Orapharyngeal Suctioning
1.
2.
Equipment:

Sterile gloves

Suction catheter

Tissues

Emesis basin

Bath towel

Suction machine

Tongue blade

Mouthwash

Lubricant

Toothettes

Normal saline or water
Perform your beginning procedures, (there may be times client will be in other places other
than their room, i.e.; the dining room or at an activity). Privacy is the optimal, but in the case
of an emergency you may need to proceed.
3.
This is not a sterile procedure as the catheter is not directed into the trachea, but always use
initially sterile and other clean equipment.
4.
Follow the care plan for suctioning. In case of an emergency however, the client may not be
care planned for suctioning. You do not need a physician’s order to suction.
5.
This procedure is done routinely for clients who are unable to handle their own secretions, or
any client who gather secretions in their mouth and are unable to expectorate.
6.
If client is in bed, rise to a good working height and elevate the head of the bed, or client
may be sitting.
7.
Place towel across client’s chest.
8.
Turn on suction machine.
9.
Put on gloves.
10.
Remove suction catheter from the sterile package and connect it to the suction machine.
11.
Ask the client to open their mouth. May have to use tongue blade and place gently between
the teeth to help keep mouth open.
12.
Introduce the catheter into the oropharynx, holding the catheter approximately six inches
from the tip, and gently pass it into the mouth and down the back of the tongue.
13.
Apply suction with the other hand while slowly moving the tongue and teeth. DO NOT LEAVE
CATHETER IN PLACE MORE THAN APPROXIMATELY 5 SECONDS.
14.
Remove the catheter from the mouth, repeat the procedure as needed until secretions are
removed.
Orapharyngeal Suctioning
(Continued)
15.
Wipe client’s face (around the mouth).
16.
Turn off suction machine and place the tip of the catheter into the package it was in.
17.
Using a toothette and a little mouth wash, wipe the inside of the mouth and teeth. (Be sure
to squeeze the excess fluid from the toothette before placing it in the mouth). You may need
to suction excess fluid from the mouth.
18.
Lubricate the lips as needed.
19.
Wash the tubing, and catheter with water, or normal saline.
20.
If indicated, measure secretions.
21.
Empty the secretions per facility protocol and wash the jar with disinfectant, rinse, and dry
well. Reconnect tubing, (if suction is left at bedside). (Usually the suction equipment is
washed and disinfected at the end of each shift, but does need to be cleaned after each use.
22.
Perform your ending procedures.
23.
Document using appropriate terminology, and report observations to the nurse.
24.
If suction machine is not left at bedside after use, remove catheter, tubing, and collection jar
if disposable and discard per facility protocol. BE SURE AND PLACE NEW TUBING AND
CATHETER WITH SUCTION MACHINE. COVER SUCTION MACHINE WITH A PLASTIC BAG OR
TOWEL AND PLACE IN ROUTINE STORAGE AREA.
Bowel and Bladder
Urinary incontinence has a major impact in long-term care facilities. It is the 2nd leading reason for
placement into facilities and the primary reason for not being accepted into ALFs and RCFs. It has
been estimated about 50% of all residents are incontinent. One study done indicated that
approximately 22% of all women who were continent at the time of admission, because incontinent
after one year and the percentage even higher for men, at 56%. The reason for this involves
cognitive and mobility function and adjustment to Nursing Home placement.
Many nursing home residents and staff believe that it is inevitable and part of the aging process.
Many will try to manage their own dribbling or incontinence with pads etc, (padding underwear with
toilet tissue), to protect their social, psychological integrity, privacy, and dignity. UI also has a
substantial social effect on residents. It has been found that it has associated morbidities, including
UTI, pressure ulcers, and falls. It is also burdensome to care for the incontinent resident and
increases staff turnover. It is because of these negative outcomes that guidelines have been
developed by regulatory agencies.
In addition to UI, other bladder disorders are common. The use of catheters to manage UI and
urinary retention in LTC is a real problem. At least 40% of all infections in LTC are UTIs and 80% of
these are due to catheters.
When a client is admitted, the nurse does an assessment to determine continency, and the
appropriateness of a retraining program, or a maintenance program. If they are continent on
admission, it is our goal that they will not become incontinent, and will remain as independent with
toileting as they can.
Bowel and bladder incontinence can be permanent or temporary. Common causes of incontinence
are:

Medication reactions

Disease processes

Trauma

Surgery

Infection

Stress and anxiety

Tumors

Mental confusion

Difficulty getting to bathroom

Problems with clothing

Loss of muscle control

Vaginal problems in women

Constipation or fecal impaction

Inability to communicate the need to use the bathroom
Contrary to common belief, incontinency is not a normal sequence to aging. It usually will suggest a
medical problem. Incontinence is common in the cognitively impaired. Many do lack the ability to
communicate the need to use the bathroom. Most, however do not forget the basic activity, and if
assisted to the bathroom, they will almost always go.
This type of client may not be appropriate for a retraining program but can be maintained on a
maintenance program where they are toileted every two hours or so with scheduling during the high fluid
intake times, such as after meals. Scheduling to times is done for a 24 hour day. Some people get very
upset if awakened during the night, and maybe can be done every four hours during the night. Again, it
needs to be personalized for the client’s needs.
General guidelines for a retraining program include:
1.
Perform the beginning procedures.
2.
Always apply the principles of standard precautions. Anticipate your needs and select the
appropriate personal protective equipment.
3.
Ensure that the urinal, bedpan, or commode are within the client’s sight, and can easily be
reached if they use them independently.
4.
Make sure the signal cord is within reach, and answer it promptly.
5.
Provide a safe clear pathway that is well lit to the bathroom.
6.
Follow the care plan exactly as written.
7.
Avoid scolding the client for accidents. Praise them for using the toilet and staying dry.
8.
If the client can not reach the bathroom independently, assist them as needed.
9.
If the client uses a wheelchair, walker or cane, keep them close to the bed so they can reach
them.
10.
Keep the client’s skin clean and dry.
11.
Assist client to adjust their clothing as needed.
12.
Assist the client to transfer on and off the toilet as needed.
13.
Provide privacy. Close the door and privacy curtains. Close the bathroom door, even if you
have to stay in the room for safety reasons.
14.
Avoid rushing the client when toileting.
Bowel and Bladder
(continued)
15.
Assist as needed with pericare and hand washing.
16.
Providing adaptive equipment can be of benefit. For example:

Raised toilet seat

Grab bar or support bar at the toilet

Toilet paper holder
Advise the nurse if you think these or any other adaptive equipment would be beneficial for
the client.
17.
Document the procedure using appropriate terminology.
18.
Report any observations to the nurse, any recommendations for care plan changes.
19.
A weekly summary will need to be completed using appropriate terminology.
20.
Meet weekly with the nurse to determine appropriateness of program.
Dressing/Grooming/Hygiene
You were taught the procedures for completing ADL tasks of dressing, grooming, an hygiene in the
CNA 1 class. We will follow the basic procedures taught in that class, but carry it further by
instructing and encouraging the client to perform these tasks themselves.
Restorative care is given to assist clients with ADLs and maintain or improve their ability to complete
the tasks. The activities of dressing, grooming and hygiene are personal, most people prefer to do
them alone, and when a person requires assistance with them, they become depressed, lose self
esteem, and hope, and often feel isolated. “Independence in self care improves self esteem, and
promotes self confidence and dignity.
The key to developing a successful program is staff participation. All staff members need to observe
the clients for clues that they can improve their self care abilities. Staff should not complete the tasks
for the sake of saving time. If a client can complete the task he/she should be allowed to do so, or at
least as much of it as possible.
All new admits are screened for rehabilitation possibilities, but there are times that a client may have
a chronic illness with exacerbations from time to time leaving them weak. These people are excellent
candidates for a restorative program. Again it takes all staff observing and reporting those
observations to determine the type of program they are candidates for. The nurse will then do an
assessment identifying the needs of the client, set the goals. The care planning team will work
together to determine the approaches to reach those goals. (Some facilities have a Physical Therapist
and/or an Occupational Therapist do an assessment and plan the care).
When determining the type of program, a person needs to remember that we need to keep the goals
measurable and reasonable. In other words, a client who has had a CVA with right sided weakness
would not be expected to be able to brush their teeth with their right hand, but we could maybe
expect them to be able with adaptive devices to put toothpaste on a tooth brush and brush their
teeth with their left hand with cuing as needed, while sitting at the sink.
At times, adaptive equipment is needed to assist a client to be able to complete a task, other times
verbal cuing or gestures may be used, other times environmental modifications may need to be
considered. For example, a client may be dependent for toileting because they are afraid of falling
related to personal items and furnishings being in the path between the bed and the bathroom. By
clearing the path to the bathroom they could be independent with toileting.
At the beginning of a program, the client may require more assistance than they will later. Be
encouraging, and curing the client we should see the amount of assistance decrease. It is very
important that all staff work together and be consistent or a program will not work effectively.
Restorative care must be given 24 hours a day, 7 days a week. Everyone needs to follow the care
plan and updates need to be made as they arise. This can occur rapidly while at times can take up to
several weeks.
Potential Candidates for Restorative Self-Care Programs include but not limited to:

Have the potential to increase their level of self care.

Have the ability to learn, even if cognitively impaired.

Can follow directions.

Have recently had restraint reduction, improving their mobility.

Have recently had surgery.

Are motivated to relearn self-care skills

Have recent paralysis or a neurological condition.

Have had a recent amputation.

Have had a CVA.

Are recovering from pneumonia.

Are recovering from heart attack.

Are recovering from hip or other fractures.

Are recovering from a stroke.

Have recently fallen.

Have generalized weakness because of acute illness.

Have cognitive impairments, but are able to follow simple directions, have good motor skills
functioning, and show potential for increasing self-care skills.
The restorative assistant is the primary caregiver for ADL retraining programs. You will teach, reinforce,
and remind clients to use skills. You will also be asked to instruct or educate other nursing assistants how
to assist the clients, after all, you probably would like to be able to leave after your shift and possibly
even have a day off from time to time.
When planning cares, schedule the task for the time of day that it would normally be done, allow for
enough time to complete the task, to avoid rushing the client.
The type of assistance that you will be providing the client will be dependents on their
ability, both physically and cognitively. Types of assistance provided are:

Set up

Positioning

Physical assist

Verbal cues

Hand-over-hand

Coaching

Pacing

Giving or receiving feedback

Encouragement and/or support
The most common levels of assistance that you will be providing are:

Independent

Standby or observation guarding

Supervision

Light contact or guarding assistance

Limited assistance

Moderate assistance

Extensive assistance

Maximum assistance

Total dependence
Documentation of daily progress is very important. This can be done in a short note or on a flow sheet. A
weekly summary then needs to be completed. Address the client’s progress, or lack of progress, toward
the care plan goals. Using the appropriate terminology make your notes direct and concise. The note
does not need to be lengthy. You will need to meet on a weekly basis with the nurse to discuss progress
and need to change the care plan. The nurse will write a short summary of client’s progress and
describing plans for continuing or modifying the program on a monthly basis.
Assistive Devices
Dressing and Grooming
1.
Hand brush
2.
Hemiplegic wash cloth
3.
Octopus suction holder
4.
Insert a foot shoe aid
5.
Button aid (plastic handle)
6.
Button aide (knob handle)
7.
Flexible sock and stocking aid
8.
Helping hand reacher
One Handed Dressing Techniques
1.
Shirts, blouses and sweaters
a. Place shirt in lap; back facing patient; neck away from patient.
b. Gather up back to expose armhole for involved arm.
c.
With normal hand-place involved hand in exposed armhole. Pull a sleeve over until it is
exposed.
d. Place normal arm through other sleeve, expose arm above elbow.
e. Pull sleeve on involved arm above elbow to mid-upper arm region.
f.
Gather shirt from hemline to collar. Keeping this gathered, duck head, pull shirt over it.
g. Pull shirt down in back and front.
2.
Button-front shirt, blouse, sweater or jacket
a. Place shirt in lab; inside of shirt facing patient; collar resting on knees away from patient.
With normal arm, expose armhole of sleeve diagonally opposite to involved hand. Place
involved hand in armhole.
b. Pull sleeve over hand until it is exposed. Grasp shirt in middle of collar. Pull sleeve well
onto involved shoulder.
c.
Reach behind neck, grasp collar. Follow around collar to bring shirt behind patient. A
dressing stick may also be used to bring shirt to other shoulder.
d. Throw other sleeve behind patient. Reach down; place arm in sleeve. Work shirt up onto
shoulder.
e. Arrange shirt and button. Begin at bottom to make buttoning easier.
f.
Throw other sleeve behind patient. Reach down; place arm in sleeve. Work shirt up onto
shoulder.
3.
Trousers
a. Cross involved leg over normal leg by placing hand under knee of involved leg and lifting
over good leg. If unable to do this; assistance of another person will be required.
b. Pick trousers up at waist – making sure they are completely open at fly.
c.
Place on lab – front facing up; legs away from patient.
d. Grasp trousers at bottom of front opening.
e. Toss down toward involved foot.
f.
Pull trouser leg up over involved foot.
g. Place involved foot on floor; place normal leg into appropriate trouser leg; pull trousers
well up over the knees.
h. If patient has good balance:
i.
4.

Stand

Pull up trousers on normal side first

Stabilize pants with elbow

Pull up trousers on affected side

Sit to fasten
If patient has poor balance:

Lay on bed to pull trousers up

Lift hips off bed or roll from side to side pulling up pants as patient rolls.

Grasp pants on inside of waist bank; palm away from body.

Pull up on normal side first

Fasten while lying down.
Socks
a. Using normal hand, cross legs by lifting involved leg across normal leg by grasping and
lifting under the knee.
b. Spread toe of sock with thumb and fingers, bring over toes.
c.
Pull sock over foot; smooth wrinkles.
d. If unable to cross leg – a footstool of appropriate height would be helpful. Rest foot on
stool and proceed as above.
5.
Shoes
a. Cross involved leg over normal leg.
b. Slip shoe over foot.
c.
Place foot on floor.
d. Place shoe horn in heel of shoe.
e. Push down on knee to push foot in shoe.
f.
6.
Wrap-lace shoe fasteners are best for typing
Bra
a. Bra which hooks in front is best.
b. To hook back-fastening bra.




Wrap bra around waist so that hooks are in front.
Stabilize the side of the bra with eyelets using affected arm.
Hood, turn bra so that hooks are in back.
Insert involved arm through strap; then normal arm. Pull, so straps are correctly
adjusted on shoulders.
Dressing Techniques for Patient with Limited Range of Motion
1.
2.
Undershirt, sweater, slip, skirt, or Johnny
a.
Roll up undershirt from hemline to neck, duck head, slip on.
b.
Tie Johnny first, then slip it on; also, replace tie with Velcro fastener.
c.
Sleeveless undershirt is best for limited shoulder range of motion.
Bra
a.
Fasten bra in front, turn it around, slip arms through straps. (Stretch straps and
bra are easier.
b.
3.
4.
Front fastening bras are best.
Girdle
a.
Maternity girdles are easiest to put on and pull up.
b.
Girdle adapted with four zipper closures are also good.
c.
Sew tape loops on each side of the girdle to make it easier to pull up.
Shorts, trousers, slacks, pajamas
a.
Use reaching tongs to grasp pants at waistband or two dressing sticks hooked in
the waistband loops will also facilitate pulling pants up if patient cannot reach
the toes.
b.
5.
6.
Throw to feet, pull half-way up:
 If in bed, wiggle from side to side to pull up.
 If sitting on bed, stand up to pull up.
Shirt, pajama top, sweater, or blouse
a.
Put most involved arm in sleeve first.
b.
With use of hood end of dressing stick, catch loose sleeve, pull up on shoulder.
c.
Push into place with stick.
Coat
a.
Lay coat on table, inside facing up
b.
Place involved arm in sleeve first.
c.
Use dressing stick to pull up on shoulder.
7.
Buckles, snaps, and buttons
a.
Use large snaps.
b.
Use buttons rather than snaps, if possible
c.
In shirt cuffs, sew buttons together with elastic thread. Button before putting
shirt on
8.
9.
10.
d.
Use button hook
e.
Substitute with Velcro; sew Velcro under button and over buttonhole.
Zippers
a.
For grasping zipper, use cup hook end of dressing stick.
b.
Lean against wall or sit on bed for ease in pulling up zipper.
Shoes
a.
For limited range of motion in upper extremities, use spring type shoe horn.
b.
For more stability, use long-handled firm, shoe horn.
c.
If manipulation of shoe is a problem, use double shoe horn.
d.
If manipulation if foot into shoe is a problem, use “Inserta Shoe Foot Aid”
Shoe fastening
a.
Use elastic shoe laces. Punch hole in tongue of shoe. Lace through tongue to
keep in place.
b.
11.
Shu-lock fastener gives good support and can be manipulated with weak hands.
Stockings and socks
a.
Stocking aide is best for weak hands and limited range of motion.
b.
Put tabs inside of socks on both sides; use cup hook end of stressing stick, insert
hook in loops and pull on.
Wheelchair at the Table
1.
2.
Correct position for eating
a.
Shoulders back
b.
Table eight at waist
c.
Elbows supported on chair or table surface
d.
Food is within 12” reach
e.
90° hip flexion
f.
90° at knees
g.
90° at ankles
h.
45° neck flexion
i.
Feet supported on the floor or foot pedals
Incorrect Position for Eating
a.
Rounded shoulders
b.
Head strained forward
c.
Elbows unsupported
d.
Posterior tilt at hips, angle greater than 90° sliding out of chair
e.
Feet unsupported and dangling
f.
Table height too high
Rehab Dining Problems and Solutions
1.
General Positioning Guidelines
a.
If the resident’s sitting balance is good, then transfer resident to a regular chair
for optimal positioning.
b.
The table surface should be at an appropriate height, between the waist and
mid-chest area; this allows the resident easy access to the tray, both visually and
physically.
c.
Food should always be within a 12” reach
d.
If the patient remains in a wheelchair, an over-the-bed table, lap tray, raised
table, or U-shaped table are alternatives.
2.
Correct position for eating
a.
Shoulders back
b.
Lap tray at waist
c.
Elbows supported on chair or lap tray
d.
Foot is within 12” reach
e.
90° hip flexion
3.
f.
90° at knees
g.
90° ankles
h.
45° neck flexion
i.
Feet supported on the floor or foot pedals
Incorrect position for eating
a.
Rounded shoulders
b.
Head strained forward
c.
Elbows unsupported
d.
Posterior tilt at hips, angle greater than 90° sliding out of chair
e.
Feet unsupported and dangling
f.
Lap tray too high
Resident in Bed
1.
Correct position for eating
a.
Raise the head of the bed to allow as close to 90° hip flexion as possible
b.
Flex the knees slightly, either using a bed pillow or raising the knee section of
the bed.
c.
If necessary, support the head using your hand or a bed pillow to achieve slight
neck flexion
2.
Incorrect position for eating
a.
Patient reclined
b.
Knees not flexed
c.
No neck flexion
d.
Improper table height
Resident in Gerichair
1.
2.
Correct position for eating
a.
Chair upright
b.
90° hip flexion
c.
90° knee flexion with feet supported
d.
Lap tray at the proper height
e.
Food within 12” reach
Incorrect position for eating
a.
Patient reclined
b.
Knees not flexed
c.
No neck flexion
d.
Improper table height
e.
Inability to reach food easily
General Guidelines for Assisting Clients with Restorative ADL Procedures
1.
Always begin by performing your beginning procedures.
2.
Keep stress and distractions to a minimum.
3.
Become familiar with procedure and the directions for completing it. (Follow the care plan).
4.
Establish a routine to decrease stress.
5.
Adapt to normal changes in the client’s cognitive function.
6.
Allow enough time for the activity.
7.
Provide enough space for the activity.
8.
Modify the environment, if needed.
9.
Make sure the client is safe and positioned in good body alignment.
10.
Provide a chair so the client can sit during the activity, if appropriate. Sitting makes tasks
easier and conserves energy.
11.
Keep distractions to a minimum.
12.
Be consistent. Perform the procedure at the same time, in the same way and in the same
environment.
13.
Stress the client’s ability, not the disability. (Say “you can do this with your left are.” Rather
than, “you can’t do this with your right arm”.)
14.
If family members are (or will be) involved with the client’s care, teach them how to help.
Advise them of how much they should and should not do. Always explain why.
15.
Be patient and persistent with the client.
16.
Keep your instructions simple. Tell, show, and ask. Give simple, one step commands. Repeat
if necessary.
17.
If necessary, begin by giving physical assistance. Allow the client to complete the sep. For
example, guide the client’s arm to the sleeve. Allow the client to place their arm in it.
18.
Be flexible.
19.
Adapt the procedure for the client. Avoid trying to adapt the client to the procedure.
20.
Guide the client in developing their own safe method of completing the task.
21.
Complete the task using the same sequence of steps each day. For example, assist the client
to dress by putting on clothing in the same order.
22.
Communicate with the client during the task, if this is not distracting.
23.
Support, encourage, and praise the client. If they complete the steps successfully, provide
immediate feedback and praise. Use praise and rewards that are most important and
effective for the client. For example, after the task is complete, take the client for a walk
outside, if this is important to them. A cup of coffee and cookies may be an effective reward
for another client. Individualize the reward to the client.
Grooming Activities
1. Equipment and aids
a.
long handled brushes or sponges
b.
brushes
c.
sponges
d.
bath lift
e.
shower chairs
2. Oral hygiene
a.
b.
Teeth should be brushed daily
The hemiplegic may be unaware of the affected side of his mouth and so may need
assistance or reminding.
Equipment




Long handled toothbrush
Toothbrush with built-up handle
Electric toothbrush
Suction cup
3. Hair care
a.
Hair should be brushed daily to stimulate circulation to the scalp and to ensure that it
does not become matted.
b.
Encouraging patients to brush their own hair provides ROM as well as good
grooming.
c.
Shampoo hair at least weekly.
d.
Dry hair quickly to prevent chilling.
Equipment:

Long handled combs and brushes
4. Dressing
Special helps
 Clothing styles adaptable to most physical handicaps include loose fitting,
washable garments made of stretchable fabric such as double knit or jersey.
 Velcro fasteners can be substituted for other types of fasteners. If needed,
although zippers and large buttons can usually be managed. It may be helpful
to attach something to the zipper placket which can be more easily grasped if
finger dexterity is a problem. Cuff buttons may be sewn on with elastic making
it unnecessary to unbutton when putting on and taking off.
 Socks which stretch easily with loose tops are best. Some stretch socks are
tight and may restrict circulation.
 Low heel shoes provide a firm support. This is especially true for patients
wearing a brace. Elastic type shoe laces may make it easier for a patient to put
on and take off shoes.
 Self help devices should be used only when necessary.
 Place clothing within easy reach.
 Remember to always dress the involved extremity first and undress the normal
extremity last.

Dressing Techniques Specific to Certain Disabilities
Problems common to both right and left hemiplegia
 Lack of feeling on affected side and muscular weakness.
 Balancing difficulty and poor muscular control.
 Extremity pain – especially shoulders.
 Low physical endurance and easy fatigue
 Fluid retention – especially affected hand, wrist, foot and ankle.
 In some cases, a visual field deficit causing inability to respond to one side.
 Emotional Liability.
 Denial of disability.
 Loss of memory.
 Confusion.
 Irresponsible and unsafe actions.
Right hemiplegia
The right hemiplegic appreciates reality and, therefore, is more likely to respond
to dressing training in the morning after bathing.
 If possible, have patient sit up.
 Place all wearing apparel and self help devices to the left and within easy reach
of the patient.
 Right handed hemiplegics respond best to demonstration, so initially allow
patient to observe while you dress them. Encourage spontaneous assistance as
given.
 Buttoning with one hand can be frustrating in the beginning so assistance should
be given. Unbuttoning can usually be done easily.
 Remember to put the affected arm in first when putting on a shirt or coat. After
demonstrating the procedure once or twice, give the patient’s left hand over the
right hand and let them put the sleeve.
Left hemiplegia








The left hemiplegic responds better in quiet surroundings without distractions.
Dressing training should be given on a one-to-one basis away from other people.
Training procedures should be broken down into one step at a time with simple
concise instructions.
A sitting position in a locked wheelchair is preferred, but patient should not be
left alone until session is completed.
Approach patient from the right side.
Buttoning and unbuttoning may be done easily with one hand, however, the
buttons and buttonholes may not always match. Verbal cueing helps direct
attention to correct button and buttonhole.
It is easier to begin training the left hemiplegic with undressing. Often the left
hemiplegic will remove the right side and neglect the left side. Verbal cueing
reminds patient of the left side. Because of this perceptual deficit, teaching the
left hemiplegic to put on a shirt can be very time consuming and frustrating.
It is helpful to attach a ribbon or some other marker to the right side of shirts
and pants or dresses.
Arthritis


The major difference in training techniques for the arthritic patient compared to
the hemiplegic is that arthritis problems are weaknesses and limited ROM,
whereas the hemiplegic’s is one handedness.
Focus on conserving energy and avoiding joint stress.
Clothing style suggested for the hemiplegic are suitable for the arthritic.
Individual needs will dictate clothing styles.
 Some self help equipment is especially designed for use with problems peculiar
to this handicap.
 Patient should be seated with clothing and adaptive equipment within easy
reach. If balance is not a problem, a stool may make it easier to reach the lower
extremities.
 Hemiplegic techniques can be used if one upper extremity is not functional.
 Avoid stress on finger joints by replacing zippers, hooks and buttons with Velcro.
Parkinson Syndrome
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Slow performance is attributed to the disease; therefore, time and patience are
essential to allow this patient to be as independent as possible.
Wearing apparel one size larger than usually worn is helpful.
Large buttons, Velcro fasteners and cuff buttons sewn with elastic are more
manageable.
Patient should be seated in an armchair.
Dressing techniques outlined for the hemiplegic can be used; however, an
additional procedure for putting on shirts, sweaters or coats can be useful to the
Parkinson patient, but is not recommended for one handed patients or for
arthritics.
In this procedure, place the shirt on the patient’s knees, label facing down, with
the collar toward the knees. The patient then places both hands in the sleeves
starting at the armhole. He then pushes the shirt up over the elbows by reaching
through the cuffs. Gathering the shirttail in both hands, he can pull the shirt over
his head and straighten it by pulling down on the shirttails. To remove the shirt
after unbuttoning, raise arms, bend elbows and place hands over the shoulders.
After gathering shirt in back with both hands, pull the shirt over head. Remove
sleeves one at a time.
To put on shoes and socks, the procedures outline for hemiplegics may be used
depending on the patients’ flexibility. Because of stiffness, he may need help in
the beginning. Shoe with buckles, elastic laces or Velcro fasteners may be easier
to manage.
Equipment and Aids
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Loose-fitting garment
Front or side fasteners
Ring or loop attachment to zippers to facilitate grasp
Elastic thread to sew on buttons
Velcro closures
Large buttons
Loose-fitting stretchable socks
Elastic shoe laces
Long handled shoe horn
Sock aid
Reacher
Button aide
Ambulation and Gait Training
The Benefits of Walking
Walking at every opportunity not only serves to exercise joints and musculature, it also helps prevent
contractures and/or tightness of the joints. Walking assists the elderly resident in reducing the
signs/symptoms of certain diseases including reducing dependent edema, lowering blood pressure,
facilitating kidney function, and helps chronic respiratory difficulties by deeper breathing and better
oxygen exchange. The entire body benefits from routine walking. It must be recognized that residents
with severe chronic heart failure must be monitored closely, although experience has shown that even
they tolerate short walks well when exercise is spaced at hourly intervals.
Terminology

Gait training: Applying skilled techniques to teach the patient to walk with or without
assistive devices such as canes, walker, braces, or splints, giving consideration to the
patient’s limitations of weight-bearing status, neurological deficits, range deficits, and
strength limitations with safety as a primary concern.

Ambulation: Practicing the gain training procedures or walking to gain endurance once the
evaluation and training skills have been applied, or simply enhancing the physical capacities
of a patient. The primary difference between Gait Training and Ambulation terminology lies
in whether the resident needs “correction and training” (gait training) vs. allowing the
resident to walk in a safe surrounding (ambulation).

Involved: The side (upper and lower extremity) of the resident that is affected by a fracture
or disease, i.e. paralysis of upper and lower extremity on one side of the resident. It may
also be referred to as the affected side or extremity.

Uninvolved: The side (upper and lower extremity) of the resident that is not affected by a
fracture or disease process, i.e. the non-paralyzed side of the resident. It may also be
referred to as the unaffected side or extremity.

Weight Bearing Status: This is how much weight a patient is able to put on his affected
extremity and does not only pertain to the legs. A person with a fractured right should may
not be able to put weight on her right arm, therefore she might need a quad cane or hemi
walker because she is unable to put the weight on her arm required to use a regular walker.
The WBS is usually determined by the physician, the patient’s diagnosis and the patient’s rate
of healing. Any change in WBS must be approved by the physician.

Non-weight bearing (NWB) means no weight on the affected extremity.

Toe touch or touch down weight bearing (TTWB or TDWB) means the patient may
touch the affected extremity to the surface for balance but should not put weight
through the extremity.
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Partial weight bearing (PWB) means the patient is only able to put part of his body
weight on the affected extremity. A body weight percentage or actual number of
pounds should be included with this WB status.

Weight bearing as tolerated (WBAT) means the patient can put as much weight on
his affected extremity as pain allows – up to his full body weight.

Assistive Devices: Appliances used to assist/help patient during ambulation.

Walkers: 4 posted devices offering maximum stability and support for patients. They
vary in size and design. Walkers with wheels so that patients do not have to lift them
are common. Some walkers also come equipped with pull down seats so that patient
may rest. Most walkers are adjustable and fold for easy storage.

Walk cane or Hemi walker: is a walker that is designed to be used with only one
hand. It provides more stability than a cane, as it still has 4 legs. It is used in the
strong hand, opposite the weak leg.

Canes: vary from 4 footed to a single straight pole. They offer anything from
moderate stability (quad cane) to minimal stability (tripod cane) to assist with
balance (straight cane). Most adjust in height. The cane is used in the hand opposite
the affected side.

Crutches: are much like extended canes that fit under the armpits or attach to the
forearms. They come in pairs and may be wooden or metal. The height is adjustable.
They offer less stability than a walker but more than a cane. There are several
different types 0 the most common being the auxiliary crutches and the forearm
crutches. These are usually excellent devices for a young, strong person with good
balance. The elderly often have difficulty using this device.
Surfaces
1.
Level surfaces are the easiest for patients to learn on.
2.
Uneven surfaces include carpeting and the outside. This is more difficult for he patient
and he may fatigue rapidly.
3.
One step – this is usually taught by the therapist. There are numerous ways of doing it.
Please find out what way is best for that particular patient from the therapist.
4.
Stairs – are difficult. Usually taught to patients just prior to returning home. See you
physical therapist for individual instruction.
General Reminders

Remember body mechanics for both patient and yourself.

Always use a safety belt.
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The patient should always wear shoes (most slippers do not provide adequate
support and traction).

Dress, robe, or pants should not drag on the floor or impair safety in any way.

Remember to secure tubes (NG, catheter).

Support patient at the back and/or close to the weaker side.

Make sure othotic and prosthetic devices are not worn, fit well, and are securely in
place before ambulating patient.

Observe patient’s vital signs and physical response before, during and after
ambulation.
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Never let your attention focus off the patient.

If physical contact is not required, stay within an arm’s reach of the patient and be
ready to assist the patient if needed.
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Make sure assistive device is at right height for patient.

Use caution going around corners, at doorways, and in new surrounding.

Your lead off foot for ambulation is usually the affected side.
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A wide base of support (the feet apart) makes for a steadier gait.
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Be aware of all precautions including weight bearing status.

Please watch your patient’s walking surface. Liquid on the floor can be a major
hazard. A small object dropped can cause a patient to stumble and fall. Protect
yourself and your patient by providing them with a safe walking environment and
using a gait belt.
Gait Patterns
The most common assistive devices for ambulation in the nursing home are walkers and canes. Crutches
rarely are used in nursing homes for safety reasons – they are more unstable than walkers or quad
canes. Crutches are used most frequently by individuals who have been using them for years.
Walker: Two basic gait patterns are used with a walker – the “step-to” and the “step-through”.
“Step-to” Pattern:
1.
Patient advances the walker
2.
The involved leg is advanced to the center of the walker.
3.
The uninvolved leg is advanced even with the involved leg. The patient should be
instructed not to step too far into the walker since this can cause a loss of stability and a
fall backwards.
“Step-through” Pattern:
1.
Patient advances the walker.
2.
The involved let is moved forward but not into center of walker.
3.
The uninvolved leg is moved forward past the involved leg to approximately the center of
the walker.
This process can be continued by making each move one at a time or can be made quicker by moving
the walker and the involved extremity at the same time. The weight and steps are kept to the middle of
the walker and not near the front bar. Moving one step at a time is slower and more stable. Moving foot
and walker simultaneously is less stable but approaches normal walking.
If the patient has difficulty picking up a walker, a wheeled walker may be useful. This type of walker has
front wheels which allow the patient to roll the walker forward. A wheeled walker should have only 2
wheels.
Steps to Ambulating a Resident with a Walker:
1.
Identify yourself to the resident.
2.
Explain to the resident what you will be doing (gain the resident’s acceptance).
3.
Survey the area you will be walking in and remove all hazards or obstacles in the area.
4.
Place the gait belt around the waist of the resident.
5.
Adjust the height of the walker to proper height for resident. (If resident has his/her own
walker, it should remain at the proper height.)
6.
Place walker in front of resident.
7.
Have resident stand-up by pushing with his/her hands on the arms of the chair or off the
bed. (Resident should never attempt to stand by pulling on the walker; at least one hand
should always be pushing from the surface his is sitting on.) If the resident is not full weight
bearing on one lower extremity, he/she should be instructed to extend the involved leg in
front of him/her when going form sitting to standing.
8.
Allow resident time to grip the walker and gain balance in standing.
9.
Instruct resident to move walker forward (you may need to keep one hand on walker to
assist resident to advance walker or keep him from advancing it too far.) When using a
walker, always make sure all 4 legs are placed firmly on the ground. Never allow a patient to
set a walker down only on its rear legs and start walking. Never step past the middle of the
walker – you could over-balance.
10.
Resident should advance involved foot (you may need to assist).
11.
Have resident place his weight on the walker and advance the uninvolved foot.
12.
Guard resident for safety. (Normally, you should be slightly behind and the involved side of
the resident, one hand on the gait belt, the other hand on the shoulder or the walker.
13.
When turning or changing direction, the resident should be instructed to take small steps
around in the same sequence, i.e. walker, involved leg, uninvolved leg. It is usually safest for
the resident to turn toward the uninvolved side.
14.
When sitting, the resident should turn around and back into the chair. He/she should be
instructed to back up until he/she feels the chair hit his/her legs, reach back for the arm of
the chair and lower himself/herself slowly into the chair. If the resident is not full weight
bearing on one lower extremity he/she should again extend the involved lower extremity in
front of himself/herself when going form stand to sit.
15.
Be sure resident is comfortable and properly positioned.
16.
Remove the gait belt.
17.
Wash your hands.
Cane: A resident who has had a stroke, is post fracture, or has balance problems, may use a cane when
ambulating. The cane should be held by the resident in the hand opposite the involved side.
Steps to Ambulating a Resident with a Cane:
Rising from Chair Instructions: When assisting the resident in rising from a chair, instruct the resident to
place one hand on the arm of the chair and the cane in the hand of the uninvolved side.
There are 3 basic steps that should be instructed to the resident.
1.
Move the cane forward approximately the distance of a normal step. Remember to keep the
cane out to the side approximately 4-6” from the foot.
2.
Step forward with involved extremity, foot should be even with cane.
3.
Step through with the uninvolved extremity (uninvolved extremity should be forward of
involved leg.) Repeat.
This process can be accomplished by making one move at a time or by simultaneously moving cane and
involved extremity. One move at a time is encouraged until the resident is familiar with each step and
adequate balance has been achieved.
There are several types of canes that may be used when ambulating. The multiple-legged (3 or 4 prong)
types are more stable than the single leg; however, a confused resident may have difficulty getting all
the cane feet flat on the ground. The Physical Therapist should evaluate the resident for appropriate cane
type on an individual basis.
Crutches: are much like extended canes that fit under the armpits or attach to the forearms. They come
in pairs and may be wooden or metal. The height is adjustable. They offer less stability than a walker but
more than a cane. There are several different types – the most common being the auxiliary crutches and
the forearm crutches. These are usually excellent devices for a young, strong person with good balance.
The elderly often have difficulty using this device.
Crutches should be placed slightly forward and to the side of the user. Weight should be on the hands
only – NEVER on the auxiliary pads.
There are 4 basic gait patterns with crutches and the patient should continue to use the pattern he was
instructed in by the Physical Therapist.
1.
Swing through/Step through (commonly used with crutches).
a.
Advance both crutches.
b.
Step with weak leg up to the crutches.
c.
Step with strong leg past the crutches and involved leg.
d.
Repeat sequence.
2.
Two point gait. This is used for patients with a partial weight bearing status.
a.
Move alternate arms and legs simultaneously. (Example – right leg moves with left
arm (crutch), then left arm (crutch) moves with right leg).
b.
3.
Repeat sequence.
Three point gait. This can be used with any assistive device with a partial weight bearing
status.
4.
a.
Advance device and weak leg together.
b.
Put weight on hands and complete step with strong leg.
Four point gait. This gait pattern requires the patient to be coordinated and have a high level
of comprehension and physical ability.
a.
Advance left crutch.
b.
Advance right foot.
c.
Advance right crutch.
d.
Advance left foot.
e.
Repeat sequence.
NEVER move the same foot ahead as the crutch that was just previously moved.
Measurement of Assistive Devices
Although the Physical Therapy Department is generally responsible for measuring each resident’s
assistive devices, it is important for the Restorative Nursing Assistant to be aware of how this is
completed. Walkers and canes are measured by height in one of two methods.
1.
The resident stands with arms hanging at the sides. Shoulders and hips must be level. The
cane, walker, or crutch handle should be at the level of the wrist crease.
2.
The resident’s hand is placed on the “hip” or rim of the pelvis. The fingers should point down.
The cane, walker, or crutch handle should be at the tip of the fingers.
Each of these methods has its limitations. When the device is measured, the RNA should stand back and
look at the resident making sure the person is supported properly. The shoulders should be level and
there should be a slight bend in the elbow.