59. CCA Study Notes: Preventing Bed Rest and Immobility Complications Through Positioning and Exercise

The Big Picture

When a client stays in bed or moves very little, the body starts losing strength and normal movement. Long periods of inactivity also create the risk of serious health problems.

Good positioning, movement, and exercise help prevent these problems. The CCA follows the care plan, helps the client stay as active as possible, uses safe body mechanics, watches for changes, and reports concerns.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Why Activity Matters

Activity supports physical and mental well-being. Illness, surgery, injury, pain, aging, chronic illness, paralysis, and progressive disorders sometimes limit a client’s activity.

Immobility means an excessive lack of exercise and activity. It creates the risk of serious complications throughout the body.

Deconditioning is the loss of muscle size, strength, and function caused by inactivity and immobility. It affects people of any age, although older clients become deconditioned more quickly.

Clients should be encouraged to stay as active as possible. When a client needs help moving, the support worker assists according to the care plan to help prevent permanent loss of joint function.

Protect Yourself While Helping the Client

Support workers also face an injury risk while helping clients exercise or move.

Use proper body mechanics at all times. Daily muscle stretching, attention to posture, and safe body mechanics may decrease your risk of injury.

Who Assesses Joint Function and Plans Exercise?

Physiotherapists and occupational therapists assess a client’s joint function. They also suggest exercises or mobility aids that help the client regain muscle strength and function.

The care plan tells the support worker:

• the client’s activity level
• which exercises the client performs

Ask your supervisor when you have questions.

Understanding Bed Rest

A physician orders bed rest to treat a health problem. Bed rest also serves several purposes:

• reduce physical activity
• reduce pain
• encourage rest
• regain strength
• promote healing

The care plan states which activities the client is allowed to perform.

Types of Bed Rest

Strict bed rest: The client stays in bed at all times. The client receives help with activities of daily living, or ADLs, as needed. A continent client uses a bedpan or urinal.

Bed rest with commode privileges: The client performs allowed ADLs, such as self-feeding, oral hygiene, bathing, shaving, and hair care. The client uses a bedside commode for elimination. The care plan states whether assistance is required.

Bed rest with bathroom privileges, or BRP: The client uses the bathroom for elimination.

Always ask your supervisor what bed rest means for the individual client.

Complications of Bed Rest and Immobility

Long-term bed rest and immobility pose a risk of serious health complications affecting every body system.

Complications include:

• pressure ulcers
• constipation
• fecal impaction
• urinary tract infections
• renal calculi, or kidney stones
• blood clots, also called thrombi
• pneumonia, an infection of the lung

Lack of activity also affects muscles and joints.

Contractures and Muscle Atrophy

A contracture is a loss of joint mobility caused by abnormal shortening of a muscle.

A contracture can begin in as little as 48 to 72 hours when the client cannot move the joint and muscle and a caregiver does not exercise them.

The shortened muscle becomes fixed in position, deformed, and unable to stretch. Contractures are not reversible.

Common locations include:

• fingers
• wrists
• elbows
• toes
• ankles
• knees
• hips

Contractures also occur in the neck and spine. They result in permanent deformity and disability.

Atrophy means tissue decreases in size or wastes away. Muscle atrophy means a muscle decreases in size or wastes away.

Preventing contractures and muscle atrophy helps maintain normal body movement.

Orthostatic Hypotension

Orthostatic hypotension can occur from a lack of mobility.

Orthostatic hypotension, also called postural hypotension, is a drop in blood pressure when a client stands.

When a client changes from lying or sitting to standing, the client might experience:

• dizziness
• weakness
• spots before the eyes
• syncope

Syncope means a brief loss of consciousness, or fainting.

Changing positions slowly helps prevent orthostatic hypotension.

Helping a Client Move From Lying to Standing

Follow the correct order. Watch for weakness, dizziness, or spots before the eyes throughout the process.

1. You might be asked to measure blood pressure, or BP, pulse, and respirations while the client lies down and then sits, if your employer allows this task. If the client reports no light-headedness or other symptoms of a BP drop, continue.
2. Place the client in Fowler’s position. Raise the head of the bed slowly. If the bed does not raise, use pillows and backrests.
   • Ask about weakness, dizziness, or spots before the eyes.
   • If symptoms occur, lower the head of the bed to a flat position or remove the backrest. Report the symptoms to your supervisor.
   • You might be asked to measure BP, pulse, and respirations if your employer allows it.
   • Keep the client in Fowler’s position for a short time. Ask about symptoms again. Continue only when symptoms are absent.
3. Help the client sit at the side of the bed with the feet dangling over the edge.
   • Ask about weakness, dizziness, or spots before the eyes.
   • If symptoms occur, help the client lie back in bed and report the symptoms to your supervisor.
4. Keep the client sitting at the side of the bed for a short time.
5. Help the client stand. Stay close and use good body mechanics.
   • Ask about weakness, dizziness, or spots before the eyes.
   • If symptoms occur, help the client sit at the side of the bed and report them.
   • You might be asked to measure BP, pulse, and respirations if employer policy allows it.
   • Continue when the client reports no symptoms.
6. Help the client sit in a chair or walk, according to the care plan.
   • Ask again about weakness, dizziness, or spots before the eyes.
   • If symptoms occur while walking, help the client sit down.
7. Report all observations and complaints.

General Ways to Prevent Complications

Good care and regular movement help prevent complications of bed rest.

Follow the care plan and:

• encourage the client to move their limbs as much as possible, depending on the care plan
• maintain good body alignment
• reposition the client at least once every 2 hours
• help with ROM exercises according to the care plan

Positioning and Supportive Devices

Supportive devices help maintain body position and alignment.

Bed Boards

Bed boards sit under the mattress to stop it from sagging. They are usually plywood covered with canvas or another material.

Two sections allow the head and foot of the bed to rise.

Footboards

Footboards sit at the foot of the mattress. They prevent plantar flexion, which can lead to footdrop.

Plantar flexion means bending the foot downward at the ankle so the toes point away from the leg.

Footdrop occurs when the foot permanently falls downward at the ankle. It is permanent plantar flexion and is not reversible.

For proper positioning:

• the soles of the feet rest flat against the footboard
• the feet remain aligned as they would in a standing position

Footboards also serve as bed cradles and keep top linens off the feet.

Trochanter Rolls

Trochanter rolls prevent the hips and legs from turning outward, called external rotation.

They are made by folding and rolling sheets to the required length. The loose end goes under the client from the hip to the knee, with the roll tucked along the body.

Pillows or sandbags also help keep the hips and knees aligned.

Hand Rolls and Hand Grips

Hand rolls and hand grips prevent contractures of the:

• thumb
• fingers
• wrist

Commercial hand rolls, foam rubber sponges, rubber balls, and finger cushions serve this purpose.

Splints

Splints keep the wrist, thumb, and fingers in a normal position. They are usually held in place with Velcro, and some contain foam padding.

Bed Cradles

Bed cradles keep the weight of top linens off the feet.

The weight of top linens can cause:

• footdrop
• pressure ulcers

Exercise During Bed Rest

Exercise helps prevent contractures, muscle atrophy, and other complications of bed rest.

Some exercise happens naturally when the client:

• performs ADLs
• turns in bed
• moves in bed without help

Muscles and joints also need additional exercise.

Using a Trapeze

A trapeze hangs from an overbed frame and helps strengthen the arm muscles.

The client holds the bar with both hands and lifts the trunk off the bed. The client also uses the trapeze to move upward or turn in bed.

Range of Motion

Range of motion (ROM) means moving a joint as far as possible without causing pain.

ROM exercises move joints through their complete range. These exercises prevent problems such as joint contractures and muscle atrophy.

Clients who need ROM exercises usually perform them at least twice a day.

Music helps some clients relax or feel motivated during ROM exercises. Ask the client whether they want music played.

Three Types of ROM Exercise

Active ROM

The client performs active ROM exercises independently.

Passive ROM

During passive ROM exercises, a staff member moves the client’s joints through the range of motion.

The client does not participate in moving the joint.

Active-Assistive ROM

During active-assistive ROM exercises, the client participates as much as possible.

The support worker assists with movements the client cannot perform alone.

Joint Movements to Recognize

Movement	Meaning
Abduction	Moving a body part away from the body’s midline
Adduction	Moving a body part toward the body’s midline
Extension	Straightening a body part
Flexion	Bending a body part
Hyperextension	Straightening a body part excessively
Dorsiflexion	Bending the toes and foot upward at the ankle
Rotation	Turning a joint
Internal rotation	Turning a joint inward
External rotation	Turning a joint outward
Plantar flexion	Bending the foot downward at the ankle
Pronation	Turning downward
Supination	Turning upward

ROM During Everyday Activities

Joint movement occurs naturally during activities such as:

• bathing
• hair care
• eating
• reaching
• walking

Clients on bed rest or those with reduced mobility from illness or injury get little activity. Their care plans therefore usually include ROM exercises.

The care plan tells you:

• which joints to exercise
• whether ROM is active, passive, or active-assistive

Ask your supervisor if you have questions.

Play and ROM for Children

Play promotes active ROM in children.

Supported activities include:

• kicking a Mylar balloon or a foam rubber ball
• playing pat-a-cake while having the child clap, kick, jump, or make other motions
• playing basketball with a wastebasket and a foam rubber ball or wadded paper
• playing video games that involve finger and hand movements
• using fingerpaints, clay, or playdough
• tricycle or wheelchair races
• searching for a hidden toy in the bed or room
• colouring and painting

Always check the child’s care plan for activity limits. Ask your supervisor when you remain unsure.

Activity Programs in Long-Term Care

Canada’s provinces have long-term care legislation ⓘ requiring an assessment and care-planning process designed to prevent unnecessary loss of ROM. Prevention includes active, active-assistive, or passive ROM exercises and splints or braces when needed.

The territories currently do not have this legislation.

In most provinces, long-term care facilities need activity programs in place for licensing ⓘ. Recreational activities exercise joints and muscles, stimulate circulation, offer social opportunities, and provide mental stimulation.

Activity coordinators plan and carry out programs with residents. Support workers:

• bring residents to and from scheduled activities
• assist the activity coordinator
• observe residents during activities to help ensure safety

Activities must reflect each client’s interests and physical and psychosocial ⓘ needs. Examples include bingo, movies, dances, exercise groups, gardening, shopping trips, museum trips, concerts, and guest speakers.

Activities should support physical, intellectual, social, spiritual, and emotional well-being.

Personal choice matters. The client chooses which activities to attend.

Choosing activities that personally interest the client promotes emotional well-being.

Clients must not be forced to participate in activities that do not interest them.

Support workers provide assistance when clients need help getting to or participating in an activity.

Clients, support workers, and others also contribute activity ideas. Share ideas and information about a client’s favourite pastimes with the health care team so the activity-planning team receives them.

ROM Safety Rules

ROM exercises performed incorrectly create a risk of muscle strain, joint injury, and pain.

Follow the client’s care plan. Some ROM exercises, especially neck exercises, carry a risk of serious injury.

When performing or assisting with ROM exercises:

• exercise only the joints you were instructed to exercise
• expose only the body part being exercised
• use good body mechanics
• support the body part being exercised
• move the joint slowly, smoothly, and gently
• do not force a joint beyond its present ROM or to the point of pain
• perform neck ROM only when employer policy allows it

In some facilities and agencies, only physiotherapists or occupational therapists perform neck exercises because of the danger of neck injuries.

What to Report and Record After ROM Exercises

After ROM exercises, report and record:

• the time the exercises were performed
• which joints were exercised
• how many times the exercises were performed on each joint
• complaints of pain or signs of stiffness or spasm
• how much the client participated in the exercises

Common Mix-Ups

Wrong Idea	Better Idea
Immobility and deconditioning mean the same thing.	Immobility is excessive lack of activity. Deconditioning is loss of muscle size, strength, and function from inactivity and immobility.
A contracture is the same as muscle atrophy.	A contracture affects joint mobility because a muscle shortens. Muscle atrophy is wasting or loss of muscle size.
Plantar flexion and footdrop mean the same thing.	Plantar flexion is downward bending of the foot. Footdrop is permanent plantar flexion.
Active ROM means a staff member moves the joint.	In active ROM, the client moves independently.
Passive ROM involves the client helping with the movement.	In passive ROM, the staff member moves the joint and the client does not participate.
Active-assistive ROM means the worker performs all movement.	The client participates as much as possible, while the support worker helps with movements the client cannot perform.