SAINT FRANCIS OF ASSISI COLLEGE
SCHOOL OF NURSING
PERFORMANCE CHECKLIST FOR RANGE OF MOTION (ROM)
NAME
DATE
:___________________________________
:___________________________________
4
3
2
1
Assessment:
SUBJECT
LEVEL/GROUP
:_________________________
:_________________________
CRITERION MEASUREMENT
1.
Be aware of the clients medical diagnosis. Understand the expected functional of a client with this diagnosis.
2.
Familiarize yourself with the clients current range of motion.
3.
Assess client consciousness and cognitive function.
Planning / Expected Outcomes:
4.
Client will maintain or improve current functional mobility.
5.
Client will regain or improve strength and movements are involved.
6.
Client will avoid complications of immobility.
Implementation:
7.
Identify client. Introduce yourself.
8.
Explain the procedure to the client.
9.
Provide for privacy, exposing only the extremity to be exercised.
10. Adjust bed to comfortable height for performing ROM.
11. Lower side rail only on the side you are working.
12. Describe the passive ROM exercises you are performing or verbally cue the client
your assistance. Wash hands and apply gloves.
to perform ROM exercise with
13. Start at the client head and perform ROM exercises down each side of the body.
14. Repeat each ROM exercise as the client tolerates to a maximum of 5 times.
15. Perform each motion in a slow, firm manner. Encourage full joint but do not go beyond the point of pain,
resistance, or fatigue.
Head:
16. With the client in a sitting position, if possible:
17. Rotation: Turn the head from side to side.
18. Flexion and Extension: Tilt the head toward the chest and then slightly upward.
19. Lateral Flexion: Tilt the head on each side so as to almost touch the ear to the shoulder.
Arm:
20. Flexion and extension; Extend a straight arm forward toward the head, then downward along the side.
21. Adduction and Abduction: Extend a straight arm toward the midline and away from the midline.
Shoulder:
22. Internal and external rotation: bend the elbow at a 90 degree angle with upper arm parallel to the shoulder.
Rotate the shoulder by moving the lower arm upward and downward.
Elbow:
23. Flexion and Extension: Supporting the arm, flex and extend the elbow.
24. Pronation and supination: Flex elbow, move the hand in a palm-up and palm down position.
Wrist:
25. Flexion and extension: Supporting the wrist, flex and extend the wrist.
26. Adduction and Abduction: Supporting the lower arm, turn wrist right to left, left to right, then rotate the wrist in a
circular motion.
Hand:
27. Flexion and Extension: Support the wrist, flex and extend the fingers.
Leg:
28. Adduction and Abduction: support the lower leg, flex the leg toward the chest and then extend the leg.
29. Adduction and abduction: Slide the leg away from the clients midline and then back to the midline.
30. Internal and external rotation: Support the lower leg, angle the foot inward and outward.
Knee:
31. Flexion and extension: Support the lower leg, flex and extend the knee.
Ankle:
32. Flexion and extension: Support the lower leg, flex and extend the ankle.
33. Inversion and eversion: Flex the ankle inward and outward.
Foot:
34. Adduction and abduction: Support the ankle, spread the toes apart and then bring them close together.
35. Flexion and extension: Support the ankle, extend the toes upward and then flex the toes downward.
36. Observe clients joints and face for signs of exertion, pain, or fatigue.
37. Replace covers and position client in proper body alignment.
38. Place side rails in original position.
39. Place call light within reach.
40. Wash hands.
Evaluation
41. Client has maintained or improved current functional mobility in all involved joints and extremities.
Client has regained or improved strength or voluntary movements in involved joints and extremities.
Client has avoided complications of immobility, including decubitus ulcers.
REMARKS ____________________________________________________
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TOTAL / % = _____/_____
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C.I. SIGNATURE
