In addition to presenting information, this manual includes exercises and scenarios to help you learn the information and be successful in practice. The following special learning aids will help you master the knowledge. 1. Objectives. Objectives are statements at the beginning of each module that tell you the key ideas you must learn. They also state what you will be able to do after completing the module. The objectives are numbered. 2. Key Terms. When acquiring any new skill, you must learn the special words related to that skill or activity. These “key terms” will help you understand specific vocabulary related to restorative care. These terms are defined at the beginning of each module. 3. Consider This. Throughout each module you will see problems under the heading “Consider This.” These are real-life situations that challenge you to apply your new knowledge. These problems also teach you what can happen if you do not follow a particular procedure. In some cases there may be several right answers. The key is to think about the situation, jot down your solutions, and discuss them with your co-workers and trainer. 4. Exercises. Throughout the modules, exercises are included to help you make sure that you understand the information you just read. Review exercises at the end of each module help you determine whether you have learned the module’s important ideas. 5. Summary. This conclusion summarizes key information you have learned in the module. A note on language. This manual uses some terms that may be different from what you use where you work. For example, the people for whom you care may be called resident, patient, or client. This manual refers to them as the person or people. Since various health care practitioners and specialists may write orders and direct a person’s care, this manual refers to them as the health care provider. The staff caring for the person are generally referred to as the health care team.

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In addition to the learning aids you will meet two fictional characters named Jean and Rosemarie. They will appear throughout this program. Getting to know them will help you apply the knowledge and skills you need when providing restorative care and will help you through your training. One of these characters has a chronic condition, which will help you to understand the importance of restorative activities to maintain the person’s optimal level of functioning. The other person recently has had a stroke. The goal for this person is to restore them to their optimal level of functioning. Meet Jean Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently.

Meet Rosemarie Rosemarie is a 78-year-old woman with high blood pressure. She lives at home with her 80-year-old husband. Rosemarie is being admitted to your facility following hospitalization for a cerebral vascular accident (stroke). A stroke is a condition that occurs when blood flowing to the brain is interrupted. The stroke left her with right-sided weakness that seems to affect her arm more than her leg. She is being admitted for rehabilitation. She will be discharged back home with services provided in her home. Rosemarie has one son.

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Restorative Care; Training for the Certified Nursing Assistant

Introduction
As a member of the interdisciplinary team, you have a role in ensuring that all people who enter the facility maintain at least the level of ability they had when they were admitted. What this means is if a person with arthritis in their hands is able to eat independently, every effort must be made to help that person continue to eat independently. Staff should not feed the person unless they develop a physical problem that interferes with their ability to do so on their own. Ensuring improvement or maintenance of a person’s independence in nursing care is known as restorative nursing. Restorative activities promote a person’s independence in activities of daily living (ADLs) like eating, bathing, dressing, toileting, continence, mobility, and positioning. Restorative activities are ways you can support people to regain or maintain their ability to care for themselves. The goal of restorative activities is to help the person achieve their optimal, or best, level of functioning in their ADLs. All the caregiving you do should involve a restorative approach. When caring for a person, you must always ask yourself, “How can I help this person be as independent as possible?” Ask yourself whenever you are helping a person, “What can I do to help this person regain or maintain their independence?”

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MODULE

1

The Influence of Movement on the Body

Lesson Summary Plan Summary Lesson Plan
Time: 3 hours 30 minutes Number of Activities: 4 Number of Skills: 0

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Learning Objectives for Module One:

At the completion of this module students will be able to: Provide an overview of the body systems Describe what happens to the body when movement is a problem Describe at least one common condition that affects movement Describe one of the more common acute conditions that affect movement

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Trainer Preparation

Obtain the following supplies and equipment

Activity 1-1
Create Flip chart 1Create Flip chart 1-1 labeled Cognitive Impairment Create Flip chart 1-2 labeled Dementia Create Flip chart 1-3 labeled Symptoms of Dementia Marker Option 1 Flip charts, markers, tape, blank flip chart paper Option 2 Create flip chart 1-1 labeled Integumentary System Create flip chart 1-2 labeled Musculoskeletal System Create flip chart 1-3 labeled Respiratory System Create flip chart 1-4 labeled Circulatory System Create flip chart 1-5 labeled Digestive System Create flip chart 1-6 labeled Urinary System Create flip chart 1-7 labeled Nervous System Create flip chart 1-8 labeled Endocrine System Create flip chart 1-9 labeled Sensory System, Eye and Ear Create flip chart 1-10 labeled Male Reproductive System Create flip chart 1-11 labeled Female Reproductive System

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Activity 1-2
Create flip chart 1-12 labeled How Movement Effects the Body

Activity 1-3
Create flip chart 1-13 labeled Common Conditions that Affect Movement Marker, tape, blank flip chart paper

Activity 1-4
Create flip chart 1-14 labeled Common Acute Conditions that Need Restorative Activities Marker, tape, blank flip chart paper C. Review the Introduction to module one with the students or ask for a volunteer to read it. Each module begins with a short introduction to the information the student will be learning.

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MODULE

1
1a

The Influence of Movement on the Body
OBJECTIVES
After studying this module you will be able to: Provide an overview of the body systems Describe what happens to the body when movement is a problem Describe at least one common condition that affects movement Describe one of the more common acute conditions affecting movement and requiring rehabilitation

Review the objectives for Module One, “The Influence of Movement on the Body”. Explain the objectives are listed at the beginning of each module and represent the key knowledge and skills students should learn. 1a

Review the Key Terms. The key terms are listed alphabetically at the beginning of each module. Each term is defined. Explain that the student may see these terms used in other modules also. 1b

1b

 KEY TERMS
Hemiparesis- weakness affecting one side of the body Hemiplegic- paralysis of one side of the body Paresis- weakness usually involving the limbs

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Introduction to Module One
1c
n this module you will review the body systems. You will learn the role of movement in keeping them healthy as well as some of the more common and acute conditions that affect movement and influence your work in restorative activities. Although all body systems are influenced by restorative activities, the skills in this program primarily focus on mobility. Mobility influences almost every body system. As you read the following overview of the body systems, think about what can happen if a person could not move.

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Review the Introduction to module one with the students or ask for a volunteer to read it. Each module begins with a short introduction to the information the student will be learning. 1c 1d

Activity 1-1

1d

Overview of Body Systems
Before you can fully understand the impact of movement on the body, you need a general sense of what each body system does, its structure and function, and what happens in the body system as the body ages.

Overview of the Body Systems At the completion of this activity students will be able to: • Identify the structure, function and agingrelated changes of each of the 11 body systems There are 2 options for this activity. Supplies needed option 1: • flip charts, markers, tape, blank flip chart paper Time: 2 hours / both options Supplies needed option 2: • flip chart 1-1 labeled Integumentary System • flip chart 1-2 labeled Musculoskeletal System • flip chart 1-3 labeled Respiratory System • flip chart 1-4 labeled Circulatory System • flip chart 1-5 labeled Digestive System • flip chart 1-6 labeled Urinary System • flip chart 1-7 labeled Nervous System • flip chart 1-8 labeled Endrocrine System • flip chart 1-9 labeled Sensory System, Eye and Ear

Integumentary System (Skin)
Structures The skin has two main layers: • The epidermis is the top layer you can see and feel. • The dermis is the thicker layer beneath the epidermis. Beneath the two layers of skin is a cushion of subcutaneous tissue. This cushion of fatty tissue helps the skin look smooth. Five structures within the skin help the skin stay healthy and help protect the body: • The oil glands, called sebaceous glands, help keep the skin moist. • The sweat glands help the body get rid of heat and waste products. • Hair roots and hair over parts of the body can add to the person’s appearance and help protect the skin. • Melanocytes are the cells that give color to the skin. • Blood vessels nourish the skin and help control body temperature (Fig. 1).

Figure 1 The skin and its components.

• flip chart 1-10 labeled Male Reproductive System
Module 1

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• flip chart 1-11 labeled Female Reproductive System Option 1 1. Begin this activity by making the following statement, before you can fully understand the impact of movement on the body you need a general sense of what the body does, its structure and function, and what happens to the body systems as the body ages. 2. Explain that the body systems will be reviewed as a group activity. 3. Explain the following group activity. Divide the students into 11 groups representing the 11 body systems. (the number of students in each group will depend on the number of students enrolled in the training).

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Tell the students to read the information on their assigned body system. Explain that each group should present the key points about the body system they are assigned from under the headings structure of the system, functions of the system, and aging changes of the system. Each group should choose a spokesperson to present the information. Each group has the option to choose a recorder to write key points onto the flip chart as the spokesperson speaks. Provide flip chart paper, markers, and tape for the groups that want to display key points. Tell the groups they have 15 minutes to prepare and 10 minutes to present. 4. After each presentation, add any key points from the student manual not presented. 5. Thank each participant for a job well done. 6. Ask the students if they have any questions about the presentations. Option 2 This preparation is for you, if you want to present the information on the 11 body systems 1. Begin this activity by displaying the flip chart labeled Integumentary System. Make 3 columns with the headings Structures, Functions, and Aging Changes. 2. Ask the students if they can recall the structures of the Integumentary system. 3. Write the student’s responses on the flip chart. 4. Discuss the student’s responses. 5. Ask the students if they can recall the functions of the Integumentary system. 6. Write the student’s responses on the flip chart. 7. Discuss the student’s responses.

Functions The skin is important because it protects the body in two ways: • It prevents germs in the environment from entering the body. This is the first line of defense against infection. • It helps control body temperature. When it is hot, the skin sweats to let out body heat by dilating blood vessels. When it is cold, blood vessels constrict to keep heat in. Some changes as you age: • Skin is less able to retain moisture. • The dermis layer of the skin thins. • Elasticity of the skin decreases. • The hypodermis layer of skin shrinks due to loss of fatty tissue.

Musculoskeletal System
Structures The musculoskeletal system is made up of bones, muscles, tendons, ligaments, and joints: • • • • • Bones are the frame for the body. Muscles allow the body to move. Tendons attach muscles to bones. Ligaments attach bones to other bones. Joints are where two or more bones come together (Fig. 2).

Figure 2 The musculoskeletal system and its components

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8. Ask the students if they can recall what happens to the Integumentary system as a person ages. 9. Write the student’s responses on the flip chart. 10. Discuss the student’s responses. 11. Review the key points from the student content under the headings Overview of the Body Systems, Integumentary System, Structures, Functions, and Some Changes as you Age. 12. Write the key points you want students to remember on the flip chart. 13. Continue this activity by following the same steps for the remaining ten body systems.

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Functions The musculoskeletal system helps give the body its shape and enables it to move. Movement is important for good health. Some changes as you age: • • • • The spinal column shortens due to compression of vertebrae and changes in posture. Minerals are lost from bones. Muscle mass diminishes. Elasticity in the muscles is lost.

Respiratory System
Structures The main structures of the respiratory system are: • The nasopharynx is the nasal passage. • The oropharynx is the mouth and oral passage. • The trachea connects the mouth and nose to the bronchi. • The right and left bronchi are the airway passages into the lungs. • he bronchioles are branches from each bronchus. These air passages inside each T lung look like an upside-down tree. • he lungs take air in, move oxygen into the blood, and remove carbon dioxide from T the blood. • The alveoli (air sacs) look like hundreds of blossoms on the bronchioles (Fig. 3).

Figure 3 he respiratory system T and its components

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Functions Breathing (respiration) is the exchange of oxygen and carbon dioxide in the lungs. This is one of the most basic and important body functions. The respiratory system takes in oxygen through the nose or mouth as we breathe in (inhale or inspire) air. The air passes through the bronchi and bronchioles and into the alveoli. The oxygen then passes into the blood vessels and is carried by the blood to all body parts. Oxygen is exchanged for carbon dioxide in the blood. The air that we breathe out (exhale or expire) gets rid of the carbon dioxide from the body. The heart and lungs work together to oxygenate the blood. Some changes as you age: • The chest wall and lung structures become more rigid. • Respiratory muscle strength decreases. • Less air is exchanged with each breath.

Circulatory System
Structures The heart and blood vessels working together make up the circulatory system. The heart is a muscular organ with four chambers. It is located behind the ribs and between the two lungs; the largest part lies in the left side of the chest. The heart pumps blood through the blood vessels to every part of the body. Every time you count a person’s pulse, you are counting how fast the heart pumps blood through the body. Three types of blood vessels carry blood to and from the heart and organs throughout the body: • Arteries carry oxygenated blood from the lungs and heart to the organs. • Capillaries, which are tiny blood vessels, connect arteries and veins and exchange oxygen for carbon dioxide inside the organs. • Veins carry deoxygenated blood from the organs back to the heart and lungs (Fig. 4).

Figure 4 The heart and its components

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Functions The circulatory system carries oxygen from the lungs and other vital nourishment to all the cells of the body. It also carries waste products to some organs so the body can get rid of them. Some changes as you age: • • • • The heart muscle wall thickens, becomes stiffer, and may increase in size. The blood vessels become more rigid and stiff. Sensors that regulate blood pressure with position changes are less sensitive. The heart rate decreases.

Digestive System
Structures • The mouth takes in food and fluid. Food is chewed and mixed with saliva, beginning the digestive process. • The esophagus is a tube that passes swallowed food and fluid from the mouth to the stomach. • The stomach is a sac-like organ that mixes food and fluid with digestive juices, preparing it for absorption. • The small intestine is a long tube-like structure where most of the absorption of nutrients takes place. • The liver produces bile, which helps digest fatty foods. • The gallbladder stores bile. • The pancreas produces digestive juices, which help break down foods for nutrients to be absorbed, and insulin, which regulates the body’s blood sugar level. • The large intestine is a long tube-like structure that moves the remaining food and waste through the body to the rectum and out of the body through the anus. • The large intestine absorbs fluids the body needs. • The anus is the opening from which food wastes, in the form of feces, come out in a bowel movement (Fig. 5).

Figure 5 The digestive system and its components

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Functions The function of the digestive system is to provide the body with a supply of nutrients and fluid and to remove food waste products. Some changes as you age: • Food passes through the digestive system more slowly. • The amount and effectiveness of digestive juices are decreased.

Urinary System
Structures The urinary system is one of the most important systems in the body. It helps the body maintain fluid balance (the amount of water in the body) and eliminate liquid wastes. The urinary system has these major structures: • The right and left kidneys maintain the body’s fluid balance by filtering out waste products and producing urine. • The right and left ureters are tubes that carry urine from the kidneys to the bladder. • The bladder is a sac-like muscle that stores urine until it is eliminated. The urethra is the tube that carries the urine from the bladder outside the body (Fig. 6).

Figure 6 The urinary system and its components Functions The urinary system eliminates waste materials from the blood and reabsorbs the proper amount of water and salt for the body. Some changes as you age: • Decreased size of kidneys • Decreased bladder capacity • Decreased bladder muscle tone • Decrease in hormones that regulate fluid volume

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Nervous System
Structures The nervous system has three major parts: • The brain is located within the protective skull. Messages are received and interpreted in the brain, which is the body’s communication center. Information is processed and stored. Thinking, reasoning, and judgment are brain functions. • The spinal cord contains nerves that control movement. It extends down the back and is protected within the spine (vertebral column). • The nerves are fibers that extend from the spinal column to all parts of the body. The nerves carry messages in both directions between the body and brain. Information received from the outside world is taken to and processed in the brain, and messages from the brain travel back to the body to control functions (Fig. 7).

Figure 7 The nervous system and its components Functions The nervous system is like a communication center. It helps you make sense of the world. The nervous system works with the sensory and endocrine systems to direct all other body systems. Some changes as you age: • Nerve impulses slow. • Blood flow to certain areas of the brain decreases.

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Endocrine System
Structures The endocrine system includes many different glands. Glands are organs that make and release hormones, which are substances that needed by different organs. The following are the major structures in the endocrine system: • The pituitary gland, located in the brain, secretes hormones and regulates other glands such as the ovaries and testes. It is often called the “master gland.” • The adrenal glands, located on top of the kidneys, secrete hormones that regulate metabolism. They also help regulate sodium, water, and potassium levels in the body. Adrenal glands release hormones that increase blood sugar, control blood vessel constriction, and help us to react in emergency situations. • Cells called the islets of Langerhans, located in the pancreas, secrete insulin, which controls the breakdown of carbohydrates (sugars) in the body. • The thyroid and parathyroid glands, located in the neck, secrete hormones that help regulate metabolism, the process of producing energy. • The female ovaries, located in the pelvic area, secrete hormones that control sexual function and are involved in pregnancy. • The male testes or testicles, located in a sac behind the penis, secrete a hormone controlling sexual function and sperm production (Fig. 8).

Pituitary Thyroid Parathyroid Thymus Adrenals Pancreas Ovaries Testes

Figure 8 The endocrine system and its components Functions The endocrine system makes hormones that help the body work properly. Their vital functions include the regulation of body energy, the breakdown of sugar for energy, and reproductive fertility. Some changes as you age: • Glands have a slower rate of releasing hormones. • Insulin production decreases. • The amount of hormones produced by the ovaries is dramatically decreased. • Male hormone production decreases but does not stop.

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Sensory System
The organs of the sensory system are the eyes, ears, nose, tongue, and skin. The sensory system gives us information from the outside world. The senses receive and send information to the brain. Aging influences the function of the senses. Sight and hearing are most commonly affected by aging. Some changes as you age: • • • Smell – the ability to identify or detect odors decreases with age, more commonly in men than in women. Taste – the ability to taste salty and sweet tastes may decrease because of changes in the tongue. Touch – the sensitivity of touch receptors and response to painful stimuli decrease.

The Eye
Structures The eye is a round ball with several major structures: • • • • • • The sclera is the “white” of the eye. The iris is the “color” of the eye. It helps regulate the amount of light that enters the eye by controlling the size of the pupil. The pupil is the opening through which light passes to get to the retina. The cornea protects the iris. The iris and lens direct and focus light on the retina. The retina is the back of the eye, where light images become nerve impulses to the brain. The brain interprets and processes the impulses into pictures (Fig. 9).

Cornea Pupil Lens Retina Figure 9 The eye and its components Functions Sight gives us knowledge about our surroundings. This is important so that we can care for ourselves. Some changes as you age: • • • • • • The cornea flattens. The lens becomes more yellow. The lens becomes more rigid or less elastic. The pupil becomes smaller. The retina becomes less efficient. The iris becomes more rigid. Commonwealth Corporation Pupil Iris

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The Ear
Structures The ear has three areas: • the inner ear • the middle ear • the outer ear (Fig. 10) Outer ear Middle ear Inner ear

Figure 10 The ear and its components These areas have different structures involved in hearing. Sound enters the outer ear and is transmitted through the middle ear to the inner ear. Nerve impulses resulting from sounds go from the inner ear to the brain for interpretation. Other structures inside the ear help the body maintain its balance. If these structures are not working properly, a person may feel dizzy. Functions The ear lets us hear. Hearing, like vision, helps us be aware of the world around us. Sounds provide clues to dangers as well as communication and pleasure. The inner ear also helps us maintain our balance. Some changes as you age: • Hearing structures in the ear become stiff. • Structures in inner ear related to balance begin to degenerate.

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Male Reproductive System
Structures The main structures of the male reproductive system are: • The penis is used for sexual intercourse and urination. • The testes are two oval-shaped glands, sometimes called the sex glands or gonads. They produce sperm cells and the male sex hormone testosterone. Sperm cells leave the body in semen. • The scrotum is the sac that holds the testes outside the body. • The prostate gland secretes one of the fluids that make up semen. • Semen is produced by the seminal vesicle (Fig. 11).

Penis Prostate gland

Testis Scrotem

Figure 11 The male reproductive system and its components Functions The reproductive system provides sexual pleasure and allows humans to reproduce. Some changes as you age: • Male hormone production decreases but does not stop. • The prostate gland enlarges. • Testicular tissue mass decreases.

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Female Reproductive System
Structures The main structures of the female reproductive system are: • The ovaries are two almond-shaped glands located in the pelvis. The ovaries hold the eggs and produce the hormones estrogen and progesterone. • The fallopian tubes are two tubes that carry the eggs from the ovaries to the uterus. • The uterus is the muscular organ that holds the fetus during pregnancy and sheds its lining during menstruation. • The vagina is the muscular canal between the uterus and the outside of the body and is used for sexual intercourse, childbirth, and the passage of menstrual flow. • The vulva is the external structure of the female sex organs. It is made up of the labia major and minor, which are the skin flaps located on both sides of the vagina, and the clitoris, which gives sexual pleasure to females (Fig. 12). Fallopian tubes Ovary

Ovary Clitoris Vulva Labia minora Labia majora

Uterus

Vagina

Figure 12 The female reproductive system and its components Functions The reproductive system provides sexual pleasure and allows humans to reproduce. Some changes as you age: • The amount of hormones produced by the ovaries dramatically decreases. • Vaginal lubrication decreases. Your knowledge of each of these systems will help you in your caregiving. As you continue through this program, think about the body system being affected by the activities of restorative care. If necessary, refer back to this module to help you understand why what you are doing is so important for maintaining the optimal function of each system.

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Consider This
CONSIDER THIS
Remember Jean? Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently. Because of her arthritis, Jean has a tendency to eat and move slowly. She recently started complaining about constipation (difficulty eliminating feces). Describe the aging changes that may be causing Jean’s constipation. Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

Ask for a volunteer to read the information about Jean. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. Because Jean’s arthritis is causing her to eat and move slowly she has developed constipation. What aging changes may be causing Jean’s constipation. Ask the students to write down what aging changes may be causing Jean’s constipation. Allow 5 minutes to write their answers. Ask a few students to read their responses and discuss each.

EXERCISES
List the systems you believe are most affected by slowed or lack of movement. Write your answers in the spaces provided.

musculatory digestive ________________________ ________________________ nervous ________________________ 1e
How movement Affects the Body
The human body is designed for constant movement. The body systems are always changing. When a person stops moving or has restricted movement, the body changes and slows down. Because body systems are connected together, even a small change in movement can affect all body systems. Because aging also slows down the functioning of body systems, the elderly living in long term care are affected even more by movement restrictions. Someone who has been in bed for even a short time may feel stiff or weak because of muscular system changes. They may have a decreased appetite or become constipated because of digestive system changes. They may feel short of breath or dizzy when moving because of circulatory and respiratory system changes. Their skin may become red in places because of integumentary system changes, and their movements may slow because of nervous system changes. Movement is essential for keeping all body systems functioning well. Think about how your body is always moving. Have you ever been sitting in a meeting or at the movies and found yourself crossing one leg and then the other or shifting your weight from side to side? Sometimes you move consciously, such as when you change position to feel more comfortable. Sometimes movement occurs without conscious thought, such as when you change position in sleep to keep the blood flowing freely to all parts of your body and to prevent Commonwealth Corporation

integumentary circulatory ________________________ ________________________ respiratory ________________________

EXERCISES
Allow the students 5 minutes to complete the exercise. Review the correct answers. Ask the students if they have any questions about this exercise. 1d

Activity 1-2

How Movements Affects the Body Objective: At the completion of this activity students will be able to: Describe what happens to the body when movement is a problem Supplies needed: Flip chart 1-12 labeled How Movement Affects the Body Marker Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled How Movement Affects the Body. 2. Ask the students what happens to a person’s body when they stop moving. 3. Write the student responses on the flip chart. 4.Discuss the student’s responses. 5. Ask the students what body systems are affected by lack of movement and to explain how they are affected.

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6. Write the student’s responses on the flip chart. 7. Discuss the student’s responses. 8. Review the key points from the student content under the heading How Movement Affects the Body. 9. Write the key points you want students to remember on the flip chart.

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stiffness. Movement of your limbs and whole body is very important. Each person you care for may differ in how much support they need for moving, but your goal is always to help them optimize their mobility. Some will have difficulty helping with their own care, but you still need to find ways for them to participate in their care and be as independent as possible. In addition, certain areas of the body are more likely to be damaged by lack of movement, particularly the skin. This can result in a pressure ulcer. Usually pressure ulcers can be prevented by proper moving and position changes. Moving and positioning can also reduce swelling and stiffness in limbs. Moving and positioning also help a person be as comfortable as possible (Fig. 13). Moving our bodies is also emotionally important. Without freedom of mobility, a person has trouble meeting basic needs, which may affect their self-esteem and independence.

Figure 13 Movement keeps the blood flowing and prevents joints from becoming stiff.

Consider This
Ask for a volunteer to read the information about Rosemarie. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. Why do you think Rosemarie is angry? Tell students to write their answer in the space provided. Allow 5 minutes to write their answer. Ask a few students to read their responses and discuss each.

CONSIDER THIS
Remember Rosemarie? Rosemarie is a 78-year-old woman with high blood pressure. She lives at home with her 80-year-old husband. Rosemarie is being admitted to your facility following hospitalization for a cerebral vascular accident (stroke). A stroke is a condition that occurs when blood flowing to the brain is interrupted. The stroke left her with right-sided weakness that seems to affect her arm more than her leg. She is being admitted for rehabilitation. She will be discharged back home with services then provided in her home. Rosemarie has one son. When Rosemarie is admitted to the facility, she is very angry. She often yells at the staff and her husband. What do you think is going on with Rosemarie? Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

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Match the body system in the left column with the effect of lack of movement in the right column. Place the correct letters on the lines provided. Body system

EXERCISES
Allow the students 5 minutes to complete the exercise. Review the correct answers. Ask the students if they have any questions about this exercise.

D ___ The muscular system

Effect of lack of movement A - movement may slow B - short of breath or dizzy C - skin may become red D - feel stiff or weak E - decreased appetite

E ___ The digestive system B ___ The circulatory and respiratory systems C The integumentary system ___ A ___ The nervous system. 1f

Common Conditions that Affect Movement
As mentioned in the Introduction of this module, restorative care involves both maintenance and improvement of daily activities. When a person has a chronic illness that can affect mobility, you must consider restorative activities at all times. Three of the most common chronic conditions that may affect mobility are: • Chronic obstructive pulmonary disease (COPD) • Congestive heart failure (CHF) • Osteoarthritis (arthritis) Following the description of each of these conditions are some suggestions of restorative activities you can perform to help maintain mobility. Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease results from many years of problems with the bronchial passageways and lungs. Bronchitis, emphysema, and asthma are types of COPD. These diseases cause a chronic inflammation that narrows the bronchioles and alveoli. This narrowing results in a loss of lung elasticity. What you can do: • Encourage deep breathing. • Encourage rest between activities. • Encourage slow deep breaths and frequent rest periods when walking. • Position the person as directed (elevate the head of the bed, lean the person over the bedside table with a pillow underneath them, or on their side with the head of the bed slightly elevated) (Fig. 14).

1f

Activity 1-3

Common Conditions that Affects Movement Objective: At the completion of this activity students will be able to: Describe at least one common condition that affects movement. Supplies needed: Flip chart 1-13 labeled Common Conditions that Affects Movement. Marker, tape, blank flip chart paper Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Common Conditions that Affect Movement. 2. Discuss the fact that restorative care involves both maintenance and improvement of daily activities. When a person has a chronic illness that affects mobility the students need to consider restorative activities at all times. The three most common chronic conditions are:

Figure 14 Keeping the head of the bed elevated will reduce a person's respiratory distress. Commonwealth Corporation

Chronic Obstruction Pulmonary Disease Congestive Heart Failure
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Osteoarthritis 3. Explain the group activity.

Group Activity Divide the students into 3 groups. Give each group their assignment. Group 1 Chronic Obstructive Pulmonary Disease, Group 2 Congestive Heart Failure, and Group 3 Osteoarthritis. Tell the students to read the information on their assigned condition. Explain that each group should present the key points about their condition and what to do for the condition. Each group should choose a spokesperson to present the information and a recorder to write key points onto the flip chart. Provide flip chart paper, markers, and tape for the groups that want to display key points. Tell the groups they have 5 minutes to prepare and 5 minutes to present. 4. After each presentation, add any key points from the student manual not presented. 5. Thank each participant for a job well done. 6. Ask the students if they have any questions about the presentations.

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Congestive Heart Failure Congestive heart failure occurs when the heart muscle weakens. The heart moves blood through the body less effectively. CHF is common in people who have had high blood pressure and coronary artery disease for years. What you can do: • Monitor respiration. • Monitor weight. (Fig. 15) • Monitor fluid intake and output. • Encourage deep breathing. • Encourage rest between activities. • Position the person as directed (elevate the head of the bed).

Figure 15 One sign of congestive heart failure is edema, especially in the legs and ankles. Osteoarthritis Arthritis is a common joint problem that causes pain and limits movement in affected joints. The two most common types are osteoarthritis and rheumatoid arthritis. Osteoarthritis is more common. It is caused by age and a lifetime of wear and tear on the joint. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) form at the sides of the joints. Rheumatoid arthritis is an inflammatory disease of the joints. Because of the inflammation, the joints become swollen, warm, and painful (Fig. 16).

Figure 16 A person with arthritis can have swollen, disfigured joints.

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What you can do: • Plan care around pain medication if needed. • Encourage the person to do as much as possible. • Encourage use of adaptive devices. • Encourage exercise. • Perform range of motion exercises as needed. • Use splints if ordered to prevent deformities.

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Activity 1-4

Common Acute Conditions that Need Restorative Activities Objective: At the completion of this activity students will be able to: Describe one of the more common acute conditions affecting movement and requiring rehabilitation. Supplies needed: Flip chart 1-14 labeled Common Acute Conditions that Need Restorative Activities Marker Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Common Acute Conditions that Need Restorative Activities. 2. Explain the most common reasons for a person entering your facility for rehabilitation services are Cerebral Vascular Accident, Myocardial Infarction, and fractures. 3. Explain the following group activity. Divide the students into 3 groups. Give each group their assignment. Group 1 Cerebral Vascular Accident

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Common Acute Conditions that Need Restorative Activities
The most common reasons for a person entering your facility for rehabilitative services after discharge from a hospital are: • Cerebrovascular accident (CVA, stroke) • Myocardial infarction (heart attack) • Fracture The type of care needed and provided depend on the outcome of the person’s acute episode. But the goal for each of these acute conditions includes encouraging the person to become mobile again. You will be guided by the person’s care plan, which is based on input from the interdisciplinary team. The following sections provide some general guidelines. Cerebrovascular Accident (CVA, Stroke) Cerebrovascular accident, or stroke, can be caused by many things, including narrowing of a blood vessel because of plaque buildup, a blood vessel rupture, or a traveling blood clot that blocks the blood flow. A stroke may cause a person to experience hemiparesis, hemiplegia, or paresis (Fig. 17).

Figure 17 Exercise can improve a person's circulation and mobility. What you can do: • Support the person’s weak or paralyzed side with assistive and adaptive devices. • Monitor swallowing closely. • Support efforts for the person to communicate. • Provide range of motion exercises to prevent muscle atrophy. • Position affected limb(s) to prevent injury.

Group 2 Myocardial Infarction Group 3 Fracture Tell the students to read the information on their assigned common acute condition. Explain each group should present the key points about their condition and what to do for the condition. Each group should choose a spokesperson to present the information.
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Each group has the option to choose a recorder to write the key points onto the flip chart as the spokesperson speaks. Provide flip chart paper, markers, and tape for the groups that want to display key points. Tell the groups they have 5 minutes to prepare and 5 minutes to present. 4. After each presentation, add any key points from the student manual not presented. 5. Thank each participant for a job well done. Ask the students if they have any questions about the presentations.

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Myocardial Infarction (Heart Attack) The heart pumps blood containing oxygen and nutrients to the entire body. The heart muscle has its own blood supply. The coronary arteries bring it blood, nutrients, and oxygen. When this blood supply is interrupted due to a blockage, a heart attack occurs. The blockage can be due to plaque or protein along with cholesterol in the inner lining of the arteries that breaks off and forms a clot. This clot can then interrupt or block the flow of blood. What you can do: • Introduce exercise as directed. • Encourage proper nutrition as directed (low-fat, low-salt foods). • Help the person talk about their stress. • Stop any activity if pain occurs. Fracture A fracture is a break in a bone, caused most commonly by a fall. The most common fracture in the elderly is a fractured hip. What you can do: • Assist the person with walking. • Perform range of motion as directed. • Support the fracture as directed. • Use assistive and adaptive device as needed. • Monitor the skin closely for pressure ulcers. Although many illnesses, diseases, and conditions affect movement, these are probably the most common. What is important to know is that some disease processes affect a person’s ability to move. This inability affects almost every system in their body and the quality of their life. Module Four covers in more detail the care of a person with a hip fracture.

Consider This
Ask for a volunteer to read the information about Jean. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. What can you do to help Jean as she walks down the hall? Tell students to write their answer in the space provided. Allow 5 minutes to write their answer. Ask a few students to read their responses and discuss each.

CONSIDER THIS
Remember Jean? Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently. Recently you have noticed that when walking to the day room, Jean holds on to the rail along the hallway walls. What can you do to help her? Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

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1h

Summary
In this module you reviewed the body systems, their structure and function, and aging changes. You also learned how movement affects the body. You learned about some common chronic and acute conditions that affect movement.

Review the Summary with the students or ask for a volunteer to read the summary. Ask the students if they have any questions about the information they have learned in this module.

1h

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MODULE

2

Key Elements to Restorative Nursing

Lesson Plan Summary
Lesson Plan Summary Time: 3 hours Number of Activities: 5 Number of Skills: 0

2

Learning Objectives for Module Two:

At the completion of this module students will be able to: Define rehabilitation and restorative care Describe the roles of the physical therapist, occupational therapist, and the speech language pathologist Explain where to get information about restorative care Describe how to prompt and cue a person

R

Explain why good nutrition is important Trainer Preparation

Obtain the following supplies and equipment

Activity 2-1
Create flip chart 2-1 labeled Rehabilitation Versus Restorative Care Marker

Activity 2-2
Create flip chart 2-2 labeled Information about the Person’s Restorative Program Marker

Additional instructions for 2-2. Each student should read the information about the person they were assigned, from their chart, medical record and care plan. Each student should focus on a problem identified, the goal and date, approaches and staff needed to assist in the goal, to present to the class. Give each student a care plan page that you have prepared, to write their information. Explain that students should focus on restoring a person’s ability to maintain or improve ADL’s. Refer the students to the example in the student content about Rosemarie. Allow 30 minutes for the students to complete this assignment. Create a care plan page with 4 columns for headings Problem, Goal/Date, Approaches and staff. One copy for each student.

Activity 2-3
Create flip chart 2-3 labeled Creating a Successful Restorative Program Create flip chart 2-4 labeled Short and Long Term Goals Create flip chart 2-6 labeled Writing Goals Marker Marker

Activity 2-4
Create flip chart 2-6 labeled Cueing, Prompting and Encouraging Marker

Activity 2-5
Create flip chart 2-7 labeled Nutrition Marker

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MODULE

2
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Key Elements in Restorative Care
OBJECTIVES
After studying this module you will be able to: Define rehabilitation and restorative care Describe the roles of the physical therapist, occupational therapist, and the speech language pathologist Explain where to get information about restorative care Explain short- and long-term goals for a person Describe how to prompt and cue a person Explain why good nutrition is important

Review the objectives for Module Two, “Key Elements to Restorative Nursing”. Explain the objectives are listed at the beginning of each module and represent the key knowledge and skills students should learn.

2a

2b

 KEY TERMS
Cue - to give a hint Dysphagia - difficulty swallowing Goal - something to achieve Prompt - to start, to initiate Aphasia - a loss or reduction of language, including talking, understanding, reading, writing, and gesturing

Review the Key Terms. The key terms are listed alphabetically at the beginning of each module. Each term is defined. Explain that the student may see these terms used in other modules also.

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Review the Introduction to module one with the students or ask for a volunteer to read it. Each module begins with a short introduction to the information the student will be learning. 2c

2c

Introduction to Module Two n this module you will learn about the difference between rehabilitation and restorative care. You will learn about the roles of the physical therapist, occupational therapist, and speech language pathologist in rehabilitation and restorative care programs. You will learn how to find information about the person and your role as a teacher/coach. Although these roles are very similar for purposes of this module, as a teacher you are describing step-by-step procedures and as a coach you are encouraging, prompting, and cueing after the person has learned the steps.

I

2d

Activity 2-1
2d

Rehabilitation versus Restorative Care Objective: At the completion of this activity students will be able to: Define rehabilitation and restorative care Describe the roles of the physical therapist, occupational therapist and speech language pathologist. Supplies needed: Flip chart 2-1 labeled Rehabilitation versus Restorative Care Marker Time: 1 hour 1. Begin this activity by displaying the flip chart labeled Rehabilitation versus Restorative Care. 2. Ask the students to define rehabilitation. 3. Write the student’s responses under Rehabilitation on the flip chart. 4. Discuss the student’s responses. 5. Review the key points from the student content under the heading Rehabilitation. 6. Write the important points you want the students to remember on the flip chart. 7. Ask for 3 volunteers to each play the role of a rehabilitation therapist. 8. Explain their assignment quietly so the rest of the students can’t hear. Volunteer 1 physical therapist Volunteer 2 occupational therapist Volunteer 3 speech language pathologist

Rehabilitation Versus Restorative Care
Rehabilitation A person who enters a facility for rehabilitation is under the direct orders of a physician. Rehabilitation focuses on retraining and teaching new skills. Rehabilitation is typically needed as the result of a direct injury. This person often needs the skills and interventions of a physical therapist (PT), occupational therapist (OT), and a speech language pathologist (SLP). Rehabilitation care is time limited. Following are the roles of each of these disciplines in rehabilitation. Physical therapists. PTs help people restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of people suffering from injuries or disease. Treatment is often exercise but may also include electrical stimulation, hot packs, cold compresses, ultrasound, deep tissue massage, and traction. Occupational therapists. OTs help people improve their ability to perform the tasks of daily living and support improvements in their environments. The therapist helps people to improve their basic motor functions and reasoning abilities and to compensate for any permanent loss of function. The goal is to help a person be as independent as possible. Speech language pathologists. SLPs help people with speech, language, and swallowing difficulties (dysphagia) that can result from a variety of causes including stroke, brain injury or deterioration, developmental delays or disorders, learning disabilities, hearing loss, aphasia, and emotional problems. Special training is available for nurse assistants who wish to work in a rehabilitation program. Certificate programs are also available for becoming a physical therapist assistant. Restorative Nursing Restorative nursing programs focus on what a person can do. Restorative nursing has two primary goals. The first is to restore abilities in a person who has experienced a loss or change in ADL abilities. The second is to maintain or improve on a person’s current abilities. Restorative nursing promotes the person’s independence, self-image, and self-esteem, therefore improving quality of life. By promoting independence, restorative nursing reduces the level of care a person needs. Restorative nursing is guided by the PT, OT, and/or SLP but is supervised by the nursing department. These activities are supervised skills, particularly structured around the activities of daily living. All nurse assistants should be aware of the program established for each person who needs support in activities of daily living. Today many nurse assistants specialize in restorative care with a primary focus on improvement in feeding assistance, incontinence, self-care, and mobility. Note: All states have a nurse practice act. The nurse practice act determines the nurse’s scope of practice. The act typically includes provisions for a nurse to delegate responsibility to an assistant as long as that person has been trained. In this capacity the nurse assistant provides care under the guidance of the registered nurse. You should be aware of what you can and cannot do in your role as a restorative aide. If you are not clear, ask your charge nurse. Commonwealth Corporation

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9. Tell the volunteers to read the information on their assigned therapist. Tell the volunteers they can role play or describe the specifics about the therapist they are assigned. The goal is for the students to listen and try to guess who they are. Allow 5 minutes for the volunteers to prepare. 10. Explain to the rest of the students that they need to guess who the volunteers are role playing. 11. Review the key points about physical therapists, occupational therapists, and speech language pathologists not presented from the volunteers. 12. Explain the role of a rehabilitation aide. 13. Ask the students to define restorative care. 14. Write the student’s responses on the flip chart under Restorative Nursing. 15. Be sure the students understand the focus with rehabilitation versus restorative care.

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EXERCISES
Write your answers in the spaces provided. 1. Define the roles of the physical therapist, occupational therapist, and speech language pathologist.

EXERCISES
Allow students 5 minutes to complete the exercise. Review the correct answers. Ask students if they have any questions about this exercise.

See definitions provided in student manual _______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ 2. Describe the difference between rehabilitation and restorative nursing.

See definitions provided in student manual ______________________________________________________________________________
______________________________________________________________________________

2e

Information About the Person’s Restorative Care
As you know, the person and family members are usually the best sources of information about the person’s needs and abilities. The person’s chart or medical record is another primary source of communication used by the interdisciplinary team. Two other primary communication tools you should be familiar with are the Minimum Data Set (MDS) and the care plan. The MDS is used to collect information about the person. All the disciplines in the facility participate in completing the MDS. All areas of the MDS are important, but for purposes of restorative care the area that assesses physical functioning and bowel/bladder continence are particularly important. Remember, this section of the course is focused primarily on mobility issues; other important areas involving restorative nursing are covered in the appendix. From the MDS assessments, the nursing staff establishes the person’s care plan. The care plan documents a person’s needs and goals as well as actions to be taken. The restorative plan focuses on maintaining or improving the person’s ability to perform the ADLs. The plan of care identifies the person’s problems and the actions needed. Goals are dated; for example, “Rosemarie will be using a walker in seven days from admission, June 20th.” Following is an example of a goal in Rosemarie’s care plan:

2e

Activity 2-2

Information About the Person’s Restorative Care Objective: At the completion of this activity students will be able to: Explain where to get information about restorative care. Supplies needed: Flip chart 2-2 labeled Information about the Person’s Restorative Care 1 care plan page with four columns labeled #1 Problem #2 Goal #3 Approaches #4 Staff Create a care plan page with 4 columns for headings Problem, Goal/Date, Approaches and staff. One copy for each student. Marker Time: 1 hour 1. Begin this activity by displaying the flip chart labeled Information about the Person’s Restorative Care. 2. Ask the students the following questions: Who can give you the best information about a person’s needs and abilities?

PROBLEM • Unable to walk independently to bathroom

GOAL • Able to walk to the bathroom with a walker within 1 week - on or before June 20th

APPROACHES • Provide instructions and demonstration of the use of a walker • Physical therapy twice daily for strengthening • Range of motion exercises three times a day • Practice getting out of bed using walker • Provide initial support with two nurse assistants walking to bathroom

STAFF • Physical therapist

• Physical therapist • Nurse assistant • Physical therapist and nurse assistant • Nurse assistant

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6. Write key points you want students to remember on the flip chart. 7. Assign each student to a resident in your facility to view the person’s chart, medical record and care plans. 8. Explain the assignment. See Trainer Preparation page for instructions. 9. After each presentation, add any key points from the student manual not presented. 10. Thank each participant for a job well done. Ask the students if they have any questions about the presentations.

What tools are used where you work by the interdisciplinary team to communicate information about a person’s needs and abilities? 3. Write the student’s responses on the flip chart 4. Discuss the student’s responses 5. Review the key points from the student content under the heading Information about the person’s restorative care.

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2f

Activity 2-3

2f

Creating a Successful Restorative Program
For the program to be successful for both maintenance and restoration of mobility, short- and long-term goals must be established. Being able to give clear directions as a teacher and to prompt/cue and encourage the person as a coach without upsetting or offending them are critical skills. Remember, helping people in the restorative process has these key elements: • Establishing short-and long-term goals • Teaching, prompting, and encouraging • Providing good nutrition • Use of assistive and adaptive devices • Exercise and mobility This module will focus on the first three elements. The care you provide should be designed based on these key elements. If you do not understand how any activity in the care plan will help the person, talk about it with the nurse or physical therapist. The use of assistive and adaptive devices, exercise, and mobility will be covered in Module Three.

Creating a Successful Restorative Program Objective: At the completion of this activity students will be able to: Explain short term and long term goals Supplies needed: Flip chart 2-3 labeled Creating a Successful Restorative Program Flip chart 2-4 labeled Short Term and Long Term Goals Flip chart 2-5 labeled Writing Goals Marker Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Creating a Successful Restorative Program. 2. Review the key points from the student content under the heading Creating a Successful Restorative Program. 3. Write the key elements needed to help people in the restorative process on the flip chart. 4. Be sure students understand the focus of this module is on the first three elements. They also need to know, if they do not understand how an activity in the care plan will help a person there are many people on the team that can help and guide them. 5. Display the flip chart labeled Short Term and Long Term Goals. 6. Ask the students what short term goals mean and to give an example of one. 7. Write the student’s responses on the flip chart. 8. Discuss the student’s responses.

Short- and Long-Term Goals
Goals are set to focus care on what we want to accomplish. Goals provide specific ways to make improvements. To help people accomplish their goals and optimize their independence, the interdisciplinary team, including you and the person, set goals. Once the goals are established, keeping in mind the person’s desires and preferences, you should be creative to find ways to help them meet their goals. Always acknowledge the person’s progress to help them feel good about their success. If the person was admitted for rehabilitation, most likely the physical therapy (PT) department will establish the goals. For example, consider Rosemarie. A short-term goal is for her to learn to use a walker safely to go the bathroom, so that she can go home. Her long-term goal is to walk short distances. You work closely with the PT department to be sure you understand the goal so you can reinforce the information with Rosemarie. You also discuss this goal with Rosemarie as you begin. Next, working again with a PT, you determine Rosemarie’s current ability to use the walker by observing and learning her capabilities. Now you are ready to help her reach her goals. For example, Rosemarie can get out of bed with some prompting from you and needs only a little help to stand up. However, she expresses fear of falling and is afraid to let go of your arm and use the walker. Under these circumstances, you may have to adjust your short-term goal to help Rosemarie feel comfortable and less fearful while using the walker to stand and transfer to the chair. To try to relieve her fears, you begin by demonstrating how to use the walker when standing up. You show her where to place the walker and where to place her hands when standing up. In addition, you reinforce the idea that using the walker is safe. Show her how the rubber stoppers on the bottom prevent slipping. Tell her you will stay close by to ease her fears and help if needed. When the person meets their short-term goal, move on to the next short-term goal until you reach the long-term goal. Keep the long-term goal in mind as you work on each short-term goal. Goals may be changed if the person shows improvement and should be revised as often as needed. Your ideas to help Rosemarie achieve her goals should fit with the care plan and should be realistic. Always discuss your ideas with the nurse or therapist before trying them.

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9. Ask the students what long term goals mean and to give an example of one. 10. Write the student’s responses on the flip chart. 11. Discuss the student’s responses. 12. Give the students 5 minutes to read the student content under the heading Short and Long Term Goals. 13. Discuss Rosemarie’s short and long term goals. 14. Refer back to the last consider this in module one about Jean holding the rail along the hallways. What short and long term goals could staff establish to help Jean walk better? 15. Display the flip chart labeled Writing Goals and discuss the fact that nurse assistants do not write goals but they do participate in establishing them. 16. Review the key points from the student content under the heading Writing Goals. 17. Write the two major components of writing goals on the flip chart.

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Writing Goals
Although you will not write the goals in the care plan, you must be aware of them. You must participate with other team members in establishing them. You should also understand what is involved when goals are written. Goals are written with two major components. They are action oriented, which means a verb is always used in the goal. For example, "Rosemarie will walk to the bathroom independently using a walker." Second, the goal always has a time frame. The goal for Rosemarie would be written as follows: “Rosemarie will walk to the bathroom independently using a walker in 7 days from admission on or before June 20th.”

EXERCISES
Write your answers in the spaces provided. Write the next goal for Rosemarie after she is successful using the walker to independently go to the bathroom. The goal should be focused on walking a further distance.

EXERCISES
Allow the students 5 minutes to complete the exercise. Review the correct answers. Ask the students if they have any questions about this exercise.

Rosemarie will walk to the activity room using a walker in 7 days _______________________________________________________________________________ on or before June 27th _______________________________________________________________________________

2g

Cueing, Prompting, and Encouraging
In your role as the daily caregiver, use restorative activities when providing care. Take the time to cue and encourage the person to help them to do tasks more independently. Cueing means that you prompt a person to get them started by telling, teaching, or showing them part or all of the needed steps (Fig. 18).

2g

Activity 2-4

Cueing, Prompting and Encouraging Objective: At the completion of this activity students will be able to: Describe how to prompt and cue a person Supplies needed: Flip chart 2-6 labeled Cueing, Prompting and Encouraging Marker Time: 20 minutes 1. Begin this activity by asking a student to volunteer to read the information under the heading Cueing, Prompting and Encouraging. 2. Display the flip chart labeled Cueing, Prompting and Encouraging. 3. Write the key points you want students to remember on the flip chart as the student reads.

Figure 18 Gentle encouragement may be necessary to get a person to participate in their own care.

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As the staff who spends the most time with the person, you are key to the person’s goals being successful. Often staff want to do something for the person because they can do it faster and it may seem easier that way, but this does not provide the best care for the person if they have the capability to do it independently or with help. How you interact with a person can help optimize their function or make them feel more dependent. Some people may need you to teach them with simple step-by-step instructions how to do everyday activities such as how getting out of bed, getting dressed, and using a walker or wheelchair. Others may simply need encouragement, prompting, or cueing—or in other words, coaching. When assisting a person, use your knowledge of how to do the procedure to teach them in clear, simple steps. Below are some suggestions to help a person learn while doing activities with them: • xplain what you want to do. If they do not understand what you are saying, say it in a E different way. Write the steps down if necessary. A • lways give a person time to respond. They may be trying but just have trouble getting started, or they may be moving slowly. • f a person looks puzzled, break down the activity into steps. For example, if you want I a person to get out of bed say, “I would like to help you get out of bed.” “Please roll toward me.” “Now bring your legs over the edge of the bed.” “Now try pushing your upper body up to a sitting position.” “Now stand up.” “Let me help you get into the chair.” • f a person still has trouble, demonstrate what to do or even start each step for them. I For example, for Rosemarie you may have to demonstrate each step since you know she is fearful since her stroke. Showing her step by step what you expect may relieve her fear of falling. • f a person is resists doing the steps, try gently encouraging them to participate. Explain I to them how important it is for them to do as much for themselves as possible.

EXERCISES
Write your answers in the spaces provided. Describe your role as a teacher and as a coach.

As a teacher you provide step by step instruction. Teacher_________________________________________________________________________ As a coach you encourage, prompt, or cue the person. Coach__________________________________________________________________________

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2h

Nutrition
Another key element for a successful restorative program is good nutrition. Nutrition affects a person’s quality of life. The person’s ability to participate in maintaining or improving their strength depends not only on movement but on good nutrition as well. Many studies have shown the maintenance or improvement in mobility and skin integrity involves proper nutrition. Nutrition is even more important for a frail, elderly person. As a caregiver, you have an important role in helping people with meals and monitoring their food intake. With an understanding of what foods are needed, and in what amounts, to maintain health, you can encourage people to make healthy food choices. (Fig. 19).

2h Nutririon

Activity 2-5

Objective: at the completion of this activity students will be able to: Explain why good nutrition is important Supplies needed: Flip chart 2-7 labeled Nutrition Time: 10 minutes 1. Begin this activity by displaying the flip chart labeled Nutrition.

Figure 19 ating a variety of food helps people E stay healthy. Good nutrition involves eating a variety of foods in appropriate amounts and maintaining a healthy body weight. Variety in your food choices helps you get all the nutrients your body needs. A person whose nutrition is poor will not feel as good or function as well as they could. Think about yourself: if you have not eaten do you feel well? Do you like what you’re doing? The same is true for the people you care for. So as you begin restorative activities, consider the person’s nutrition.

2. Ask the students how nutrition can play a role in a restorative program. 3. Write the student’s responses on the flip chart. 4. Discuss the student’s responses. 5. Review the key points from the student content under the heading Nutrition. 6. Write the important points you want students to remember.

CONSIDER THIS
Remember Jean? Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently. Jean has been complaining she is too tired to get up. The last few days you noticed she has not been finishing her meals. When asked about this, she says everything is cold and she is not hungry. What are some things you can do to help Jean get adequate nutrition? Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

Consider This
Ask for a volunteer to read the information about Jean. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. How can you help Jean get adequate nutrition? Ask the students to write down their answers. Allow 5 minutes to write their answers. Ask a few students to read their responses and discuss each.

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Review the Summary with the students or ask for a volunteer to read the summary. Ask the students if they have any questions about the information they have learned in this module. 2i

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Summary
In this module you learned the difference between rehabilitation and restorative care. You learned the roles of a PT, OT, and SLP in rehabilitative care. You learned where to find information about a person and their restorative care needs, as well as the two major components of short- and long-term goals. You learned how important it is to give clear direction and how to prompt, cue, and encourage a person with their restorative activities, and your role as teacher and coach. Finally, you learned how important good nutrition is for the person’s health and the success of their restorative program.

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MODULE

3 Mobility Activities: For Maintenance and Restoration

Lesson Plan Summary
Time: 9 hours 30 minutes additional time will be needed for skill practice and check off Number of Activities: 8 Number of Skills: 22

2

Learning Objectives for Module Three

At the completion of this module students will be able to: Describe the basic principle of moving, positioning and exercise Demonstrate common positions Demonstrate common transfer techniques Demonstrate technique of ambulating with a gait belt Demonstrate range of motion exercises Demonstrate the use of assistive and adaptive devices

R

Trainer Preparation

Obtain the following supplies and equipment

Activity 3-1
Create flip chart 3-1 labeled Basic Principles of Assisting with Restorative Activities Create flip chart 3-2 labeled Protecting Yourself Marker

Activity 3-2
Create flip chart 3-3 labeled Positioning Markers, tape, blank flip chart paper

Activity 3-3
Create flip chart 3-4 labeled Common Preparation and Common Completion Steps 1 hospital style bed with side rails, 1 draw sheet, 2 flat sheets or 1 flat and 1 fitted sheet, 3 pillow cases, 3 pillows

Activity 3-4
Create flip chart 3-5 labeled Bed Positioning 1 hospital style bed with side rails, 1 draw sheet, 2 flat sheets or 1 flat and 1 fitted sheet, 3 pillow cases, 3 pillows Marker

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Activity 3-5
Create flip chart 3-6 labeled Moving Marker 1 hospital style bed with side rails, 1 draw sheet, 2 flat sheets or 1 flat and 1 fitted sheet, 1 pillow case, 1 pillow, wheelchair to transfer bed to chair, mechanical lift with instructions, for the students to view guard belt Marker

Activity 3-6
Create flip chart 3-7 labeled Assisting with Ambulation Gait belt Marker

Activity 3-7
Create flip chart 3-8 labeled Benefits of Exercise Create flip chart 3-9 labeled Key Elements of ROM Exercise 1 hospital style bed with side rails, 1 draw sheet, 2 flat sheets or 1 flat and 1 fitted sheet, 1 pillow case, 1 pillow Marker

Activity 3-8
Create flip chart 3-10 labeled Assistive Devices Marker Marker Display of assistive and adaptive devices some suggestions are listed below Dycem Plate guard Scoop plate Nose cut glass Mug with handles Rocker knife Offset spoon Built up/weighted handles Swivel utensils Universal cuff Braces Canes Quad cane with small or large base Standard walker Hemi-walker Wheeled walker Prosthetics Orthotic devices Splints Trapeze Dressing aids Hand splint Harris hemi-sling

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MODULE

3 Mobility Activities: For Maintenance and Restoration
OBJECTIVES
After studying this module you will be able to: Demonstrate common positioning techniques Describe the basic principles of moving, positioning, and exercise List special conditions to consider when moving and positioning a person Demonstrate use of positioning devices when a person is being repositioned Demonstrate common transfer techniques Demonstrate the technique of ambulating with a gait belt Demonstrate range of motion exercises Demonstrate the use of assistive and adaptive devices

3a

Review the objectives for Module Three, “Mobility Activities: For Maintenance and Restoration”. Explain the objectives are listed at the beginning of each module and represent the key knowledge and skills students should learn.

3a

3b

 KEY TERMS
Contracture - permanent shortening of a muscle or by scar tissue resulting in limb deformity Gait - how someone walks Prosthesis - artificial substitute for a missing body part

Review the objectives for Module Three, “Mobility Activities: For Maintenance and Restoration”. Explain the objectives are listed at the beginning of each module and represent the key knowledge and skills students should learn.

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Introduction to Module Three
Review the Introduction to module one with the students or ask for a volunteer to read it. Each module begins with a short introduction to the information the student will be learning. 3c 3d 3c

I

n this module you will review the key principles for how and when to position, move, walk, or exercise with a person. This review is necessary for applying this knowledge and these techniques when caring for a person in a restorative program. You may have to modify some of these basic skills to help a person with a chronic and/ or acute mobility condition. To successfully modify these skills, you must first have mastered them.

Activity 3-1

3d

Basic Principles of Assisting with Restorative Activities
As you know, almost all of your restorative activities involve assisting the person with movement. Whether you are positioning the person or assisting with ambulation, you must always do some preparation first. Before you begin these activities, you should observe the person’s abilities and ask the nurse, physical therapist, or your co-workers about their capabilities. You must also understand your own limitations. For example, you should never try to move someone from their bed to a chair alone if they need two people for this. To prevent injury to yourself or the person you are moving, think about what you are trying to accomplish. Consider your own and the person’s capabilities, as well as the environment where you are working. Following are questions to consider: Questions about yourself: • Can you do what’s needed on your own? • Have you learned and practiced this skill? • Do you understand the person’s restorative goal? • How much help does this person need? • oes the person have any special needs or behaviors to consider? (Remember RoseD marie and her fear - she would not let go of your arm.) • oes the person have any physical condition that affects their movement, like oneD sided weakness or a recent wound? • How much weight or motion is the person allowed to place on the limb? • Does the person use an assistive device? • Does the person understand what you are asking them to do? • Can the person see and hear you and tolerate what you are about to do? • What equipment do you need? • Do you have adequate lighting? • Have you minimized distractions? • Are any obstacles in your way? • Is the bed at the proper height? • Is everything needed close? • Have you checked all tubing and equipment around the person?

Basic Principles of Assisting with Restorative Activities Objective: At the completion of this activity students will be able to: Describe the basic principles of moving, positioning and exercise Supplies needed: Flip chart 3-1 labeled Basic Principles of Assisting with Restorative Activities Flip chart 3-2 labeled Protecting Yourself Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Basic Principles of Assisting with Restorative Activities and make 3 columns with headings: You/Others/ Environment. 2. Ask the students to list things they would think about before leaving home to go to work. Ask them to consider their family, pets, and their environment. (For example, turning off the lights) 3. Write the student’s responses on the flip chart listing each question. 4. Discuss the student’s responses. 5. Review the key points from the student content under the heading Basic Principles of Assisting with Restorative Activities including the questions about yourself, the person and the environment. 6. Display the flip chart labeled Protecting Yourself.

Questions about the person:

Questions about the environment:

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7. Ask for a volunteer to read the student content under the heading Protecting Yourself. 8. Ask for another volunteer to act as a person needing assistance with transferring from sitting to standing position. 9. Explain that you will demonstrate the steps for protecting yourself after the volunteer reads them. 10. Record the 4 basic steps to consider before you begin any procedure on the flip chart. 11. After the volunteer reads the example for assisting Rosemarie with a shower be sure students understand the steps to prepare, to assist with the procedure, and to complete.

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You must know the answers to all these questions before you begin any restorative activity. In addition, you must also be sure you use good communication skills in all restorative activities. You must be sure the person and your co-workers know exactly what you are trying to accomplish. Giving clear directions is important. Everyone must know what to do and when to start to do it.

Protecting Yourself
Another principle you need to remember is that you should use equipment as needed for support when doing any restorative activity. The goal of using equipment is to minimize the risk of injury to both you and the person. You should also keep in mind the principles of body mechanics, including: • Get help if needed. • Keep one foot slightly in front of the other. • Always maintain a broad base of support by keeping your feet 10-12 inches apart. • Always bend your knees and keep your back neutral. • Use counting as a communication tool for other helpers and the person. The caregiver with the heaviest part of the person’s body does the counting. • Hold the person close to your body when transferring (Fig. 20). • When transferring, turn your whole body as a unit. Do not lift and twist.

Note: You may want to review the rationale for preparing and completion by asking the students to explain what each is and to give the reason why it is important. An example would be for number 1, what does it mean to knock on and wait for permission to enter? Student response “Knocking on the door and waiting for permission sends a message of respecting one’s privacy and dignity before entering a person’s home.”

Figure 20 While moving the person, bring them as close to you as possible The following sections review the skills for positioning, moving in and out of bed (transferring), walking, and range of motion exercise. Before you begin any procedure, remember to consider the basic four steps: 1. You have a clear understanding of the person’s capabilities. 2. You prepare to do the procedure, including gaining permission from the person. 3. You carry out the procedure. 4. You complete the procedure.

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Consider the following example. Rosemarie wants to take a shower before her son and husband arrive for a visit. If you consider the questions above, your preparation for the shower will include the following steps: To prepare for a shower you would: 1. Knock on Rosemarie’s door, and wait for her permission to enter. 2. Introduce yourself and say, “Good morning, Rosemarie.” 3. Check with her to be sure she wants to take a shower. 4. Schedule the shower room. 5. Ask her how much help she needs and if there is anything special you should know. You may have to help determine what help she needs, since her stroke left her with right-sided weakness in her arm. 6. Wash your hands. 7. Gather all supplies needed for the shower, such as a washcloth, towels, and bath blanket. 8. As needed, prepare Rosemarie’s own supplies, such as soap, deodorant, clean clothes, and lotions. To assist with the procedure: 1. Help her to the shower. Be sure she is completely covered during the transfer. 2. Help Rosemarie get ready. Encourage her to do as much as possible. 3. Turn on the water and check the water temperature. Ask her if the water temperature feels OK. 4. Provide her as much privacy as possible. 5. Assist with washing as needed. At the completion of the shower you would: 1. Assist with drying and dressing (if there is a dry dressing area in the shower area). 2. Return her to her room. 3. Assist her to her chair. 4. Provide the call light and check if she needs anything. 5. Wash your hands. 6. Report and document the activity. Because you prepared in advance and asked yourself the questions above, you can complete the shower without having to stop to get other supplies and risking a potential injury by leaving Rosemarie alone. You were also able to complete the task without any concerns or problems.

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3e

Positioning
Positioning is how you help people sit, lie down, or change position when they cannot move independently. Even people who can move by themselves may need help with positioning. They may have trouble getting comfortable or have skin problems from not changing positions often enough. The best positions for a person depends on their body type, medical needs, equipment needs, skin condition, and comfort. As with all restorative activities, you must observe a person and work with the nurse and physical therapist to choose the best way to position them. For example, when positioning a person, look for and consider some of these factors: • posture concerns (such as rounded back, forward head, leaning to one side) • skin redness or breakdown • casts or splints • contractures in arms, legs, hands, or feet (in a stiff position or swollen) • equipment such as intravenous tubes or oxygen In addition, consider other circumstances when providing restorative care. The circumstances or the person’s condition may affect how you should modify a procedure. The following sections describe different circumstances and conditions and what you need to do.

3e

Activity 3-2

Positioning Objective:At the completion of this activity students will be able to: List special conditions to consider when moving and positioning a person Supplies needed: Markers, tape, blank flip chart paper Time: 1 hour 1. Begin this activity by displaying the flip chart labeled Positioning. 2. Review the key points from the student content under the heading Positioning. 3. Write what to look for and consider when positioning on the flip chart. 4. Explain the following group activity. Divide the students into 7 groups. Give each group their assignment. Group 1 Cardiopulmonary Issues Group 2 Sensory Issues Group 3 Dementia Issues Group 4 Amputation Group 5 Prothesis Group 6 Casts Group 7 Contractures Tell the students to read the information on their assigned topic. Explain each group should present the key points about the Issue/Condition that may affect how they would modify a procedure. Each group should choose a spokesperson to present the information Each group has the option to choose a recorder to write key points on the flip chart as the spokesperson speaks. Provide flip chart paper, markers and tape. Tell the groups they have 5 minutes to prepare and 5 minutes to present. 5. After each presentation, add any key points from the student content not presented. 6. Thank each participant for a job well done. 7. Ask students if they have any questions about the presentations.

Cardiopulmonary Issues
A person with cardiopulmonary issues may experience shortness of breath, pain, and fear during moving and positioning activities. What you should do: • Ask the person if they have concerns about exercise. Explain that exercise will improve their blood circulation. • Allow frequent rests during exercise. • Monitor the person’s balance when walking or moving from one place to another. • Position the person so they are comfortable and breathing is easiest. This is often done by elevating the head of the bed or having the person lean over a table. (Be sure to place a pillow on the table). • Assist the nurse with oxygen therapy. • Follow the care plan exactly and report any changes. • If necessary when walking with the person, have another staff member follow with a chair for rest periods.

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Sensory Issues
Sight A person whose eyesight is diminished will have difficulty walking and moving around in their room. They may also be unsteady on their feet, being unable to distinguish changes in flooring heights or surfaces. In addition they will need more support with ADLs. What you should do: • Keep all furniture and personal belongings in the same spot. • Maintain adequate lighting. • Minimize clutter. • Use assistive and adaptive devices as ordered or needed, such as eyeglasses or a magnifying glass. • Use touch if appropriate to let the person know you are present. • Talk while doing care so the person knows you are there. Hearing A person whose hearing is impaired may have difficulty with directions you provide them. Depending on the cause of the hearing loss, they also may have balance problems, which may result in falls or other injuries from bumping into walls, furniture, etc. What you should do: • Be sure the person wears their hearing aid. • Minimize background noise. • Stand facing the person at eye level when speaking. • Speak slowly and clearly. • Speak in normal voice tone. • Use prompts and objects to help understanding. • Write things down.

Dementia Issues
A person with dementia will have memory loss. They will have difficulty remembering how to do the ADLs. They will also have difficulty finding their way around an environment that once was familiar. A person with dementia will have difficulty understanding and communicating the spoken word. Mobility will be an issue because they eventually forget how to walk. They may shuffle or walk unsteadily. Eating*, swallowing*, and incontinence* become a problem as well as behavior issues. *These issues are addressed in Appendices of this manual

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What you should do: • Speak in short sentences. • Ask questions that require only simple answers. • Break tasks down into step-by-step procedures. • Use cues and prompts to get the person started. • Repeat steps as needed. • Assist with ambulation. • Use adaptive/assistive devices as needed.

Amputation
A person who has had a limb amputated will need additional support with ADLs. With a leg amputation walking may be difficult. In addition, with a recent amputation, wound care may be necessary. What you should do: • Wash and dry the stump thoroughly. • Keep the socket, sock, and sheath, and insert clean and dry at all times. • Encourage the person’s use of their prosthesis. • Monitor skin for any reddened area or breakdown, and report this to the nurse immediately. • Encourage the use of other assistive devices as needed.

Prosthesis
Following an amputation or injury, or with a congenital defect in which a limb or missing, a prosthesis can be used to increase mobility and other activities of daily living. The prosthesis is made specifically for the person. What you should do: • Assist the person in the use of the prosthesis. • Monitor the person’s skin. • If the person complains that the prosthesis is hurting or uncomfortable, report this immediately.

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Casts
A cast is applied when a bone and or a joint has been damaged. The cast protects the broken bone and helps the area rest and heal. What you should do: • Monitor swelling. Elevate the affected area using pillows, trying to keep it above the heart. • Squeeze the nail bed of the casted limb until it turns white, then release the pressure to see if the pink color returns. • Have the person move their fingers or toes frequently. • Report any changes or rough areas on the cast that may cause tissue injury. • Be sure not to get the cast wet during bathing.

Contractures
A contracture is a deformity caused by a permanent shortening of a muscle or by scar tissue. A contracture can occur in a person for a number of reasons, such as joint pain, inactivity such as in prolonged periods of bed rest, muscle imbalance, and immobilization. What you should do: • Provide ROM exercise to all joints, especially if a person is on bedrest. • Encourage movement and walking as much as possible. • Encourage the use of adaptive equipment for ADLs. • Be sure to use splints and other positioning devices as needed and ordered to prevent problems and promote comfort. • Monitor the person’s skin for redness and breakdowns, and report any immediately to the nurse.

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3f

Most Common Positions
The following sections describe skills for positioning and moving, including transfers, walking, and range of motion exercises. As with all skills you perform, you must do certain steps before and after the skill. What you do is influenced by both your abilities and the person’s capabilities, the supplies needed, the skill to be done, and where the skill is being performed. The most common preparation and completion steps are listed below: Common Preparation Steps 1. 2. 3. 4. 5. 6. 7. 8. 9. Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work.

3f

Activity 3-3

Most Common Positions At the completion of this activity students will be able to: Demonstrate common positioning techniques Supplies needed: Flip chart 3-4 labeled Common Preparation and Completion Steps 1 hospital style bed with side rails, 1 draw sheet, 2 flat sheets or 1 flat and 1 fitted sheet, 3 pillow cases, 3 pillows Time: 2 hours/add 2 hours for practice/add 4 hours for practice and check off 1. Begin this activity by displaying the flip chart labeled Common Preparation and Completion Steps. 2. Review the steps with the students. 3. Explain how you will demonstrate each procedure, how students will practice and how you will check off each student for mastery. (For instruction for practice, skill check off and a skill attainment record, see the back of this manual) 4. One recommended option for the skills demonstration is to ask a student to volunteer to read each step and another student to volunteer to act as a person needing assistance. To demonstrate each step ask the volunteer reader to pause after reading each step so you can demonstrate it.

10. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. 11. Wash your hands. 12. Wear gloves, goggles, mask, and gown when needed. 13. Offer help with the procedure but only as needed. 14. Use the proper container for dirty items. 15. Observe the person and take advantage of the time to have a conversation. Common Completion Steps 1. 2. 3. 4. 5. 6. 7. 8. 9. Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record.

10. Report any changes in the person or in their environment to the charge nurse.

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Procedure 1. Moving the Person from Supine Position to Sitting Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Help the person roll onto their side toward you, or you can elevate the head of the bed. (Fig. 1) Using your arm closer to the head of the bed, reach under the person’s head and put your hand under their shoulder. Support their head by resting it on your forearm. (Fig. 2) With your other hand, reach behind the person’s knee. (Fig. 3) Using your legs and arms to do the lifting, bring the person’s head and trunk up as you swing their legs down to the sitting position. Hold the person’s legs, letting their knees rest in the crook of your elbow. (Fig. 4) Help the person get comfortable in the sitting position. (Fig. 5)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

(Fig. 5)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 2. Moving the Person from Sitting to Supine Position Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Place one hand behind the person’s shoulder, resting their head and neck on your forearm. Place your other hand under their knees, and resting their legs in the crook of your elbow. (Fig. 1) Using good body mechanics, help the person lift their legs up onto the bed. Gently lower their trunk and head onto the bed. (Fig. 2)

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(Fig. 1)

(Fig. 2)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 3. Moving Up in Bed When a Person Can Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Put the head of the bed down as far as tolerated by the person. Move the pillows against the headboard. Help the person bend their knees up, with their feet flat on the bed. Place one arm under the person’s upper back behind the shoulders and the other under their upper thighs. (Fig. 1) On the count of three, have the person push their feet down into the mattress and lift up their buttocks (bridging) while you help move them toward the head of the bed.

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 4. Moving Up in Bed When a Person is Unable to Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Get assistance from another staff person. Put the head of the bed down as far as tolerated by the person. Remove the pillow and place it against the headboard. Have the person cross their hands over their chest. (Fig. 1) If used, roll the draw sheet up until you and your helper both have a tight grip on it with both hands. Keep your palms up if that gives you more strength for moving. (Fig. 2) Using good body mechanics, on the count of 3, you and your helper lift the person up to the head of the bed . You can do this in stages until the person is in position. Unroll the draw sheet and tuck it in.

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(Fig. 1)

(Fig. 2)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 5. Moving to the Side of the Bed When a Person Can Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Stand on the side of the bed to which you plan to move the person. Help the person bend their knees up, keeping their feet flat on the bed. Help the person to lift up their buttocks, and move their buttocks to the side of the bed. (Fig. 1) Help the person move their legs to the side, and then their head and upper body. Do this by sliding your arms under them and gliding them toward you. You can do this in stages to reach the desired position.

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 6. Moving to the Side of the Bed When a Person Cannot Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Stand on the side to which you plan to move the person. Have the person fold their arms across their chest. (Fig. 1) Place your hands under the person’s head, neck, and shoulders and move them toward you on your arms. (Fig. 2) Place your arms under the person’s hips, and move them toward you. (Fig. 3) Place your arms under their legs, and move them toward you.

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(Fig. 1)

(Fig. 2)

(Fig. 3)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 7. Moving a Person to the Side of the Bed Using a Draw Sheet Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Get assistance from another staff person. Have the person cross their hands over their chest. If used, roll the draw sheet up until you and your helper both have a tight grip on it with both hands. Keep your palms up if that gives you more strength for moving. (Fig. 1) Using good body mechanics, on the count of 3, you and your helper lift the person to the side of the bed . You can do this in stages until the person is in position. Unroll the draw sheet and tuck it in.

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 8. Turning a Person from Supine to Side-lying for Personal Care Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Have the person bend their knees up, and place their feet flat on the bed. (Fig. 1) Place one hand on the person’s shoulder and the other hand on the hip farther away from you. (Fig. 2) On the count of 3, roll the person toward you. Continue personal care. (Fig. 3)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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3g

Activity 3-4

Bed Positioning Objective: At the completion of this activity students will be able to: Demonstrate use of positioning devices when a person is being repositioned Supplies needed: Flip chart 3-5 labeled Bed Positioning 1 hospital style bed with side rails 1 draw sheet 2 flat sheets or 1 flat and 1 fitted sheet 3 pillow cases 3 pillows Marker Time: 1 hour/add 1 hour for practice/add 2 hours for practice and check off 1. Begin this activity by displaying the flip chart labeled Bed Positioning. 2. Write key points you want students to remember about changing bed positions. 3. Ask for a volunteer to read the steps for procedures 9 through 11, one at a time, and a volunteer to act as a person needing assistance as you demonstrate these procedures. 4. Instruct the students on the model you have chosen for skill/procedure practice and check off.

3g

Bed Positioning
Proper positioning in bed is particularly important for a person with a paresis or paralysis and for those who cannot independently change position in bed, or who have contractures. Most people have an established schedule for lying in a particular position at particular times, and position is usually changed at least every 2 hours.

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Procedure 9. Positioning a Person Prone (Stomach Lying) Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Place a flat pillow on the person’s stomach. Turn the person onto their abdomen. Make sure that they are not lying on their arm. Be sure their toes are not hanging over the edge of the mattress, or use a large pillow to support the feet so that the toes do not touch the mattress. Support the head with a flat pillow. Make sure that their face is turned to one side. One arm should be lying straight against the body. The other should be stretched out overhead.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 10. Positioning a Person Supine (Back Lying) Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Turn the person onto their back, being sure their body is in proper alignment. (Fig. 1) Place a pillow under their head and shoulders and one under the knees. (Fig. 2) Put sand bags or small pillows alongside the hips to maintain alignment if needed; and between the person's arm and their side. (Fig. 3) Support the feet against a footboard and place a pillow or roll uder their ankles to elevate their feet off the bed. If needed, place hand rolls in the person’s hands to support their fingers and thumbs and prevent contractures. (Fig. 4)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 11. Positioning a Person Side-Lying Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Turn the person onto their side by using Skill Procedure number 8, Turning a Person from Supine to Side-lying. The arm on the underside is supported by the mattress. (Fig. 1) Place a pillow under the head and neck. (Fig. 2) Tuck a pillow behind the back by tucking the long edge of the pillow between the bed and the person’s body at their back. Roll the opposite long edge of the pillow under itself so that the person has a firm roll to rest upon. (Fig. 3) Place a pillow under the upper arm to support it. (Fig. 4) The leg on the underside is supported by the mattress. Flex the upper leg. Place pillows under the thigh, leg, and foot for support. (Fig. 5) If needed, place hand rolls in the person’s hands to support their fingers and thumbs and prevent contractures.

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

(Fig. 5)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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These skills are used when providing care for anyone who cannot move or has difficulty moving themselves into various positions. At times you will be required to move someone who is unable to move; in that case you are required to change their position every 2 hours. You will use various positioning devices to help you support the person’s position for comfort. Pillows, wedges, hand rolls, foot boards, and sand bags can be used to maintain support and provide comfort to the person in the position.

EXERCISES
Explain how students will practice and when you will check off skills/procedures.

EXERCISES
Demonstrate your mastery of each of these moving and positioning skills: • Moving the Person from Supine Position to Sitting • Moving the Person from Sitting to Supine Position • Moving Up in Bed When a Person Can Help • Moving Up in Bed When a Person is Unable to Help • Moving to the Side of the Bed When a Person Can Help • Moving to the Side of the Bed When a Person is Unable to Help

3h Moving

Activity 3-5

• Moving a Person to the Side of the Bed Using a Draw Sheet • Turning a Person from Supine to Side-lying for Personal Care • Positioning a Person Prone (Stomach Lying) • Positioning a Person Supine (Back Lying) • Positioning a Person Side-Lying

Objective:At the completion of this activity students will be able to: Demonstrate common transfer techniques Flip chart 3-6 labeled Moving 1 hospital style bed with side rails 1 draw sheet 2 flat sheets or 1 flat and 1 fitted sheet 1 pillow case 1 pillow Wheelchair to transfer bed to chair Mechanical lift with instructions, for the students to view Guard belt Marker Time: 2 hours/additional time will be needed for practice and check off 1. Begin this activity by displaying the flip chart labeled Moving 2. Review the key points from the student content under the heading Moving. 3. Write the key points you want students to remember on the flip chart. 4. Ask for a volunteer to read the steps for procedures 9 through 11, one at a time, and a volunteer to act as a person needing assistance as you demonstrate these procedures. 5. Instruct the students on the model you have chosen for skill/procedure practice and check off. 3h

Moving
Any move will be successful if you first consider the person and situation. Remember to consider the questions listed earlier when preparing to move a person. Remember not to move a person by pulling on their arm or the skin under their arm. Pulling can damage blood vessels or nerves or even break or dislocate a bone. The use of a gait/transfer or guard belt can help you prevent injury to the person. Placing a guard belt around the person’s waist helps you move them safely and prevents injury. The belt prevents the person from straining or injuring their arms or legs. People feel more secure moving using the belt. At some times a belt should not be used, such as if the person has a broken rib, abdominal wound, a G-tube, or a colostomy.

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Procedure 12. Putting a Guard Belt on a Person Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Hold the belt with the label on the outside (most manufacturers label the outside). (Fig. 1) Place the belt around the person’s waist over their clothes while they are either lying or sitting. (Fig. 2) With the belt around the person’s waist, put the end through the buckle (or attach the Velcro or plastic fastener), and tighten the belt firmly, being sure you can get your fingers under it to hold it when transferring the person. You may have to tighten it again when the person stands. (Fig. 3)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Guarding and Physical Assistance
Following are guidelines sometimes used to determine what level of assistance a person may need with a transfer: Total assistance = two people or mechanical lift Maximal assistance = 75 % assistance by one person Moderate assistance = 50 % assistance by one person Minimum assistance = 25% assistance by one person Standby assistance = need for supervision by one person Independent = no physical or cognitive assistance required

Procedure 13. The Stand Pivot Transfer Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Stand in front of the person. Place one of your legs between the person’s legs and the other close to the target you are moving toward, such as a chair. (Fig. 1) Hold onto the guard belt on both sides. If you are not using a guard belt, put your arms around the person’s waist. Ask the person to push down on the bed with their hands, lean forward, and stand up. If they cannot do this, ask them to put their arms around your waist. Note: Do not let the person hold you around your neck, which could injure you. (Fig. 2) On the count of 3, ask them to lean forward and stand up. (Fig. 3). You can help the person stand by leaning your body back and up, thereby bringing the person’s body forward. Once the person is standing, pivot (turn on your feet or take small steps) to turn them until the backs of their knees are against the chair. (Fig. 4) Ask the person to reach back for the arm of the chair with one or both hands if possible. (Fig. 5) Help the person bend their knees and sit. (Fig. 6) Once the person is sitting, ask or help them to push back in the chair by pushing down with their feet on the floor and their arms on the armrests.

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

(Fig. 5)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 14. Assisted Transfer with an Assistive Device (One Person) Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Have the person sit on the side of the bed, place the assistive device in their hand (cane) or in front of them (walker). Stand to the side of the person on the side opposite the device. (Fig. 1) Ask the person to push down on the bed with their hands and stand on the count of 3. You can help them by pulling up and forward on the back of the guard belt with one hand while pushing down on the walker or cane to keep it stable until the person grasps the assistive device. (Fig. 2) For people using a walker: after they are standing, help them put both hands on the walker. (Fig. 3) Help the person move toward the chair. (Fig. 4) Help the person back up to the chair. Ask if they can feel the chair against the back of their knees. (Fig. 5) When the person is in front of the chair, ask them then to reach back and put one hand on the armrest. (Fig. 6) Help the person reach back with the other hand for the arm of the chair and slowly sit down. (Fig. 7)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

(Fig. 5)

(Fig. 6)

(Fig. 7)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 15. Transferring a Person from a Chair to a Bed Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Position the chair so that the person’s stronger side is closest to the bed, commode, or toilet. (Fig. 1) If the person is in a wheelchair, ask them to move their feet off the footrests. Raise up the footrests and move them out of the way.. Ask the person to slide forward to the edge of the chair. Use either the stand pivot technique or the assistive device transfer procedure in reverse to move the person from the chair and into bed. (Fig. 2)

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(Fig. 1)

(Fig. 2)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse. Commonwealth Corporation Module 3

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Procedure 16. Moving a Person with a Mechanical Lift
Note: in order to properly use a mechanical lift, you must follow the manufacturer’s instructions. You should never use a lift you have not been trained to use.

Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Adjust the head of the bed as flat as possible. Place the sling under the person by first turning the person toward you. Help the person move toward you while your helper on the other side of the bed pushes the fan-folded sling under the person as far as possible. Then help the person back toward the other side, and pull the sling under them. (Fig. 1) Place the lift frame facing the bed with its legs under the bed. Lock the wheels on the base. (Fig. 2) Elevate the head of the bed so the person is partially sitting up. Attach the sling to the lift following the manufacturer’s directions. (Fig. 3) Ask the person to cross their arms over their chest before operating the lift. Follow the manufacturer’s directions for raising the person to a sitting position. While you operate the lift, your helper should help you guide the person. (Fig. 4) Once the person is in a sitting position, raise the lift until they are 6 to 12 inches over the bed and chair height. Unlock the swivel, if the lift has one, or use the steering handle to move the person directly over the chair. You may need to support the person’s legs. Tell the person that you are now going to lower them into the chair. Your helper should guide the person into the chair by moving the sling. Press the release button to slowly lower them down. (Fig. 5) Once the person is safely in the chair, unhook the sling and remove the lift. Position the person in the chair, leaving the sling under them (unless the sling is removable) until it is time to return to bed. Pull the metal bars of the sling out so that the person does not lean against or sit on them. (Fig. 6)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 17. Moving a Person Up in a Chair Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Place a guard belt on the person. Standing on both sides of the person, you and your helper each grasp the guard belt with one hand and puts the other hand under the person’s knees. Ask the person to cross their arms in front of their chest. Using good body mechanics, on the count of 3, breathe out and lift the person back in the chair. . (Fig. 1)

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 18. Positioning a Person in a Wheelchair Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Place a wheelchair cushion on the seat Be sure the seat width is wide enough to allow approximately ½ inch of clearance on either side of the person. If the seat is too wide the chair will not provide enough side support for the person. Be sure the seat depth allows 2-3 inches of clearance from the back of the person’s knee to the front of the seat, so that circulation is not impaired. Adjust the footrest height so that when the person is sitting they have 2 inches of clearance above the floor. The knee should be at the level of the pelvis or slightly higher. Their feet should be able to rest flat on the footrest. Adjust the armrests so that they are 1 inch higher than the distance from the seat cushion to just under the person’s elbow.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 19. Returning a Person to Bed Using a Mechanical Lift Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Position the lift facing the chair. Attach the sling to the lift following the manufacturer’s directions. (Fig. 1) Raise the person up with the lift. Your helper guides the person by holding the sling. (Fig. 2) Swing the frame of the lift over the bed and slowly lower the person down onto the bed. (Fig. 3) Unless the person will spend only a short time in bed, roll them to one side to remove the sling (which could cause skin irritation if left under the person). (Fig. 4) Position the person as preferred

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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EXERCISES
Explain how students will practice and when you will check off skills/procedures.

EXERCISES
Demonstrate your mastery of each of these moving and transfer skills: • Putting a Guard Belt on a Person • The Stand Pivot Transfer • Assisted Transfer with an Assistive Device (One Person) • Transferring a Person from a Chair to a Bed • Moving a Person with a Mechanical Lift • Moving a Person Up in a Chair • Positioning a Person in a Wheelchair • Returning a Person to Bed Using a Mechanical Lift

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Activity 3-6

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Assisting with Ambulation
Walking is an important restorative activity that helps the person maintain their independence. It is an effective and excellent way for a person to exercise and maintain optimal function. Walking is also called ambulation. Ambulation requires strength, endurance, balance, coordination, sensory input, a certain level of alertness and cognition, and a desire and motivation to walk. Using mobility devices involves assessment, fit, training, and ongoing checks for appropriateness and safety. To walk in the community or on a driveway, grass, or up and down curbs or stairs, the person may need more help and should be referred to the physical therapist for assessment. Think about Rosemarie, who needs this information before she can go home and live with her husband. You may hear the word gait used when discussing ambulation. Gait refers to how someone walks. There are two phases of the gait cycle: • Stance phase: when the foot is on the ground. • Swing phase: when the foot is off the ground and moving forward The two gait phases are influenced by many things, including posture, balance, weight bearing status, standing tolerance/endurance, visual scanning, ability to start a movement, etc. All of these factors must be coordinated to keep a person walking and to prevent them from falling. When assisting a person to ambulate, you need to know their: • Weight bearing status - You must always be aware of a person's weight bearing status. A physician might order a change in weight bearing after surgery or if there is a problem with pain or wound management. • Endurance status - You need to know person's endurance level, which affects how far or how long they can ambulate. Endurance is affected by physical fitness level, pain, fear, and decreased breathing capacity. • Vision and perceptual issues - Problems with vision or the ability to correctly perceive what's around them will impact a person’s safety. You need to know if the person has any problems.

Assisting with Ambulation Objective: At the completion of this activity students will be able to: Demonstrate the technique of ambulating with a gait belt Supplies needed: Flip chart 3-7 labeled Assisting with Ambulation Gait belt Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Assisting with Ambulation. 2. Ask students what they know about walking. 3. Write the student’s responses on the flip chart. 4. Discuss the student’s responses. 5. Review the key points from the student content under the heading Assisting with Ambulation. 6. Ask the students to explain the following terms relating to ambulation. Stance phase Swing phase Weight bearing status Endurance status Vision and perceptual issues 7. Review the terms and definitions the students are unsure of. 8. Be sure students know how to use a gait belt

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If a person needs assistance or supervision when walking, use a gait belt around their waist. Before you begin ambulation, you need to know the following: • Do they use an assistive device? • How much help, if any, do they need to walk? • How much cuing do they need to stay safe? • Do they need a brace, prosthesis, or other equipment? • How far can they walk safely? • Do you need another staff person to help? • How much weight can they place on their legs while walking? Once you have determined a person’s situation and abilities, you can help them walk (Fig. 23). Combine short walks with other activities such as getting out of bed, walking to and from the bathroom, walking to meals, activities, etc. Encourage people who can walk on their own to do so throughout the day. For example, a person who has just used the toilet will be walking back to their chair. If this person can walk a short way without becoming tired, place the chair outside the room or down the hall instead of next to the bathroom, and have them walk to the chair. If the person has been assigned to an ambulation program by the physical therapy or nursing department, make sure to follow the daily ambulation schedule and record your results. It is very important for the person to maintain their function and mobility by walking as assigned and whenever possible. Muscles must be used to keep their strength and function; as they say, “If you don’t use it, you lose it.” It takes only a short time for a person to lose their mobility skills.

CONSIDER THIS
Remember Jean? Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently. Because Jean has not been eating much, she has not been taking her walks. You notice she has been asking for the commode instead of walking to the bathroom. She says her legs are too stiff and she is afraid she will not make it to the bathroom. What can you do about this situation? Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

Consider This
Ask for a volunteer to read the information about Jean. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. What can you do about the situation?

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Activity 3-7

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Assisting with Range of Motion Exercises
In addition to walking, you will be involved in other forms of exercise for both maintaining and restoring mobility. Remember, exercise is an important restorative activity and should be part of a person’s daily routine. All people benefit from exercise, and you can help a person’s rehabilitation by including exercise in your nursing care activities. An exercise program can greatly increase a person’s muscle strength and flexibility and is a key factor for them to regain mobility. Many facilities offer regular group exercise programs. Encourage those you care for to participate in such programs. Following are benefits of exercise: • Increased joint flexibility • Improved muscle strength • Increased bone density • Cardiovascular conditioning and increased endurance • Improved balance • Improved coordination • Increased self-confidence and self-esteem • Decreased anxiety • Decreased depression • May help in weight control • Maintenance of normal body functions (skin integrity, circulation, digestion, elimination, and pulmonary)

Assisting with Range of Motion Exercises Objective: At the completion of this activity students will be able do: Demonstrate range of motion exercises Demonstrate the technique of ambulating with a gait Supplies needed: Flip chart 3-8 labeled Benefits of Exercise Flip chart 3-9 labeled Key Elements of ROM Exercise 1 hospital style bed with side rails 1 draw sheet 2 flat sheets or 1 flat and 1 fitted sheet 1 pillow case 1 pillow Marker Time: 1 hour 30 minutes/additional time will be needed for practice and check off 1. Begin this activity by displaying the flip chart labeled Benefits of Exercise. 2. Ask students what the benefits are for exercising. 3. Write student responses on the flip chart 4. Discuss the student’s responses. 5. Review the key points from the student content under the heading Assisting with Range of Motion Exercises. 6. Write any benefits of exercise from the list students have not mentioned.

EXERCISES
List at least five benefits of exercise. Write your answers in the spaces provided.

See benefits of exercise. _______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

EXERCISES
Allow students 5 minutes to complete the exercise. Review the correct answers. Ask students if they have any questions about this exercise.

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Range-of-Motion Exercises
Range-of-motion (ROM) exercises are one of the most common restorative programs you will encounter. ROM exercises involve moving each joint in the body through its full range of motion within the person’s ability. The person’s physician, along with the physical therapist and nurse, designs their ROM exercise program depending on their needs, capabilities, and motivation. What is range of motion? • Range of motion is the optimal mobility expected at a joint of the body. • It is a method of moving the joints of the body through their normal range of possible motion. There are three types of joint motions: • One-plane freedom of motion is found in hinge joints. This motion occurs in the elbow and knee joints. • Two-plane freedom of motion occurs in joints with natural motion in two planes, such as occurs in the wrist joint. Flexion and extension and radial and ulnar deviation all occur in this joint. • Three-dimensional or compound motion occurs in the hip and shoulder joints. These motions are flexion and extension, abduction and adduction, and rotation. What is the purpose of range of motion and exercise programs? • Maintain or increase joint movement • Maintain or increase muscle strength and length • Prevent loss of function in ADLs • Prevent contractures and skin breakdown • Prevent pain due to poor muscle tone and contractures

7. Display the flip chart labeled ROM Exercises. 8. Review the key points from the student content under the heading Range of Motion Exercises and key elements of a ROM program. 9. Write the different key elements and types of ROM exercise on the flip chart. 10. Ask for a volunteer to read the steps for procedure 20 range of motion exercise, one at a time, and a volunteer to act as a person needing ROM exercises as you demonstrate this procedure.

Key Elements of a ROM Program
• Positioning is important! The person should be in the position of greatest comfort to allow for maximum range of motion. Review the care plan to be sure you know which exercises to perform. • Be gentle with the person to minimize unnecessary pain. Be sure to remove any obstacles in the way of a movement if there is a chance you might bang into something. • Explain to the person what you would like to do and why. • Keep both hands on the person’s extremity for the best support of the joint during each exercise. When moving a joint, have one hand above and the other hand below the joint. • Make sure to tell the person what you are doing before each movement. Ask the person often how they are doing and if they feel any pain from a motion or the position of your hands. Watch the person’s facial expressions because they may not always be able to tell you when they are uncomfortable. • Follow the care plan for how often to perform ROM exercises. As much as possible, also have the person use their arms and legs throughout the day. • For your comfort and to prevent muscle strain or injury, remember your own body mechanics. Be sure the bed is at a comfortable working height and you are as close as possible to prevent reaching too far.

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• You should be able to complete a person’s ROM exercises in 15 minutes if you prepare ahead. Tell the person what time you will be coming to do the exercise. Be sure they are ready and in comfortable clothing. You can also incorporate ROM exercises into other activities of daily living like bathing and grooming.

Following are the different types of ROM exercise:
Active range of motion exercise (AROM). In active ROM exercises the person moves the body part independently using their own muscle power. The person may only need to be reminded to do the exercises. If the program is structured, they may need you to read the exercise program aloud as they are doing it. Active assisted range of motion exercise (AAROM). In active assisted exercises, you help move the body part. Some people need you to help them by supporting the limb during the exercise. This is common when a body part is healing or if the person does not have enough strength to move the limb in full ROM independently. Passive range of motion exercise (PROM). Passive exercises are performed when a person cannot move a part of the body at all or enough to help with the exercise. In this situation you perform the exercise by moving the joint yourself. At different times the same person may perform different types of ROM exercises. They may be able to move some joints better than others. Allow the person to do as much as they can.

Consider This
Ask for a volunteer to read the information about Rosemarie. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. Describe what type of range of motion exercises Rosemarie needs. Ask the students to write down their answers. Allow 5 minutes to write their answers. Ask a few students to read their responses and discuss each.

CONSIDER THIS
Remember Rosemarie? Rosemarie is a 78-year-old woman with high blood pressure. She lives at home with her 80-year-old husband. Rosemarie is being admitted to your facility following hospitalization for a cerebral vascular accident (stroke). A stroke is a condition that occurs when blood flowing to the brain is interrupted. The stroke left her with right-sided weakness that seems to affect her arm more than her leg. She is being admitted for rehabilitation. She will be discharged back home with services then provided in her home. Rosemarie has one son. Describe what type of ROM exercise program she would benefit from. Which joints on each side of her body should be exercised? Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

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Procedure 20. Range of Motion Exercise Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps Shoulder
Flexion: bring the whole arm up toward the person’s head in front of the body. Extension: bring the arm straight back to their side. (Fig. 1) Abduction: move the arm away from the body out to the side. (Fig. 2) Adduction: bring the arm back toward the side. (Fig. 3) Internal rotation: turn the shoulder in. (Fig. 4) External rotation: turn the shoulder out.

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(Fig. 1)

(Fig. 2)

(Fig. 3) (Fig. 4)

Skill Steps Elbow
Flexion: bend the elbow. (Fig. 1) Extension: straighten the elbow. Supination: turn the palm up. (Fig. 2) Pronation: turn the palm down. (Fig. 3)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

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Skill Steps Wrist
Flexion: bend the wrist down. (Fig. 1) Extension: bend the wrist back. (Fig. 2) Ulnar deviation: with the hand held at the same level as the forearm, move the hand toward the little finger side. (Fig. 3) Radial deviation: with the hand as above, move the hand toward the thumb side. (Fig. 4)

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(Fig. 1)

(Fig. 2)

(Fig. 3) (Fig. 4)

Skill Steps Hand
Finger abduction and adduction: spread fingers apart and then move back together. (Fig. 1) Finger flexion: bend the fingers at each of the finger joints (three on each finger, two on the thumb). (Fig. 2) Finger extension: straighten the fingers out at the finger joints. (Fig. 3) Opposition: touch each fingertip to the thumb. (Fig. 4)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

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Skill Steps Hip
Flexion: bring the knee toward the chest. (Fig. 1) Extension: lay the leg down straight. (Fig. 2) Abduction: bring the hip out to the side by moving the leg. (Fig. 3) Adduction: bring the hip back toward the side by moving the leg. (Fig. 4) Internal rotation: turn the hip inward by moving the leg. (Fig. 5) External rotation: turn the hip outward by moving the leg.

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

(Fig. 5)

Skill Steps Knee
Flexion: bend the knee. (Fig. 1) Extension: straighten the knee. (Fig. 2)

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(Fig. 1)

(Fig. 2)

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Skill Steps Ankle
Dorsiflexion: bend the top of the foot up toward the face. Plantarflexion: point the foot down, like stepping on a gas pedal. Inversion: turn the bottom of the foot inward. Eversion: turn the bottom of the foot outward.

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Skill Steps Foot
Toe flexion: bend the toes down. (Fig. 1) Toe extension: straighten the toes back up. (Fig. 2)

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(Fig. 1)

(Fig. 2)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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EXERCISES
Explain how students will practice ROM exercises and when you will check off skills/procedures. 3k

EXERCISES
Demonstrate your mastery of the skill for passive range of motion exercises.

Use of Assistive and Adaptive Devices
Many kinds of devices are used to improve a person’s function, including braces, walking devices, splints, a trapeze, or dressing aids. Often the therapist assigns this equipment to the person during their rehabilitation to increase their safety and function. You must become familiar with each piece of equipment and understand how and why it is used so you can help the person through the restorative process. Persons may forget to use their equipment or resist using it even if it helps keep them safe from injury. Talk with the nurse or therapist about a person’s abilities, and help identify equipment they can use to improve their functioning. For example, you may observe a problem such as a person having difficulty using a fork. You tell the nurse, and together with the therapist you find an assistive device that will help this person. A simple change in eating utensils can dramatically improve a person’s nutritional status (Fig. 25).

3k

Activity 3-8

Assistive Devices Objective: At the completion of this activity students will be able do: Demonstrate the use of assistive devices Create flip chart 3-10 labeled Assistive Devices Marker Assistive and adaptive devices (see trainer preparation for a list of assistive and adaptive devices to display) Time: 1 hour additional time will be needed for skill/procedure practice and check off 1. Begin this activity by displaying the flip chart labeled Assistive Devices. 2. Display the assistive devices for students to view 3. Ask for a few volunteers to wear a few assistive devices throughout the activity. Tell the volunteers to take notes on how they feel as they are wearing the device. 4. Review the key points from the student content under the heading Use of Assistive Devices, Assistive Devices, Safety Guidelines for Assistive Devices, Prostheses, Orthotics, and Putting on a hand splint. 5. Ask for a volunteer to read the steps for procedures 21 and 22, one at a time, and a volunteer to act as a person needing a hand splint and Harris Hemi sling as you demonstrate these procedures. 6. Review the key points from the student content under the heading Adaptive Equipment. 7. Display the items you have and review each with the students.

Figure 21 There are many kinds of devices that can be used to improve a person's function.

CONSIDER THIS
Remember Jean? Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently. You talk with the charge nurse about Jean not eating as much as formerly. A team meeting is held to discuss a solution. Why do you think Jean would benefit from using adaptive eating utensils? Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

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Consider This
Ask for a volunteer to read the information about Jean. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. Why do you think Jean would benefit from using adaptive eating utensils? Ask the students to write down their answers. Allow 5 minutes to write their answers. Ask a few students to read their responses and discuss each.

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Assistive Devices
When a person cannot support their full weight (not full weight bearing), they use an assistive device for ambulation. A walker provides maximal support, while a cane usually provides less. Following are the most common assistive devices that provide extra weight-bearing support: Cane - an added point of support: • used when a person has a weaker side • held in the hand opposite the weak leg • the person advances the cane along with the weak leg, then advances the stronger leg Quad cane with small or large base - gives four points of support: • used when the person needs more support for balance • held in the hand opposite to the weak leg • all four points should be flat on the floor • the person usually walks more slowly Standard walker - gives more points of support on both sides: • the person lifts the walker up and places it comfortably ahead, flat on the floor • the person is in the stance phase when lifting the walker for the next step • often used for those with an orthopedic condition that restricts their weight bearing • can be fatiguing, and the person usually walks more slowly • provides maximum support for balance problems Hemiwalker - provides support for an affected arm Wheeled walker - gives more points of support on both sides: • the wheels in front allow for easier initiation of movement (“get going”) and propulsion (“keep going”) • allows the person to use a left-right-left-right smooth walking pattern • less fatiguing, and the person usually walks at a normal speed • often used with visually impaired persons to provide a safety barrier around them Remember, the hand grips of mobility devices should be comfortable for the person to hold, with only a slight bend of the elbow.

Safety Guidelines for Assistive Devices
• The rubber tips should be free of dirt and lint, not worn, and routinely checked. • The mobility device should be tested by the caregiver before being used with the person. • The person’s weight bearing status should be checked.

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Prostheses and Orthotics
Prostheses are devices made specifically for a person to improve function for a missing body part, such as an artificial limb. (Fig. 22)

Figure 22 Prosthetic devices are made specifically for each person.

Figure 23 Orthotic devices are used to support a person's limbs.

Orthotic devices, or orthoses, are equipment made specifically for a person to improve or restore function of a limb or body part, such as braces, splints, and shoe inserts. The purpose and function of prostheses and orthoses are: • to position or immobilize a joint for protection or relief of pain • to increase range of motion • to decrease spasticity and/or prevent joint deformity or contracture • to prevent skin breakdown • to allow for increased function • to stabilize and assist weakened muscles (Fig. 23) When a person uses any of these devices, follow these guidelines for proper use and maintenance: • Follow the schedule established by the physical therapist or nurse. • Maintain good hygiene of the skin in contact with the prosthesis or orthosis. Skin should be clean and dry before applying any aids. • Check skin after each use of the equipment for red areas, pressure areas, or other skin irritations. Remove the equipment if this occurs and notify the nurse or physical therapist. • Do not place a splint or plastic orthosis of any kind on a heater or a windowsill because it may melt or lose its proper shape. • Make sure the person is wearing their brace or immobilizer if indicated for transfers or other activities. • Decreased or loss of sensation may also require attention to positioning to prevent skin breakdown and injury to the person. • If a piece of equipment needs repair, consult the nurse or therapist. • If you have a question about a piece of equipment, ask the therapist or nurse for information or assistance.

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Putting on a Hand Splint
The resting hand splint is a splint commonly used to position a person’s hand in an anatomically neutral or functional position. The splint may also provide support for weakened muscles, stabilize joints, assist in normalizing abnormal muscle tone, relieve pain, and prevent deformity and contractures. All splints should be part of a maintenance exercise or range of motion program. They must be taken off at intervals. The wearing schedule should be established by a therapist and documented in the person’s chart. If you are responsible for applying the splint, you should know the schedule and adhere to it. Make sure the splint is clean and in good repair before applying it. Check the person’s hand for pressure sores or reddened areas, discoloration, and swelling. If there is a skin problem or if the splint no longer fits correctly (such as the wrist “pops up” or the splint digs into the forearm), it should not be applied; notify the therapist or nurse.

Procedure 21. Putting on Hand Splint Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Inspect the splint to make sure it is clean and in good condition. Inspect the person’s skin, especially areas where it comes into contact with the splint. Open the hand and fingers to a neutral position, and position the splint in the hand. Position the person’s thumb and fingers appropriately in the splint, and then check the position of the wrist and forearm. Secure the straps over the wrist and then over the thumb and fingers. Finish securing all straps and check that they fit snugly without impairing circulation. Inspect the splint and the person’s hand and arm to ensure that the splint fits correctly in all areas. After the splint is applied, position the person’s arm on a supportive surface or in a sling as directed by the therapist.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 22. Putting on Harris Hemi-Sling
Properly using a hemi-sling is important for maintaining the integrity of the shoulder joint when the person’s arm is paralyzed. It should be worn whenever the person is out of bed, unless a lap board or arm trough is used.

Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
The sling is put on like a jacket or sweater. Drape the elbow guard over the involved shoulder, and put the uninvolved arm through the wrist support. Place the elbow in the elbow guard. Place the wrist through the wrist support. Hook the top buckle. Secure the Velcro strap to the underside of the elbow guard. To remove the sling, simply unhook the buckle and release the Velcro strap. Do not unhook or release any of the other straps.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Adaptive Equipment
Adaptive equipment includes aids to support a person with their activities of daily living. The occupational therapist helps decide which devices will be most beneficial for the person. Your description of the person’s needs is critical in the decision-making process about devices. Some examples are: • long-handled sponge • reachers • sock aide • long-handled shoe horn, • elastic shoe laces • raised toilet seat • grab bars • tub benches • dressing stick • button hook

EXERCISES
Write your answers in the spaces provided. List the assistive, prosthetic, orthotic, and adaptive devices you work with on your unit. For each one, describe how it is being used.

See student content. _______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

3l

Summary
In this module you reviewed the skills needed to help maintain or restore a person’s mobility. You reviewed positioning, transferring, ambulation, and ROM skills. You learned about various assistive and adaptive devices available to ensure a successful restorative program.

Review the Summary with the students or ask for a volunteer to read the summary. Ask the students if they have any questions about the information they have learned in this module. 3l

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MODULE

4 Additional Knowledge and Skills

Lesson Plan Summary
Time: 1 hour Number of Activities: 2 Number of Skills: ?

2 R

Learning Objectives for Module Four

At the completion of this module students will be able to: Explain the importance of proper positioning of a person with a hip fracture Explain the importance of mobility for maintaining skin integrity

Trainer Preparation

Obtain the following supplies and equipment

Activity 4-1
Create flip chart 4-1 labeled Hip Fractures Marker

Activity 4-2
Create flip chart 4-2 labeled Maintaining Skin Integrity Markers, tape, blank flip chart paper

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MODULE

4

Additional Knowledge and Skills
OBJECTIVES
After studying this module you will be able to: Explain the importance of proper positioning of a person with a hip fracture Explain the importance of mobility for maintaining skin integrity

4a

Review the objectives for Module Four, “Additional Knowledge and Skills.” Explain the objectives are listed at the beginning of each module and represent the key knowledge and skills students should learn. 4a Review the Key Terms. The key terms are listed alphabetically at the beginning of each module. Each term is defined. Explain that the student may see these terms used in other modules also. 4b

4b

 K EY TERMS
Shearing - rubbing that occurs whenever there is friction on the surface of the skin

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Introduction to Module Four
Review the Introduction to module 4c one with the students or ask for a volunteer to read it. Each module begins with a short introduction to the information the student will be learning. 4c 4d

I

n this module you will be introduced to two common areas affected by mobility: hip fractures and pressure ulcers. You will find that all the knowledge and skills you learned in the first three modules will be required for a successful outcome in both these areas. In addition, your role as teacher and coach is very important during the rehabilitation of a person with a hip fracture who plans to be discharged.

Activity 4-1

4d

Hip Fractures
The most common fracture in the elderly is a fractured hip. Hip fractures may occur from a fall or from other stresses on the hip, especially when osteoporosis is present. Osteoporosis is caused by a gradual loss of calcium and other minerals from the bones. The signs and symptoms of hip fractures include: • swollen, black and blue area at the break site • complaints of pain or altered sensation • inability to put weight on the leg • an abnormal shape leg, including possible shortening of the limb

Hip Fractures Objective: At the completion of this activity students will be able to: Explain the importance of proper positioning of a person with a hip fracture Supplies needed: Flip chart 4-1 labeled Hip Fractures Chair Walker Toilet/commode Hospital style bed Marker Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Hip Fractures. 2. Ask the students if they have taken care of any person with a hip fracture. 3. Discuss the student’s responses. 4. Review the key points from the student content under the headings Hip Fractures, Using a Walker, Chair Positioning, Sitting, Toilet Transfer, Tub Transfer, Bed Transfer, Bed Positioning, and Car Positioning. 5. As you review the content display items and demonstrate as much as you are able such as using a walker, chair positioning, sitting, toilet transfer, bed transfer and bed positioning. It will not be possible to demonstrate a car transfer or tub transfer in a classroom setting.

Surgery is the treatment of choice. Most people will need rehabilitation following a hip fracture. The surgeon then provides treatment instructions and hip degree precautions. This means that the hip can be raised, or the trunk angled, only to a certain degree limit. Typically the hip is not moved past 60 or 90 degrees. It is important to monitor this during all sitting and self-care activities and during transfers. A precaution is also ordered regarding adducting the hip beyond the midline (such as not crossing the legs). It is important to watch for this when the person is lying down or sitting. In bed, an abductor pillow or brace is placed to keep the person from crossing their legs at the midline. The abductor pillow is placed so that its widest part is at the ankles. The straps should be secure but not tight. They should be loose enough that you can insert two fingers under the straps. When the person is sitting in a wheelchair, the abductor pillow can be placed sideways between the person’s legs to keep them apart and away from the midline while still allowing the person to keep their feet on the footrests. The purpose is to keep the person’s hip in correct alignment so that it heals properly. You play an important role in the care of a person with a hip fracture: • Report any abnormality you see in the person’s leg. • Report any pain. • Learn to position and transfer the person properly. • Assist with the ambulation plan as directed. • Assist the person with mobility according to their care plan. • o ROM exercises to keep other joints and muscles working, as directed on the perD son’s care plan. • Use proper transfer techniques to prevent any harmful movement at the fracture site. • Encourage the person’s independence.

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• Support a person going to physical or occupational therapy for rehabilitation. Help them to use the toilet. Encourage and assist them to dress in comfortable clothing. • Follow the physical therapist’s guidelines for movement, such as walking with a walker. • Recognize that the person may fear falling and fracturing the bone again and therefore may avoid some activities. Be supportive and offer help until the person feels secure. • Follow the instructions of the nurse and physical therapist for positioning the person properly in bed and in a chair. Improper positioning can slow the healing of a fracture. The goals of care for hip fractures are: • Prevent complications from the fracture, such as muscle weakness and joint abnormalities. • Help the person regain their former level of mobility. • Teach and coach the person in the following areas to regain their independence:  using a walker  chair positioning  sitting  toilet transfer  tub transfer  bed transfer  bed positioning  car transfer

Using A Walker
Explain the following steps (Fig. 24) to the person:

Figure 24 You can help a person achieve their short and long-term goals. 1. Keep your hip properly aligned and straight when using a walker. Do not put more weight on the hip than specified. Only put as much weight on the leg as the therapist allows. This will change from very little weight to as much weight as tolerated. 2. Do not rotate the hip at all. This means that you should not turn it inward or outward. Also avoid turning the foot inward, because this will result in the hip also rotating inward. 3. Do not take a step until the walker is flat on the floor, and do not pull up on the walker when rising from sitting.

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Chair Positioning
Always use a firm, sturdy chair with armrests. Sitting on several pillows and putting one behind the small of the back helps maintain the hip in a 90 degree position. Explain to the person that they should: 1. Back up to the chair until you feel the back of your knees touching it. 2. Then move the injured leg out as you reach back for the armrests and lower your body slowly into the chair, keeping the injured leg straight out. 3. When getting up, scoot forward in the chair, keeping your hip positioned at 90 degrees. Push up using the armrests, keeping the injured leg out in front.

Sitting
For an anterior hip fracture, explain to the person: 1. Keep the hip at a right angle (90 degrees) or at an angle greater than 90 degrees until the therapist says you may bend farther forward. 2. Use an abduction pillow. If ordered for several days after surgery, keep the operated leg elevated to control swelling. 3. After 2 to 14 days, with the therapist’s permission, you may bend forward as far as comfortable. For a posterior hip fracture, explain: 1. Keep the hip at a right angle (90 degrees) or at an angle greater than 90 degrees for 6 to 8 weeks, until the therapist says you may bend forward.

Toilet Transfer
Use a toilet commode or other equipment recommended by the therapist. Explain the following steps: 1. Back up to the toilet until you feel the back of your knees touching it. Reach back for the armrests, and slowly lower yourself onto the toilet, keeping your injured leg out in front. 2. Bend your knee and hip on the non-injured side as you lower yourself onto the seat. 3. Reverse the procedure for getting up, pushing on the armrests. Get your balance before grasping the walker. For an anterior hip fracture, explain to the person: 1. Your therapist may suggest the use of different equipment, depending on your individual condition.

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Tub Transfer
Explain the following steps: 1. Using the walker, walk to the side of the tub. Stop next to the chair and turn so that you are facing away from the tub. 2. Reach back with one hand for the back of the chair. Keep one hand on the walker. 3. Sit down on the chair, keeping the injured leg straight out. 4. Lift your legs over the side of the tub and turn to sit facing the faucet. Use a long-handled sponge and shower hose to wash. 5. To transfer out of the tub, turn in your chair while lifting your legs over the side of the tub. Stand outside the tub, pushing off from the chair.

Bed Transfer
Remember: use a firm bed. Avoid a low bed. Explain the following steps: 1. Sit down on the edge of the bed the same way as you would on a chair. 2. Enter the bed, leading with the injured side if possible. 3. Start two-thirds of the way down the bed, and slide your buttocks so that your injured leg comes onto the bed first and you are lying flat on your back. 4. When moving, try to move your body as a whole, keeping your legs apart.

Bed Positioning
Explain the following steps: 1. Keep pillows between your legs when you are lying on your side. This is to keep your hip from rotating inward. It is generally recommended that you lie on your injured side. 2. When lying in bed on your back, do not inwardly rotate your hip (don’t point your toes inward). 3. Keep a pillow between your legs when lying on your back.

Car Transfer
Explain the following steps: 1. Back up to the car using your walker. 2. Enter from the side that allows your injured leg to be supported by the car seat. For example, to support an injured left leg, enter the car on the driver’s side. 3. Lower yourself slowly to the seat. 4. Back onto the seat in a semi-reclining position. With an anterior hip fracture: with your therapist’s permission, you may pivot into the seat and face forward. As you can see, you will play a major role as teacher and coach as a person with a hip fracture recovers to their optimal level of function.

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EXERCISES
Allow students 5 minutes to complete the exercises. Review the correct answers. Ask students if they have any questions about this exercises.

EXERCISES
Describe five important things you can do for a person after a hip fracture. Write your answers in the spaces provided.

See student content. _______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

EXERCISES
List the three goals of care for a person with a hip fracture. Write your answers in the spaces provided:

Prevent complication _______________________________________________________________________________ Regain former level of mobility _______________________________________________________________________________ teach/ coach person to regain independence _______________________________________________________________________________

4e

Activity 4-2

4e

Maintaining Skin Integrity
The condition of a person’s skin often reflects their overall health status. Maintaining intact, healthy skin is a major focus of care for all people in all health care settings. One of the biggest challenges and goals of all health care providers is to prevent the formation of pressure ulcers. Many factors affect a person’s skin integrity, but being immobile or staying in the same position for even short periods of time puts a person at risk. If a person’s skin health is not maintained, they may develop a pressure ulcer. This is also called a decubitus ulcer, or bedsore. Pressure ulcers are a breakdown of the skin caused by pressure, friction, shearing, or too much moisture. Pressure ulcers form when a person remains in one position too long and cannot or does not change positions frequently enough. Pressure over even a short period of time decreases the flow of blood to the area, reducing the nourishment and oxygen the skin receives. Skin cells die, blood vessels break, and an open wound forms. Think about what happens when you sleep: you may fall asleep on your back but wake up on your side. While you are awake and asleep your brain tells your body when there is too much pressure on a body area. Your brain sends a message and you automatically change position to relieve the pressure, in many cases you are not even aware. People with a debilitating disease or condition, however, need your help to change position to relieve pressure. Frequent position changes and exercise help prevent the formation of pressure ulcers.

Maintaining Skin Integrity Objective: At the completion of this activity students will be able to: Explain the importance of mobility for maintaining skin integrity Supplies needed: Flip chart 4-2 labeled Maintaining Skin Integrity Marker Time: 30 minutes 1. Begin this activity by displaying the flip chart labeled Maintaining Skin Integrity. 2. Ask students if they have ever cared for a person with a pressure ulcer. 3. Discuss the student’s responses. 4. Review the key points from the student content under the headings Maintaining Skin Integrity, Pressure Ulcer Stages, Treatment of Pressure Ulcers, and Preventing Pressure Ulcers.

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Pressure ulcers occur most often where the skin is thin and you can easily feel bone underneath. The most common areas are the elbows, shoulder blades, hips, base of the spine (coccyx), and heels. Other common problem areas are the ears, under the breasts, between the buttocks, and other areas experiencing frequent rubbing, friction, or moisture. Friction and shearing forces occur when skin rubs against an object or another area of skin. For example, the side of a person’s leg may rub against the side of their wheelchair, or the inside of the knee may rub against the other knee. In such cases, rubbing a few times can cause the skin to tear—and frequent rubbing can cause blood vessel or tissue damage and skin breakdown. This can also happen when the person is moved or pulled across the bed, such as during positioning. Another cause is due to moisture build-up in areas such as under a female’s breasts or between the buttocks or in the groin area of an incontinent person. Prolonged moisture can cause the skin to weaken or break down. A person who is incontinent is at greater risk for skin breakdown. Weakened skin can contribute to the formation of a pressure ulcer.

Pressure Ulcer Stages
The National Pressure Ulcer Advisory Panel has redefined the stages of pressure ulcers, adding two additional stages to the original four:

Stage 1
Intact skin with non-blanchable redness (does not become lighter in color when pressed with a finger) of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area, or the feel and look of the skin may be different from the surrounding tissue.

Stage2
Partial-thickness loss of dermis (layer of skin tissue) seen as a shallow open ulcer with a red or pink wound bed, without slough (dying skin tissue forming a crust). May also be seen as an intact or ruptured blister.

Stage 3
Full-thickness loss of skin tissue. Subcutaneous fat may be visible, but bone, tendon, and muscle tissue are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (skin tissue dying below the surface).

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Stage 4
Full-thickness tissue loss with bone, tendon, or muscle tissue showing through the wound. Slough or eschar (a thick crust) may be present on some parts of the wound bed. Often undermining and tunneling are present.

Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Deep Tissue Injury Purple localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue. Source www.NPUAP.org

Treatment of Pressure Ulcers
Preventing pressure ulcers is one of the most important jobs you can do. Treatment and healing are difficult, painful, and costly for the person, family, and facility staff. It is important at all times to work with the nurse, using the strategies outlined in the next section. Your role is to report information. These strategies help prevent pressure ulcers from occurring. Many of these strategies are related to care principles you have learned in this program. You must keep the person mobile with ambulation and other exercise programs. Reposition them frequently and provide adequate nutrition. If you keep these strategies in mind, you will be successful in preventing pressure ulcers.

Preventing Pressure Ulcers
Mobility- Help the person to exercise by performing ROM exercise and assisting with walking. Exercise increases the circulation of blood to the skin, supplying nourishment the skin needs to be healthy. If a person cannot walk or tolerate ROM exercise frequent changes in position are needed to relieve pressure and keep blood flowing to all areas of the body. Remember, to prevent friction and shearing never slide the person across the bed. Always use available lifting devices. Nutrition- Ensure that the person eats enough food. Adequate protein, vitamins, and minerals are needed for healthy skin. Report any change in the person’s weight or how much food they eat particularly if they are not eating enough protein. A protein supplement may be necessary. Make sure the person drinks enough fluid. Adequate fluid intake helps all body systems and keeps the skin moist. Observation- Inspect the person’s skin daily. Check under all skin folds daily. Keep these areas clean and dry. Report any reddened areas immediately.

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Toileting- Help the person with toileting as needed. Monitor them frequently for incontinence. If the person is incontinent, wash and dry the perineal area thoroughly. Make sure the person is never left in wet clothes or in any product used for incontinence that is wet. Bathing and moisturizing- Keep the person’s skin clean and dry. Moisturize their skin daily. Use the person’s own products; if they do not usually use such products and you notice their skin is dry, ask the charge nurse what to use. Reporting- Immediately report any change in the condition of the person’s skin.

CONSIDER THIS
Remember Jean? Jean is an 84-year-old woman who has osteoarthritis. Osteoarthritis is caused by a lifetime of wear and tear on joints. The cartilage in joints between bones thins and breaks down, resulting in less shock absorbency. Because of this, bony protuberances (swelling, bumps) appear at the sides of the joints. Jean has been in your facility for a year because she could no longer care for herself. She has great difficulty walking. She uses a walker with support and adaptive devices for eating. She needs support with all activities of daily living. She has one son and two daughters who visit frequently. Because of her decreased appetite and her lack of exercise, you notice a reddened area on her elbow. Describe some things you can do to prevent that area from breaking down. Write your answers in the spaces provided. __________________________________________________________________________ __________________________________________________________________________

Consider This
Ask for a volunteer to read the information about Jean. Explain that these scenarios or case studies help students think about information they just learned and apply it to real life practical situations. They also help students learn to think about other view points and different ways to think about situations. What can you do to prevent Jean’s skin from breaking down? Ask the students to write down their answers. Allow 5 minutes to write their answers.

4f

Summary
This module introduced you to two very common conditions: hip fractures and pressure ulcers. Although you may have learned about them in your initial training, they are included in this program because they are impacted by the restorative activities of mobility: positioning, transferring, walking, and exercise. All your knowledge in these areas can be applied when caring for people with these two conditions, to result in a successful outcome.

Ask a few students to read their responses and discuss each.

Review the Summary with the students or ask for a volunteer to read the summary. Ask the students if they have any questions about the information they have learned in this module. 4f

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The Appendix contains information about additional restorative matters. It is the author’s intent to present this section as a valuable resource for you and your students. If you choose to incorporate some or all of the content into your training, we suggest that you design your lesson plan similar to restorative care. When designing your lesson plan be sure to include the following features: • Lesson plan summary • Objectives • Key terms to study • Introduction • Activity instructions As each new heading or subject matter is introduced you should set up a new activity. Each activity should be set up the same by first stating what number the activity is, objective(s) for that particular activity, supplies needed, any notes, and time allotted. For assistance in custom instructional design for Appendix contact: CC&R Health Care Solutions, Inc. P.O. Box 520086 Winthrop, A 02152 1-877-539-0109

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Appendix A: Preventing Falls

As a member of the interdisciplinary team you will play a major role in preventing people from falling. Falls are the leading cause of death from injury among people age 65 and older. The rate of fall-related deaths in older adults has risen significantly in the last decade. Falls threaten the lives, health, and independence of all older adults in the United States. Every 18 seconds an older adult is treated in an emergency room for a fall-related injury. Every 35 minutes someone dies as a result of a fall or fall-related injury. Each year, falls affect one in three adults 65 and older. Approximately 20% to 30% of falls result in moderate to severe injuries. Two-thirds of those who experience a fall will fall again within six months. Yet falls are not an inevitable part of aging. There are many strategies to help prevent falls. The most common injuries from falls are traumatic brain injuries (TBI) and injuries to the hips, legs, and feet. Hip fractures are the most common fall-related fractures. According to the CDC, by the year 2020 the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion dollars. These costs increase rapidly with the person’s age. According to the CDC, an average long term care facility with 100 beds reports 100 to 200 falls per year. Approximately 1800 older adults die in these facilities each year from fall-related injuries. About 35% of these falls occur with people who cannot walk. These numbers are high because of the characteristics of this population, not necessarily because of issues with long term care facilities. The people living in long term care typically— • are old and frail • have chronic conditions or illnesses • are unable to walk • have poor nutrition status • have problems with thinking and memory and may wander • have difficulties with the activities of daily living The most common causes of falls in a long-term care facility are muscle weakness and problems with walking, gait, and balance.

Objectives
After studying this appendix you will be able to: Describe the impact of a fall on the person’s quality of life Describe risk factors for falls Describe at least 10 general ways that falls can be prevented Describe ways to prevent falls based on identified risk factors Describe your role if a person starts to fall

Introduction to Preventing Falls
In this appendix you will learn about the financial impact falls have on the health care system. You will learn the impact a fall has on a person’s quality of life. You will learn the risk factors contributing to falls, and ways falls can be prevented. You will also learn ways to prevent falls based on identified risk factors, and lastly, you will learn your role if a person starts to fall.

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How Falls Impact Quality of Life
Serious injuries from falls can significantly reduce the quality of a person’s life because of both the injury and resulting complications. Older adults who experience hip or skull fractures from a fall more often die from serious complications such as pneumonia or emboli than do people with the same health conditions who did not experience a fall. The most profound effect of a fall is the loss of independent functioning. After a fall the person often declines in many physical functions such as mobility, ambulation, the activities of daily living, and nutritional habits. As a result of this decline, the person also feels a psychosocial impact. They may not be able to engage in activities they once enjoyed, leading to depression and feelings of isolation.

Fall Risk Factors
Older adults are most at risk for falling. Older men are more likely to die from falls. Women are likely to have more nonfatal fall injuries. The cause of falls often involves multiple risk factors. The more risk factors a person has, the greater their risk for falling. Many risk factors contribute to falls, such as age, normal physical aging changes (especially involving the senses of sight, inner ear function, and touch), medications, chronic illness, lack of exercise, and environmental hazards. Age and Aging Changes Statistics show that the risk of falling increases with age and is greater for women than for men. Falling is often caused by losing one’s balance. Balance is controlled by the senses of sight, inner-ear function, and touch (tactile sensation). Physiological changes occur in the senses as a person ages that contribute to the increased risk of losing balance and falling, including the following: Sight: • The cornea flattens, resulting in a reduced ability to focus at normal reading distances. • The lens becomes more rigid or less elastic, allowing a person to see objects clearly only at a greater distance. • The pupil becomes smaller, resulting in less light reaching inner eye and causing difficulty with seeing in poorly lit conditions. • The retina becomes less efficient, resulting in reduced spatial discrimination. • The iris becomes more rigid, resulting in the eyes not adjusting well to changes in amount of light. • In addition, cataracts and glaucoma can alter a person’s depth perception, peripheral vision, and visual acuity can cause a glare. Inner ear function: • The inner ear structure begins to degenerate, resulting in reduced ability to maintain balance. Touch or tactile: • The sensitivity of touch receptors and response to painful stimuli are both diminished.

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After a person slips a little bit, in order to recover they must detect that they are falling—this requires good functioning of vision, the inner ear, and the sense of touch. After detecting that they have begun to fall, they must be able to move well in order to recover. There are three stages of slipping and falling: • Initiation: the beginning of a slip • Detection: the person realizes they are slipping • Recovery or fall In all three stages of falling, age affects the person’s abilities because they have gait changes, sensory changes, and musculoskeletal changes. Aging changes in other body systems may also contribute to falls, as follows: • The circulatory system: As a person ages, the heart rate may decrease, causing more frequent dizziness. Internal sensors that regulate blood pressure with position changes become less sensitive, causing drops in blood pressure that may cause dizziness when the person changes position. • The urinary system: As a person ages, the bladder decreases in capacity, causing more frequent urination. Thus the person has to get to the bathroom more often. • The nervous system: As a person ages, nerve impulses slow down, causing a slower response time to situations, which may result in injury. • The musculoskeletal system: As a person ages, minerals are lost from the bones, making fractures more likely. Loss of muscle mass causes loss of strength and elasticity, which can lead to reduced mobility and more likely injury. Medications Medication side effects and interactions can cause balance problems, reduced coordination, sedation, lightheadedness, and dizziness, all of which can lead to falling. In addition, medications that affect the central nervous system—such as sedatives, antidepressants, and antipsychotics—can contribute to falls by reducing the person’s mental alertness, affecting balance and gait, and causing drops in systolic blood pressure when the person stands or changes positions too quickly. The more medications a person takes, the higher their risk for side effects and interactions. Researchers at Johns Hopkins in 2004 studied the effects of medication changes on falls in a long term care facility. They found that the short-term risks for single and reoccurring falls were three times higher in the two days following a medication change. Medication changes included either an increase or decrease in dosage and changes in the medication type. Chronic Illness Older adults have more chronic illnesses than younger people. Chronic illnesses such as arthritis, osteoporosis, and dementia increase a person’s risk of falling. Arthritis is a common joint problem that causes pain and limits movement in joints. The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is more common. It is caused by aging and a lifetime of wear and tear on the joints. The cartilage in the joints between the bones thins and breaks down, resulting in less shock absorbency. Rheumatoid arthritis is an autoimmune disease that causes red, swollen, and painful inflamed joints. A person with arthritis may have difficulty walking or moving from place to place due to stiffness and swollen, painful joint inflammation. Osteoporosis is a key cause of fractures in elderly women. In a person with osteoporosis, bones become more porous and brittle and therefore less resistant to stress. Bone fractures occur more often. Osteoporosis is caused by a deficiency in calcium and vitamin D, hormone changes that occur with aging, and decreased physical activity. Dementia is a term used for the symptoms of cognitive impairment or loss of mental functions such as thinking, memory, and reasoning. Dementia is part of a disease process that can be reversible or irreversible. The most common type of irreversible dementia is Alzheimer’s disease. As this disease progresses, the person loses more and more abilities. In the middle stage, the person may wander from place to place. Wandering puts the person at a greater risk of falling. In the late stage, the person loses physical abilities such as mobility—to the point of not remembering how to walk. Loss of mobility also puts the person at greater risk for falling.

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Lack of Exercise Lack of regular exercise puts a person at risk for falling. It takes only 3 to 5 days for the negative effects of little or no exercise to occur. The effects of immobility or lack of exercise on the musculoskeletal system include poor muscle tone, decreased strength, and loss of bone mass and flexibility. These changes put a person more at risk for falling. Environmental Hazards In long term care facilities, 16-24% of falls are related to environmental hazards. These hazards include the following: • Wet floors • Darkness and poor lighting • Incorrect bed heights • Improperly fitted or maintained wheelchairs • Poorly working call system • Lack of necessary bed rails • Clutter • Improperly placed or absent grab bars In addition to these risk factors, there are other reasons why an older adult may fall. Examples of other risk factors that may cause or contribute to falls include the following: • Staff’s difficulty in moving patients, or assisting them to the restroom, due to understaffing • Not enough staff on duty to answer call buttons • Failure to properly train staff in lifting and handling techniques • Failure of the staff to adequately supervise people • Poor foot care • Improper use of restraints • Weakness and gait problems associated with malnutrition and/or dehydration

Fall Prevention
Preventing falls should be constantly on the mind of every health care professional. The impact of falls on the person who falls, their family, the staff, and the entire health care system is immense. But many of the risk factors for falls that have been identified can be prevented. A lack of knowledge about risk factors and how to prevent them contributes too many falls. Lack of knowledge leads to not taking preventive action. Every staff, employee, and person involved in caring for an older adult should be trained to identify risk factors for falling and to prevent them. Education is the key to preventing falls. Prevention involves an interdisciplinary approach. Prevention should involve all employees, including housekeeping, kitchen staff, and maintenance crew. The most effective prevention programs combine medical treatment, rehabilitation, and environmental changes. Every individual must be evaluated for risk factors. Once their risk factors are identified, a plan must be put into place with action steps simply outlined for all staff to understand and adhere to. The plan should be continually evaluated and updated. Medical problems should be addressed and controlled as much as possible. Staff must be educated about each individual’s risk factors and their current medical conditions and treatments. Prevention strategies must be formulated to include ways to maintain safe environmental conditions. The individual’s medications should be reviewed on a schedule. Other measures may include protective devices such as hip protectors or pads applied to prevent a hip fracture. Every plan should be clearly documented so all staff can review the details for each person. Every individual person should have a preventive fall care plan.

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As a nurse assistant, you will participate in meetings to discuss people who have a history of falls or who have fallen recently. You may be asked about how a person sits in their wheelchair or chair. For example, does the person slide forward or slouch in the chair, lean over onto one side, or lean forward? Your knowledge about the people you work with will help the team determine whether a piece of equipment or device can help prevent them from falling. For example, seating devices can support a person’s posture, and motion-detection devices can be used to turn on a light or alarm when a person approaches stairs or opens a door. Support handles can be installed in the person’s bathroom, along with a raised toilet seat that makes it easier to get on and off the toilet. All these devices can help prevent a person from falling. People in a long term care facility must not be restrained. Remember it’s a person’s right to be free from restraints. Always keep this in mind, and never restrain a person because you think that will prevent a fall. All people must be able to move freely. Seat belts on a person’s wheelchair may be used to remind them to call the nurse when they want to get up from the chair. These straps usually fasten together with Velcro and should be used only if the person can easily open the belt. Side bed rails may be used when they are part of the person’s care plan. Side rails can help a person turn and reposition in bed. They can provide a handhold for getting into or out of bed. They give some people a feeling of comfort and security. Follow your facility’s policy for the use of side rails. A health care provider’s order is required for their use. Note: Side rails should never be raised automatically for any person. In fact, some people may become injured or even die if they become caught in the rail or between the mattress and rail. A person can be seriously injured if they try to climb over a rail and fall. A person who is frail or elderly, who is confused or in pain, or who has uncontrolled body movements or other conditions is at greater risk of injury when side rails are used. Remember to always follow your facility’s policy for their use. To prevent or minimize falls, consider all the factors that can contribute to a person’s falls. You will also work with the interdisciplinary team to prevent falls. Talk with other staff and share your ideas about what needs to be changed. You can also discuss the person’s routines with the team. For example, you might share the information that a person drinks lots of fluids late in the day and goes to bed early, and then often gets up in the night to go the bathroom. If the night staff are aware of this, they can assist with toileting more often and possibly prevent a fall. You can also ensure that the path to the bathroom is free from clutter and well lighted. Make sure there are no obstacles in the person’s pathway, such as chairs or equipment not being used. Ensuring that the bed is locked and in the lowest position is also your responsibility. Some general fall prevention tips for a nurse assistant to incorporate into the person’s daily care are as follows: • Know your own limits. • Use a gait belt. • Wear proper footwear. • Use proper body mechanics. • Check that equipment, such as brakes on wheelchairs, is working and that mobility devices fit properly. • Observe a walking person for shortness of breath, profuse sweating, increased respiration, and fatigue. If you see any of these, stop and assist the person to sit or lie down, and get help. • Plan ahead, and ask yourself questions before any activity, such as: ™ ™ ™ ™ ™ How far will this person walk? Do I need a wheelchair in case the person gets tired? Do I need help? What are this person’s limits? Is there any new information I should know about the person?

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• Answer call lights promptly to assist a person, thereby preventing accidents and falls. • Identify a person at risk for falls and monitor them frequently. • Use proper positioning techniques and equipment such as wedge cushions, canes, and walkers. • Assist a person with toileting according to a schedule and more frequently as needed. • When dressing a person, assist them in selecting proper footwear. • Encourage a person to attend activities. • Use a gait belt for all transfers. • Use proper lifting, transferring, and transporting techniques. Ask for help when lifting. Do not try to lift a person alone. • Leave the bathroom light on if the person gets up in the middle of the night. This can be a night light guiding the path to the bathroom. Leave some light on in the person’s room, common areas, dayrooms, and corridors for safety. • Encourage people to call for assistance. • Report any change in a person’s condition to the charge nurse. • Always knock and introduce yourself to the person when entering their room. Try not to startle the person, and speak in a calm reassuring tone. Engage the person in conversation. A secure, non-agitated person is less likely to fall. Be aware that transporting a person improperly can cause a fall and serious injury. Follow these guidelines: • • • • • • • • Ask for assistance when lifting or transporting a person. Watch for proper placement of a person’s feet when seated in a wheelchair or geriatric chair. Use footrests. Be sure they are sitting properly and are comfortable when being transported. Push; don’t pull a wheelchair or recliner. Always keep the recliner in the back position with the person’s feet elevated. When waiting for the elevator, assist the person to sit down to wait rather than stand. Don’t overcrowd the elevator when transporting a person. Lock wheelchairs while in an elevator. Make sure ambulating people are holding onto the grab rail when in an elevator.

Specific fall prevention measures to improve age-related changes include the following: • Encourage a person to wear their glasses, and clean the glasses often to improve visibility. • Encourage a person to wear their hearing aids. Be sure the batteries are working and the aids properly placed to improve hearing. • Regular eye exams are important to monitor for cataracts and glaucoma. • Point out grab bars and other aids to help a person needing extra support who may feel weak or dizzy from blood pressure changes, especially when walking. Encourage frequent rest periods. • Be sure lighting is sufficient, especially at night for a person needing to go to the bathroom. • Be sure the pathway to the bathroom is free from clutter. • Assist the person as needed with care and walking.

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• Place a call light within the person’s reach and explain how to use it and where it is placed. • Encourage the person to use the call light for assistance if needed when going to the bathroom. • Encourage good nutrition and proper exercise for a person with loss of muscle mass and strength. Specific fall prevention measures related to medication issues include the following: • As a nurse assistant you may not know what medications a person is taking, but you can make observations and report them. For example, you may notice that at night after a person receives their evening medications, they have trouble keeping their balance. • Become more observant and report any changes you notice about the person, especially after receiving medications. • The charge nurse may share some observations staff have made about a new or changed medication. You may be asked to watch for signs of side effects such as dizziness or fatigue that may lead to falling. You may also be asked to check a person’s blood pressure after a medication is administered that could cause a drop in blood pressure, resulting in dizziness and falling. Specific fall prevention measures for a person with chronic illness include the following: • Assist a person with arthritis as needed with walking. • Know the person’s history and limits, and never push them beyond their capabilities. • Encourage the person’s use of any assistive devices to improve function and prevent falls. • Report any unsteadiness or balance problems to the charge nurse. • Report to the charge nurse any new or increased dementia symptoms such as wandering, agitation, or aggression, especially late afternoon changes. • Be aware that older adults get tired as the day goes on and may be slower to react or require more assistance. • Encourage a person with osteoporosis to drink or eat foods rich in calcium, such as yogurt, milk, cheese, fish, broccoli, and almonds. • Encourage a person with osteoporosis to get some exposure to sunlight each day if possible, for the natural formation of vitamin D. Vitamin D enhances the absorption of calcium into the blood to help strengthen bones. • Encourage weight-bearing exercises. Specific fall prevention measures to improve a person’s exercise routine include the following: • Before you encourage a person to begin to exercise, you must check with the charge nurse to be sure it is an appropriate action and the person has no medical issues. • Encourage a person who lacks exercise to begin to exercise by moving slowly and increasing movement for at least 15 minutes every other day, to improve their strength, balance, and flexibility. • Encourage a person who lacks exercise to attend a scheduled beginner exercise class. • Report a person’s desire to begin exercising, because the person’s health care provider may want a physical therapist to evaluate the person for proper techniques and to instruct the person and staff. • For a person who is immobile, passive range of motion exercises may be incorporated into the person’s daily routine to increase strength, flexibility, and motion of all extremities before they are strong enough to participate in an exercise program. • Be sure the person’s shoes fit properly and have rubber soles for exercise. Make sure their shoes are tied at all times.

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Specific fall prevention measures to improve environmental hazards include the following: • You are responsible for keeping the person’s immediate environment clean, safe, and free of clutter. These measures must be incorporated into the activities of daily living. • You are also responsible for reporting any safety issues needing repair or missing parts, such as broken locks on wheelchairs or missing light bulbs in fixtures that light the person’s path to the bathroom at night. • The call light should be in reach for use at all times. • Move any clutter or obstacles in a person’s room to allow plenty of space to work or maneuver a wheelchair. • Move any over-bed tables that might create an obstacle. • Offer to open the blinds in a person’s room or turn on lights if needed to brighten a dark area. To prevent falls, every employee should take responsibility and be involved in safety monitoring and prevention measures. Some safety monitoring and prevention measures include the following: • Clean up spills right away. • Keep hallways clear of carts and clutter whenever possible. Items needed in halls such as laundry carts or dietary trucks should be kept to one side of the corridor so that hand rails on the other side are free for use. • Use a “wet floor” sign to indicate wet areas. Remove the sign promptly after the area dries so that it does not become an obstacle. • Report any equipment breakdowns or problems. • Be familiar with your facility’s system to identify a person at risk for falls. • Look into rooms when going up and down halls to see if any person needs assistance. • Report any other safety hazards you observe to the maintenance department or administration at once.

Stopping a Fall
If you are transferring or walking a person and they start to fall, what do you do? This can be a frightening experience for both of you. Be prepared for a possible fall, and if the person starts to fall, use these steps to help them: • First, get a good grip on the gait or guard belt. Try to pull up on the guard belt and ask the person to try to stand back up. • If you cannot stop a person from continuing to fall, move behind them, hold onto the guard belt with both hands or gently hold them around the chest, and support them on your knee. • Use good body mechanics. • Call for help. If you cannot hold a person up until help arrives and they are falling to the floor, do the following: • Gently lower the person to the floor as best you can and as slowly as possible to avoid injury to both of you. • Once the person is in a safe, stable position such as sitting or lying on the floor, then: • Call for help. • Do not leave the person, because they are likely to be afraid. • Reassure them that help is on the way. • If possible, ask someone else to get help so you can stay with the person.

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• If you must leave the person to get help, then: • Help them lie down with their head supported. • Explain you are going to get help and will be right back. • Be sure they are safe on the floor. If a person falls and seems injured or if you are unsure if they are hurt, do not move them but do the following: • Call for help. • Leave the person on the floor until a nurse or physician examines them. • Do not leave the person alone unless absolutely necessary. • If you feel the person’s condition is serious and no one is answering your call for help, you may have to run for help. When help arrives and it is determined that you can move the person, help them back to a sitting position on the floor as follows: • If the person can walk fairly well, ask for help raising the person to a standing position. • You and another staff person should stand on each side of the person. Both of you then grasp the guard belt firmly on both sides and pull the person up while holding onto the guard belt. • Be sure the person is not dizzy and feels safe to walk.

Summary
In this appendix you learned about the financial impact falls have on the health care system. You learned how a fall impacts a person’s quality of life. You learned risk factors contributing to falls, and ways falls can be prevented. You also learned ways to prevent falls based on identified risk factors, and lastly, your role if a person starts to fall.

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Appendix B: Feeding Assistance

As a member of the interdisciplinary team, you play a major role in ensuring that all the people you care for receive adequate food and fluid. Adequate nutrition is vital for maintaining a person’s health. In addition, a positive experience with eating and dining impacts a person’s quality of life. With a restorative approach to eating and dining, the ultimate goal is for the person to be able to eat independently in a desirable atmosphere. Some people may be unable to fully reach this goal, but any improvement in functioning is desirable. Any loss or decline in a person’s functioning, unless it is unavoidable, is never acceptable. Remember, in Maslow’s hierarchy of needs, food meets a basic physical need for survival. In addition, food and eating serve many other purposes and meet many other needs. Food appeals to our senses of taste, smell, and touch. Food can provide satisfaction and comfort. Warm foods can provide comfort on a cold day, and cold foods refreshment on a hot summer day. The smell of a favorite food leads to feelings of anticipation, and some food smells bring fond memories. Food is often used as a reward for a job well done. Food is also associated with rituals that are important in many cultures. Dining provides an opportunity for people to come together and share a common experience. Eating is a central part of most social events, celebrations, meetings, and other get-togethers. It also provides an opportunity for socializing. As the caregiver who spends the most time with the person, you can influence the person’s experience with eating and dining. Note: The word eating is used here to refer to the food one eats. The word dining is used to refer to the overall experience and atmosphere accompanying eating.

Objectives
After studying this appendix you will be able to: Describe what is involved in determining a person’s baseline nutritional status Define conditions often associated with weight loss or anorexia Describe what can make eating more pleasant Describe proper positioning for eating Demonstrate the skill for feeding a person List and describe adaptive equipment used in feeding List common signs of dysphagia Describe what to do if a person begins to choke

Key Terms
Altered nutritional status (ANS) - unintended and unexpected change in intake of nutrients resulting in undesired change in weight Anorexia - loss of desire to eat enough to meet one’s daily needs Aspiration - accidental sucking of food particles or fluid into the lungs

Introduction to Feeding Assistance
In this appendix you will learn the importance of understanding the nutritional needs of the people you care for. You will learn how a person’s nutritional status is determined and about conditions associated with altered nutritional status (ANS) resulting in weight loss and anorexia. You will learn ways you can make eating more pleasant and desirable. You will also learn what you can do to support a person who is having difficulty with eating. You will learn the signs and symptoms of dysphagia. Finally, you will learn what to do if a person chokes.

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Note: Although weight gain also can cause adverse clinical issues, the primary focus of this appendix is the person with ANS resulting in weight loss.

Determining a Person’s Baseline Nutritional Status
To determine a person’s nutritional needs, their normal nutritional status first must be understood. This is called their baseline status. A person’s nutritional status should be evaluated as soon as possible after they enter a facility and whenever their health status changes in any way. Evaluating a Person’s Nutritional Status Determining a person’s baseline status involves many members of the interdisciplinary team. The nursing department, health care provider, dietician, speech/language therapist, occupational therapist, and physical therapist all play key roles in a successful restorative dining/eating program. Below are the roles of team members for evaluating a person’s baseline and supporting their nutritional status. Nursing staff: • Monitor the person’s intake and weight • Report changes in the person’s status • Weigh the person on schedule • Interview the person and family members to determine food preferences • Encourage the person to dine in social areas or their locations of choice • Provide for pleasant surroundings • Prepare the person for dining • Maintain the person’s safety when dining • Encourage the use of assistive devices as needed • Assist the person with feeding, based on the person’s needs • Reinforce feeding skills learned in therapy Dietitian: • Evaluates information gathered by nursing staff • Provides menu options that are: • nutritious and based on the person’s dietary needs • appealing • appropriate for the person’s food preferences and choices • prepared according to the person’s needs Speech/language therapist: • Evaluates the person for swallowing difficulties • Works with the person to improve swallowing Occupational therapist: • Works with the person to improve their ability to self-feed • Determines appropriate assistive devices for the person’s use

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Physical therapist: • Works with the person to increase their mobility, range of motion, and strength All team members are responsible for monitoring the person’s progress toward goals and making changes in the care plan as needed to meet the person’s changing needs. The team determines the person’s nutritional status using weight, body mass index, food choices, and nutritional risk factors. Weight When admitted to the facility, the person should be weighed weekly for the first four weeks. If their weight does not change during the four-week period, routine monitoring then includes weighing the person monthly. The person’s care plan tells you what you need to do. If possible, weigh the person on the same scale and at the same time of day (preferably in the morning before breakfast) without clothing or shoes. The scale should be calibrated every time it is moved. The facility’s maintenance department may have to do the calibrating on some scales. Follow the manufacturer’s recommendations. Often a person’s body mass index (BMI) is used in the evaluation of their nutritional status. Body mass index is calculated using this formula: BMI = [weight (in lb)/height (squared)] X 704. You will not do the calculation yourself. The nursing or dietary staff do the calculation, but you need to understand the results. Below is the scale used to determine a person’s nutritional status. Definition Severely underweight Underweight Desirable Overweight Obese Food Choices As you get to know a person, you learn about their food preferences. If the person cannot tell you, ask family members and friends. A person may eat poorly if they dislike the food being served. Your observations of what the person eats and what they leave behind will help the dietary department serve foods the person will eat. It is important to learn what kinds of food the person likes to eat, in what amounts, and at what times. As you observe the person eating, estimate the percentage of food eaten by serving portion and by food group: meat, fruit, dairy, vegetable, and grain. This information will help the dietitian tailor meals to match the person’s preferences. Identifying Risk Factors for Altered Nutritional Status On admission, quarterly, and whenever the person has a health status change, an assessment using the minimum data set (MDS) is conducted. This assessment helps the staff see if the person is at risk or has a predisposing factor for weight loss. Items on the MDS that relate to nutritional risk factors are: • Swallowing problems • Syringe (oral feeding) • Chewing problems • Inability to self-feed (upper body impairment of mobility and coordination, body positioning, inability to grasp utensils) • Taste alterations • Mechanically altered diet (chopped, thickened, puree) Score 30

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• Therapeutic diets • Leaves 25% of food at meals • Significant weight loss The MDS assessment is typically performed by the MDS coordinator with input from other team members. You may be asked questions that relate to the MDS. Your observations of the person are critical for the assessment to be accurate and complete. In addition, other factors can contribute to a person’s weight loss or put them at risk. The conditions most often associated with weight loss or anorexia are: • Depression • Constipation • Vomiting • Nausea • Diarrhea • Chronic pain • Dementia/delirium • Chronic infections • Presence of pressure ulcers • Underlying infection • Use of multiple medications • End-stage major organ system disease • Terminal illness Identifying risk factors a person has when admitted or develops while at the facility requires that staff interview the person and observe them eating. You play a vital role in identifying and communicating information to the team, which will create a care plan for supporting the person. Interviews are first conducted on admission. Throughout the person’s stay at the facility, questions should be asked about their appetite, eating habits, and any weight loss. Remember: if the person cannot answer the question, ask family members and friends. Be sure to get permission from the person’s guardian before asking questions to ensure you do not violate the person’s privacy. Routinely watch the person eat looking for functional disabilities that could make eating difficult. If you observe any of the following conditions, report this information immediately: • A decline in food intake over several days • Refusal of food for two or more meals in a row • Persistent, unintended, or unexpected weight loss for three consecutive months • Weight change of 5% in one month, 7.5% in three months, or 10% in six months Most people lose weight because of anorexia. The most likely causes include depression, infections, and drug reactions. Other people lose weight despite eating all the food they receive. If the person is eating 75% to 100% of all meals and still losing weight, the most likely cause is that they are not consuming enough calories. Other causes include an increased metabolic need and malabsorption.

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Inadequate caloric intake. A person’s weight influences their need for more or fewer calories. For example, a person who weighs 175 lb or more may need more than 2000 calories a day. Also, people who fidget or are constantly pacing may need additional food to compensate for the energy expended in these activities. Increased metabolic need. Infections, advanced illness, or the presence of pressure ulcers increases a person’s need for more calories, particularly calories from protein. Malabsorption. A person with frequent diarrhea may have a problem with malabsorption. The causes may include pancreatic insufficiency, bacterial overgrowth in the small intestine, or lactose intolerance. In your role as caregiver you will not be responsible to know all this information. But you do have the responsibility to report any change you observe to the nurse.

Making Eating and Dining More Desirable
You can influence how a person feels about meal time. The taste of the food, the atmosphere where the meal is served, and the preparation of the person all impact their experience with meals. Sometimes simple changes can increase a person’s appetite. The following sections list things that can influence a person’s appetite at mealtime. As you review these lists, think about those things you can do. Other things may involve different departments. You should be aware of them even if you are not directly involved. Prepare the Environment • Ensure that the environment in the room where meals are served is pleasant and conducive to eating. For example, try to reduce noise, confusion, and distractions. • Have more than one meal sitting. Multiple sittings for smaller groups are preferable. People who are alert and can eat independently help people who need verbal cues to encourage them to eat. • Adopt a flexible staffing pattern that enables nursing staff to move to floors or units where more people need assistance at meal times. • Use non-nursing staff and volunteers at meal times to help set up trays and enhance socialization at mealtimes. This frees staff to assist people who need the most help. Training family members to help feed selected people is encouraged. • Adjustable tables help by accommodating chairs of various heights. Note: Facilities may train and employ feeding assistants. These staff members take a state-approved training program and successfully complete a competency evaluation. (See the “Other Resources” section later in this appendix for more details.) Prepare the Person • Encourage the person to use the toilet and freshen up before the meal. • Check that the person is wearing their eyeglasses, dentures, and hearing aids. Be sure they are clean and in good working order. • Make sure the person is sitting in a comfortable yet supportive chair; one with armrests is best. • Make sure the person is close to the table. The person should need to reach no more than 12 inches for food or utensils. If the person is seated in a wheelchair, make sure the wheelchair can fit under the table. • Be sure the person maintains good body alignment: the neck bent forward slightly with the chin tucked in; shoulders upright; back and hips straight against the chair; hips, knees, and ankles bent at a 90-degree angle; and feet flat on the floor. If the person’s feet do not touch the floor, provide a foot stool. • Use positioning devices such as wedge cushions and supportive pillows to help support a person. • The person’s elbows should be on the table for stability.

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Prepare the Food • Make every effort to ensure that all foods offered are attractive and taste good. Use garnishes, seasonings, and sweets as appropriate to enhance the appearance and taste of dishes. • Consider offering an alcoholic beverage or sweets before the meal. • Try using the smell of freshly cooked food as an enhancement to eat. Other Ways to Help a Person Based on Their Needs 1. Provide choices for the person. Allowing a person to make decisions according to their preferences gives them a feeling of control and helps promote a feeling of self-worth and independence. Offer the person choices and let them decide. Let the person decide when and where they want to eat. Let the person decide the order in which they want to eat foods and drink liquids. Ask the dietary staff for substitutes if the person does not like what is offered. 2. Reinforce feeding skills learned in therapy. When reinforcing a person’s feeding skills learned in therapy, you act as a teacher. In this role you must follow through exactly with what the therapist taught so that they person is not confused about what they should be doing. Because of differences in a person’s abilities, different methods are used to teach skills to different people. Before working with a person, ask the therapist what method to use. If you can, attend a therapy session with the person. Repeat the same approaches each time you work with the person to reinforce their skills consistently. 3. Provide guidance. You can use a variety of prompts or cues (verbal, visual, and tactile) to guide a person learning feeding skills. Prompts are used to direct or remind a person to perform a particular action. Depending on what works best for the person, you may use one or more of these prompts. The next section describes several examples of using prompts.

Supporting a Person with Feeding
Some of the people you care for will be learning all over again how to eat, while others need only to maintain their current ability. You must know each person’s capabilities so that you can provide the right amount and type of assistance. Learn their capabilities by asking the person, checking the care plan, asking members of the interdisciplinary team, and asking a family member. You want to provide the right balance that allows for the person’s independence. Take your cues from the person, and follow the care plan. Allow enough time for the person to complete their meal. Never rush when you are working with a person on their feeding skills. You will have to prompt and cue a person who is relearning or is forgetful. For example, you can say things like the following: “Lift your spoon.” “Pick up some potatoes.” “Put the potatoes in your mouth.” “Chew the peaches.” “Swallow.” Alternatively, you can demonstrate how to hold a cup in a particular way or touch the person’s hand to prompt them to pick up the knife. For some people who require your assistance to hold and move their utensils, you can use hand-over-hand techniques. This allows the person to perform an action while you provide support. For example, you can place your

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hand over the hand of a person who is unable to cut their meat. Your hand provides the needed support while allowing the person to move. As the person becomes more independent, you can gradually withdraw your support. Praise and encouragement when supporting a person’s attempts at self-feeding are very important. Your role as a coach providing positive reinforcement will help the person to continue working toward goals. Some people require more support than others. You may have to feed them yourself, not just prompt or cue them. If you are responsible for feeding a person, you must first position them properly. Procedure 1 outlines how to position a person. Procedure 2 outlines how to feed a dependent person. Procedure 1. Positioning for Eating 1. Position the person in a dining chair, if possible. 2. Their feet are positioned firmly on the floor, footrest, or footstool. 3. Their body is in good alignment. 4. Their weight is supported equally on their hips. 5. The small of their back is against the chair back. 6. Their upper torso is as upright as possible. 7. Bolsters or pillows are placed to support their position. 8. Their head and neck are in an upright position. 9. Their chin is slightly tucked, not up or back. 10. The table height is comfortable for the person. If the table is too high, lower the table or raise the person’s seat. If the seat is raised, make sure adjustments are made to support their feet. Procedure 2. Feeding the Dependent Person 1. Position the person appropriately. Do not feed or medicate the person in a reclined position. 2. Make sure the person is awake and as alert as possible. 3. Assist the person in actively participating as much as possible in the feeding process. 4. Sit in a comfortable position facing or to one side of the person. 5. Give only small amounts of food and liquid at a time. Never use a syringe to feed the person. 6. Bring food from the center and up from below so that the person dips their head slightly to receive it. 7. Watch the person carefully. Be alert for signs of aspiration or distress. 8. Make sure that the food is completely chewed and swallowed before giving more food. 9. Do not stand while feeding the person. 10. Do not allow yourself to be distracted while feeding. 11. After feeding, carefully check the person’s mouth for any “pocketed” food that may remain. Clear it away before leaving the dining room. 12. Allow the person to sit up for 30 minutes after a meal before reclining or going to bed. Using Assistive/Adaptive Devices Assistive devices include special eating devices as well as dentures, glasses, and hearing aids. All assistive devices should be clean before use and in good working order. If a person eats with a particular device, be sure that it is available at all meals. If the person refuses to use the device or is uncomfortable using it, tell the nurse.

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Assistive devices for eating are special tools that help promote a person’s independence and ease of eating. These devices are specially selected based on the person’s individual needs. People with the following problems benefit from these devices: • Difficulty controlling neck and arm movements • Limited range of motion (neck, elbow, wrist, hand, fingers, thumb) • Limited strength and endurance • Positioning problems (leaning to the side, poor head control) Similar to regular feeding utensils (plates, cups, forks, knives, and spoons), assistive eating devices have special features that make them easier to use, such as angled utensils or built-up and non-slip handles. Many devices are available to promote a person’s self-feeding. Following are some examples of assistive devices for eating: • Dycem is a non-slip plastic available in rolls or precut mats. It provides a good surface for plates, glasses, bowls, etc. to prevent them from sliding around during use. • A plate guard clips onto the edge of the plate. It may be made of metal or plastic. The guard provides a backdrop for a person with only one usable arm/hand to scoop food against in order to load a spoon or fork. The guard is placed on the side of the plate opposite the usable hand. • A scoop plate is a plate with a raised edge all the way around as a backdrop for a person with only one usable arm/hand to scoop food against in order to load a spoon or fork. • A nose-cut glass allows the person to drink without tilting their head back or extending their neck. • A mug with handles may be easier to use by people with weakness or tremor. A spouted lid may also help prevent spilling when the person brings the mug to their mouth. • A rocker knife is used by people who have only one useable hand to cut food. Rather than sliding the knife back and forth in the customary manner, the rocker knife is held in place on the food and rocked back and forth to cut the food through. • An offset spoon is easier for people who have limited wrist motion. The angled bowl allows the person to use a cross grasp and bring the food to their mouth without rotating their wrist. • Built-up/weighted handles on flatware are useful for many people who have difficulty maintaining a good grip on standard-size flatware. Flatware with a larger handle is much easier to hold onto. For people with tremor, weighted handles may help inhibit the tremor and minimize spillage. • Swivel utensils are effective for people without tremor whose wrist or finger motion is limited or absent. Some people find them easier to load and unload. • A universal cuff may be strapped to the hand and a utensil inserted into the pocket if a person cannot independently hold a utensil. The person then does not have to maintain a grip on the utensil while bringing food to their mouth.

Dysphagia
Although feeding oneself may seem a simple task, it actually is complex and requires coordination of the brain and body. Think about a person sitting at a table before a place setting. For the person to self-feed, the brain must be able to recognize what to do with the food and the utensils. The person must be sitting in a good position and be able to reach the food. The nerves and muscles of the person’s neck, arm, and hand must work together to bring the food from the plate into their mouth. If one or more of these things do not occur, the person cannot selffeed.

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In addition, aging changes often affect a person’s ability or desire to eat. Many of these changes can make dining an unpleasant and difficult experience. Some people who experience these changes may not enjoy or be able to participate in the dining experience as when they were younger. They may feel a sense of loss because dining is not as meaningful as it once was. Dysphagia is a common problem that influences a person’s ability to eat. Dysphagia is the inability to safely consume liquids or food by mouth, often because of changes in brain function. The person may have reduced oral sensation, impaired tongue mobility, and/or a delayed swallow response time. They may lack protective responses such as coughing, gagging, and choking. Water and thin liquids are among the most difficult substances to swallow. People who have experienced a stroke, head injury, chronic obstructive pulmonary disorder (COPD), or dementia commonly have difficulty swallowing medications, food, and/or liquids. The speech/language therapist will evaluate the cause of the person’s difficulty swallowing. The four stages of swallowing are monitored in this evaluation. These stages are as follows: 1. Oral preparatory stage: The process of taking in the food/bolus, mixing it with saliva, sealing the mouth with the lips closed, and progressing into the oral stage. 2. Oral stage: The process of taking the food which has been moistened by saliva, masticating (chewing) it, and then using the tongue to propel or push the food toward the back of the throat. 3. Pharyngeal stage: The reflexive stage of swallowing, which takes generally 2-3 seconds to complete. Food or liquid (now a bolus or ball) is positioned at the back of the throat where it stimulates sensors in the mouth, triggering the swallow reflex. 4. Esophageal stage: The final stage of the swallow, when the food or liquid bolus is on its way to the stomach to be digested. (Typically a speech/language pathologist does not address problems occurring only in this stage.) Determining the cause of the problem leads to putting a plan in place for feeding the person. Every effort should be made to support the person with oral feeding. You may not immediately notice that a person is having difficulty swallowing. Watch for the following signs and symptoms and report them to the charge nurse immediately to prevent complications. The signs and symptoms of dysphagia to watch for include the following: • A spike or increase in body temperature • Coughing, choking, or vomiting • Spitting out food • Weight loss • Disinterest in food • Dehydration • Behavior changes In addition, you must watch for and report any signs of aspiration, such as the following: • Wet, gurgling voice • Coughing • Choking • Nasal regurgitation • Runny eyes or nose • Increased body temperature • Increased respiratory congestion

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If a person is reported to have difficulty with swallowing, you must follow the careplan to support the person when eating. The speech/language therapist will work with the person to determine the most effective strategies for safe oral intake. Following are some things you can do to make swallowing safer: Environmental changes: • Decrease distractions. • Add soft music. Positioning changes: • Have the person maintain a 90-degree angle at the table or in bed or a wheelchair. • Present food on the person’s strong side. • Check the person’s mouth for food pocketing. • Have the person maintain an upright position for 30 minutes after meals. Adaptive equipment: • Use a sip cup to slow down the speed of drinking. • Use a straw (only for those prescribed) to slow down the speed of drinking and prevent leakage. Food changes: • Change food consistency by adding gravy to meat and/or mixing in vegetables or other thickening agents. • Alternate liquids and solids (a sip of drink, a bit of food, a sip of drink). • Limit the amount of food in each forkful or spoonful. • Provide small bites. • Control the amount by using a spoon or pinched straw. When feeding the person, use a metal teaspoon. Present 1/3 to 1/2 teaspoon of food at a time. More or less may be difficult for the person to swallow. Watch the person’s throat for a visible swallow, and then wait several seconds before giving more food. Because of reduced oral sensation, impaired tongue mobility, and/or delayed swallow response time, the person needs more time to chew and moisten food, maneuver it into position, and swallow it completely. Encourage the person to take as long as needed. Because of poor tongue control and/or reduced sensation inside the mouth, particles of food may remain in the person’s oral cavity after eating. Visual inspection of the inside of the mouth is necessary. Check under dentures and between the cheeks and gums. Do not rinse food particles down the throat with liquid. Use a swab or toothette to remove particles from the mouth. Be sure the person remains sitting upright for 30 minutes after any oral intake.

Choking
Choking usually happens when food or another object gets stuck in a person’s throat. People are at risk of choking when: • Their bites of meat or other food are too large or poorly chewed. • They talk or laugh too much while eating.

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• Their dentures do not fit well. • They have a chronic illness or stroke that causes weakness and difficulty with swallowing. When a person is choking, you should do the following: 1. Ask the person, “Are you choking?” The person will not be able to answer you if their airway is completely blocked. 2. Call for help. 3. Never leave the person. 4. Give the Heimlich maneuver (Procedure 3 described below). When performed properly, this procedure can dislodge the object from the person’s throat. A choking victim who is still conscious usually grabs or gestures at their throat. If the throat is completely blocked, you must act quickly. You have only 4 to 8 minutes to save the person’s life. A person whose airway is completely blocked may have these signs: • The skin, lips, and nails may look bluish. • They have difficult, noisy breathing or are not breathing at all. • They cannot speak. • They will very soon become unconscious. • They cannot cough with force. A person may also have only a partial airway obstruction. This person can breathe at least partially and may be able to speak and cough, but likely is having difficulty breathing and may not be getting enough oxygen. If the person cannot eject the food or other object from their throat by forceful coughing, the charge nurse may seek emergency medical help. The charge nurse may ask you to call 911 for help. You must be familiar with the emergency equipment used in your facility because the charge nurse may also ask you to get oxygen, suction, or other equipment. You can learn the Heimlich maneuver in an outside CPR or first aid course or from a certified CPR or first aid instructor in your facility. Procedure 3 describes the steps of the Heimlich maneuver. Procedure 3. The Heimlich Maneuver If the person is sitting or standing: 1. Stand behind the person. 2. Wrap your arms around the person’s waist, and try to lean the person slightly forward. 3. Make a fist with one hand and put it on the person’s stomach below the rib cage and a little above the navel. Keep your thumb against their stomach, and place your other hand over your fist. 4. Sharply thrust your fist inward and upward. This forces a burst of air from the lungs to dislodge the food or object. 5. Repeat the thrusts until the blockage is dislodged. If the person is standing when they become unconscious, gently lower them to the floor. Once they are on the floor: 1. Place the person on their back. 2. Kneel down at the person’s side. 3. Place the heel of one hand on the lower part of the person’s sternum, located midline on the person’s chest. Place your other hand directly on top of it and interlock your fingers. 4. Push down on the sternum to a depth of about 2 inches, keeping your arms straight and your shoulders

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directly over the middle of the person’s body. Your chest compressions should be hard and fast. 5. Begin CPR. Remember the ratio is 30 compressions to two quick breaths. 6. Continue until help arrives or the object is visible in the person’s mouth and can be removed. Other Resources CMS has published nutrition care alerts. Nurse assistants can use this guide to ensure they recognize warning signs of poor nutrition and are taking proper steps to maintain and improve a person’s nutritional health. The guide is designed to be used everyday with every person. The guide addresses four common nutrition-related conditions: unintended weight loss, dehydration, pressure ulcers, and complications from tube feeding. Warning signs are printed on the left side of the page, with action steps for nursing assistants beside them in the center. Action steps for other care providers, such as physicians, nurses, dietitians, and pharmacists, are included on the right side. The guide helps you maintain or improve the nutritional health of the people you care for. You can order nutrition care alerts from www.CMS.gov. Another resource is the use of feeding assistants. CMS allows long term care facilities in the United States to use feeding assistants. All paid feeding assistants must successfully complete a state-approved training program. Training requirements include a minimum 8 hours of coursework including feeding techniques, assisting with feeding and hydration, communication and interpersonal skills, responding to a person’s behavior, safety, emergency procedures (including the Heimlich maneuver), infection control, the person’s rights, recognizing and reporting changes, and maintaining feeding records. Paid feeding assistants must follow these guidelines: • Feeding assistants work under the supervision of a registered nurse or a licensed practical nurse. • In an emergency, the feeding assistant must call the charge nurse for help. • Feeding assistants should feed only those people who do not have feeding complications such as difficulty swallowing, intravenous feedings, G-tube or J-tube feedings, or recurrent episodes of aspiration. • All feeding assignments must be based on the charge nurse’s assessment and the latest information written on the person’s assessment and care plan.

Summary
In this appendix you learned how a person’s baseline nutritional status is evaluated. You learned what conditions contribute to weight loss and anorexia. You learned ways to make eating and the whole dining experience more pleasant and desirable. You learned what is involved in positioning and feeding a person, including the use of assistive devices for feeding. It is important always to watch for the signs and symptoms of dysphagia. Finally, you learned about choking and the importance of responding quickly with the Heimlich maneuver.

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Bibliography Restorative Care
AHCA. Managing Continence. St. Louis. Mosby-Year Book. 1994 AMDA. Urinary Incontinence. Silver Spring. AHCPR. 1996 Association. 1996 Atchinson D. Restorative Nursing: a Concept Whose Time has come. February 1992. Biofeedback for Incontinence. April 2003. www.furology.com Bones, Joints and Muscles: cast care. 1997. www.baptistonline.org Bowel Incontinence. 2005. www.cchs.net Brennan M. When Vision and Hearing Fail: dual sensory impairment among older adults. 2008. www.lighthouse.org Butcher S. Reductions in Functional Balance. August 2004. www.jcrjournal.com Casey M. How to be a Nurse Assistant. Washington. AHCA. 1995 Casey M. How to be a Nurse Assistant Fourth Edition. Washington. AHCA. 2008 CMS. Federal Register. Rules and Regulations. 26 September 2003. Commonwealth Corporation. Death and Dying: Caring for the Terminally Ill. Boston: Commonwealth Corporation. December 2007 Cost of Falls among Older Adults. www.cdc.gov Falls Among Older Adults. www.cdc.gov Falls. 20 February 2008. www.agedcarecrisis.com Fecal Incontinence. 2008 www.mayoclinic.org Holleman J, E Mayfield et.al: Dehydration and Fluid Maintenance. Washington. AMDA 2001 How to Care for an Amputee. 2008. www.ehow.com June 2008. www.findarticles.com Kasprak J. Regulation of Feeding Assistants. 10 January 2007. www.cga.ct.gov

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Kennard C. Behavioral Treatment of Fecal Incontinence for People with Dementia. 18 September 2006. alzheimers.about.com Langan M. External Incontinence Devices. 30 May 2008. www.nlm.gov Lapier T. Rehabilitation Issues in Patients Recovering from Coronary Artery Bypass Surgery. www.findarticles.com Lewis M, J Kidder. Nutrition Practice Guidelines for Dysphagia. Chicago. The American Dietetic Mayfield E, J Vance. Altered Nutritional Status. Washington. AMDA. 2001 Morris J, L Lipsitz et.al: Quality Care in the Nursing Home. St. Louis. Mosby-Year Book 1997 Newman D. Understanding Electrical Stimulation for Incontinence. June 2002 www.seekwellness.com Occupational Therapists. December 2007. www.bls.gov Physical Therapists. December 2007. www.bls.gov Smith C. Advance for Occupational Therapy Practitioners. 2008. www.Advanceweb.com Speech-Language Pathologists. December2007. www.bls.gov Thayer K. Establishing an Effective Dysphagia Program. 15 September 2003. www.speechpathology.com The Later Stages of Dementia. May 2003. www.alzheimers.org Tremblay K. C Barber. Preventing Falls in the Elderly. December 2005. www.extcolostate.edu Urinary Incontinence in Adults. March 1996. www.ahrq.gov Urinary Incontinence in Adults. March 1996. www.ahrq.gov When Amputation Becomes Necessary. 7 July 2003. www.hopkinshospital.org

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Bibliography Restorative care
AHCA. Managing Continence. St. Louis. Mosby-Year Book. 1994 AMDA. Urinary Incontinence. Silver Spring. AHCPR. 1996 Atchinson D. Restorative Nursing: a Concept Whose Time has come. February 1992. Biofeedback for Incontinence. April 2003. www.furology.com Bones, Joints and Muscles: cast care. 1997. www.baptistonline.org Bowel Incontinence. 2005. www.cchs.net Brennan M. When Vision and Hearing Fail: dual sensory impairment among older adults. 2008. www.lighthouse.org Butcher S. Reductions in Functional Balance. August 2004. www.jcrjournal.com Casey M. How to be a Nurse Assistant. Washington. AHCA. 1995 Casey M. How to be a Nurse Assistant Fourth Edition. Washington. AHCA. 2008 CMS. Federal Register. Rules and Regulations. 26 September 2003. Commonwealth Corporation. Death and Dying: Caring for the Terminally Ill. Boston: Commonwealth Corporation. December 2007 Cost of Falls among Older Adults. www.cdc.gov Falls Among Older Adults. www.cdc.gov Falls. 20 February 2008. www.agedcarecrisis.com Fecal Incontinence. 2008 www.mayoclinic.org Holleman J, E Mayfield et.al: Dehydration and Fluid Maintenance. Washington. AMDA 2001 How to Care for an Amputee. 2008. www.ehow.com June 2008. www.findarticles.com Kasprak J. Regulation of Feeding Assistants. 10 January 2007. www.cga.ct.gov

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Kennard C. Behavioral Treatment of Fecal Incontinence for People with Dementia. 18 September 2006. alzheimers.about.com Langan M. External Incontinence Devices. 30 May 2008. www.nlm.gov Lapier T. Rehabilitation Issues in Patients Recovering from Coronary Artery Bypass Surgery. www.findarticles.com Lewis M, J Kidder. Nutrition Practice Guidelines for Dysphagia. Chicago. The American Dietetic Mayfield E, J Vance. Altered Nutritional Status. Washington. AMDA. 2001 Morris J, L Lipsitz et.al: Quality Care in the Nursing Home. St. Louis. Mosby-Year Book 1997 Newman D. Understanding Electrical Stimulation for Incontinence. June 2002 www.seekwellness.com Occupational Therapists. December 2007. www.bls.gov Physical Therapists. December 2007. www.bls.gov Smith C. Advance for Occupational Therapy Practitioners. 2008. www.Advanceweb.com Speech-Language Pathologists. December2007. www.bls.gov Thayer K. Establishing an Effective Dysphagia Program. 15 September 2003. www.speechpathology.com The Later Stages of Dementia. May 2003. www.alzheimers.org Tremblay K. C Barber. Preventing Falls in the Elderly. December 2005. www.extcolostate.edu Urinary Incontinence in Adults. March 1996. www.ahrq.gov Urinary Incontinence in Adults. March 1996. www.ahrq.gov When Amputation Becomes Necessary. 7 July 2003. www.hopkinshospital.org

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Final Exam Restorative Care Student Part A Circle one answer 1. What is the biggest effect of lack of movement on the body? A. Body shape changes B. Body systems slow down C. Staff have to do more for the person D. The person complains of pain more often 2. The speech language pathologist helps a person with dysphagia do which of the following? A. Learn to ambulate B. Develop fine motor skills C. Learn how to improve their work environment D. Learn to swallow to prevent aspiration 3. Where do you find the restorative nursing goals for a person? A. In their medical history B. In their care plan C. In the MDS D. In their admission notes 4. When you cue a person, you do what? A. Prompt them how to begin an activity B. Do the activity for them C. Ask the person to tell you what they are doing D. Tell the charge nurse the person needs help 5. What is the goal of using equipment when moving and positioning a person? A. To help you do your job faster B. To try different ways to move or position the person C. To minimize the risk of injury to you and the person being moved D. To help you with your body mechanics

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6. Which of the following can cause problems with balance when walking? A. Shoe size B. Endurance status C. Adaptive devices D. Staff walking in front of them 7. What does moderate assistance mean when moving a person from a bed to a chair? A. The person needs 75% assistance from one person B. The person needs a mechanical lift C. The person needs 50% assistance from one person D. The person needs supervision from one person 8. Which is a purpose of range of motion exercise? A. It gives a person something to do B. It keeps staff busy with exercise C. It maintains or increases the person’s joint movement D. It provides activity for the physical therapy department 9. Prosthetic devices help a person improve function in which of the following areas? A. They provide support with eating utensils B. They provide support with dressing devices C. They provide support with household chores D. They provide support with using a limb that is missing 10. Which is the most common fracture in the elderly? A. Hip fracture B. Ankle fracture C. Wrist fracture D. Toe fracture

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Part B Complete each of the following sentences with the correct key term. (fill in the blank) 1. the body. is the term used when a person has weakness affecting only one side of

2. Restorative care promotes _________________, _____________ _______________, and ___________ _______________. 3. ________________ provide specific ways to make improvements. 4. The goal of using equipment is to minimize _________________ of injury. 5. ________________ is how you help people sit or lie down. 6. A ____________________ is a deformity caused by a permanent shortening of a muscle or by scar tissue. 7. The use of a ______________ belt can help you prevent injury to the person. 8. ______________ ________ _______________ is the optimal mobility in a joint of the body. 9. Ambulation is another name for _________________________. 10. Pressure ulcers are a breakdown of the skin caused by pressure, _____________, _______________, or too much moisture. Part C Write your answers in the spaces provided. 1. List the two components of a written goal. ________________________________________ ________________________________________ 2. List three questions to consider about yourself before moving or positioning a person. ________________________________________ ________________________________________ ________________________________________

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2. List five questions to consider about the person before moving or positioning them. ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ 3. List five things you should consider before walking a person. ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 4. Describe each of the following types of exercise. Active ROM______________________________________ Active assisted ROM______________________________ Passive ROM_____________________________________ 5. List three assistive devices and the purpose of each. Name 1. 2. _____________________________ 3. _____________________________ Purpose ________________________________________ ________________________________________ ________________________________________

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Final Exam Restorative Care (Trainer) Part A Circle one answer 1. What is the biggest effect lack of movement has on the body? A. Body shape changes B. Body systems slow down (Ans. B) Page 21 C. Staff has to do more for the person D. The person complains of pain more often 2. The speech language pathologist helps a person with dysphagia do which the following? A. Learn to ambulate B. Develop fine motor skills C. Learn how to improve their work environment D. Learn to swallow to prevent aspiration (Ans. D) Page 29

3. Where do you find the restorative nursing goals for a person? A. In their medical history B. In their care plan (Ans. B) Page 30 C. In the MDS D. In their admission notes 4. When you cue a person you do what? A. Prompt them on how to begin an activity (Ans. A) Page 32 B. Do the activity for them C. Ask the person to tell you what they are doing D. Tell the charge nurse the person needs help 5. What is the goal of using equipment when moving and positioning a person? A. To help you do your job faster B. To try different ways to move or position the person C. To minimize the risk of injury to you and the person being moved (Ans. C) Page 38 D. To help you with your body mechanics

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6. Which of the following can cause problems with balance when walking? A. Shoe size B. Endurance Status (Ans. B) Page 87 C. Adaptive devices D. Staff walking in front of them 7. What does moderate assistance mean when moving a person from a bed to a chair? A. The person needs 75% assistance from one person B. The person needs a mechanical lift C. The person needs 50% assistance from one person (Ans. C) Page 70 D. The person needs supervision from one person 8. What is a purpose of range of motion exercise? A. It gives a person something to do B. It keeps staff busy with exercise C. It maintains or increases the person’s joint movement (Ans. C) Page 90 D. It provides activity for the physical therapy department 9. Prosthetic devices help a person improve function for which of the following? A. They provide support with eating utensils B. They provide support with dressing devices C. They provide support with household chores D. They provide support with using a limb that is missing (Ans. D) Page 99 10. What is the most common fracture in the elderly? A. Hip fracture (Ans. A) Page 26 B. Ankle fracture C. Wrist fracture D. Toe fracture Part B Complete each of the following sentences with the correct key term. (fill in the blank) 1. is the term used when a person has weakness affecting only one side of the body.

2. Restorative Care promotes _________________, _____________ _______________, and ___________ _______________. Commonwealth Corporation

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3. ________________ provide specific ways to make improvements. 4. The goal of using equipment is to minimize _________________ of injury. 5. ________________ is how you help people sit, or lie down. 6. A ____________________ is a deformity caused by permanent shortening of a muscle or by scar tissue. 7. The use of a ______________ belt can help you prevent injury to the person. 8. ______________ ________ _______________ is the optimal mobility in a joint of the body. 9. Ambulation is another name for _________________________. 10. Pressure ulcers are a breakdown of the skin caused by pressure, _____________, _______________, or too much moisture. Answers 1. Hemiparesis 2. Independence, self image, self esteem 3. Goals 4. Risk 5. Positioning 6. Contracture 7. Gait 8. Range of Motion 9. Walking 10. Friction, shearing Part C Write your answer in the space provided. 1. List the two components of a written goal. (Page 32)

________________________________________ ________________________________________ 2. List three questions to consider about yourself before moving or positioning a person. (Page 37) ________________________________________ ________________________________________ ________________________________________

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2. List five question to consider about the person before moving or positioning them. (Page 37) ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ 3. List five things you should consider before walking a person. (Page 88) ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 4. Describe each of the following types of exercise. (Page 91) Active ROM______________________________________ Active Assistive ROM______________________________ Passive ROM_____________________________________ 5. List three assistive devices and the purpose of each. (Page 98) Name 1. _____________________________ 2. _____________________________ 3. _____________________________ Purpose ________________________________________ ________________________________________ ________________________________________

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Skill Attainment Procedure for all Skills Part 1: Skills Demonstration Take a few minutes to explain how you will demonstrate skills and conduct skill practice. Be sure to explain that students must perform the skills with 100% mastery. Tell students to open the student manual to the skill you are about to demonstrate. Ask for one volunteer to read each step of the skill, while the rest of the students read along. Ask for another student to role-play the person being cared for while you demonstrate the skill on them. Demonstrate each step of the skill after it is read to you. Ask students to observe your demonstration. Answer any questions students may have. Note: As the steps are read, ask the volunteer reader to pause after each step to allow time for the students to look up from the Student Manual to watch as you demonstrate that step. You may want to ask the group to hold all questions to the end of the demonstration so the focus remains on the demonstration. Part 2: Skills Practice Break the class into groups. You will need 3 students in a group for every skill or group of skills to practice efficiently. The students should bring their student manual and the supplies needed to the skill practice area. Explain how students should practice the skill. Each student must have a turn in each of the 3 roles one student should read the skill step by step, while a second student performs the steps and the third student plays the role of the person being cared for. Each student in the group must have a turn at the three different roles. Give students time to practice the skills. Observe the students’ skill practice. Offer your support as you observe each group during practice. Tell the students that they need to understand the reason for each step and must perform the entire skill with 100% accuracy. Note: Occasionally a student will not want the skill read aloud as they practice it. Encourage this student to allow the skill to be read to them anyway, so that they can gain knowledge from listening while performing each step and so the rest of the group can benefit from the repetition. Repetition is especially important for the skills that require students to think about what to do to prepare, to perform the skill, and then, complete. Note: It is important to allow enough time for students to practice each skill. To run a successful skills lab every student must be engaged and busy. This is a great time for the trainer to move about the lab to get a sense of the students who will need the most guidance. Part 3: Skills Check-off Ask students to let you know when they are ready for skill check-off. Trainers can use the skill attainment record to record the students who perform the skill with 100% accuracy and understand the rationale for each step. When observing each student’s demonstration, ask the student to bring their student manual to the skill check off area and refer to the appropriate skill in the student manual. Explain that you want the student to demonstrate the skill without any cueing or prompting from others. Explain that you expect the student to begin with Preparation, the procedure and then the completion steps. As the student is demonstrating the skill the trainer should place a mark next to any steps the student misses or performs incorrectly, and then review the skill privately with the student. Allow the student more practice time to repeat the skill until they perform the steps correctly. For each skill that a student masters, write P for pass under the student’s name on the Skills Attainment Record. For any skill the student needs to repeat, write R in pencil. Continue these steps until all the students have been checked off. Note: The number of students will determine the length of time needed for skills practice and check off. You may decide to bring in other trainers to assist you if time is a factor.

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Skill Attainment Record
Make a copy of this record for each class, and keep this original. List the names of students along the top of the table. List Procedure number in the boxes in the first column. You will need to make a copy for additional procedures and students. As students demonstrate the skills, mark a P (pass) or R (repeat) in the appropriate box. Students need to master all skills/procedures before completing the training.

Moving the Person from Supine Position to Sitting

Moving the Person from Sitting to Supine Position

Moving Up in Bed When a Person Can Help

Moving Up in Bed When a Person is Unable to Help

Moving to the Side of the Bed When a Person Can Help Moving to the Side of the Bed When a Person is Unable to Help Moving a Person to the Side of the Bed Using a Draw Sheet Turning a Person from Supine to Side-lying for Personal Care Positioning a Person Prone (Stomach Lying)

Positioning a Person Supine (Back Lying)

Positioning a Person Side-Lying

Student Name

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Putting a Guard Belt on a Person

The Stand Pivot Transfer

Assisted Transfer with an Assistive Device (One Person)

Transferring a Person from a Chair to a Bed

Moving a Person with a Mechanical Lift

Moving a Person Up in a Chair

Positioning a Person in a Wheelchair

Returning a Person to Bed Using a Mechanical Lift

Passive range of motion exercises.

Putting on Harris Hemi-Sling

Putting on Hand Split

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Student Name

Procedure 1. Moving the Person from Supine Position to Sitting Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Help the person roll onto their side toward you, or you can elevate the head of the bed. (Fig. 1) Using your arm closer to the head of the bed, reach under the person’s head and put your hand under their shoulder. Support their head by resting it on your forearm. (Fig. 2) With your other hand, reach behind the person’s knee. (Fig. 3) Using your legs and arms to do the lifting, bring the person’s head and trunk up as you swing their legs down to the sitting position. Hold the person’s legs, letting their knees rest in the crook of your elbow. (Fig. 4) Help the person get comfortable in the sitting position. (Fig. 5)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

(Fig. 5)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

R

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Procedure 2. Moving the Person from Sitting to Supine Position Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Place one hand behind the person’s shoulder, resting their head and neck on your forearm. Place your other hand under their knees, and resting their legs in the crook of your elbow. (Fig. 1) Using good body mechanics, help the person lift their legs up onto the bed. Gently lower their trunk and head onto the bed. (Fig. 2)

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(Fig. 1)

(Fig. 2)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

R

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Procedure 3. Moving Up in Bed When a Person Can Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Put the head of the bed down as far as tolerated by the person. Move the pillows against the headboard. Help the person bend their knees up, with their feet flat on the bed. Place one arm under the person’s upper back behind the shoulders and the other under their upper thighs. (Fig. 1) On the count of three, have the person push their feet down into the mattress and lift up their buttocks (bridging) while you help move them toward the head of the bed.

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

R

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Procedure 4. Moving Up in Bed When a Person is Unable to Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Get assistance from another staff person. Put the head of the bed down as far as tolerated by the person. Remove the pillow and place it against the headboard. Have the person cross their hands over their chest. (Fig. 1) If used, roll the draw sheet up until you and your helper both have a tight grip on it with both hands. Keep your palms up if that gives you more strength for moving. (Fig. 2) Using good body mechanics, on the count of 3, you and your helper lift the person up to the head of the bed . You can do this in stages until the person is in position. Unroll the draw sheet and tuck it in.

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(Fig. 1)

(Fig. 2)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

R

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Procedure 5. Moving to the Side of the Bed When a Person Can Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

158

Skill Steps
Stand on the side of the bed to which you plan to move the person. Help the person bend their knees up, keeping their feet flat on the bed. Help the person to lift up their buttocks, and move their buttocks to the side of the bed. (Fig. 1) Help the person move their legs to the side, and then their head and upper body. Do this by sliding your arms under them and gliding them toward you. You can do this in stages to reach the desired position.

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 6. Moving to the Side of the Bed When a Person Cannot Help Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

R

Commonwealth Corporation

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Skill Steps
Stand on the side to which you plan to move the person. Have the person fold their arms across their chest. (Fig. 1) Place your hands under the person’s head, neck, and shoulders and move them toward you on your arms. (Fig. 2) Place your arms under the person’s hips, and move them toward you. (Fig. 3) Place your arms under their legs, and move them toward you.

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(Fig. 1)

(Fig. 2)

(Fig. 3)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 7. Moving a Person to the Side of the Bed Using a Draw Sheet Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Get assistance from another staff person. Have the person cross their hands over their chest. If used, roll the draw sheet up until you and your helper both have a tight grip on it with both hands. Keep your palms up if that gives you more strength for moving. (Fig. 1) Using good body mechanics, on the count of 3, you and your helper lift the person to the side of the bed . You can do this in stages until the person is in position. Unroll the draw sheet and tuck it in.

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(Fig. 1)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 8. Turning a Person from Supine to Side-lying for Personal Care Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Have the person bend their knees up, and place their feet flat on the bed. (Fig. 1) Place one hand on the person’s shoulder and the other hand on the hip farther away from you. (Fig. 2) On the count of 3, roll the person toward you. Continue personal care. (Fig. 3)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 9. Positioning a Person Prone (Stomach Lying) Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Place a flat pillow on the person’s stomach. Turn the person onto their abdomen. Make sure that they are not lying on their arm. Be sure their toes are not hanging over the edge of the mattress, or use a large pillow to support the feet so that the toes do not touch the mattress. Support the head with a flat pillow. Make sure that their face is turned to one side. One arm should be lying straight against the body. The other should be stretched out overhead.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 10. Positioning a Person Supine (Back Lying) Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Turn the person onto their back, being sure their body is in proper alignment. (Fig. 1) Place a pillow under their head and shoulders and one under the knees. (Fig. 2) Put sand bags or small pillows alongside the hips to maintain alignment if needed; and between the person's arm and their side. (Fig. 3) Support the feet against a footboard and place a pillow or roll uder their ankles to elevate their feet off the bed. If needed, place hand rolls in the person’s hands to support their fingers and thumbs and prevent contractures. (Fig. 4)

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(Fig. 1)

(Fig. 2)

(Fig. 3)

(Fig. 4)

Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 11. Positioning a Person Side-Lying Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Commonwealth Corporation

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Skill Steps
Turn the person onto their side by using Skill Procedure number 8, Turning a Person from Supine to Side-lying. The arm on the underside is supported by the mattress. (Fig. 1) Place a pillow under the head and neck. (Fig. 2) Tuck a pillow behind the back by tucking the long edge of the pillow between the bed and the person’s body at their back. Roll the opposite long edge of the pillow under itself so that the person has a firm roll to rest upon. (Fig. 3) Place a pillow under the upper arm to support it. (Fig. 4) The leg on the underside is supported by the mattress. Flex the upper leg. Place pillows under the thigh, leg, and foot for support. (Fig. 5) If needed, place hand rolls in the person’s hands to support their fingers and thumbs and prevent contractures.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 12. Putting a Guard Belt on a Person Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Hold the belt with the label on the outside (most manufacturers label the outside). (Fig. 1) Place the belt around the person’s waist over their clothes while they are either lying or sitting. (Fig. 2) With the belt around the person’s waist, put the end through the buckle (or attach the Velcro or plastic fastener), and tighten the belt firmly, being sure you can get your fingers under it to hold it when transferring the person. You may have to tighten it again when the person stands. (Fig. 3)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 13. The Stand Pivot Transfer Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Stand in front of the person. Place one of your legs between the person’s legs and the other close to the target you are moving toward, such as a chair. (Fig. 1) Hold onto the guard belt on both sides. If you are not using a guard belt, put your arms around the person’s waist. Ask the person to push down on the bed with their hands, lean forward, and stand up. If they cannot do this, ask them to put their arms around your waist. Note: Do not let the person hold you around your neck, which could injure you. (Fig. 2) On the count of 3, ask them to lean forward and stand up. (Fig. 3). You can help the person stand by leaning your body back and up, thereby bringing the person’s body forward. Once the person is standing, pivot (turn on your feet or take small steps) to turn them until the backs of their knees are against the chair. (Fig. 4) Ask the person to reach back for the arm of the chair with one or both hands if possible. (Fig. 5) Help the person bend their knees and sit. (Fig. 6) Once the person is sitting, ask or help them to push back in the chair by pushing down with their feet on the floor and their arms on the armrests.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 14. Assisted Transfer with an Assistive Device (One Person) Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Have the person sit on the side of the bed, place the assistive device in their hand (cane) or in front of them (walker). Stand to the side of the person on the side opposite the device. (Fig. 1) Ask the person to push down on the bed with their hands and stand on the count of 3. You can help them by pulling up and forward on the back of the guard belt with one hand while pushing down on the walker or cane to keep it stable until the person grasps the assistive device. (Fig. 2) For people using a walker: after they are standing, help them put both hands on the walker. (Fig. 3) Help the person move toward the chair. (Fig. 4) Help the person back up to the chair. Ask if they can feel the chair against the back of their knees. (Fig. 5) When the person is in front of the chair, ask them then to reach back and put one hand on the armrest. (Fig. 6) Help the person reach back with the other hand for the arm of the chair and slowly sit down. (Fig. 7)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 15. Transferring a Person from a Chair to a Bed Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Position the chair so that the person’s stronger side is closest to the bed, commode, or toilet. (Fig. 1) If the person is in a wheelchair, ask them to move their feet off the footrests. Raise up the footrests and move them out of the way.. Ask the person to slide forward to the edge of the chair. Use either the stand pivot technique or the assistive device transfer procedure in reverse to move the person from the chair and into bed. (Fig. 2)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 16. Moving a Person with a Mechanical Lift
Note: in order to properly use a mechanical lift, you must follow the manufacturer’s instructions. You should never use a lift you have not been trained to use.

Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Adjust the head of the bed as flat as possible. Place the sling under the person by first turning the person toward you. Help the person move toward you while your helper on the other side of the bed pushes the fan-folded sling under the person as far as possible. Then help the person back toward the other side, and pull the sling under them. (Fig. 1) Place the lift frame facing the bed with its legs under the bed. Lock the wheels on the base. (Fig. 2) Elevate the head of the bed so the person is partially sitting up. Attach the sling to the lift following the manufacturer’s directions. (Fig. 3) Ask the person to cross their arms over their chest before operating the lift. Follow the manufacturer’s directions for raising the person to a sitting position. While you operate the lift, your helper should help you guide the person. (Fig. 4) Once the person is in a sitting position, raise the lift until they are 6 to 12 inches over the bed and chair height. Unlock the swivel, if the lift has one, or use the steering handle to move the person directly over the chair. You may need to support the person’s legs. Tell the person that you are now going to lower them into the chair. Your helper should guide the person into the chair by moving the sling. Press the release button to slowly lower them down. (Fig. 5) Once the person is safely in the chair, unhook the sling and remove the lift. Position the person in the chair, leaving the sling under them (unless the sling is removable) until it is time to return to bed. Pull the metal bars of the sling out so that the person does not lean against or sit on them. (Fig. 6)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 17. Moving a Person Up in a Chair Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Place a guard belt on the person. Standing on both sides of the person, you and your helper each grasp the guard belt with one hand and puts the other hand under the person’s knees. Ask the person to cross their arms in front of their chest. Using good body mechanics, on the count of 3, breathe out and lift the person back in the chair. . (Fig. 1)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 18. Positioning a Person in a Wheelchair Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Place a wheelchair cushion on the seat Be sure the seat width is wide enough to allow approximately ½ inch of clearance on either side of the person. If the seat is too wide the chair will not provide enough side support for the person. Be sure the seat depth allows 2-3 inches of clearance from the back of the person’s knee to the front of the seat, so that circulation is not impaired. Adjust the footrest height so that when the person is sitting they have 2 inches of clearance above the floor. The knee should be at the level of the pelvis or slightly higher. Their feet should be able to rest flat on the footrest. Adjust the armrests so that they are 1 inch higher than the distance from the seat cushion to just under the person’s elbow.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 19. Returning a Person to Bed Using a Mechanical Lift Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Position the lift facing the chair. Attach the sling to the lift following the manufacturer’s directions. (Fig. 1) Raise the person up with the lift. Your helper guides the person by holding the sling. (Fig. 2) Swing the frame of the lift over the bed and slowly lower the person down onto the bed. (Fig. 3) Unless the person will spend only a short time in bed, roll them to one side to remove the sling (which could cause skin irritation if left under the person). (Fig. 4) Position the person as preferred

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 20. Range of Motion Exercise Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps Shoulder
Flexion: bring the whole arm up toward the person’s head in front of the body. Extension: bring the arm straight back to their side. (Fig. 1) Abduction: move the arm away from the body out to the side. (Fig. 2) Adduction: bring the arm back toward the side. (Fig. 3) Internal rotation: turn the shoulder in. (Fig. 4) External rotation: turn the shoulder out.

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Skill Steps Elbow
Flexion: bend the elbow. (Fig. 1) Extension: straighten the elbow. Supination: turn the palm up. (Fig. 2) Pronation: turn the palm down. (Fig. 3)

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Skill Steps Wrist
Flexion: bend the wrist down. (Fig. 1) Extension: bend the wrist back. (Fig. 2) Ulnar deviation: with the hand held at the same level as the forearm, move the hand toward the little finger side. (Fig. 3) Radial deviation: with the hand as above, move the hand toward the thumb side. (Fig. 4)

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Skill Steps Hip
Flexion: bring the knee toward the chest. (Fig. 1) Extension: lay the leg down straight. (Fig. 2) Abduction: bring the hip out to the side by moving the leg. (Fig. 3) Adduction: bring the hip back toward the side by moving the leg. (Fig. 4) Internal rotation: turn the hip inward by moving the leg. (Fig. 5) External rotation: turn the hip outward by moving the leg.

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Skill Steps Knee
Flexion: bend the knee. (Fig. 1) Extension: straighten the knee. (Fig. 2)

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Skill Steps Ankle
Dorsiflexion: bend the top of the foot up toward the face. Plantarflexion: point the foot down, like stepping on a gas pedal. Inversion: turn the bottom of the foot inward. Eversion: turn the bottom of the foot outward.

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Skill Steps Foot
Toe flexion: bend the toes down. (Fig. 1) Toe extension: straighten the toes back up. (Fig. 2)

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 21. Putting on Hand Splint Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
Inspect the splint to make sure it is clean and in good condition. Inspect the person’s skin, especially areas where it comes into contact with the splint. Open the hand and fingers to a neutral position, and position the splint in the hand. Position the person’s thumb and fingers appropriately in the splint, and then check the position of the wrist and forearm. Secure the straps over the wrist and then over the thumb and fingers. Finish securing all straps and check that they fit snugly without impairing circulation. Inspect the splint and the person’s hand and arm to ensure that the splint fits correctly in all areas. After the splint is applied, position the person’s arm on a supportive surface or in a sling as directed by the therapist.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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Procedure 22. Putting on Harris Hemi-Sling
Properly using a hemi-sling is important for maintaining the integrity of the shoulder joint when the person’s arm is paralyzed. It should be worn whenever the person is out of bed, unless a lap board or arm trough is used.

Common Preparation Steps
Check the care plan. Knock on the door and wait for permission to enter. Introduce yourself. Check the person’s identification according to your facility’s policies. Tell the person what you would like to do and ask if this time is ok. Determine the person’s abilities. Provide necessary equipment to help you with the procedure. Explain the procedure. Gather supplies needed both from outside and inside the person’s room. Prepare the equipment and environment. For example, lock the wheelchair or bed wheels, adjust the height of the bed, lower side rails if used, and move things aside to provide adequate space to work. Provide privacy by closing the door or pulling the curtain completely around the bed and closing the shades. Wash your hands. Wear gloves, goggles, mask, and gown when needed. Offer help with the procedure but only as needed. Use the proper container for dirty items. Observe the person and take advantage of the time to have a conversation.

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Skill Steps
The sling is put on like a jacket or sweater. Drape the elbow guard over the involved shoulder, and put the uninvolved arm through the wrist support. Place the elbow in the elbow guard. Place the wrist through the wrist support. Hook the top buckle. Secure the Velcro strap to the underside of the elbow guard. To remove the sling, simply unhook the buckle and release the Velcro strap. Do not unhook or release any of the other straps.

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Common Completion Steps
Complete the procedure without any distractions or interruptions. Provide for the person’s comfort. Make sure the person is in proper body alignment. Check with the person to be sure everything is satisfactory. Put the call light or other call device close to the person. Make sure the bed is lowered. Dispose of all used items in the proper container. Wash your hands. Record the completed procedure in the person’s facility record. Report any changes in the person or in their environment to the charge nurse.

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