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Nursing Rehabilitation

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Nursing Rehabilitation

Nursing Rehabilitation

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  • 1. Rehabilitation Nursing Nurse Licensure Examination Review
  • 2. Rehabilitation
    • A dynamic, health oriented process that assists an ill person or a disabled person to achieve the greatest possible level of physical, mental, spiritual, social and economic functions
  • 3. DISABILITY
    • Restriction or lack of ABILITY to PERFORM activities in a NORMAL manner
  • 4. IMPAIRMENT
    • Loss or ABNORMALITY of psychological, physiological and anatomic structure and FUNCTION
  • 5. Focus of Rehabilitation
    • Maximizing the remaining capabilities of the patient
  • 6. Initiation of Rehabilitation
    • At the time of ADMISSION
  • 7. NURSING INTERVENTIONS
    • 1. Self care deficits
    • 2. Impaired physical mobility
    • 3. Impaired skin integrity
    • 4. Altered elimination pattern
  • 8. SELF-CARE DEFICITS
    • Assess the ability of the patient to perform ADLs (activities of daily living)
    • Bathing
    • Grooming
    • Toileting
    • Dressing
    • Feeding
  • 9. Self-care deficits: Interventions
    • 1. Foster Self-care abilities
      • Allow as much time as possible independence within safe limits
    • 2. Give positive reinforcements for the successful attempt
    • 3. Recommend assistive devices
    • 4. Focus on gross movements initially, then finer motor
  • 10. Self-care deficits: Interventions
    • 5. Monitor frustrations and tolerance
    • 6. Assist in accepting self-care dependence
  • 11. IMPAIRED PHYSICAL MOBILITY
    • Complications of IMMOBILITY
    • 1. Contractures
    • 2. Foot drop
    • 3. DVT
    • 4. Hypostatic pneumonia
    • 5. Pressure ulcers
  • 12. IMPAIRED PHYSICAL MOBILITY
    • Complications of IMMOBILITY
    • 6. muscle atrophy
    • 7. osteoporosis
    • 8. dependent edema
    • 9. urine stasis
    • 10. constipation
  • 13. IMPAIRED PHYSICAL MOBILITY
    • ASSESSMENT
    • Assess patient’s ability to move
    • Assess muscle tone, strength
    • Assess joint movement and positioning
  • 14. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 1. Position properly to prevent contractures
    • Place trochanter roll from the iliac crest to the midthigh to prevent EXTERNAL rotation
    • Place patient on wheelchair 90 degrees with the foot resting flat on the floor/foot rest
    • Place foot board or high-heeled shoes to prevent foot drop
  • 15. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 2. Maintain muscle strength and joint mobility
    • Perform passive ROME
    • Perform assistive ROME
    • Perform active ROME
    • Move the joints three times TID
  • 16. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 3. Promote independent mobility
    • Warn patient of the orthostatic hypotension when suddenly standing upright
  • 17. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 4. Assist patient with transfer
    • Assess patient’s ability to participate
    • Position yourself in front of the patient
    • Lock the wheelchair or the bed wheel
    • Use devices such as transfer boards, sliding boards, trapeze and sheets
  • 18. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 4. Assist patient with transfer
    • In general, the equipments are placed on the side of the STRONGER , UNAFFECTED body part
    • Nurses assist the patient to move TOWARDS the stronger side
    • In moving the patient, move to the direction FACING the nurse
  • 19. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 5. Assist patient to prepare for ambulation
    • Exercise such as quadriceps setting, gluteal setting and arm push ups
    • Use rubber ball for hand exercise
  • 20. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in crutch ambulation
    • Measure correct crutch length
    • LYING DOWN
    • Measure from the Anterior Axillary Fold to the HEEL of the foot then:
      • Add 1 inch (Kozier)
      • Add 2 inches (Brunner and Suddarth)
  • 21. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in crutch ambulation
    • Measure correct crutch length
    • STANDING (Kozier)
    • Mark a distance of 2 inches to the side from the tip of the toe (first mark)
    • 6 inches is marked (second mark) ahead from the first
    • Measure 2 inches below the axilla to the second mark
  • 22. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in crutch ambulation
    • Measure correct crutch length
    • STANDING (Kozier)
    • Make sure that the shoulder-rest of the crutch is at least 1- 2 inches below the axilla
  • 23. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in crutch ambulation
    • Measure correct crutch length
    • Utilizing the patient’s HEIGHT
    • Height MINUS 40 cm or 16 inches
  • 24. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in crutch ambulation
    • Measure correct crutch length
    • Hand piece should allow 20-30 degrees elbow flexion
  • 25. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in crutch GAIT
    • A. 4 point gait
    • B. three-point gait
    • C. two point gait
    • D. swing to gait
    • E. swing through gait
  • 26. GAIT
  • 27. 4-point gait
    • Safest gait
    • Requires weight bearing on both legs
    • Move RIGHT crutch ahead (6 inches)
    • Move LEFT foot forward at the level of the RIGHT crutch
    • Move the LEFT crutch forward
    • Move the RIGHT foot forward
  • 28. 3-point gait
    • Requires weight bearing on the UNAFECTED leg
    • Move BOTH crutches and the WEAKER LEG forward
    • Move the STRONGER leg forward
  • 29. 2-point gait
    • Faster than 4-point
    • Requires more balance
    • Partial bearing on BOTH legs
    • Move the LEFT crutch and RIGHT foot FORWARD together
    • Move the RIGHT crutch and LEFT foot forward together
  • 30. Swing-to gait
    • Usually used by client with paralysis of both legs
    • Prolonged use results in atrophy of unused muscle
    • Move BOTH crutches together
    • Lift body weight by the arms and swing to the crutches (at the level)
  • 31. Swing-through gait
    • Move BOTH crutches together
    • Lift body weight by the arms and swing forward, ahead of the crutches (beyond the level)
  • 32. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in ambulation with a walker
    • Correct height of the walker must allow a 20-30 degrees of elbow flexion
  • 33. IMPAIRED PHYSICAL MOBILITY Nursing Interventions
    • 6. Assist patient in ambulation with a cane
    • Correct cane measurement:
    • With elbow flexion of 30 degrees, measure the length from the HAND to 6 inches lateral to the tip of the 5 th toe
  • 34.  
  • 35. Impaired Skin integrity
    • Pressure ulcers
    • Are localized areas of dead soft tissue that occurs when pressure applied to the skin overtime is more than 32 mmHg leading to tissue damage
  • 36. Pressure sores
  • 37. Impaired Skin integrity
    • INITIAL SIGN OF PRESSURE ULCER:
    • ERYTHEMA or redness of the skin that DOES NOT blanch
  • 38. Impaired Skin integrity
    • Weight bearing Bony prominences
    • 1. Sacrum and cocygeal area
    • 2. Ischial tuberosity
    • 3. Greater trochanter
    • 4. Heel and malleolus
    • 5. Tibia and fibula
    • 6. Scapula and elbow
  • 39. Pressure areas
  • 40. Risk Factors for pressure ulcers
    • 1. Patients with sensory deficits
    • 2. Decreased tissue perfusion
    • 3. Decreased nutritional status
    • 4. Friction and shearing forces
    • 5. Increased moisture and edema
  • 41. Pressure ulcer stages
    • Stage 1- non-blanchable Erythema
    • Stage 2- skin breakdown in dermis
    • Stage 3- ulceration extends to the subcutaneous tissue
    • Stage 4- ulcers involve the muscle and bone
  • 42.  
  • 43.  
  • 44. Nursing Interventions
    • RELIEVE THE PRESSURE
    • Turn and reposition every 1-2 Hours
    • Encourage weight shifting actively, every 15 minutes
  • 45. Nursing Interventions
    • POSITION PATIENT PROPERLY
    • Follow the recommended sequence
    • Lateral  prone  supine  lateral
    • Position patient with the bed elevated at NO MORE THAN 30 degrees
    • Utilize the bridging technique
  • 46. Nursing Interventions
    • UTILIZE PRESSURE RELIEVING DEVICES
    • Use floatation pads
    • Use air, water or foam mattresses
    • Oscillating and kinetic bed
  • 47. Nursing Interventions
    • IMPROVE MOBILITY
    • Active and passive exercises
  • 48. Nursing Interventions
    • IMPROVE TISSUE PERFUSION
    • Exercise and repositioning are the most important activities
    • AVOID MASSAGE ON THE REDDENED AREAS
  • 49. Nursing Interventions
    • IMPROVE NUTRITIONAL STATUS
    • HIGH protein
    • HIGH vitamin C diet
    • Measure body weight
    • Assess hemoglobin and albumin
  • 50. Nursing Interventions
    • REDUCE FRICTION AND SHEAR
    • Lift and not drag patient
    • Prevent the presence of wrinkles and creases on bed sheets
  • 51. Nursing Interventions
    • REDUCE IRRITATING MOISTURE
    • Adhere to a meticulous skin care
    • Promptly clean and dry the soiled areas
    • Use mild soap and water
    • Pat dry and not rub
    • Lotion may be applied
    • AVOID powders (cause dryness)
  • 52. Nursing Interventions
    • PROMOTE WOUND HEALING
    • Dictum: Remove the pressure
  • 53. Nursing Interventions
    • PROMOTE WOUND HEALING
    • Stage 1
    • Remove pressure
    • Reposition Q 2
    • Never massage the area
  • 54. Nursing Interventions
    • PROMOTE WOUND HEALING
    • Stage 2
    • Clean with sterile SALINE only
    • Antiseptic solutions may damage healthy regenerating tissue and delay healing
    • Wet saline dressings are helpful
  • 55. Nursing Interventions
    • PROMOTE WOUND HEALING
    • Stage 3 and 4
    • Necrotic tissues are debrided
    • Administer analgesics before cleansing
    • Do a mechanical flushing with saline solution
    • Topical ointments may be applied UNTIL granulation tissue appears then only saline irrigation is recommended

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