NurseReview.Org - Nursing Rehabilitation

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<p>Rehabilitation Nursing</p> <p>Nurse Licensure Examination Review</p> <p>RehabilitationA</p> <p>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</p> <p>DISABILITY Restriction</p> <p>of ABILITY to PERFORM activities in a NORMAL manner</p> <p>or lack</p> <p>IMPAIRMENTLoss</p> <p>or ABNORMALITY of psychological, physiological and anatomic structure and FUNCTION</p> <p>Focus of Rehabilitation Maximizing</p> <p>the remaining capabilities of</p> <p>the patient</p> <p>Initiation of Rehabilitation At</p> <p>the time of ADMISSION</p> <p>NURSING INTERVENTIONS1.</p> <p>Self care deficits 2. Impaired physical mobility 3. Impaired skin integrity 4. Altered elimination pattern</p> <p>SELF-CARE DEFICITS Assess</p> <p>the ability of the patient to perform ADLs (activities of daily living) Bathing Grooming Toileting Dressing Feeding</p> <p>Self-care deficits: Interventions 1.</p> <p>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</p> <p>Self-care deficits: Interventions5.</p> <p>Monitor frustrations and tolerance 6. Assist in accepting self-care dependence</p> <p>IMPAIRED PHYSICAL MOBILITYComplications of IMMOBILITY 1. Contractures 2. Foot drop 3. DVT 4. Hypostatic pneumonia 5. Pressure ulcers</p> <p>IMPAIRED PHYSICAL MOBILITYComplications of IMMOBILITY 6. muscle atrophy 7. osteoporosis 8. dependent edema 9. urine stasis 10. constipation</p> <p>IMPAIRED PHYSICAL MOBILITYASSESSMENT Assess patients ability to move Assess muscle tone, strength Assess joint movement and positioning</p> <p>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</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p>2. Maintain muscle strength and joint mobility Perform passive ROME Perform assistive ROME Perform active ROME Move the joints three times TID</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions3. Promote independent mobility Warn patient of the orthostatic hypotension when suddenly standing upright</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions4. Assist patient with transfer Assess patients 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</p> <p>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</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p>5. Assist patient to prepare for ambulation Exercise such as quadriceps setting, gluteal setting and arm push ups Use rubber ball for hand exercise</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions6. Assist patient in crutch ambulation</p> <p>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)</p> <p> 6.</p> <p>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</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p> 6.</p> <p>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</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p> 6.</p> <p>Assist patient in crutch ambulation Measure correct crutch length Utilizing the patients HEIGHT Height MINUS 40 cm or 16 inches</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions 6.</p> <p>Assist patient in crutch ambulation Measure correct crutch length Hand piece should allow 20-30 degrees elbow flexion</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions6. 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</p> <p>GAIT</p> <p>4-point gait Safest</p> <p>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</p> <p>3-point gait Requires</p> <p>weight bearing on the UNAFECTED leg Move BOTH crutches and the WEAKER LEG forward Move the STRONGER leg forward</p> <p>2-point gait Faster</p> <p>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</p> <p>Swing-to gait Usually</p> <p>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)</p> <p>Swing-through gait Move</p> <p>BOTH crutches together Lift body weight by the arms and swing forward, ahead of the crutches (beyond the level)</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions6. Assist patient in ambulation with a walker Correct height of the walker must allow a 20-30 degrees of elbow flexion</p> <p>IMPAIRED PHYSICAL MOBILITY Nursing Interventions6. Assist patient in ambulation with a cane Correct cane measurement: With</p> <p>elbow flexion of 30 degrees, measure the length from the HAND to 6 inches lateral to the tip of the 5th toe</p> <p>Impaired Skin integrityPressure 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</p> <p>Pressure sores</p> <p>Impaired Skin integrityINITIAL SIGN OF PRESSURE ULCER:ERYTHEMA</p> <p>or redness of the skin that DOES NOT blanch</p> <p>Impaired Skin integrityWeight 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</p> <p>Pressure areas</p> <p>Risk Factors for pressure ulcers1.</p> <p>Patients with sensory deficits 2. Decreased tissue perfusion 3. Decreased nutritional status 4. Friction and shearing forces 5. Increased moisture and edema</p> <p>Pressure ulcer stages Stage Stage Stage</p> <p>1- non-blanchable Erythema 2- skin breakdown in dermis 3- ulceration extends to the subcutaneous</p> <p>tissue Stage</p> <p>4- ulcers involve the muscle and bone</p> <p>Nursing Interventions RELIEVE</p> <p>THE PRESSURE Turn and reposition every 1-2 Hours Encourage</p> <p>weight shifting actively, every</p> <p>15 minutes</p> <p>Nursing Interventions POSITION</p> <p>PATIENT PROPERLY Follow the recommended sequence Lateral prone supine lateral Position</p> <p>patient with the bed elevated at NO MORE THAN 30 degrees Utilize the bridging technique</p> <p>Nursing Interventions UTILIZE</p> <p>PRESSURE RELIEVING DEVICES Use floatation pads Use air, water or foam mattresses Oscillating and kinetic bed</p> <p>Nursing Interventions IMPROVE</p> <p>MOBILITY Active and passive exercises</p> <p>Nursing Interventions IMPROVE</p> <p>TISSUE PERFUSION Exercise and repositioning are the most important activities AVOID</p> <p>MASSAGE ON THE REDDENED</p> <p>AREAS</p> <p>Nursing Interventions IMPROVE</p> <p>NUTRITIONAL STATUS HIGH protein HIGH vitamin C diet Measure body weight Assess hemoglobin and albumin</p> <p>Nursing Interventions REDUCE</p> <p>FRICTION AND SHEAR Lift and not drag patient Prevent the presence of wrinkles and creases on bed sheets</p> <p>Nursing Interventions REDUCE</p> <p>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)</p> <p>Nursing Interventions PROMOTE Dictum:</p> <p>WOUND HEALING</p> <p>Remove the pressure</p> <p>Nursing Interventions PROMOTE Stage</p> <p>WOUND HEALING</p> <p>1</p> <p> Remove</p> <p>pressure Reposition Q 2 Never massage the area</p> <p>Nursing Interventions PROMOTE Stage Clean</p> <p>WOUND HEALING</p> <p>2</p> <p>with sterile SALINE only Antiseptic solutions may damage healthy regenerating tissue and delay healing Wet saline dressings are helpful</p> <p>Nursing Interventions PROMOTE</p> <p>WOUND HEALING Stage 3 and 4 Necrotic</p> <p>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</p>