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

of ABILITY to PERFORM activities in a NORMAL manner

or lack

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

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

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

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

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)

 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

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
 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)

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  Stage  Stage

1- non-blanchable Erythema 2- skin breakdown in dermis 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  Dictum:

WOUND HEALING

Remove the pressure

Nursing Interventions
 PROMOTE  Stage

WOUND HEALING

1

 Remove

pressure  Reposition Q 2  Never massage the area

Nursing Interventions
 PROMOTE  Stage  Clean

WOUND HEALING

2

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

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