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Wednesday, October 17, 2007

Nursing Rehabilitation :: Fundamentals Of Nursing :: Review For Nursing Licensure Examination

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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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