Angela Thompson v. Parkwood Skilled Nursing and Rehabilitation
Nursing Rehabilitation
Transcript of 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
Nursing Interventions
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
Nursing Interventions
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
Measure correct crutch length
Utilizing the patients HEIGHT
Height M INUS 40 cm or 16 inches
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IMPAIRED PHYSICAL
MOBILITY
Nursing Interventions
6. Assist patient in crutch
ambulation
Measure correct crutch length
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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Impaired Skin integrity
I NI TI AL SIGN OF PRESSURE ULCER:
ERYTHEMA or redness of the skin that
DOES NOT blanch
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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
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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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Nursing Interventions
RELIEVE THE PRESSURE
Turn and reposition every 1-2 Hours
Encourage weight shifting actively, every
15 minutes
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Nursing Interventions
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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Nursing Interventions
UTILIZE PRESSURE RELIEVING
DEVICES
Use floatation pads
Use air, water or foam mattresses
Oscillating and kinetic bed
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Nursing Interventions
IMPROVE MOBILITY
Active and passive exercises
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Nursing Interventions
IMPROVE TISSUE PERFUSION
Exercise and repositioning are the most
important activities
AVOID MASSAGE ON THE REDDENED
AREAS
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Nursing Interventions
IMPROVE NUTRITIONAL STATUS
HIGH protein
HIGH vitamin C diet
Measure body weight
Assess hemoglobin and albumin
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Nursing Interventions
REDUCE FRICTION AND SHEAR
Lift and not drag patient
Prevent the presence of wrinkles and
creases on bed sheets
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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)
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Nursing Interventions
PROMOTE WOUND HEALING
Dictum: Remove the pressure
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Nursing Interventions
PROMOTE WOUND HEALING
Stage 1
Remove pressure
Reposition Q 2
Never massage the area
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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
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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 salineirrigation is recommended