Nursing Rehabilitation

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

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

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

Focus of Rehabilitation
Maximizing the remaining capabilities of the patient

Initiation of Rehabilitation
At the time of ADMISSION

NURSING INTERVENTIONS
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

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

Self-care deficits: Interventions
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
6. muscle atrophy
7. osteoporosis
8. dependent edema
9. urine stasis
10. constipation

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

2. Maintain muscle strength and joint mobility
Perform passive ROME
Perform assistive ROME
Perform active ROME
Move the joints three times TID

3. Promote independent mobility
Warn patient of the orthostatic hypotension when suddenly standing upright

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
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

5. Assist patient to prepare for ambulation
Exercise such as quadriceps setting, gluteal setting and arm push ups
Use rubber ball for hand exercise

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)

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

STANDING (Kozier)
Make sure that the shoulder-rest of the crutch is at least 1- 2 inches below the axilla

Utilizing the patient’s HEIGHT
Height MINUS 40 cm or 16 inches

Hand piece should allow 20-30 degrees elbow flexion

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

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

3-point gait
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

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)

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

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 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 sores

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

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

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

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

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

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

IMPROVE MOBILITY
Active and passive exercises

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

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

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

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)

PROMOTE WOUND HEALING
Dictum: Remove the pressure

Stage 1
Remove pressure
Reposition Q 2
Never massage the area

Stage 2
Clean with sterile SALINE only
Antiseptic solutions may damage healthy regenerating tissue and delay healing
Wet saline dressings are helpful

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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Nursing Rehabilitation

by Nurse ReviewDotOrg on Oct 17, 2007

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Nursing Rehabilitation — Presentation Transcript