9.1. INTRODUCTION TO PROMOTE INDEPENDENCE THROUGH REHABILITATION/RESTORATIVE CARE

Chapter 8 discussed how nursing assistants help clients with mobility with actions ranging from repositioning them in bed, transferring them out of bed to a chair, or ambulating them in the hallway. This chapter will focus on how the nursing assistant promotes client functioning and independence through rehabilitation and restorative care.

Acute health events and chronic illnesses can reduce a client’s level of functioning and independence. For example, clients who experience a stroke or hip fracture or live with chronic disease like heart failure or chronic obstructive pulmonary disorder (COPD) often require assistance in completing their activities of daily living (ADLs). Any condition that requires bed rest can cause muscle atrophy, decreased lung function, and other complications. Clients recovering from illnesses or injury may require therapy performed by the licensed therapy team to return lost levels of function. As their functioning is restored, the nursing assistant can help clients retain the highest possible level of functioning and independence and promote their physical and mental well-being.

9.2. THE REHABILITATION PROCESS

After an individual experiences an acute illness, injury, or significant change in health status, there is always a period of recovery. During recovery, some individuals participate in rehabilitation. Rehabilitation helps people regain body functions they lost due to medical conditions or injury. Rehabilitation can help improve many body functions, including bowel and bladder problems, chewing and swallowing, problems thinking or reasoning, movement or mobility, speech, and language.[1]

The goal of the rehabilitation is to return the person to their prior level of function before the health event. The length of time for recovery varies for each individual, and there are several factors that can influence its progression. A list of factors that can affect an individual’s recovery process include the following:

• Comorbidities: Comorbidities are coexisting health conditions. Having another chronic diagnosis or other acute condition may slow the progression of healing. Here are some examples of how comorbidities affect healing and recovery:
  • If a person has diabetes, their healing process is slower, and their risk of infection is higher.
  • If a person has chronic respiratory or cardiac conditions such as asthma, chronic obstructive pulmonary disease (COPD), or heart failure, their endurance to complete rehabilitation exercises may be decreased.
  • If a person has dementia, they may not remember they are injured and may try to move without assistance, resulting in a fall or further injury to the affected area.
• Age: As people age, healing slows down, and the functioning of various body systems declines. Older adults are more likely to have comorbidities and complications related to these coexisting conditions that can slow or even halt the rehabilitation process.
• Motivation: If a person lives with severe chronic illness or experienced health events that previously required rehabilitation, they may feel like giving up or not putting in the effort to return to their prior level of functioning. Some people prefer someone assisting them with their ADLs for a variety of reasons, such as experiencing increased pain with movement, severe fatigue, or feeling lonely and desiring increased interaction with others.
• Resources: Resources include support from family members or friends who offer encouragement, nearby health care providers in the community, and transportation available to get to appointments. Insurance also plays a role in recovery because the amount of reimbursement for rehabilitation services is determined by insurance coverage.

The types of therapy provided are determined by the individual’s illness or injury. The roles and responsibilities of different disciplines will be further discussed in the “Members of the Therapy Team” section of this chapter. Rehabilitation may begin in an acute care setting when intensive interventions are required several times throughout the day and then transfer to a short-term stay or rehabilitation unit in a long-term care facility for further rehabilitation. In the long-term care facility, they typically see therapists once or twice a day until they are independent enough to return to their previous home environment. Both of these situations are referred to as in-patient therapy because the rehabilitation treatment occurs in a facility where the client is staying. However, in some cases, the individual can return home and visit a therapist once or twice a week, which is referred to as out-patient therapy. Out-patient therapy is commonly prescribed for post-operative rehabilitation, such as that required for a hip, knee, or shoulder replacement.

Therapists determine the types of interventions needed and the frequency of treatments based on each individual’s situation. Therapists provide rehabilitation treatment for as long as the client continues to improve, but it will conclude when their progress plateaus (i.e., their level of function remains the same and no longer improves). Sometimes an individual is unable to achieve their prior level of functioning and must remain in a long-term care facility for assistance and supportive care for the remainder of their life. When this occurs, the individual will have a restorative care plan that is further discussed in the “Rehabilitation Versus Restorative Care” section of this chapter.

9.3. MEMBERS OF THE THERAPY TEAM

In a short-term stay unit of a long-term care facility, there is typically a therapy gym where rehabilitation interventions are performed. Therapists may be employees of the facility or may work for another health care organization that contracts with the long-term care facility to provide therapy to its residents.

The therapy team is part of the interprofessional health care team as previously discussed in Chapter 2.3, “Members of the Health Care Team and Nursing Home Structure.” It is helpful to understand the roles and responsibilities of each type of therapy discipline, especially if you work on a short-term stay or rehabilitation unit. Occupational therapists, speech therapists, and physical therapists are the most common types of therapists. Respiratory therapists may be present in long-term care settings that have specialized ventilator units.

Occupational Therapists (OT): Occupational therapists assess, plan, implement, and evaluate interventions to help clients achieve their highest possible level of independence in completing their activities of daily living (ADLs) such as bathing, grooming, eating, and dressing. OTs also teach clients how to use adaptive devices to complete their ADLs. Adaptive devices include long shoehorns (to assist clients with putting shoes on), sock pulls (to independently pull on socks), adaptive silverware (to facilitate independent eating), grabbers (to pick items up from the floor), and special devices to manipulate buttoning so the client can dress and button their clothing independently. These devices are further discussed in the “Promoting Independence During ADLs” section. OTs may also assess the client’s home for safety and their need for assistive devices when they return home (if they are able to do so). For example, OTs may recommend home environment modifications such as ramps, grab rails, and handrails to ensure client safety and independence.[1]

Physical Therapists (PT): Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate interventions related to clients’ functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range of motion. They supervise exercises tailored for a client’s condition and teach them how to use assistive devices like walkers and canes.[2]

Speech Therapists (ST): Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example, clients with expressive aphasia understand what other people say but struggle to get words out, speak in very short sentences, and omit words. They may say, “Want food,” or “Bathroom go.” Speech therapists teach these clients how to use word boards and other electronic devices to facilitate communication. STs also assess clients with swallowing disorders (i.e., dysphagia) and determine if they require thickened liquids or a modified diet to prevent aspiration of substances into their lungs. STs collaborate with other members of the health care team, including nurses, dieticians, and health care providers.[3]

Respiratory Therapists (RT): Respiratory therapists treat respiratory-related conditions in patients. Their specialized respiratory care includes managing oxygen therapy; drawing arterial blood gasses; managing patients on specialized oxygenation devices such as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers; intubating patients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene measures like chest physiotherapy; and serving an integral role in maintaining a client’s airway during cardiac and respiratory arrests.[4]

9.4. COMPLICATIONS OF IMMOBILITY

Movement, activity, and mobility positively affect one’s overall health. When someone is recovering from a severe illness or injury, their mobility is often reduced, and they may be unable to perform ADLs. Health care team members play a vital role in preventing the physical and mental decline in functioning that can occur from immobility by proactively implementing interventions.

Risks of immobility are well-known, and complications are viewed as avoidable. In fact, many insurance companies do not reimburse health care agencies for complications resulting from immobility, like pressure injuries, because they are viewed as avoidable with the proper care. Therefore, nursing assistants must be diligent in their actions and observations to maintain their client’s health and prevent complications.

See Table 9.4 for potential complications of immobility by body system and additional preventative measures that will keep clients as healthy as possible. Promoting clients’ independence in completing their ADLs and encouraging activity as tolerated can help prevent all these complications of immobility. “Encouraging activity as tolerated” means involving the resident in movement while also adhering to mobility restrictions noted in the care plan and observing for respiratory changes that indicate the resident may be lacking endurance to maintain the activity. Sometimes a client’s lack of endurance in completing activities requires the nursing assistant to segment their ADLs. Segmenting ADLs refers to breaking up tasks to accommodate the client’s activity intolerance. An example of segmenting ADLs would be assisting a person to bathe in bed as independently as possible, letting them rest after bathing, and then returning later to assist them with dressing and grooming to get them ready for the day.

Devices to Prevent Contracture

The “Applying Prosthetics and Orthotics” section in Chapter 8 describes devices such as a foot split to prevent musculoskeletal contracture. There are additional devices that can prevent a client’s hand contracture, as well as prevent their fingernails from creating open skin areas in their palm. The first type of hand device is a cone that slides into the palm of the hand and is kept in place with a soft elastic band. The cone should not be forced into the fingers but placed gently. A second type of device is a palm protector that is softer than the cone and separates the fingers from one another. If neither of these devices is available, a washcloth can be rolled and placed underneath the fingers. See Figure 9.1[1] for an image of a cone and palm protector, and Figure 9.2[2] for images showing application of these devices.

Figure 9.2

a.) Cone on Client’s Hand, b.) Palm Protector Viewed on the Palm of a Client’s Hand, and c.) Palm Protector Viewed on the Dorsal Side of Client’s Hand

ange of Motion (ROM)

Active and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. ROM exercises facilitate movement of specific joints and promote mobility of the extremities. Because changes in joints can occur after just three days of immobility, ROM exercises should be started by the nursing assistant as soon as they are directed by the nurse as safe to do so.

There are three types of ROM exercises: passive, active, and active assist. Passive range of motion is movement applied to an individual’s joint by another person or by a passive motion machine. When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part. For example, clients who undergo knee replacement surgery may be prescribed a passive range of motion machine that continuously flexes and extends the patient’s knee while they are lying in bed. See Figure 9.3[3] for an image of a passive motion machine.

Figure 9.3

Passive Motion Machine

Active range of motion is movement of a joint by the individual with no outside force aiding in the movement. A staff member may provide verbal cues to complete the action, but the movement is done independently by the client.

Active assist range of motion is joint movement by an individual with partial assistance from an outside force. For example, during the recovery period after shoulder surgery, a client attends physical therapy and receives 50% assistance in moving their arm with the help of a physical therapy assistant.

Several terms are used to refer to certain body movements during range of motion exercises, such as abduction, adduction, flexion, and extension. Abduction refers to the movement of a limb away from the body’s midline. For example, hip abduction is the movement of the leg away from the midline of the body. We use this action every day when we step to the side, get out of bed, and get out of the car. Adduction refers to moving a limb towards the midline. For example, if a person has their fingers spread wide apart, bringing them back together is adduction. Flexion is movement that decreases the angle between two bones and extension is movement that increases the angle between two bones. For example, a bicep curl during weight lifting demonstrates both flexion and extension. Flexion occurs when the bicep muscle contracts and the elbow joint bends, lifting the weight. Extension occurs when the arm is straightened back to starting position, increasing the angle between the elbow joint.

When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist. The plan is tailored to the needs of the individual and will include the specific joints to move. Typically, larger joints such as shoulders, elbows, hips, knees, and ankles are included in ROM exercises, but ROM can be also applied to smaller joints such as the fingers and wrists.

When assisting with ROM exercises, the nursing assistant must support any joints below the joint being exercised to prevent injury. For instance, if the shoulder is being exercised, the nursing assistant places their hands underneath the elbow and wrist to support them. The joint should be moved gently and only to the point to where there is slight resistance. A joint should never be forced to achieve full ROM if there is resistance. For example, a client who has had limited mobility for several years may have a joint that can only be moved a few inches, but it is important to maintain that mobility, no matter how small.

While providing ROM, the nursing assistant must observe for objective and subjective signs of pain. The resident should be asked if they are experiencing any pain during the movement, and the assistant should watch for nonverbal signs of pain like grimacing, clenching the teeth, groaning, or labored breathing. Refer to the “Objective and Subjective Signs of Pain” subsection in Chapter 6.3 to review observations to make and report. See the steps for providing ROM for the shoulder and hip joints in the “ROM Exercises for the Shoulder” and “ROM Exercises for the Hip and Knee” Skills Checklists later in this chapter.

Incentive Spirometry

When a client experiences immobility, normally healthy alveoli can collapse and cause decreased lung function. Decreased lung function can reduce a person’s stamina and their ability to perform activities, referred to as activity intolerance. To prevent a decrease in lung function, reduce the build-up of fluids in the airways, and prevent pneumonia, clients are often prescribed incentive spirometry to keep their bronchioles open. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. See Figure 9.4[4] for an image of a client using an incentive spirometer. Nursing assistants are often expected to encourage clients to use their incentive spirometer hourly.

Figure 9.4

Using an Incentive Spirometer

The nurse or respiratory therapist initially teaches the client how to use the incentive spirometer but encouraging and observing clients complete this action every hour is commonly delegated to a nursing assistant. The client should sit upright (if possible), place the mouthpiece in their mouth, and create a tight seal with their lips around it. They should breathe in slowly and as deeply as possible through the tubing, with the goal of raising the piston to their prescribed level. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly. The client should attempt to hold their breath for as long as possible (at least five seconds) and then exhale and rest for a few seconds. Coughing is expected, and clients should be encouraged to expel any mucus (not swallow it). This technique should be repeated by the client ten times every hour while they are awake. Report completion of the activity to the nurse who documents frequency and effectiveness of this intervention.[5]

Compression Stockings

Deep-vein thrombosis (DVT) is a common complication for clients experiencing immobility. When blood is not moving much due to client inactivity, it can coagulate (i.e, form a clot). This blockage reduces blood flow to the affected area. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. If the clot breaks free, it can travel to the lungs and become fatal.

The best way for nursing assistants to prevent DVT is to assist clients to ambulate or otherwise complete as much activity as they can tolerate. Some clients are prescribed compression stockings, also referred to as thrombo-embolic-deterrent hose (TED hose). Compression stockings promote the return of fluid back into circulation by gently providing pressure on veins. They are commonly used for clients with swelling of their extremities (edema) caused by cardiac conditions that cause fluid retention.

Compression stockings require a physician’s order and should be applied in the morning and taken off at night. They should be applied upon awakening because edema is usually at its lowest point after lying in bed overnight. However, as the client sits or stands upright during the day, blood tends to pool in the lower legs. The pressure from compression stockings helps return fluid into the cardiovascular system and may reduce the risk for DVT.

When removed at night, the compression stockings should be washed by hand in the sink with soap and water and then hung to air dry. Do not send them to the laundry or put them on a heater to dry because this can cause shrinking and ruin the hose. Clients often have two or more pairs of compression stockings to ensure they dry completely before wearing them again in the morning.

Compression stockings may be knee length or hip length. See Figure 9.5[6] for an image comparing both lengths. The amount of pressure the hose applies to the legs is prescribed. For example, some compression stockings may seem like slightly tight socks, whereas other stockings for clients with severe edema are custom-made to fit very tightly and may have a zipper for ease of application.

Figure 9.5

Thigh-high TED Hose (left) and Knee-high TED Hose (right)

When applying stockings, proper placement on the heel is important. The stockings have a square marker around the heel to guide correct placement on the heel. It can be difficult to see this square but stretching the fabric around the heel area should make it more visible. See Figure 9.6[7] for an image of locating the heel marker. If there is writing on the stocking, it should be on the outside and facing away from the skin when worn.

Figure 9.6

Locating the Heel Marker on TED Hose

When applying TED hose, find the heel marker first. You can gather or roll the sides of the hose down to the heel or choose to turn the stocking inside out to the heel marker. If turned inside out, put your hand inside the hose, hold at the top of the heel marker with your thumb and forefinger, and then pull the top of the stocking down to the heel marker. See Figure 9.7[8] for a demonstration of these techniques. Use any of these techniques to place the stocking on the heel, and then check for proper placement of the heel marker before applying the rest of the stocking. See Figure 9.8[9] for heel placement.

Figure 9.7

TED Hose Gathered (left), Rolled (center), and Turned Inside Out (right) to Place on Client’s Heel

Figure 9.8

Ensure Proper Placement of Heel Marker on Heel

After the heel of the stocking is placed properly on the client’s heel, check that the hose is not twisted. Make any adjustments before proceeding because the hose will be very difficult to adjust after it is pulled up the leg. When you have the hose positioned correctly, pull the remainder of the stocking up to the knee or hip, depending upon the length of the hose. Check that there are no wrinkles in the hose and that the client has no discomfort.

The toe of the stocking is typically open to allow for easy assessment of the client’s circulation. The fabric should be completely over the toes, or completely at the base of the toes, to prevent skin breakdown or blockage of circulation to the toes. See Figure 9.9[10] for images of both types of applications of the toe opening of the stocking.

Figure 9.9

a.) and b.) TED Hose Covering Toes and c.) TED Hose at the Base of the Toes

Regular socks or slippers can be placed over the TEDs for warmth if desired. For specific steps in applying TED hose, see the “Application of Compression Stockings (TED Hose)” Skills Checklist at the end of the chapter.

9.5. REHABILITATION VERSUS RESTORATIVE CARE

As previously explained in “The Rehabilitation Process” section, speech therapists, occupational therapists, and physical therapists create the client’s rehabilitation plan with the goal of returning them to their level of function prior to the injury or illness. When an individual has progressed to their highest level of functioning, a restorative care plan is established to ensure this level of function is maintained. Although therapists provide rehabilitation therapy, nursing assistants are responsible for providing restorative care planned by the therapy team.

Common restorative plans include assisting with ambulation (Chapter 8.5); performing passive or active range-of-motion (ROM) exercises (Chapter 9.6); assisting with activities of daily living (ADLs) (Chapter 5.2); and applying prosthetics, splints, and orthotics (Chapter 8.6). Providing restorative care should be documented because it is an integral part of keeping residents as independent as possible and maintaining their overall health and quality of life. If the client resides in a facility that receives Medicare reimbursement, restorative care is reported as part of the person’s quarterly minimum data set (MDS) assessment. (To review aspects of MDS, see Chapter 1.5, “Documenting and Reporting.”) If it is found that a resident experienced a decline in mobility because their restorative care plan was not being followed appropriately, the facility must provide therapy at no charge to restore their prior level of function.

Restorative care can occur individually or within a group. An individual activity means the nursing assistant is working with one resident at a time on that resident’s specific restorative needs. Restorative care can also occur in a group setting, such as an exercise group where residents follow the lead of an aide and participate as they are able. As discussed in the Chapter 8.6, “Applying Prosthetics and Orthotics” section, it is the nursing assistant’s responsibility to know how to properly perform restorative care, as well as keep residents safe from injury during restorative activities. If you are unsure about any aspect of restorative care, seek instruction from your supervising nurse.

Although clients benefit from restorative care and are encouraged to participate, they do have the right to refuse to participate in restorative care, just as they do in any other aspect of their health care. Certain situations, such as those described below, can make it difficult to motivate residents to participate in restorative care[1]:

• The resident has cognitive deficits that make the benefits of restorative care difficult to understand or impair their ability to participate.
• The resident has been dependent on others for their daily care for a long time.
• The resident experiences pain associated with the activity.
• The resident (or their caregiver) is fearful of falling or becoming injured when performing the activity.
• There is unfamiliarity or the lack of a trusting relationship between the caregiver and resident.

If these circumstances occur, the nursing assistant should continue to encourage the resident to participate in the restorative care in a respectful manner. It may be helpful to delay the care and reapproach the resident at a different time of day. If the resident displays any subjective or objective signs of pain, it should be reported to the nurse for assessment and treatment. Involving loved ones in explaining the importance of restorative care can also enhance a resident’s participation, along with reassurance from a nurse or therapist who oversees the restorative plan. If the resident continues to decline participation despite these attempted approaches, the nursing assistant should report the situation to the nurse, as well as document it was the resident’s choice to not participate in restorative care activities despite the approaches attempted.

For more information on restorative care, see Restorative Care’s Effect on Activities of Daily Living Dependency in Long-stay Nursing Home Residents.

9.6. PROMOTING INDEPENDENCE DURING ADLS

As a health care professional, it is your responsibility to maintain residents’ optimal levels of functioning by encouraging their participation and independence in completing activities of daily living (ADLs). While it may be quicker and more efficient to wheel someone to the dining room rather than assisting them to walk there, it is detrimental to their health to do so. As previously discussed in the “Complications of Immobility” section of this chapter, many interventions prevent decline in residents’ functioning, including encouraging activity as tolerated, and promote independence in completing ADLs with segmenting as needed. Independence in completing ADLs not only prevents complications of immobility but also enhances their quality of life by promoting mental wellness through enhancement of their autonomy and self-esteem.

However, some clients may prefer others to completely care for them because the movements are painful or involve more effort than they are willing to exert. As you gain more experience as a nursing assistant, you will learn to find the delicate balance between promoting health and following client preferences.

Always encourage clients to complete as many ADLs as they can, segmenting them if needed. When you notice a client is becoming fatigued or irritable when performing a task, it is often a good time to begin assisting the client. It does not matter how little a person is able to do for themselves; they should be given the time and opportunity to do so. For nonverbal clients, consider using a white board, communication book, or other device to assist in their communication. These actions demonstrate respect for the person’s dignity, as well as promote their physical health and cognitive involvement in their own care. Refer to the Chapter 8.3, “Promoting Joint Mobility and Activity” section for other ways to encourage mobility and independence.

The therapy team will assess the client and recommend aids that can promote independence to complete daily tasks. Common aids for ADLs may include a reacher, sock aid, bath sponge, and an elongated shoehorn. All these tools allow a person to reach objects or complete hygiene needs with less bending or stretching. They may be used temporarily during the rehabilitation process until full ROM is achieved, especially after joint replacement surgeries. See Figure 9.10[1] for an image of these assistive devices.

Figure 9.10

Reacher, Sock Aid, Elongated Shoehorn, and Elongated Bath Sponge (top to bottom).

Sock Aid

To utilize the sock aid, the sock is placed around the plastic mold. The person holds the rope handles and then puts their foot into the sock. They pull on the ropes to get the sock completely on the foot without bending over to the floor. See Figure 9.11[2] for an image of the placement of a sock on a sock aid and Figure 9.12[3] for an image of getting the sock on the foot.

Figure 9.11

Placing a Sock on the Sock Aid

Figure 9.12

Putting a Sock on the Foot Using a Sock Aid

Please also review assistive devices to promote independence with feeding in “Assistance With Nutrition and Fluid Needs.”

9.7. ASSISTING WITH SENSORY DEFICITS

An impairment of one or more senses can occur in clients of any age, in addition to the aging process causing a decline in all sensory functioning. Sensory impairments, especially vision and hearing impairments, can impact the way a person navigates through the environment and thus increases their risk for falls. Refer to Chapter 11.8, “Neurological System” for additional information about sensory impairments. Information regarding communicating with individuals affected by sensory deficits can be found in the Chapter 1.3, “Strategies for Communicating With Patients With Impaired Hearing, Vision, and Speech” subsection. Interventions that can be performed by nursing assistants to reduce safety risks are described below.

Visual Impairment

The human eye changes around age 40 and decreases an individual’s ability to see close-up objects clearly and makes reading more difficult, although distance vision remains intact. Depth perception also becomes distorted, meaning the person cannot accurately determine the distance between themselves and another object.

Other eye conditions may occur with age that impair vision. Some people develop cataracts, a clouding of the clear lens of the eye. Cataracts can be observed in a person’s eye by the appearance of a cloudiness in their pupil. See Figure 9.13[1] for a simulated image of a person with cataracts.

Figure 9.13

Simulated Image of a Cataract

Glaucoma is a visual condition caused by elevated pressure on the optic nerve, resulting in loss of peripheral vision, blind spots, or even blindness across the entire visual field.

Macular degeneration is another visual condition that results in a blind spot in an individual’s center field of vision. It is the leading cause of vision loss in people over 50. See Figure 9.14[2] for a simulated image of what a person with macular degeneration may experience.

Figure 9.14

Simulated Vision of a Person With Macular Degeneration

The Snellen chart is a common tool for assessing distant vision.[3] See Figure 9.15[4] for a simulated image of how a person with 20/20 vision sees the Snellen chart compared to simulated visual experiences of those with levels of low vision and blindness.

Figure 9.15

Simulated Views of the Snellen Chart With 20/20 Vision Compared to Levels of Impaired Vision

To learn more about cataracts, visit the MedlinePlus webpage on cataracts.

To experience what someone with cataracts may see, watch the following YouTube video[5]: See What I See: Cataracts.

To learn more about glaucoma, visit the National Eye Institute web page on glaucoma.

To experience what someone with glaucoma may see, watch the following YouTube video[6]: Glaucoma Simulation – Busy Road.

To learn more about macular degeneration, visit the American Academy of Ophthalmology’s What is Macular Degeneration? web page.

To experience what someone with macular degeneration may see, watch the following YouTube video[7]: See What I See: AMD.

The simplest interventions for maintaining safety for clients with visual impairment include ensuring they are wearing their prescribed eyeglasses, the glasses are clean, and their living areas are well-lit. There should be no clutter, area rugs, or other small objects on the floor or in a direct path to the bathroom, closet, or exit door of the room to prevent tripping. Keeping the room and personal belongings arranged in a consistent manner allows residents to remain aware of the room set-up, making it easier for them to navigate despite impaired vision. If their visual impairment is severe, tell them where personal items are located before leaving the room, especially the call light and frequently used things like facial tissue, beverages, television remotes, or phones. When ambulating a resident with poor vision, tell them when they are getting close to an object that could pose a fall risk.

Hearing Loss

The most common form of hearing loss occurs as a natural part of aging and is called presbycusis. This type of hearing loss is typically worse at higher frequency sounds, so it interferes with speech recognition and music appreciation. Men tend to experience greater hearing loss than females, perhaps because they have historically worked in louder environments, but it is unknown how much the differences in hearing between genders are caused by biological or social factors.[8]

Hearing can impact an individual’s safety risks. For example, the sense of hearing allows a person to locate objects around them making noise without much conscious thought. For example, sounds like fire alarms or ambulance sirens warn people of emergencies. To understand how sound affects safety, try wearing noise-canceling headphones or earplugs while seated in a populated, busy area. Notice how the lack of hearing changes your perception of movement and the location of objects in your environment.

To assist individuals with hearing loss, use other senses, such as vision and touch, to aid in communication. Stand directly in front of the person when you are speaking, use appropriate gestures to guide actions, and use a light touch to gain their attention or assist in movement. People with hearing loss may become frustrated if they are unable to communicate effectively and may withdraw from interaction with others if hearing loss is profound. Be sure to utilize communication techniques described in the Chapter 1.3 subsection “Impaired Hearing” to prevent isolation.

Hearing aids make sounds louder but do not help in every environment. Even with hearing aids, it can be difficult for individuals to hear a conversation in a large open space or if there is other background noise such as music, television, or other conversations.

If a resident has hearing aids, be sure they are cleaned regularly, and change the batteries once a week. Wax can be removed with a monofilament tool provided with the hearing aids. Some hearing aids have rechargeable batteries that should be charged each night while the resident sleeps. See Figure 9.16[9] for a hearing aid in a case with a battery and a cleaning tool.

Figure 9.16

Hearing Aid in a Case With a Battery and Cleaning Tool

Hearing aids are expensive for residents to purchase, so it is important to always handle them with care and store them in an appropriate place, so they are not lost. If you are unsure of how to fit a hearing aid into a resident’s ear, ask for assistance from the nurse. Hearing aids can fit completely inside the ear or over the top of the ear. See Figure 9.17[10] for an example of a hearing aid that is placed over the top of the ear and Figure 9.18[11] for a simulated hearing aid placed inside a mannequin ear.

Figure 9.17

Hearing Aid on Top of the Ear

Figure 9.18

Simulated Hearing Aid Placed Inside a Mannequin Ear

To experience what someone with hearing loss may hear, watch the following YouTube video[12]: Hearing Loss Simulator – Hear What Hearing Loss Sounds Like.

Speech Impairment

Speech impairment is common for individuals who have had a stroke or who have experienced injuries to certain parts of their brain. These injuries can make forming words and understanding conversations difficult. The medical terms for these conditions are expressive aphasia and receptive aphasia.

People with aphasia can become very frustrated. Everyone has experienced a time when they were trying to think of a word but couldn’t remember it. Imagine how it would feel if this was your experience every time you were trying to communicate with someone. Just as can happen with people with hearing loss, clients with aphasia may isolate themselves, avoid interaction, or become agitated and even aggressive if not approached appropriately.

Interventions when working with a client with a speech impairment include allowing the person extra time to form words or to process what was spoken to them. The feeling of being rushed can make aphasia worse, so providing ample time to process and respond is key. Writing conversations on a whiteboard may also be helpful, depending upon the cognition of the person.

A speech therapist plays an integral role in assessing a resident with aphasia and creating a communication plan. A communication book may be created so the person can point to images of common phrases or requests instead of trying to remember or say the words. See Figure 9.19[13] for an example of a communication board. Refer to the Chapter 1.2, “Overcoming Communication Barriers” subsection for additional information on overcoming barriers.

Figure 9.19

Communication Board

To learn more about speech impairment, view the following YouTube video[14]: Aphasia: The Disorder That Makes You Lose Your Words – Susan Wortman-Jutt.

9.8. FALL PREVENTION

“Prevent residents from falling” is one of the National Patient Safety Goals for long-term care centers. Client falls in long-term care centers, hospitals, or homes are very common and can cause serious injury and death. Older adults have the highest risk of falling. Each year, three million older people are treated in emergency departments for fall injuries, and over 800,000 are hospitalized because of a head injury or hip fracture resulting from a fall. Many older adults who fall, even if they’re not injured, become afraid of falling. This fear may cause them to limit their everyday activities. When a person is less active, they become weaker, which further increases their chances of falling.[1]

Many conditions increase an individual’s risk for falls, including the following[2]:

• Lower body weakness
• Vitamin D deficiency
• Difficulties with walking and balance
• Medications, such as tranquilizers, sedatives, antihypertensives, or antidepressants
• Vision problems
• Foot pain or poor footwear
• Environmental hazards, such as throw rugs or clutter that can cause tripping

Most falls are caused by a combination of risk factors. The more risk factors a person has, the greater their chances of falling. Many risk factors can be changed or modified to help prevent falls.[3] The best way to prevent falls is to follow these guidelines:

• Keep residents as strong and mobile as possible
• Utilize the interventions described in the “Assisting With Sensory Deficits” section of this chapter to address any sensory impairments
• Use proper transfer techniques as outlined in Chapter 8.4
• Report any weakness, confusion, or change in condition
• Encourage fluid and nutritional intake to prevent dizziness and promote strength

Residents are assessed for their potential fall risk by the nursing staff or therapists when they are admitted to a facility, at regular intervals during their stay, and any time there is a change in their condition or when certain medications are ordered. Nursing assistants do not perform this assessment but should be aware of factors that can increase fall risk.

View a PDF sample of a fall risk assessment: Johns Hopkins Fall Risk Assessment Tool.

9.9. SKILLS CHECKLIST: RANGE OF MOTION (ROM) EXERCISES FOR THE SHOULDER

Note: Includes Shoulder Flexion/Extension and Abduction/Adduction Movements

1.

Gather Supplies: None

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Raise the bed height if needed.
• Position the resident in supine position (with the bed flat).
• Place one of your hands under the resident’s elbow with your palm facing up.
• Place your other hand under the resident’s wrist with your palm facing up.
• Watch the resident for objective signs of pain during movement.
• Move their arm gently and stop if there is any resistance.
• While keeping the resident’s arm straight, raise their arm up and over their head (i.e., flexion).
• Ask the resident if they are experiencing any pain during movement.
• Stop the ROM exercise if the resident reports pain or displays objective signs of pain.
• Bring the resident’s arm back down to their side (i.e., extension).
• Complete flexion and extension movements of the shoulder according to the order in the restorative care plan.
• Continue to support the elbow and wrist of the resident.
• Keeping the resident’s arm straight, move their entire arm out away from the body (i.e., abduction).
• Move their arm gently and stop if there is any resistance.
• Ask the resident if they are experiencing any pain during movement.
• Return the resident’s arm to their side (adduction).
• Complete abduction and adduction movements of the shoulder according to the order in the restorative care plan.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check on resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report ROM performed and any skin issues, pain with movement, or other changes noted with the resident.

9.10. SKILLS CHECKLIST: RANGE OF MOTION (ROM) FOR THE HIP AND KNEE

Note: Includes abduction/adduction of the hip and flexion/extension of the hip and knee movements.

1.

Gather Supplies: None

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Raise the bed height if needed.
• Position the resident in the supine position (with the bed flat).
• Place one of your hands under the resident’s knee with your palm facing up.
• Place your other hand under the resident’s ankle with your palm facing up.
• Watch for any objective signs of pain during movement.

Abduction/Adduction for Hip:

• Keeping the resident’s leg straight, gently move their entire leg away from their body (i.e., abduction).
• Move their leg gently and stop if there is any resistance.
• Ask the resident if they are experiencing any pain during movement.
• Stop the ROM movement if the resident reports pain or displays objective signs of pain.
• Keeping the resident’s leg straight, move their entire leg toward their body (i.e., adduction).
• Complete abduction and adduction movements of the hip according to the order in their restorative care plan.
• Continue to correctly support joints by keeping one of your hands under the resident’s knee and the other hand under the resident’s ankle.

Flexion/Extension of Knee and Hip:

• Bend the resident’s knee and hip up toward the resident’s trunk (i.e., flexion of hip and knee at the same time).
• Move the resident’s leg gently and stop if there is any resistance.
• Ask the resident if they are experiencing any pain during movement.
• Stop the ROM movement if the resident reports pain or displays objective signs of pain.
• Straighten their knee and hip (i.e., extension of knee and hip at the same time).
• Complete flexion and extension movements of the knee and hip according to the order in the restorative care plan.

1.

Post-Procedure Steps:

• Perform hand hygiene.
• Check on resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report ROM performed and any skin issues, pain with movement, or other changes noted with the resident.

9.11. SKILLS CHECKLIST: APPLICATION OF COMPRESSION STOCKINGS (TED HOSE)

1.

Gather Supplies: Compression stockings

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Raise the bed height if needed.
• Position the resident in the supine position (bed flat).
• Expose only the leg you will be placing the stocking on.
• Roll, gather, or turn the stocking inside out to the heel.
• Place the stocking over the resident’s toes, foot, and heel.
• Check the placement of heel marking.
• Roll or gently pull the stocking up their leg.
• Check the resident’s toes for possible pressure from stocking.
• Adjust stocking as needed; stocking should be wrinkle-free to the knee or hip, depending on length of stocking.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check on resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report application of TED hose and any skin issues, pain with movement, or other changes noted with the resident.

9.12. LEARNING ACTIVITIES

IX. GLOSSARY

Abduction

The movement of a limb away from the body’s midline. For example, hip abduction is the movement of the leg away from the midline of the body when getting out of bed.

Active assist range of motion

Movement of a joint by an individual with partial assistance from an outside force.

Active range of motion

Movement of a joint by the individual with no outside force aiding in the movement.

Activity intolerance

The reduction of a person’s stamina and their ability to perform activities.

Adduction

The movement of a limb towards the midline. For example, if a person has their fingers spread wide apart, bringing them back together is adduction.

Built-up handles

Specialized silverware that allows the use of utensils by individuals with limited functional ability of their fingers (such as severe arthritis) to hold a smaller handle.

Cataracts

A vision condition causing clouding of the clear lens of the eye.

Coagulate

Form a clot.

Comorbidities

Coexisting health conditions.

Compression stockings

Stockings that apply gentle pressure to a limb to reduce edema; also referred to as thrombo-embolic-deterrent (TED) hose.

Deep-vein thrombosis (DVT)

A blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system.

Depth perception

The ability to determine distance between oneself and another object.

Dysphagia

A swallowing disorder.

Edema

Fluid retention causing swelling in the extremities.

Expressive aphasia

A speech disorder where a person understands what other people say but struggles to form words.

Extension

Movement that increases the angle between two bones. For example, extension occurs when doing a bicep curl and the arm is straightened back to starting position, increasing the angle between the elbow joint.

Flexion

Movement that decreases the angle between two bones. For example, contracting the bicep to lift a weight upwards is flexion.

Glaucoma

A visual condition that occurs due to high pressure on the optic nerve that results in loss of peripheral vision, blind spots, or even blindness across the entire visual field.

In-patient therapy

Rehabilitation treatment that occurs in a facility where the client is staying.

Macular degeneration

A visual condition that causes a blind spot in the center field of vision and is the leading cause of vision loss in people over 50.

Occupational therapists

Therapists who assess, plan, implement, and evaluate interventions to help clients achieve their highest possible level of independence in completing their activities of daily living (ADLs), such as bathing, grooming, eating, and dressing.

Out-patient therapy

Rehabilitation treatment that occurs when an individual is staying at home and visits a therapist once or twice a week.

Passive range of motion

When passive range of motion is applied, the joint of an individual receiving the exercise is completely relaxed while the outside force moves the body part.

Physical therapists

Licensed health care professionals who assess, plan, implement, and evaluate interventions related to clients’ functional abilities in terms of strength, mobility, balance, gait, coordination, and joint range of motion.

Presbycusis

Hearing loss that occurs due to the aging process.

Receptive aphasia

A speech condition that causes difficulty in understanding conversations.

Rehabilitation

Therapy to help people regain body functions they lost due to medical conditions or injury.

Respiratory therapists

Therapists who treat respiratory-related conditions in patients.

Segmenting ADLs

Breaking up activities of daily living (ADLs) to accommodate a client’s activity intolerance.

Snellen chart

A common tool used for assessing distant vision.

Speech therapists

Therapists who assess, diagnose, and treat communication and swallowing disorders.

Weighted silverware

Specialized silverware with a weighted handle for individuals with tremors or unsteady hands.