Rehabilitation Nursing Nurse Licensure Examination Review

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

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

DISABILITY Restriction or lack of ABILITY to PERFORM activities in a NORMAL manner

Restriction or lack of ABILITY to PERFORM activities in a NORMAL manner

IMPAIRMENT Loss or ABNORMALITY of psychological, physiological and anatomic structure and FUNCTION

Loss or ABNORMALITY of psychological, physiological and anatomic structure and FUNCTION

Focus of Rehabilitation Maximizing the remaining capabilities of the patient

Maximizing the remaining capabilities of the patient

Initiation of Rehabilitation At the time of ADMISSION

At the time of ADMISSION

NURSING INTERVENTIONS 1. Self care deficits 2. Impaired physical mobility 3. Impaired skin integrity 4. Altered elimination pattern

1. Self care deficits

2. Impaired physical mobility

3. Impaired skin integrity

4. Altered elimination pattern

SELF-CARE DEFICITS Assess the ability of the patient to perform ADLs (activities of daily living) Bathing Grooming Toileting Dressing Feeding

Assess the ability of the patient to perform ADLs (activities of daily living)

Bathing

Grooming

Toileting

Dressing

Feeding

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

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

Self-care deficits: Interventions 5. Monitor frustrations and tolerance 6. Assist in accepting self-care dependence

5. Monitor frustrations and tolerance

6. Assist in accepting self-care dependence

IMPAIRED PHYSICAL MOBILITY Complications of IMMOBILITY 1. Contractures 2. Foot drop 3. DVT 4. Hypostatic pneumonia 5. Pressure ulcers

Complications of IMMOBILITY

1. Contractures

2. Foot drop

3. DVT

4. Hypostatic pneumonia

5. Pressure ulcers

IMPAIRED PHYSICAL MOBILITY Complications of IMMOBILITY 6. muscle atrophy 7. osteoporosis 8. dependent edema 9. urine stasis 10. constipation

Complications of IMMOBILITY

6. muscle atrophy

7. osteoporosis

8. dependent edema

9. urine stasis

10. constipation

IMPAIRED PHYSICAL MOBILITY ASSESSMENT Assess patient’s ability to move Assess muscle tone, strength Assess joint movement and positioning

ASSESSMENT

Assess patient’s ability to move

Assess muscle tone, strength

Assess joint movement and positioning

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

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

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

2. Maintain muscle strength and joint mobility

Perform passive ROME

Perform assistive ROME

Perform active ROME

Move the joints three times TID

IMPAIRED PHYSICAL MOBILITY Nursing Interventions 3. Promote independent mobility Warn patient of the orthostatic hypotension when suddenly standing upright

3. Promote independent mobility

Warn patient of the orthostatic hypotension when suddenly standing upright

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

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

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

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

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

5. Assist patient to prepare for ambulation

Exercise such as quadriceps setting, gluteal setting and arm push ups

Use rubber ball for hand exercise

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)

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)

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

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

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

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

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

6. Assist patient in crutch ambulation

Measure correct crutch length

Utilizing the patient’s HEIGHT

Height MINUS 40 cm or 16 inches

IMPAIRED PHYSICAL MOBILITY Nursing Interventions 6. Assist patient in crutch ambulation Measure correct crutch length Hand piece should allow 20-30 degrees elbow flexion

6. Assist patient in crutch ambulation

Measure correct crutch length

Hand piece should allow 20-30 degrees elbow flexion

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

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

GAIT

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

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

3-point gait Requires weight bearing on the UNAFECTED leg Move BOTH crutches and the WEAKER LEG forward Move the STRONGER leg forward

Requires weight bearing on the UNAFECTED leg

Move BOTH crutches and the WEAKER LEG forward

Move the STRONGER leg forward

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

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

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)

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)

Swing-through gait Move BOTH crutches together Lift body weight by the arms and swing forward, ahead of the crutches (beyond the level)

Move BOTH crutches together

Lift body weight by the arms and swing forward, ahead of the crutches (beyond the level)

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

6. Assist patient in ambulation with a walker

Correct height of the walker must allow a 20-30 degrees of elbow flexion

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

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

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

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

Pressure sores

Impaired Skin integrity INITIAL SIGN OF PRESSURE ULCER: ERYTHEMA or redness of the skin that DOES NOT blanch

INITIAL SIGN OF PRESSURE ULCER:

ERYTHEMA or redness of the skin that DOES NOT blanch

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

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

Pressure areas

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

1. Patients with sensory deficits

2. Decreased tissue perfusion

3. Decreased nutritional status

4. Friction and shearing forces

5. Increased moisture and edema

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

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

Nursing Interventions RELIEVE THE PRESSURE Turn and reposition every 1-2 Hours Encourage weight shifting actively, every 15 minutes

RELIEVE THE PRESSURE

Turn and reposition every 1-2 Hours

Encourage weight shifting actively, every 15 minutes

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

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

Nursing Interventions UTILIZE PRESSURE RELIEVING DEVICES Use floatation pads Use air, water or foam mattresses Oscillating and kinetic bed

UTILIZE PRESSURE RELIEVING DEVICES

Use floatation pads

Use air, water or foam mattresses

Oscillating and kinetic bed

Nursing Interventions IMPROVE MOBILITY Active and passive exercises

IMPROVE MOBILITY

Active and passive exercises

Nursing Interventions IMPROVE TISSUE PERFUSION Exercise and repositioning are the most important activities AVOID MASSAGE ON THE REDDENED AREAS

IMPROVE TISSUE PERFUSION

Exercise and repositioning are the most important activities

AVOID MASSAGE ON THE REDDENED AREAS

Nursing Interventions IMPROVE NUTRITIONAL STATUS HIGH protein HIGH vitamin C diet Measure body weight Assess hemoglobin and albumin

IMPROVE NUTRITIONAL STATUS

HIGH protein

HIGH vitamin C diet

Measure body weight

Assess hemoglobin and albumin

Nursing Interventions REDUCE FRICTION AND SHEAR Lift and not drag patient Prevent the presence of wrinkles and creases on bed sheets

REDUCE FRICTION AND SHEAR

Lift and not drag patient

Prevent the presence of wrinkles and creases on bed sheets

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)

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)

Nursing Interventions PROMOTE WOUND HEALING Dictum: Remove the pressure

PROMOTE WOUND HEALING

Dictum: Remove the pressure

Nursing Interventions PROMOTE WOUND HEALING Stage 1 Remove pressure Reposition Q 2 Never massage the area

PROMOTE WOUND HEALING

Stage 1

Remove pressure

Reposition Q 2

Never massage the area

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

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

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

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