Nursing Rehabilitation

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Nursing Rehabilitation - Presentation Transcript

  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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Nursing Rehabilitation

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