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Review For Nursing Licensure Examination :: Fundamentals Of Nursing :: Nursing Rehabilitation Slide Transcript
Slide 1: Rehabilitation Nursing Nurse Licensure Examination Review
Slide 2: 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
Slide 3: DISABILITY Restriction or lack of ABILITY to PERFORM activities in a NORMAL manner
Slide 4: IMPAIRMENT Loss or ABNORMALITY of psychological, physiological and anatomic structure and FUNCTION
Slide 5: Focus of Rehabilitation Maximizing the remaining capabilities of the patient
Slide 6: Initiation of Rehabilitation At the time of ADMISSION
Slide 7: NURSING INTERVENTIONS 1. Self care deficits 2. Impaired physical mobility 3. Impaired skin integrity 4. Altered elimination pattern
Slide 8: SELF-CARE DEFICITS Assess the ability of the patient to perform ADLs (activities of daily living) Bathing Grooming Toileting Dressing Feeding
Slide 9: 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
Slide 10: Self-care deficits: Interventions 5. Monitor frustrations and tolerance 6. Assist in accepting self-care dependence
Slide 11: IMPAIRED PHYSICAL MOBILITY Complications of IMMOBILITY 1. Contractures 2. Foot drop 3. DVT 4. Hypostatic pneumonia 5. Pressure ulcers
Slide 12: IMPAIRED PHYSICAL MOBILITY Complications of IMMOBILITY 6. muscle atrophy 7. osteoporosis 8. dependent edema 9. urine stasis 10. constipation
Slide 13: IMPAIRED PHYSICAL MOBILITY ASSESSMENT Assess patient’s ability to move Assess muscle tone, strength Assess joint movement and positioning
Slide 14: 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
Slide 15: 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
Slide 16: IMPAIRED PHYSICAL MOBILITY Nursing Interventions 3. Promote independent mobility Warn patient of the orthostatic hypotension when suddenly standing upright
Slide 17: 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
Slide 18: 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
Slide 19: 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
Slide 20: 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)
Slide 21: 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
Slide 22: 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
Slide 23: 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
Slide 24: IMPAIRED PHYSICAL MOBILITY Nursing Interventions 6. Assist patient in crutch ambulation Measure correct crutch length Hand piece should allow 20-30 degrees elbow flexion
Slide 25: 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
Slide 26: GAIT
Slide 27: 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
Slide 28: 3-point gait Requiresweight bearing on the UNAFECTED leg Move BOTH crutches and the WEAKER LEG forward Move the STRONGER leg forward
Slide 29: 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
Slide 30: 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)
Slide 31: Swing-through gait Move BOTH crutches together Lift body weight by the arms and swing forward, ahead of the crutches (beyond the level)
Slide 32: 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
Slide 33: 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
Slide 35: 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
Slide 36: Pressure sores
Slide 37: Impaired Skin integrity INITIAL SIGN OF PRESSURE ULCER: ERYTHEMA or redness of the skin that DOES NOT blanch
Slide 38: 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
Slide 39: Pressure areas
Slide 40: 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
Slide 41: 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
Slide 44: Nursing Interventions RELIEVE THE PRESSURE Turn and reposition every 1-2 Hours Encourage weight shifting actively, every 15 minutes
Slide 45: 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
Slide 46: Nursing Interventions UTILIZE PRESSURE RELIEVING DEVICES Use floatation pads Use air, water or foam mattresses Oscillating and kinetic bed
Slide 47: Nursing Interventions IMPROVE MOBILITY Active and passive exercises
Slide 48: Nursing Interventions IMPROVE TISSUE PERFUSION Exercise and repositioning are the most important activities AVOID MASSAGE ON THE REDDENED AREAS
Slide 49: Nursing Interventions IMPROVE NUTRITIONAL STATUS HIGH protein HIGH vitamin C diet Measure body weight Assess hemoglobin and albumin
Slide 50: Nursing Interventions REDUCE FRICTION AND SHEAR Lift and not drag patient Prevent the presence of wrinkles and creases on bed sheets
Slide 51: 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)
Slide 52: Nursing Interventions PROMOTE WOUND HEALING Dictum: Remove the pressure
Slide 53: Nursing Interventions PROMOTE WOUND HEALING Stage 1 Remove pressure Reposition Q 2 Never massage the area
Slide 54: 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
Slide 55: 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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