Rehabilitation NursingRehabilitation Nursing

Nurse Licensure Examination Review

RehabilitationRehabilitation

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

DISABILITYDISABILITY

Restriction or lack of ABILITY to PERFORM activities in a NORMAL manner

IMPAIRMENTIMPAIRMENT

Loss or ABNORMALITY of psychological, physiological and anatomic structure and FUNCTION

Focus of RehabilitationFocus of Rehabilitation

Maximizing the remaining capabilities of the patient

Initiation of RehabilitationInitiation of Rehabilitation

At the time of ADMISSION

NURSING INTERVENTIONSNURSING INTERVENTIONS

1. Self care deficits2. Impaired physical mobility3. Impaired skin integrity4. Altered elimination pattern

SELF-CARE DEFICITSSELF-CARE DEFICITS

Assess the ability of the patient to perform ADLs (activities of daily living)

BathingGroomingToiletingDressingFeeding

Self-care deficits: InterventionsSelf-care deficits: Interventions

1. Foster Self-care abilities– Allow as much time as possible

independence within safe limits2. Give positive reinforcements for the

successful attempt3. Recommend assistive devices4. Focus on gross movements initially,

then finer motor

Self-care deficits: InterventionsSelf-care deficits: Interventions

5. Monitor frustrations and tolerance

6. Assist in accepting self-care dependence

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Complications of IMMOBILITY1. Contractures2. Foot drop3. DVT4. Hypostatic pneumonia5. Pressure ulcers

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Complications of IMMOBILITY6. muscle atrophy7. osteoporosis8. dependent edema9. urine stasis10. constipation

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

ASSESSMENT Assess patient’s ability to moveAssess muscle tone, strengthAssess joint movement and positioning

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions1. Position properly to prevent contracturesPlace trochanter roll from the iliac crest to

the midthigh to prevent EXTERNAL rotationPlace patient on wheelchair 90 degrees with

the foot resting flat on the floor/foot restPlace foot board or high-heeled shoes to

prevent foot drop

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions2. Maintain muscle strength and joint

mobilityPerform passive ROMEPerform assistive ROMEPerform active ROMEMove the joints three times TID

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions

3. Promote independent mobilityWarn patient of the orthostatic

hypotension when suddenly standing upright

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions

4. Assist patient with transferAssess patient’s ability to participatePosition yourself in front of the patientLock the wheelchair or the bed wheelUse devices such as transfer boards,

sliding boards, trapeze and sheets

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions4. Assist patient with transferIn 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 IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions5. Assist patient to prepare for

ambulationExercise such as quadriceps setting,

gluteal setting and arm push upsUse rubber ball for hand exercise

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions6. Assist patient in crutch ambulation

Measure correct crutch lengthLYING DOWNMeasure from the Anterior Axillary Fold to

the HEEL of the foot then:– Add 1 inch (Kozier)– Add 2 inches (Brunner and Suddarth)

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions6. Assist patient in crutch ambulationMeasure correct crutch lengthSTANDING (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 firstMeasure 2 inches below the axilla to the

second mark

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions6. Assist patient in crutch ambulationMeasure correct crutch lengthSTANDING (Kozier)Make sure that the shoulder-rest of the

crutch is at least 1- 2 inches below the axilla

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions6. Assist patient in crutch ambulation

Measure correct crutch lengthUtilizing the patient’s HEIGHTHeight MINUS 40 cm or 16 inches

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions 6. Assist patient in crutch

ambulation

Measure correct crutch length Hand piece should allow 20-30

degrees elbow flexion

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing 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

GAITGAIT

4-point gait4-point gait

Safest gaitRequires weight bearing on both legsMove RIGHT crutch ahead (6 inches)Move LEFT foot forward at the level of

the RIGHT crutchMove the LEFT crutch forwardMove the RIGHT foot forward

3-point gait3-point gait

Requires weight bearing on the UNAFECTED leg

Move BOTH crutches and the WEAKER LEG forward

Move the STRONGER leg forward

2-point gait2-point gait

Faster than 4-pointRequires more balancePartial bearing on BOTH legsMove the LEFT crutch and RIGHT foot

FORWARD togetherMove the RIGHT crutch and LEFT foot

forward together

Swing-to gaitSwing-to gait

Usually used by client with paralysis of both legs

Prolonged use results in atrophy of unused muscle

Move BOTH crutches togetherLift body weight by the arms and swing to

the crutches (at the level)

Swing-through gaitSwing-through gait

Move BOTH crutches togetherLift body weight by the arms and swing

forward, ahead of the crutches (beyond the level)

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions6. Assist patient in ambulation with a walker Correct height of the walker must allow a 20-30

degrees of elbow flexion

IMPAIRED PHYSICAL IMPAIRED PHYSICAL MOBILITYMOBILITY

Nursing InterventionsNursing Interventions6. 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 integrityImpaired Skin integrity

Pressure ulcersAre 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 soresPressure sores

Impaired Skin integrityImpaired Skin integrity

INITIAL SIGN OF PRESSURE ULCER:

ERYTHEMA or redness of the skin that DOES NOT blanch

Impaired Skin integrityImpaired Skin integrity

Weight bearing Bony prominences1. Sacrum and cocygeal area2. Ischial tuberosity3. Greater trochanter4. Heel and malleolus5. Tibia and fibula6. Scapula and elbow

Pressure areasPressure areas

Risk Factors for pressure ulcersRisk Factors for pressure ulcers

1. Patients with sensory deficits2. Decreased tissue perfusion3. Decreased nutritional status4. Friction and shearing forces5. Increased moisture and edema

Pressure ulcer stagesPressure 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 InterventionsNursing Interventions

RELIEVE THE PRESSURETurn and reposition every 1-2 Hours

Encourage weight shifting actively, every 15 minutes

Nursing InterventionsNursing Interventions

POSITION PATIENT PROPERLYFollow the recommended sequenceLateral prone supine lateral

Position patient with the bed elevated at NO MORE THAN 30 degrees

Utilize the bridging technique

Nursing InterventionsNursing Interventions

UTILIZE PRESSURE RELIEVING DEVICES

Use floatation padsUse air, water or foam mattressesOscillating and kinetic bed

Nursing InterventionsNursing Interventions

IMPROVE MOBILITYActive and passive exercises

Nursing InterventionsNursing Interventions

IMPROVE TISSUE PERFUSIONExercise and repositioning are the most

important activities

AVOID MASSAGE ON THE REDDENED AREAS

Nursing InterventionsNursing Interventions

IMPROVE NUTRITIONAL STATUSHIGH proteinHIGH vitamin C dietMeasure body weightAssess hemoglobin and albumin

Nursing InterventionsNursing Interventions

REDUCE FRICTION AND SHEARLift and not drag patientPrevent the presence of wrinkles and

creases on bed sheets

Nursing InterventionsNursing Interventions

REDUCE IRRITATING MOISTUREAdhere to a meticulous skin carePromptly clean and dry the soiled areasUse mild soap and waterPat dry and not rubLotion may be appliedAVOID powders (cause dryness)

Nursing InterventionsNursing Interventions

PROMOTE WOUND HEALING

Dictum: Remove the pressure

Nursing InterventionsNursing Interventions

PROMOTE WOUND HEALINGStage 1

Remove pressureReposition Q 2Never massage the area

Nursing InterventionsNursing Interventions

PROMOTE WOUND HEALINGStage 2

Clean with sterile SALINE onlyAntiseptic solutions may damage healthy

regenerating tissue and delay healingWet saline dressings are helpful

Nursing InterventionsNursing InterventionsPROMOTE WOUND HEALINGStage 3 and 4

Necrotic tissues are debridedAdminister analgesics before cleansingDo a mechanical flushing with saline solutionTopical ointments may be applied UNTIL

granulation tissue appears then only saline irrigation is recommended