Course

Restorative care is a type of specialized direct care that optimizes and restores the client's level of functional status to prevent declines in day to day abilities. Functional status refers to an individual's ability to perform the wide range of tasks that are needed for daily living (Elsawy and Higgins, 2011). Daily living tasks, better known as the activities of daily living, include routine self-care functions that many people take for granted such as bathing, feeding oneself, transferring, toileting, continence, and grooming. 

The role of restorative care in the maintenance and/or restoration of functional status is crucial because clients that permanently lose the ability to perform activities of daily living on their own will become dependent on caregivers to do everything for them. On the other hand, clients that maintain the ability to independently perform self-care tasks tend to have a reduced risk of falls, skin breakdown, weight loss, dehydration, incontinence of bowel and bladder, and other serious issues. In general, clients that avoid these problematic issues experience a tremendously enhanced quality of life.

A client's specific restorative care activities are dictated by a restorative plan of care. A restorative plan of care is a document that helps guide care activities so that they are personalized to each restorative client's individualized needs. The client's overall health condition and disease processes play a role in the creation of the care plan (Toney-Butler and Thayer, 2019). The overarching goal of a restorative plan of care is to make sure that a patient’s functional abilities in the sphere of daily living activities do not exhibit any type of decline unless the clinical situation indicates the decline could not be prevented. The initial restorative plan of care is usually prepared by a licensed nurse, but any member of the restorative care team is permitted to contribute to it.

No two clients should have the exact same restorative plan of care due to the variety of different problems they have. Restorative care is individualized in accordance with the restorative plan of care since not all clients have the same functional needs. For instance, Mrs. Daniels might be capable of feeding herself without any issues, but needs intensive bowel and bladder retraining. Meanwhile, Mr. Edwards is completely continent of bowel and bladder and able to toilet himself without any noted problems. However, he needs dining assistance due to some functional declines he has experienced over the past three months. 

Restorative care can include, but is not limited to, skills such as range of motion exercises, ambulation and gait training, bed mobility, dining assistance, locomotion or wheelchair use, fall preventative techniques, activities of daily living and more (Thompson, 2016). The restorative nursing assistant plays an important role in the delivery of restorative care. Restorative nursing assistants are the members of the allied healthcare team that are entrusted with giving restorative care to clients to maintain and/or restore physical function and quality of life.

A restorative nursing assistant is a certified nurses aide (CNA) with additional specialized duties and responsibilities related to the delivery of safe restorative patient care. Restorative nursing assistants work closely with registered nurses, occupational and physical therapists, and speech-language pathologists and are trained to function "in a maintenance capacity in the therapist's or consultant’s absence" (Oklahoma State Department of Health [OSDH], 2020). Essentially, the restorative nursing assistant administers the prescribed treatments to a specified patient load to keep consistence with the restorative program each day. Patients that have been prescribed restorative care are required to receive services at least six days per week.

Legalities are involved in the role and responsibilities of restorative nursing assistants. The Onmibus Reconciliation Act of 1987, better known as OBRA for short, legally requires that the needs of nursing home residents be met. OBRA guidelines read, “each resident must receive and the facility must provide the necessary care and services to attain or maintain the residents’ highest practicable physical, mental, and psychosocial well-being” (OBRA, 1987). Restorative care promotes the restoration and/or maintenance of function so patients remain as independent as possible; in addition, provision of competent restorative care is a legal responsibility of the restorative nursing assistant.

Restorative care is delivered to patients by licensed and/or certified members of nursing staff in strict accordance with the restorative plan of care. Members of nursing staff typically include registered nurses (RNs), licensed practical nurses (LPNs), licensed vocational nurses (LVNs) and restorative nursing assistants. The restorative nursing assistant works under the indirect supervision of the restorative nurse supervisor. These restorative care services include, but are surely not limited to, the following basic nursing tasks (OSDH, 2020): 

1. Range of motion exercises to prevent contracted musculature. 
2. Bowel and bladder training to restore continence. 
3. Self-help skill training. 
4. Behavioral modification under the direction of a qualified consultant. 
5. Ambulation. 
6. Re-motivation. 
7. Use of adaptive equipment.

Two distinct vocational training pathways are available to those who wish to become restorative nursing assistants. The most common career pathway is completion of a state-approved nurse aide training program (NATP) and on-the-job training as a restorative nursing assistant after having attained state certification as a CNA. The second way is to successfully complete a specialized restorative aide training program at a community college, regional state university or private vocational school. Most formal restorative aide training programs cover topics such as restorative care, safe transfers, neurological disease processes that cause weakness, proper body mechanics, prosthetic devices and adaptive equipment. 

In sum, the restorative nursing assistant's primary responsibility is to provide restorative care per specialized care plans due to lofty expectations arising from OBRA legislation. Namely, OBRA arose in the 1980s to address public perceptions regarding deficiencies in the quality of nursing home care. OBRA was enacted with restorative goals interwoven specifically and deliberately into its wording, such the enhancement or maintenance of each resident’s ability to ambulate, bathe, and complete other daily living tasks.

Use of proper body mechanics is of the utmost importance when providing patient care because it ensures that the restorative nursing assistant is utilizing the body in the safest manner possible. Furthermore, the use of good body mechanics helps to greatly minimize the chances of accidental injuries to self, other staff and patients. The term body mechanics is defined as "the coordinated effort of muscles, bones and the nervous system to maintain balance, posture, and alignment during moving, transferring and positioning patients" (Doyle and McCutcheon, 2015).

As a general rule of thumb, the healthcare worker gives oneself far more stability by standing with the feet separated, so it is recommended that the restorative nursing assistant stand with the feet approximately 12 inches apart or shoulder width separation. In the realm of body mechanics, a widened base of support serves as "the foundation for stability" (Doyle and McCutcheon, 2015). Conversely, a narrower stance reduces stability and increases the restorative nursing assistant's odds of sustaining falls, injuries and other poor outcomes.

The center of gravity, defined as the general area where the majority of the the weight is situated within one's body or item, is an important concept in body mechanics. When a person is in a standing position, the center of gravity is normally concentrated in the pelvic area. A lower center of gravity enhances stability and is attainable by bending one's knees, bringing the center of gravity closer to the base of support and ensuring the back is straight (Doyle & McCutcheon, 2015). When lifting an object or person, it is better for the restorative nursing assistant to hold the load closer to the center of gravity and use his/her knees when lifting, rather than the back.

Restorative nursing assistants should never twist at the waist because this action throws their bodies out of proper alignment. Body alignment, better known as posture, is defined as the manner in which "the head, trunk, arms and legs are aligned with one another when the back is straight" (North Carolina Department of Health and Human Services [NCDHHS], 2019). Proper body alignment is essential for direct healthcare workers such as restorative nursing assistants due to safety reasons. Correct alignment contributes to overall balance and greatly reduces musculoskeletal strain; without this balance, the risk of falls and injuries goes up (Doyle and McCutcheon, 2015).

Unfortunately, falls are a frequent occurrence in the restorative care environment. If a patient or client is in the process of falling down, the restorative nursing assistant should not ever attempt to catch the client or try to stop the fall midway. Attempting to stop the fall could result in serious injuries to the restorative nursing assistant as well as the client. In addition, the act of catching a falling client can throw the restorative nursing assistant's body out of proper alignment. Instead, the healthcare worker should execute a maneuver called a controlled letdown. If a client is falling, control the direction of the fall by easing him/her to the floor while protecting the head until the charge nurse is available to assess for injuries (NCDHHS, 2019). 

Range of motion is the medical term used to describe the distance and direction a joint moves between a bent position and an outstretched position (Olean Physical Therapy, 2020). The bent position of a joint is properly referred to as flexion, whereas the stretched-out position is known as extension. To improve the range of motion on a particular bodily joint, a client might be prescribed a regimen of range of motion exercises by either the rehabilitation physician or a physical therapist. Range of motion exercises are therapeutic mobilizations of joints designed to increase the extent of movement possible without resulting in pain (Reddy, 2015). 

Patients experience remarkable benefits from the initiation and performance of range of motion exercises on a regular basis. Range of motion exercises promote joint mobility, enhance circulation to the limbs, reduce pain and discomfort, maintain flexibility and prevent contractures from developing (Reddy, 2015). It is especially important to prevent the development of a contracture since this problem is correctable only through surgery. Contractures, also known as contracted body parts, are the permanent shortening of bodily tissues such as muscles, tendons, ligaments or skin, making it extremely difficult or outright impossible to move the nearby joints (Bodine, 2018). Once a client's body part becomes contracted, his/her ability to self-perform daily living activities tends to decline.

Several health issues can result in restricted range of motion, including swelling, muscle spasms, infection, inflammation, and disease processes such as arthritis (Olean Physical Therapy, 2020). The late effects of a cerebrovascular accident (stroke) can also cause limited range of motion. Furthermore, some patients experience profound deconditioning and weakness after recovering from illnesses such as pneumonia, cancer, or a severe exacerbation of congestive heart failure. Deconditioning is the sum of reversible changes that occur throughout the human body due to lack of use and physical inactivity. Patients with deconditioning often experienced reduced range of motion that can be helped by a restorative program that includes range of motion exercises.

The client's health problems are normally included in the personalized restorative plan of care along with the type and frequency of range of motion exercises that have been prescribed. Once range of motion exercises have been ordered for a client that has been selected to participate in the restorative care program, the restorative nursing assistant is generally the allied healthcare team member responsible for performing this skill. When performing range of motion exercises, the restorative nursing assistant must be mindful of a number of principles:

1. Work from top to bottom (e.g., from shoulder to ankle).
2. Never push a joint past the point of resistance.
3. Continually ask the patient throughout the exercises if he/she feels any pain.
4. Stop performing the range of motion exercises if the patient is in pain.
5. Utilize slow, gentle, gliding motions when moving joints.
6. Support the joint with one hand when performing range of motion exercises.
7. Report any changes in condition to the nurse or physical therapist.
8. Always document the patient's participation in range of motion exercises.

The use of adaptive devices and prosthetics is significant in the realm of restorative care because these tools are capable of helping patients achieve a degree of modified independence. Differently worded, patients that participate in the restorative program are better able to accomplish their activities of daily living such as feeding and dressing independently when they have these uniquely designed devices at their disposal. The occupational therapist is the healthcare professional with the responsibility to find the correct adaptive devices for restorative and rehabilitative patients' unique needs. 

Adaptive devices, also known as assistive devices, independent living aids or adaptive technologies, are tools that assist patients with self-performance of various daily living activities. Recall that the main activities of daily living are the tasks of feeding, bathing, dressing, toileting, continence, grooming and transfers. Restorative care programs incorporate adaptive devices so patients gain more independence when completing everyday tasks. Prosthetic devices are artificial replacements for missing or deformed body parts to improve patients' function and/or appearance (NCDHHS, 2019). Dentures, prosthetic arms, prosthetic legs and prosthetic eyes are examples of prosthetic devices.

A bed cradle is a type of adaptive device designed to ensure blankets and sheets remain off the legs and feet while in bed, thereby making bed mobility and repositioning easier for patients. In addition, bed cradles prevent the development of foot drop and pressure ulcers to the feet and ankles by keeping the weight of heavy bed covers off the lower extremities. A footboard is an adaptive device that helps prevent foot drop by maintaining proper placement of the feet. keeping the feet in place. Pillows and cushions of different shapes (wedge-shaped, cylindrical-shaped) are also considered adaptive devices that facilitate bed mobility and positioning.

A wide array of adaptive devices exist for the purpose of helping patients attain greater independence with feeding. Adaptive devices for eating include angled utensils that are designed to help patients with limited arm and/or wrist mobility, as well as sipper cups that allow patients with hand tremors and unsteadiness of the upper extremities consume fluids independently without spilling. Large-grip utensils, also called built-up handle utensils, enable patients with weak grip strength and/or arthritis to eat independently because the wider handles require less grip strength to hold. Plates with high lips around the edges reduce food spillage by helping keep food items on the plate.

With the use of certain adaptive devices, patients with physical or visual limitations are able to dress themselves. Patients with limited reach can use a long-handled shoehorn to independently put on and take off shoes, while those who lack fine motor coordination or a weak hand can use a button hook or zipper pull for dressing (Fulton, 2015). Showering on an independent basis is also possible for some patients with the help of adaptive aids. For instance, long-handled sponges allow patients with limited reach to wash their backs, lower legs during showers and feet (Fulton, 2015). Shower chairs and shower stools enable patients to safely remain in showering stalls and/or bathtubs for longer periods of time. 

Patients can perform grooming and personal hygiene activities independently with the use of specific adaptive devices. Assistive devices for grooming include electric toothbrushes, specially-designed denture care kits and fingernail brushes (NCDHHS, 2019). These tools enable patients to groom themselves without depending on a caregiver to perform grooming tasks. Toothpaste dispensers can assist patients with limited finger/hand function or visual impairments to apply "the correct amount of toothpaste on their toothbrush" (Fulton, 2015).

In summary, the proper use of adaptive devices and prosthetics helps the restorative nursing assistant provide the most optimal care possible. This is because the correct use of adaptive devices and prosthetic devices supports the patients' maximum functional status by providing them with the tools that enable them to accomplish a modified level of independence. In the sphere of restorative care, independence is always viewed in a more positive light than dependency. Thus, adaptive devices and prosthetics allow restorative nursing assistants to encourage pathways to independence for their patients.  

Mobility is defined as one's ability to move around freely. So, mobility aids, also known as ambulation devices or supportive devices, are specially designed tools that assist patients to walk or move from one place to another. Patients with conditions such as weakness, disabilities, paraplegia or certain disease processes generally need to use mobility aids to move around with maximal freedom and independence. Mobility aids include devices such as crutches, wheelchairs, motorized scooters, canes and walkers. 

Typically, the physical therapist is the healthcare professional on the restorative care team with the responsibility for conducting a comprehensive patient assessment that facilitates an informed determination and prescription of the most appropriate mobility aid for each patient. However, the restorative nursing assistant should have some familiarity with the correct use of the different mobility aids in order to better assist each patient who might be utilizing one to move around in the safest manner possible. 

Crutches are mobility aids that used in pairs to enable patients to walk while minimizing and/or eliminating the amount of weight placed upon one of the legs. A physical therapist or rehabilitation physician often prescribes crutches to patients with lower extremity injuries such as fractures, ankle sprains or leg muscle strains. To use them, the patient extends both crutches a comfortable distance in front of the feet, then they move the injured leg or foot up even with the crutches (Saint Mary's College, 2010). The patient must put weight on his hands and place absolutely no weight on the injured leg or foot while stepping a short distance in front of the crutches with the uninjured leg.

Some patients who cannot bear any weight on both legs might require a wheelchair as the mobility aid of choice. This is because, out of all of the aforementioned mobility aids, wheelchairs tend to offer the most stability. A wheelchair is a chair on wheels for patients who have been rendered unable to walk either temporarily or permanently. Wheelchairs can be manually powered by the person's self-propelling action or pushed by another person. Wheelchairs can also be electronically powered by way of a rechargeable battery.

Motorized scooters, also called mobility scooters, are battery-operated single occupant electronic transport vehicles with between three and five wheels that are utilized as mobility aids (Thoreau, 2015). Motorized scooters are steered using a joystick or handlebar. Patients that reside in extended care facilities do not need to be able to transfer themselves or be able to walk to use a motorized scooter since caregivers are available to assist with transferring. However, clients that reside in the community must be able to walk short distances to use motorized scooters. Unlike wheelchairs, mobility scooters are often treated as vehicles in the sense they are not guaranteed access into buildings, so "this means that in order to access services and activities users must be able to walk" (Thoreau, 2015).

A cane, also called a walking aid or ambulation aid, is a short stick that helps patients walk or ambulate safely if weakness is present. Different types of canes exist. For example, the C-cane is a simply-designed straight cane with a c-shape curved handle at the top and one rubber tip at the bottom. Meanwhile, the quad cane has four rubber tips at the bottom to offer a greater degree of stability for the ambulatory patient. To safely use a cane when one leg is weak or painful, hold the cane on the unaffected side; therefore, a patient with a weak right leg must hold the cane in the left hand (HealthlinkBC, 2018).  

Patients who are able to walk but require far more support than a cane can reasonably offer might be served very well by the use of a walker. A walker, also known as a walking frame, is an ambulation aid that provides a stable framework for walking. Standard walkers tend to be prescribed to older patients who are very unstable with a cane and lack the ability to safely control a rolling walker (Hernandez, 2012). Rolling walkers generally have four wheels. Rolling walkers are used for patients who have unsteady gait "but who do not need to bear a substantial amount of weight on the device" (Hernandez, 2012). 

First of all, the bowel (large intestine) helps facilitate the elimination of stool, and the bladder is the organ that holds urine prior to its excretion from the body. Incontinence of the bowel and bladder, defined as the inability to voluntarily control the emptying of these organs of elimination, should never be considered a normal part of aging! On the other hand, multiple neurological disorders such as spinal cord injury, multiple sclerosis and diabetes mellitus can result in bowel and bladder incontinence. Restoring continence is possible in many cases. The restoration of continence is a main goal of restorative care.  

The restorative nursing assistant can be greatly supportive to patients who participate in bladder retraining programs. Simply put, bladder retraining entails training the bladder to urinate on a set schedule, not whenever the patient gets the sudden urge to use the restroom (Interstitial Cystitis Association, 2015). Most bladder training programs involve a one-month time period of requiring the patient to hold urine in the bladder for a set amount of time prior to using the restroom. Patients that consistently adhere to the directions set forth in their individualized bladder retraining program often see results in just a few short weeks.

The restorative nursing assistant can also support patients as they complete bowel training programs to treat bowel incontinence, also known as fecal incontinence. Bowel training is a technique that helps patients afflicted with a loss of bowel control through attempting to train their bodies to use the restroom at roughly the same time each day. By adhering to consistent bowel movement times, the overarching goal is to help the patient's body become trained to have regular bowel movements without incontinent episodes. A typical bowel training participant would sit on the toilet at specific timed intervals even if he or she does not feel the need to pass stool.     

Documentation is essential for patients on bowel and bladder training programs. After all, no proof of a patient's progress with regaining continence exists without meticulous documentation. Typically, the restorative nursing assistant will complete much of the required documentation on a document called a toileting diary or voiding diary. A toileting diary helps the restorative care team see if a new toileting pattern will keep patients from having incontinent episodes or if reminders at certain times can help them get to the bathroom timely. The information that the restorative nursing assistant gathers and accurately documents is essential in order to formulate the patient's personalized care plan. 

Bailey, R. (2019). Anatomical Position: Definitions and Illustrations. ThoughtCo. Retrieved April 17, 2020 from https://www.thoughtco.com/anatomical-position-definitions-illustrations-4175376

Bodine, W.A. (2018). Contractures. Winchester Hospital. Retrieved April 17, 2020 from https://www.winchesterhospital.org/health-library/article?id=11932

Doyle, G.R., and McCutcheon, J.A. (2015). Clinical Procedures for Safer Patient Care. Victoria, BC: BCcampus. Retrieved from https://opentextbc.ca/clinicalskills/

Elsawy, B., and Higgins, K. (2011). The Geriatric Assessment. American Family Physician, 83(1), 48-56.

Endsjo, A. (2017). Fowler's Position: Beyond the Bed. Permobil Blog. Retrieved April 17, 2020 from https://hub.permobil.com/blog/fowlers-position-beyond-the-bed

Fulton, C. (2015). Adaptive Equipment. AgeSmart Blog. Retrieved April 19, 2020 from http://www.agesmart.org/adaptive-equipment/

HealthlinkBC. (2018). Using a Cane. Retrieved April 19, 2020 from https://www.healthlinkbc.ca/health-topics/zt1156

Hernandez, C.R. (2012). Choosing the Correct Walker. The University of Arizona Center on Aging. Retrieved April 20, 2020 from https://nursingandhealth.asu.edu/sites/default/files/walkers.pdf

Interstitial Cystitis Association. (2015). Bladder Retraining. Retrieved April 19, 2020 from https://www.ichelp.org/diagnosis-treatment/management-of-ic-pain/bladder-retraining/

North Carolina Department of Health and Human Services. (2019). State-approved Curriculum Nurse Aide Training Program: Module I. Retrieved on April 17, 2020 from https://info.ncdhhs.gov/dhsr/hcpr/curriculum/pdf/moduleI.pdf

Oklahoma State Department of Health. (2020). Section 310:675-9-3.1 - Rehabilitative or restorative nursing services. Retrieved on April 16, 2020 from https://casetext.com/regulation/oklahoma-administrative-code/title-310-oklahoma-state-department-of-health/chapter-675-nursing-and-specialized-facilities/subchapter-9-resident-care-services/section-310675-9-31-rehabilitative-or-restorative-nursing-services

Olean Physical Therapy. (2020). Range of Motion Exercises. Retrieved April 17, 2020 from https://www.oleanpt.com/library/4317/RangeofMotionExercises.html