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

or lack
of ABILITY to
 Restriction

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
 IMPAIRED PHYSICAL
MOBILITY
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
 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
 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
 IMPAIRED PHYSICAL
MOBILITY
Nursing Interventions

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
 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
 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
 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)
 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
 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
 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
 IMPAIRED PHYSICAL
MOBILITY
Nursing Interventions
 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
GAIT
 4-point gait
 Safestgait
 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
 Requiresweight 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)
 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
 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 5th 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
 Impaired Skin integrity
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
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
 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
 Nursing Interventions
 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
 Nursing Interventions
 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
 Nursing Interventions
 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)
 Nursing Interventions
 PROMOTE WOUND HEALING

 Dictum: Remove the pressure

 Nursing Interventions
 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
 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