This is part 4 of a series Jonathan Rosenfeld and I are doing regarding 6 common causes of bed sores in nursing home and hospital patients. Today, we are discussing contractures.
What are contractures? People who are physically inactive for long periods of time are at risk for developing contractures. Obviously, many nursing home residents suffer from inactivity due to mental infirmities or physical limitations. As a direct result of physical inactivity and the failure to regularly move a limb or joint through its full range of motion, muscle fibers begin to break down and joints begin to stiffen, which can lead to the affected limb slowly pulling toward the body and becoming rigid. It is not uncommon to see nursing home residents with contracted hands, arms, or legs, oftentimes leaving them in the "fetal position" making it very difficult to give them the care they require.
Are contractures preventable? Contractures are very painful and the process of restoring a person's range of motion can be excruciating. Consequently, prevention is substantially better than restoration. Sadly, many nursing home residents who suffer from contractions do so because some nursing home facilities lack a sufficient number of staff members or the staff members fail to provide the proper preventive measures. To prevent contractures, the nursing staff should properly assess the resident's risk for contractures and implement an individualized care plan. The purpose of the care plan is to make all nurses aware of the methods to use for that particular resident to prevent the resident from developing contractures. Periodically, the resident should be re-assessed and an updated care plan prepared, if needed.
Using the following methods can help prevent or lessen the severity of contractures:
EXERCISE
Range of motion exercises are arguably the most important weapon in preventing contractures. For residents in nursing homes, facility staff need to take the time to properly exercise and stretch the limbs and joints of immobile residents. Passive range of motion exercises (those which involve gently rotating the at-risk body parts clockwise and counterclockwise) should be performed at least twice a day. For example, to prevent hand contractures, each finger should be gently stretched and rotated as far as possible. Properly trained nurses and nurse aides should understand the dangers of contractures, the simple exercises that can be done to prevent them and the short amount of time it takes to perform these exercises. Nurse aides can perform some of these exercises while bathing the individual or while changing their clothes. Physical therapists, obviously, are more aware of the dangers of contractures and the exercises used to prevent them. For those residents at risk of developing contractures, nurses should seek assistance from the physical therapy staff.
POSITIONING
The position of nursing home residents is crucial. If a nursing home resident can sit in a chair, staff should make sure that the resident is properly seated with their feet resting comfortably on a flat surface, such as a foot lift. Dangling feet can lead to "tip-toe" contractures. To prevent leg contractures, the resident should not be allowed to sleep with her legs in a bent or twisted position. Rather, pillows or cushions should be placed between the legs to help prevent contractures.
SPLINTING
Splinting devices can be very useful in helping prevent painful and debilitating contractures. Examples of such devices include special boots and wrist splints can be used to help prevent fingers and toes from drawing up and stiffening. Knee and elbow braces are also an option to help keep those joints from stiffening in place, but will still allow the resident free range of motion.
Contractures can develop quickly and frequently affect the hands, feet, legs, and arms. In the event of a person who has severely contracted, restoration, if possible, can take up to one year and can be an excruciating process of the affected person. Splinting devices can help prevent your loved one from having to go through the pain of trying to reverse contractures.
If you have a loved one who is at risk for contractures or who has contractures, what should the nursing staff do?
According to nurse Suzanne Frederick, "Nurses should follow the nursing process by properly assessing the resident's risk for contractures and implementing an individualized care plan to prevent and/or treat the limited range of motion or contracture. Once a resident is recognized as at risk for contractures through proper assessments, the nursing staff should implement a range of motion exercise program for the resident based on his/her functional ability. The consistent implementation of the range of motion exercise program should be documented in order to evaluate the resident's response to this treatment."
In addition to common sense nursing practices, nursing homes should follow the federal regulations that apply to residents who have or who are at risk for contractures. For example, federal regulation 42 CFR §483.25(e)(2) states:
"Based on the comprehensive assessment of a resident, the facility must ensure
that -- A resident with a limited range of motion receives appropriate treatment and
services to increase range of motion and/or to prevent further decrease in range of
motion."
If you have a loved one who is at risk for contractures or who has contractures, what should you do?
• Insist that your loved one receive stretching exercises twice daily.
• Insist that all necessary preventive devices are used.
• Visit often and make sure that staff members are attentive to the needs of your loved one.
• Be respectful, but firm that your loved one receives the care they deserve.
Unlike some problems and physical limitations that can be easily reversed, contractures are an especially troublesome issue given the difficulty associated with reversing the process. Family members should not hesitate to ensure that their loved ones receive the care they need and are required.
