Nursing Rehabilitation

8/14/2019 Nursing Rehabilitation

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Rehabilitation Nursing

A Review of Common Concepts


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Rehabilitation

A dynamic, health oriented process that

assists an ill person or a disabled person

to achieve the greatest possible level ofphysical, mental, spiritual, social and

economic functions

Emphasizes INDEPENDENCEABILITIES not disabilities


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DISABILITY

Restriction or lack of ABI L I TY to

PERFORM activities in aNORMAL manner


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IMPAIRMENT

Loss or ABNORMALITY of

psychological, physiologicaland anatomic structure and

FUNCTION


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Focus of Rehabilitation

Maximizing the remaining capabilities of

the patient

The rehabilitation process helps the

patient achieve an acceptable quality of

life with dignity and independence


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Initiation of Rehabilitation

At the time of ADMISSION


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NURSING INTERVENTIONS

1. Self care deficits

2. Impaired physical mobility3. Impaired skin integrity

4. Altered elimination pattern


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SELF-CARE DEFICITS

Assess the ability of the patient to

perform ADLs (activities of daily living)

Bathing

Grooming

Toileting

Dressing

Feeding


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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


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Self-care deficits: Interventions

5. Monitor frustrations and

tolerance6. Assist in accepting self-care

dependence


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IMPAIRED PHYSICAL

MOBILITYComplications of IMMOBILITY

1. Contractures

2. Foot drop

3. DVT

4. Hypostatic pneumonia 5. Pressure ulcers


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IMPAIRED PHYSICAL

MOBILITYComplications of IMMOBILITY

6. muscle atrophy

7. osteoporosis

8. dependent edema

9. urine stasis 10. constipation


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IMPAIRED PHYSICAL

MOBILITYASSESSMENT

Assess patients ability to move

Assess muscle tone, strength

Assess joint movement and positioning


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions1. Position properly to prevent contractures

Place trochanter roll from the iliac crest to

the midthigh to prevent EXTERNALrotation

Place patient on wheelchair 90 degrees

with the foot resting flat on the floor/footrest

Place foot board or high-heeled shoes to

prevent foot drop


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions2. Maintain muscle strength and joint

mobility

Perform passive ROME

Perform assistive ROME

Perform active ROME

Move the joints three times TID


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions

3. Promote independent mobility

Warn patient of the orthostatic

hypotension when suddenly standing

upright


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IMPAIRED PHYSICAL

MOBILITY


4. 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


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions4. 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


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions5. Assist patient to prepare for

ambulation

Exercise such as quadriceps setting,

gluteal setting and arm push ups

Use rubber ball for hand exercise


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IMPAIRED PHYSICAL

MOBILITY


6. Assist patient in crutch ambulation

Measure correct crutch length LYING DOWN

Measure from the Anter ior Axi l lary Fold to

the HEEL of the foot then:

Add 1 inch (Kozier)

Add 2 inches (Brunner and Suddarth)


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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 sidefrom the tip of the toe (first mark)

6 inches is marked (second mark) aheadfrom the f irst

Measure 2 inches below the axi l la to the

second mark


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions 6. Assist patient in crutch ambulation


Utilizing the patients HEIGHT

Height M INUS 40 cm or 16 inches


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IMPAIRED PHYSICAL

MOBILITY


6. Assist patient in crutch

ambulation


Hand piece should allow 20-30

degrees elbow flexion


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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


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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


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3-point gait

Requi res weight bearing on the

UNAFECTED leg

Move BOTH crutches and the WEAKERLEGforward

Move the STRONGER leg forward


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Swing-to gait

Usually used by client with paralysis of

both legs

Prolonged use results in atrophy ofunused muscle

Move BOTH crutches together

L ift body weight by the arms and swing to

the crutches (at the level)


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Swing-through gait

Move BOTH crutches together

Lift body weight by the arms and swing

forward, ahead of the crutches (beyondthe level)


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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


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IMPAIRED PHYSICAL

MOBILITY

Nursing Interventions6. Assist patient in ambulation with a cane

Correct cane measurement:

With elbow flexion of 30 degrees, measure

the length f rom the HAND to 6 inches lateral

to the tip of the 5thtoe


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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

P


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Pressure sores


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I NI TI AL SIGN OF PRESSURE ULCER:

ERYTHEMA or redness of the skin that

DOES NOT blanch


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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


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Pressure areas


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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


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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


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RELIEVE THE PRESSURE

Turn and reposition every 1-2 Hours

Encourage weight shifting actively, every

15 minutes


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POSITION PATIENT PROPERLY

Follow the recommended sequence

Lateralpronesupinelateral

Position patient wi th the bed elevated at

NO MORE THAN 30 degrees

Utilize the bridging technique


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UTILIZE PRESSURE RELIEVING

DEVICES

Use floatation pads

Use air, water or foam mattresses

Oscillating and kinetic bed


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IMPROVE MOBILITY

Active and passive exercises


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IMPROVE TISSUE PERFUSION

Exercise and repositioning are the most

important activities

AVOID MASSAGE ON THE REDDENED

AREAS


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IMPROVE NUTRITIONAL STATUS

HIGH protein

HIGH vitamin C diet

Measure body weight

Assess hemoglobin and albumin


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REDUCE FRICTION AND SHEAR

Lift and not drag patient

Prevent the presence of wrinkles and

creases on bed sheets


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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)


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PROMOTE WOUND HEALING

Dictum: Remove the pressure


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Stage 1

Remove pressure

Reposition Q 2

Never massage the area


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Stage 2

Clean with sterile SALINE only

Antiseptic solutions may damage healthy

regenerating tissue and delay healing

Wet saline dressings are helpful


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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 salineirrigation is recommended

Nursing Rehabilitation

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