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Nursing Rehabilitation

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Nursing Rehabilitation

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Nursing Rehabilitation

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

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