Skill 9-5

Providing Range-of-Motion Exercises

Range of motion (ROM) is the complete extent of movement of which a joint is normally capable. When a person performs routine activities of daily living (ADLs), they are using muscle groups that help to keep many joints in an effective ROM. When all or some of the normal ADLs are impossible due to illness or injury, it is important to give attention to the joints not being used or to those that have limited use. When the patient does the exercise themself, it is referred to as active ROM. Exercises performed by the nurse or caregiver without participation by the patient are referred to as passive ROM. Exercises should be as active as the patient's physical condition permits. Allow the patient to do as much independent activity as their condition permits. Initiate ROM exercises as soon as possible; routine activity and mobilization of patients is an important activity and is appropriate for most patient populations (Arnold et al., 2018; Liu et al., 2018; Nack et al., 2019; Tasheva et al., 2020).

Delegation Considerations

Patient teaching regarding ROM exercises cannot be delegated to assistive personnel (AP). Reinforcement or implementation of ROM exercises may be delegated to AP as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

No special equipment or supplies are necessary to perform ROM exercises. Wear nonsterile gloves and/or other PPE, as appropriate.

Assessment

Review the health record and plan of care for any conditions or prescribed interventions that limit mobility. Perform a pain assessment before the time for the exercises. If the patient reports pain, administer the prescribed medication in sufficient time to allow for the full effect of the analgesic. Assess the patient's ability to perform ROM exercises. Inspect and palpate joints for redness, tenderness, pain, swelling, or deformities.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired active range of motion
Fatigue
Deconditioning

Outcome Identification and Planning

The expected outcome to achieve when performing ROM exercises is that the patient completes the exercises and maintains or improves joint mobility. Other outcomes include improving or maintaining muscle strength and preventing muscle atrophy and contractures .

Implementation

Action	Rationale
1. Review the prescribed interventions and plan of care for patient activity. Identify any movement limitations.	Reviewing the prescribed interventions and care plan validates the correct patient and correct procedure. Identification of limitations prevents injury.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Close the curtains around the bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016). Adjust the head of the bed to a flat position or as low as the patient can tolerate.	Closing the door or curtains provides for privacy. Proper bed height helps reduce back strain while performing the procedure.
5. Stand on the side of the bed where the joints are to be exercised. Lower side rail on that side, if in place. Uncover only the limb to be used during the exercise.	Standing on the side to be exercised and lowering the side rail prevent strain on the nurse's back. Proper draping provides for privacy and warmth.
6. Perform the exercises slowly and gently, providing support by holding the areas proximal and distal to the joint. Repeat each exercise two to five times, moving each joint in a smooth and rhythmic manner. Stop movement if the patient reports of pain or if you meet resistance.	Slow, gentle movements with support prevent discomfort and muscle spasms resulting from jerky movements. Repeated movement of muscles and joints improves flexibility and increases circulation to the body part. Pain may indicate the exercises are causing damage.
7. While performing the exercises, begin at the head and move down one side of the body at a time. Encourage the patient to do as many of these exercises independently as possible.	Proceeding from head to toe, one side at a time, promotes efficient time management and an organized approach to the task. Both active and passive exercises improve joint mobility and increase circulation to the affected part, but only active exercise increases muscle mass, tone, and strength and improves cardiac and respiratory functioning.
8. Move the chin down to rest on the chest (Figure 1). Return the head to a normal upright position (Figure 2). Tilt the head as far as possible toward each shoulder (Figure 3).	These movements provide for flexion, extension, and lateral flexion of the head and neck.
9. Move the head from side to side, bringing the chin toward each shoulder (Figure 4).	These movements provide for rotation of neck.
10. Start with the arm at the patient's side (Figure 5) and lift the arm forward to above the head (Figure 6). Return the arm to the starting position at the side of the body.	These movements provide for flexion and extension of the shoulder.
11. With the arm back at the patient's side, move the arm laterally to an upright position above the head (Figure 7), and then return it to the original position. Move the arm across the body as far as possible (Figure 8).	These movements provide for abduction and adduction of the shoulder.
12. Raise the arm at the side until the upper arm is in line with the shoulder. Bend the elbow at a 90-degree angle (Figure 9) and move the forearm upward and downward, then return the arm to the side.	These movements provide for internal and external rotation of the shoulder.
13. Bend the elbow and move the lower arm and hand upward toward the shoulder (Figure 10). Return the lower arm and hand to the original position while straightening the elbow.	These movements provide for flexion and extension of the elbow.
14. Rotate the lower arm and hand so the palm is up (Figure 11). Rotate the lower arm and hand so the palm of the hand is down.	These movements provide for supination and pronation of the forearm.
15. Move the hand downward toward the inner aspect of the forearm (Figure 12). Return the hand to a neutral position even with the forearm (Figure 13). Then move the dorsal portion of the hand backward as far as possible.	These movements provide for flexion, extension, and hyperextension of the wrist.
16. Bend the fingers to make a fist (Figure 14), and then straighten them out (Figure 15). Spread the fingers apart (Figure 16) and return them back together. Touch the thumb to each finger on the hand (Figure 17).	These movements provide for flexion, extension, abduction, and adduction of the fingers.
17. Extend the leg and lift it upward (Figure 18). Return the leg to the original position beside the other leg.	These movements provide for flexion and extension of the hip.
18. Lift the leg laterally away from the patient's body (Figure 19). Return the leg back toward the other leg and try to extend it beyond the midline (Figure 20).	These movements provide for abduction and adduction of the hip.
19. Turn the foot and leg toward the opposite leg to rotate it internally (Figure 21). Turn the foot and leg outward away from the opposite leg to rotate it externally (Figure 22).	These movements provide for internal and external rotation of the hip.
20. Bend the leg and bring the heel toward the back of the leg (Figure 23). Return the leg to a straight position (Figure 24).	These movements provide for flexion and extension of the knee.
21. At the ankle, move the foot up and back until the toes are upright (Figure 25). Move the foot with the toes pointing downward (Figure 26).	These movements provide for dorsiflexion and plantar flexion of the ankle.
22. Turn the sole of the foot toward the midline (Figure 27). Turn the sole of the foot outward (Figure 28).	These movements provide for inversion and eversion of the ankle.
23. Curl the toes downward (Figure 29), and then straighten them out (Figure 30). Spread the toes apart (Figure 31) and bring them together (Figure 32).	These movements provide for flexion, extension, abduction, and adduction of the toes.
24. Repeat these exercises on the other side of the body. Encourage the patient to do as many of these exercises independently as possible.	Repeating motions on the other side provides exercise for the entire body. Self-esteem, self-care, and independence are encouraged through the patient performing the exercises on their own.
25. When finished, make sure the patient is comfortable, with the side rails up and the bed in the lowest position. Place the call bell and other essential items within reach.	Proper positioning with raised side rails and proper bed height provide for patient comfort and safety. Having the call bell and other essential items within reach promotes safety.
26. Remove gloves and any other PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcome has been met when the patient has completed the exercises and maintained or improved joint mobility and muscle strength, and muscle atrophy and contractures have been prevented.

Documentation

Guidelines

Document the exercises performed, any significant observations, and the patient's reaction to the activities.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

While you are performing ROM exercises, the patient reports feeling tired: Stop the activity for that time. Reevaluate the nursing care plan. Space the exercises out at different times of the day. Schedule exercise times for the parts of the day the patient is typically feeling more rested.
While exercising your patient's leg, he reports sudden, sharp pain: Stop the exercises. Assess the patient for other symptoms. Notify the health care team of the event, the patient's uncomfortable reaction, and your assessment findings. Joints should be moved until there is resistance, but not pain. Communicate uncomfortable reactions and halt exercises. Revise activity plan, if necessary.

Special Considerations

General Considerations

Incorporate the exercises when possible into daily activities, such as during bathing.
Prescribed interventions for ROM exercises for patients with acute arthritis, fractures, torn ligaments, joint dislocation, acute myocardial infarction, and bone tumors or metastases should include? Keep specific instructions for performance.

Older Adult Considerations

Avoid neck hyperextension and attempts to achieve full ROM in all joints with older adults.

EVIDENCE FOR PRACTICE

Exercise and Respiratory Function

ROM exercises improve joint mobility; increase circulation, muscle mass, muscle tone, and muscle strength; and improves cardiac and respiratory functioning. Exercises should be as active as the patient's physical condition permits. ROM exercises should be initiated as soon as possible as part of a patient's care plan, because body changes can occur after only a few days of impaired mobility.

Related Research

Cho, S. H., Lee, J. H., & Jang, S. H. (2015). Efficacy of pulmonary rehabilitation using cervical range of motion exercise in stroke patients with tracheostomy tubes. Journal of Physical Therapy Science, 27(5), 1329-1331. https://doi.org/10.1589/jpts.27.1329

This study examined the effect of cervical range-of-motion exercises on pulmonary and coughing function in poststroke patients with tracheostomy tubes who had no history of respiratory disease. Participants were randomly assigned to either an experimental group or a control group. The experimental group performed cervical range-of-motion exercises with a physical therapist five times a week for 8 weeks; the control group did not perform cervical range-of-motion exercises. Measurements of pulmonary function and coughing ability were obtained for both groups at the beginning and at the end of the 8 weeks. When the measurements were compared, the control group did not show any significant changes in pulmonary or coughing function. The experimental group showed a statistically significant increase in pulmonary and coughing function. The researchers concluded that cervical range-of-motion exercises can effectively improve the pulmonary function and coughing ability of stroke patients with tracheostomy tubes.

Relevance for Nursing Practice

An exercise program that includes ROM exercises can generate positive effects in enhancing physical function of stroke survivors. Methods to assist patients in maintaining or increasing physical activity should be a part of routine nursing care. Nurses are in ideal positions to discuss the effects of exercise with patients and include exercise programs in the care plan.

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Skill 9-5

EVIDENCE FOR PRACTICE