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Restorative: the basis of nursing care.

I want to relate an experience I had on a recent "professional" visit to a nursing facility - a 66-bed home in a rural area that, as far as I am concerned, sets the standards for nursing home care and shows what can be achieved and maintained when employees care.

When I walked in the door, nothing smacked my senses except a welcome feeling. Every inch of the floor, including the corners, was shiny clean. There was no odor, not even the air freshener scent that causes one to ponder what odor is being masked. The residents were well dressed, well groomed and looked happy. And - to me, the key factor - the staff looked happy.

This home has just started a true restorative range-of-motion program, and staffers are excited about the improvements they have helped achieve in the first two weeks. They have adopted our organization's policy of (in extremely simple terms) "massage and slow, gentle stretch" with all contracture patients, instead of the old range-of-motion (ROM) exercise.

If truth be told, we have always known that ROM wasn't done. During a typical shift, beds were made, resident hygiene tasks completed, meals served, residents fed and cleaned up, and charting done; ROM was left until last, and if time ran short it just wasn't done. Perhaps, with what we know today, that might have been a blessing for contracted patients.

True, the "pumping" exercise of ROM caused some movement of the muscles, increased blood flow and, if done properly, would certainly go a long way toward preventing contractures. But once a contracture has been allowed to start, ROM does not provide the prolonged, low-load, passive stretching to begin reversing shortened muscles and tendons - in fact, it can cause pain and damage to internal structures, especially if an overzealous staff person pushes the joint beyond the point of resistance. Think about it: When you do ROM, where is the limb when you finish? It is pulled inward toward the body, in its original flexed position.

The old saw "no pain, no gain" might apply to contractures caused by trauma or surgery because they form thick collagen fibers (or scar tissue) that must be broken through to achieve increased range of motion of that joint. But almost all of the contractures seen in a nursing home are the result of immobility - there are no thick collagen fibers to break through. They form as a result of that joint not being fully extended enough each day to prevent the devastating shortening of muscles and tendons.

Besides slow, gentle massage, another point to remember in this updated approach to nursing home contractures is to never use static bracing on someone with muscle tone or spasticity, because doing so can increase the tone and actually worsen the contracture. Patients wearing a static brace who experience an episode of tone can even break the brace by the amount of force exerted at the joint. There must be flexibility in the bracing to allow the extremity to "work through" the tone so that it relaxes. If the appropriate bracing is applied - after massage and slow, gentle stretch - to just the point of resistance, permanent elongation can be achieved over time, possibly a very short time, depending on the person.

Because of work like this, restorative programs have become the basis for all care in a nursing home. Just look at your MDS and see how everything relates to restorative nursing in one way or another. It is hard work, but extremely rewarding when you know you have played a role in helping to restore some normalcy to a human body and dignity to the soul.

Karen L. Bonn, RN, ROF, a former director of nursing, is founder and president of Restorative Medical, Inc., Brandenburg, Kentucky.
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Author:Bonn, Karen L.
Publication:Nursing Homes
Date:Sep 1, 1999
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