Med surge chapter 10 principles of rehabilitation

What level of albumin is considered risk for pressure ulcer

3g/dl

Continuing and transitional care

A home care or transitional care nurse may visit the patient prior to discharge, interview the patient and the family, and review the ADL sheet to learn which activities the patient can perform. This helps to ensure that continuity of care is provided and that the patient does not regress yet maintains the independence gained while in the hospital or rehabilitation setting. The family may need to purchase, borrow, or improvise needed equipment, such as safety rails, a raised toilet seat or commode, or a tub bench. Ramps may need to be built or doorways widened to allow full access. Family members are taught how to use equipment and are given a copy of the equipment manufacturer's instruction booklet, the names of resource people, lists of equipment-related supplies, and locations where they may be obtained. A written summary of the care plan is included in family education. The patient and family members are reminded about the importance of routine health screening and other health promotion strategies. A network of support services and communication systems may be required to enhance opportunities for independent living. The nurse uses collaborative, administrative skills to coordinate these activities and pull together the network of care. The nurse also provides skilled care, initiates additional referrals when indicated, and serves as a patient advocate and counselor when obstacles are encountered. The nurse continues to reinforce prior patient education and helps the patient to set and achieve attainable goals. The degree to which the patient adapts to the home and community environment depends on the confidence and self-esteem developed during the rehabilitation process and on the acceptance, support, and reactions of family members, employers, and community members. There is a growing trend toward independent living by people with severe disabilities, either alone or in groups that share resources. Preparation for independent living should include training in managing a household and working with personal care attendants as well as training in mobility. The goal is integration into the community—living and working in the community with accessible housing, employment, public buildings, transportation, and recreation. State rehabilitation administration agencies provide services to assist people with disabilities in obtaining the help they need to engage in gainful employment. These services include diagnostic, medical, and mental health services. Counseling, training, placement, and follow-up services are available to help people with disabilities select and obtain jobs. If the patient is transferred to a long-term care facility, the transition is planned to promote continued progress. Independence gained continues to be supported, and progress is fostered. Adjustment to the facility is promoted through communication. Family members are encouraged to visit, to be involved, and to take the patient home on weekends and holidays if possible. (Hinkle 190) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Areas of specialty in rehabilitation

Although rehabilitation must be a component of every patient's care, specialty rehabilitation programs have been established in general hospitals, free-standing rehabilitation hospitals, and outpatient facilities. The Commission for the Accreditation of Rehabilitation Facilities (CARF) sets and promotes quality standards for these programs. CARF also offers a consultative accreditation and continuous improvement service for rehabilitation facilities in North and South America, Europe, Asia, and Africa (see link to CARF Web site in chapter resources). Some of these programs are described below: Stroke recovery programs and traumatic brain injury rehabilitation emphasize cognitive remediation, helping patients compensate for memory, perceptual, judgment, and safety deficits as well as teaching self-care and mobility skills. Other goals include helping patients swallow food safely and communicate effectively. Neurologic disorders treated in addition to stroke and brain injury include multiple sclerosis, Parkinson disease, amyotrophic lateral sclerosis, and nervous system tumors. Spinal cord injury rehabilitation programs promote understanding of the effects and complications of spinal cord injury (SCI); neurogenic bowel and bladder management; sexuality and fertility enhancement; self-care, including prevention of skin breakdown; bed mobility and transfers; and driving with adaptive equipment. The programs also focus on vocational assessment, training, and reentry into employment and the community. Model Spinal Cord Injury Centers designated by the National Institute of Disability Research and Rehabilitation (NIDRR) and SCI rehabilitation systems are operated by individual states. Orthopedic rehabilitation programs provide comprehensive services to patients with traumatic or nontraumatic amputation, patients undergoing joint replacements, and patients with arthritis. Independence with a prosthesis or new joint is a major goal of these programs. Other goals include pain management, energy conservation, and joint protection. Cardiac rehabilitation for patients who have had myocardial infarction begins during hospitalization and continues on an outpatient basis. Emphasis is placed on monitored, progressive exercise; nutritional counseling; stress management; sexuality; and risk reduction. Pulmonary rehabilitation programs may be appropriate for patients with restrictive or chronic obstructive pulmonary disease or ventilator dependency. Respiratory therapists help patients achieve more effective breathing patterns. The programs also teach energy conservation techniques, self-medication, and home ventilator management. Comprehensive pain management programs are available for people with chronic pain, especially low back pain. These programs focus on alternative pain treatment modalities, exercise, supportive counseling, and vocational evaluation. Comprehensive burn rehabilitation programs may serve as step-down units from intensive care burn units. Although rehabilitation strategies are implemented immediately in acute care, a program focused on progressive joint mobility, self-care, and ongoing counseling is imperative for burn patients. Pediatric rehabilitation programs meet the needs of children with developmental and acquired disabilities, including cerebral palsy, spina bifida, traumatic brain injuries, and spinal cord injuries. (Hinkle 166) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Assessment of functional ability

Comprehensive assessment of functional capacity is the basis for developing a rehabilitation program. Functional capacity is a person's ability to perform ADLs and instrumental activities of daily living. Activities of daily living (ADLs) are those self-care activities that the patient must accomplish each day to meet personal needs; they include personal hygiene/bathing, dressing/grooming, feeding, and toileting. Many patients cannot perform such activities easily. Instrumental activities of daily living (IADLs) include those complex skills needed for independent living, including meal preparation, grocery shopping, household management, finances, and transportation. The nurse observes the patient performing specific activities (e.g., eating, dressing) and notes the degree of independence; the time taken; the patient's mobility, coordination, and endurance; and the amount of assistance required. The nurse also carefully assesses joint motion, muscle strength, cardiovascular reserve, and neurologic function, because functional ability depends on these factors as well. Observations are recorded on a functional assessment tool. These tools provide a way to standardize assessment parameters and include a scale or score against which improvements may be measured. They also clearly communicate the patient's level of functioning to all members of the rehabilitation team. Rehabilitation staff members use these tools to provide an initial assessment of the patient's abilities and to monitor the patient's progress in achieving independence. One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (FIM™) (Keith, Granger, Hamilton, et al., 1987). The FIM™ is a minimum data set, measuring 18 self-care items including eating, bathing, grooming, dressing upper body, dressing lower body, toileting, bladder management, and bowel management. The FIM™ addresses transfers and the ability to ambulate and climb stairs and also includes communication and social cognition items. Scoring is based on a seven-point scale, with items used to assess the patient's level of independence. The Alpha FIM™, a short version of the FIM™, is used frequently within 72 hours of admission in acute care settings to measure functional independence and the amount of assistance the patient needs to perform ADLs. Although there are many disease-specific tools used to assess the patient's functional ability, some frequently used generic measures (Christakou, Papadopoulos, Patsaki, et al., 2013) include the following: The PULSES profile (Granger, Albrecht, & Hamilton, 1979) is used to assess physical condition (e.g., health/illness status), upper extremity functions (e.g., eating, bathing), lower extremity functions (e.g., transfer, ambulation), sensory function (e.g., vision, hearing, speech), bowel and bladder function (i.e., control of bowel or bladder), and situational factors (e.g., social and financial support). Each of these areas is rated on a scale from one (independent) to four (greatest dependency). The Barthel Index (Mahoney & Barthel, 1965) is used to measure the patient's level of independence in ADLs, continence, toileting, transfers, and ambulation (or wheelchair mobility). This scale does not address communicative or cognitive abilities. The Patient Evaluation Conference System (PECS) (Harvey, Hollis, & Jellinek, 1981), which contains 15 categories, is a comprehensive assessment scale that includes such areas as medications, pain, nutrition, use of assistive devices, psychological status, vocation, and recreation. The Disability Rating Scale (DRS) is a measure of impairment, disability, and handicap and is intended to assess general functional changes over the course of recovery (Wright, 2011). A detailed functional evaluation of secondary conditions related to the patient's disability, such as muscle atrophy and deconditioning, skin integrity, bowel and bladder control, and sexual function, together with residual strengths unaffected by disease or disability, is necessary. In addition, the nurse assesses the patient's physical, mental, emotional, spiritual, social, and economic status, as well as cultural and familial environment. These elements may provide a context to the functional findings and influence the rehabilitation plan. For example, the patient's perception of what it means to have a disability and the implications that this might have on familial and social roles can influence the rehabilitation process. (Hinkle 167) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

CARF

Promotes and sets quality standards for rehabilitation programs and proves consultative accreditation and continuous education programs

Nursing interventions elimination

PROMOTING URINARY CONTINENCE After the nature of the urinary incontinence has been identified, a plan of nursing care is developed based on an analysis of the assessment data. Various approaches to promote urinary continence have been developed (Roe, Flanagan, & Maden, 2015). Most approaches attempt to condition the body to control urination or to minimize the occurrence of unscheduled urination. Selection of the approach depends on the cause and type of the incontinence. For the program to be successful, participation by the patient and a desire to avoid incontinence episodes are crucial; an optimistic attitude with positive feedback for even slight gains is essential for success. Accurate recording of intake and output and of the patient's response to selected strategies is essential for evaluation. At no time should the fluid intake be restricted to decrease the frequency of urination. Sufficient fluid intake (2,000 to 3,000 mL per day, according to patient needs) must be ensured. To optimize the likelihood of voiding as scheduled, measured amounts of fluids may be given about 30 minutes before voiding attempts. In addition, most of the fluids should be consumed before evening to minimize the need to void frequently during the night. (Hinkle 186-187) goal of bladder training is to restore the bladder to normal function. Bladder training can be used with cognitively intact patients experiencing urge incontinence. A voiding and toileting schedule is developed based on an analysis of the assessment data. The schedule specifies times for the patient to try to empty the bladder using a bedpan, toilet, or commode. Privacy should be provided during voiding efforts. The interval between voiding times in the early phase of the bladder training period is short (90 to 120 minutes). The patient is encouraged not to void until the specified voiding time. Voiding success and episodes of incontinence are recorded. As the patient's bladder capacity and control increase, the interval is lengthened. Usually, there is a temporal relationship between drinking, eating, exercising, and voiding. Alert patients can participate in recording intake, activity, and voiding and can plan the schedule to achieve maximum continence. Barrier-free access to the toilet and modification of clothing can help patients with functional incontinence achieve self-care in toileting and continence. Habit training is used to try to keep patients dry by strict adherence to a toileting schedule and may be successful with stress, urge, or functional incontinence. If the patient is confused, caregivers take the patient to the toilet according to the schedule before involuntary voiding occurs. Simple cuing and consistency promote success. Periods of continence and successful voiding are positively reinforced. Biofeedback is a system through which patients learn to consciously contract urinary sphincters and control voiding cues. Cognitively intact patients who have stress or urge incontinence may gain bladder control through biofeedback. Pelvic floor exercises (Kegel exercises) strengthen the pubococcygeus muscle. The patient is instructed to tighten the pelvic floor muscles for 4 seconds 10 times, and this is repeated 4 to 6 times a day. Stopping and starting the stream during urination is recommended to increase control. Daily practice is essential. These exercises are helpful for cognitively intact women who experience stress incontinence. Suprapubic tapping or stroking of the inner thigh may produce voiding by stimulating the voiding reflex arc in patients with reflex incontinence. However, this method is not always effective, owing to a lack of detrusor sphincter muscle coordination. As the bladder reflexively contracts to expel urine, the bladder sphincter reflexively closes, producing a high residual urine volume and an increased incidence of urinary tract infection. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence attributed to an overdistended bladder. The nurse emphasizes regular emptying of the bladder rather than sterility. Patients with disabilities may reuse and clean catheters with bleach or hydrogen peroxide solutions or soap and water and may use a microwave oven to sterilize catheters. Aseptic intermittent catheterization technique is required in health care institutions because of the potential for bladder infection from resistant organisms. Intermittent self-catheterization may be difficult for patients with limited mobility, dexterity, or vision; however, family members can be taught the procedure. Self-catheterization is also particularly pertinent for patients with SCI, because most of these patients do not have voluntary control of urination. Even those patients with spinal cord injuries who can voluntarily void should measure their residual urine (the amount of urine that remains in the bladder after voluntary or involuntary voiding) by self-catheterization. Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections associated with their use. Short-term use may be needed during treatment of severe skin breakdown due to continued incontinence. Patients with disabilities who cannot perform intermittent self-catheterization may elect to use suprapubic catheters for long-term bladder management. Suprapubic catheters are easier to maintain than indwelling catheters. External catheters (condom catheters) and leg bags to collect spontaneous voidings are useful for male patients with reflex or total incontinence. The appropriate design and size must be chosen for maximal success, and the patient or caregiver must be taught how to apply the condom catheter and how to provide daily hygiene, including skin inspection. Instruction on emptying the leg bag must also be provided, and modifications can be made for patients with limited hand dexterity. Incontinence pads (briefs) may be useful at times for patients with stress or total incontinence to protect clothing but should be avoided whenever possible. Incontinence pads only manage, rather than solve, the incontinence problem. In addition, they have a negative psychological effect on patients, because many people think of the pads as diapers. Every effort should be made to reduce the incidence of incontinence episodes through the other methods that have been described. When incontinence pads are used, they should wick moisture away from the body to minimize contact of moisture and excreta with the skin. Wet incontinence pads must be changed promptly, the skin cleansed, and a moisture barrier applied to protect the skin. It is important for the patient's self-esteem to avoid use of the term diapers. PROMOTING BOWEL CONTINENCE The goals of a bowel training program are to develop regular bowel habits and to prevent uninhibited bowel elimination. Regular, complete emptying of the lower bowel results in bowel continence. A bowel training program takes advantage of the patient's natural reflexes. Regularity, timing, nutrition and fluids, exercise, as well as correct positioning promote predictable defecation (Hotouras, Ribas, Allison, et al., 2014). The nurse records defecation time, character of stool, nutritional intake, cognitive abilities, and functional self-care toileting abilities for 5 to 7 days. Analysis of this record is helpful when designing a bowel program for patients with fecal incontinence. Consistency in implementing the plan is essential. A regular time for defecation is established, and attempts at evacuation should be made within 15 minutes of the designated time daily. Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation. However, if the patient had a previously established habit pattern at a different time of day, it should be followed. The anorectal reflex may be stimulated by a rectal suppository (e.g., glycerin) or by mechanical stimulation (e.g., digital stimulation with a lubricated gloved finger or anal dilator). Mechanical stimulation should be used only in patients with a disability who have no voluntary motor function and no sensation as a result of injuries above the sacral segments of the spinal cord, such as patients with quadriplegia, high paraplegia, or severe brain injuries. The technique is not effective in patients who do not have an intact sacral reflex arc (e.g., those with flaccid paralysis). Mechanical stimulation, suppository insertion, or both should be initiated about 30 minutes before the scheduled bowel elimination time, and the interval between stimulation and defecation is noted for subsequent modification of the bowel program. Once the bowel routine is well established, stimulation with a suppository may not be necessary. The patient should assume the normal squatting position and be in a private bathroom for defecation if at all possible, although a padded commode chair or bedside toilet is an alternative. An elevated toilet seat is a simple modification that may make use of the toilet easier for the patient with a disability. Seating time is limited in patients who are at risk for skin breakdown. Bedpans should be avoided. A patient with a disability who cannot sit on a toilet should be positioned on the left side with legs flexed and the head of the bed elevated 30 to 45 degrees to increase intra-abdominal pressure. Protective padding is placed behind the buttocks. When possible, the patient is instructed to bear down and to contract the abdominal muscles. Massaging the abdomen from right to left facilitates movement of feces in the lower tract. PREVENTING CONSTIPATION The record of bowel elimination, character of stool, food and fluid intake, level of activity, bowel sounds, medications, and other assessment data are reviewed to develop the plan of care. Multiple approaches may be used to prevent constipation. The diet should include adequate intake of high-fiber foods (vegetables, fruits, bran) to prevent hard stools and to stimulate peristalsis. Daily fluid intake should be 2 to 3 L unless contraindicated. Drinking prune juice (120 mL) 30 minutes before a meal once daily is helpful in some cases when constipation is a problem. Physical activity and exercise are encouraged, as is self-care in toileting. Patients are encouraged to respond to the natural urge to defecate. Privacy during toileting is provided. Stool softeners, bulk-forming agents, mild stimulants, and suppositories may be prescribed to stimulate defecation and to prevent constipation. Evaluation Expected patient outcomes may include: Demonstrates control of bowel and bladder function Experiences no episodes of incontinence Avoids constipation Achieves independence in toileting Expresses satisfaction with level of bowel and bladder control Achieves urinary continence Uses therapeutic approach that is appropriate to type of incontinence Maintains adequate fluid intake Washes and dries skin after episodes of incontinence Achieves bowel continence Participates in bowel program Verbalizes need for regular time for bowel evacuation Modifies diet to promote continence Uses bowel stimulants as prescribed and needed Experiences relief of constipation Uses high-fiber diet, fluids, and exercise to promote defecation Responds to urge to defecate (Hinkle 187-188) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

The rehabilitation team

Rehabilitation is a creative, dynamic process that requires a team of professionals working together with patients and families. The interdisciplinary team members include health professionals who make unique contributions to the rehabilitation process. Communication, collaboration, understanding of roles, and educational levels of team members are all important considerations in building an effective interdisciplinary team (Papadimitriou & Cott, 2015; Strasser, Burridge, Falconer, et al., 2014; White, Gutierrez, Mclaughlin, et al., 2013). In addition to nurses, members of the rehabilitation team may include physicians, nurse practitioners, physiatrists, physical therapists, occupational therapists, recreational therapists, speech-language therapists, psychologists, psychiatric liaison nurses, spiritual advisors, social workers, vocational counselors, orthotists or prosthetists, and sex counselors. (Hinkle 165) Nurses assume an equal or, depending on the circumstances of the patient, a more critical role than other members of the health care team in the rehabilitation process. The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process (Clark-Wilson, Giles, & Baxter, 2014; Clark & Bassett, 2014). See Chart 10-1 for a Nursing Research Profile on multiprofessional and interdisciplinary teamwork in the rehabilitation setting. Principles that undergird the process of patient-centered rehabilitation-focused care include the following: Rehabilitation encompasses all domains of personhood: physical, psychosocial, emotional, cultural, spiritual, and cognitive (Chang & Johnson, 2013). Rehabilitation is a continuous process. Rehabilitation requires active patient participation. Rehabilitation is goal directed. Rehabilitation requires multiprofessional and interdisciplinary teamwork (Camicia et al., 2014; Dean et al., 2012; Kolar, 2014; O'Sullivan, Schmitz, & Fulk, 2013). In working toward maximizing independence, nurses affirm the patient as an active participant and essential part of the health care delivery process (Bamm et al., 2015b). Indeed, the patient is a key member of the rehabilitation team, the focus of the team's effort, and the one who determines the final outcomes of the rehabilitation process. The patient participates in goal setting, in learning to function using their remaining abilities, and in adjusting to living with disabilities. Nurses also recognize the importance of informal caregivers as support team members in the rehabilitation process circle of care (Hanson, Armstrong, Green, et al., 2012; Knudson-Martin, Huenergardt, Lafontant, et al., 2015; Price & Lau, 2013). The patient's family is also incorporated into the team. Families are dynamic systems; therefore, the disability of one member affects other family members. Only by incorporating the family into the rehabilitation process can the family system adapt to the change in one of its members. The family provides ongoing support, participates in problem solving, and learns to participate in providing ongoing care. The nurse develops a therapeutic and supportive relationship with the patient and family. The nurse emphasizes the patient's assets and strengths, positively reinforcing the patient's efforts to improve self-concept and self-care abilities. During nurse-patient interactions, the nurse actively listens, encourages, and shares patient and family successes. Using the nursing process, the nurse develops a plan of care designed to facilitate rehabilitation, restore and maintain optimal health, and prevent complications (Clarke, 2014). Coping with the disability, fostering self-care, identifying mobility limitations, and managing skin care and bowel and bladder training are areas that frequently require nursing care. The nurse acts as a caregiver, educator, counselor, patient advocate, case manager, and consultant. The nurse is often responsible for coordinating the total rehabilitative plan and collaborating with and coordinating the services provided by all members of the health car (Hinkle 165-166) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Rehabilitation

Rehabilitation is a goal-oriented process that enables people with acute or chronic disorders, including those with physical, mental, or emotional disabilities or impairments; activity limitations; and participation restrictions to (1) identify, reach, and maintain optimal physical, sensory, intellectual, psychological, and/or social functional levels and (2) focus on existing abilities to facilitate independence, self-determination, and social integration (Camicia, Black, Farrell, et al., 2014; Kearney & Cronin, 2014; Miller, 2014). During rehabilitation, patients adjust to disabilities by learning how to use available resources with a focus on overall health promotion (Hyde & Kautz, 2014). In rehabilitation, abilities, not disabilities, are emphasized. Rehabilitation is an integral part of nursing because every major illness or injury carries the threat of disability or impairment, which involves a loss of function or an abnormality in the body structure or function. Rehabilitation nursing is a specialty that focuses on returning patients to optimal functionality through a holistic approach to care. The Association of Rehabilitation Nurses (ARN) has developed an ARN Competency Model for Professional Rehabilitation Nurses with resources (ARN, 2014). The domains in the model (nurse-led interventions, promotion of successful living, leadership and interprofessional care) encompass all competencies needed to promote rehabilitation nursing of persons with disability and/or chronic illness (Vaughn et al., 2016). The principles of rehabilitation are basic to the care of all patients, and rehabilitation efforts should begin during the initial contact with a patient. Ultimately, the goal of rehabilitation nursing is to assist the patient to attain and maintain optimum health as defined by the patient (Bamm, Rosenbaum, Wilkins, et al., 2015a; Chang & Johnson, 2013; Dean, Siegert, & Taylor, 2012). If restoring the debilitated patient's ability to function independently or at a pre-illness or pre-injury level of functioning is not possible, the aims of rehabilitation are to maximize independence and prevent secondary disability as well as to promote a quality of life acceptable to the patient. This includes assessing and treating physical as well as psychological disorders and comorbidities after illness or injury (Craig, Perry, Guest, et al., 2015). Rehabilitation services are required by more people than ever before because of advances in technology that save or prolong the lives of seriously ill and injured patients and patients with disabilities. Increasing numbers of patients who are recovering from serious illnesses or injuries are returning to their homes and communities with ongoing needs. Significant disability caused by war and terrorism also increases the demand for rehabilitation services. All patients, regardless of age, gender, ethnic group, socioeconomic status, or diagnosis, have a right to rehabilitation services. A person is considered to have a disability, such as a restriction in performance or function in everyday activities, if he or she has difficulty talking, hearing, seeing, walking, climbing stairs, lifting or carrying objects, performing activities of daily living (ADLs), doing schoolwork, or working at a job. The disability is considered severe if the person cannot perform one or more activities, receives federal benefits because of an inability to work, uses an assistive device for mobility, or needs help from another person to accomplish basic activities. The purpose of assistive technology is to incorporate devices to improve the functional capabilities of persons with disabilities; these may include any item, piece of equipment, or product system that may be acquired commercially, off the shelf, modified, or customized. Types of assistive technology may include adaptive devices, which help a person with a disability to either modify or change the environment (e.g., an access ramp used in place of steps for a person who uses a wheelchair), and assistive devices, which help a person with a disability perform a given task (e.g., a lap board with pictures used to assist a person who cannot talk to communicate). (See Chapter 9 for further discussion on disabi (Hinkle 164-165) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Educating patients about self care

Significant expenditures of time and resources are necessary to ensure that patients gain the skills and confidence to self-manage their health effectively after discharge from the hospital (Schmidt, 2013). Formal programs provide patients with effective strategies for interpreting and managing disease-specific issues and skills needed for problem solving, as well as building and maintaining self-awareness and self-efficacy. Self-care programs often use multifaceted approaches, including didactic teaching, group sessions, individual learning plans, and Web-based resources. When planning the approach to self-care, the nurse must consider the individual patient's knowledge, experience, social and cultural background, level of formal education, and psychological status. The preparation for self-care must also be spread out over the course of the recovery period, and it must be monitored and updated regularly as the patient masters aspects of self-care. Preparation for self-care is also highly relevant for informal caregivers of patients in rehabilitation. When a patient is discharged from acute care or a rehabilitation facility, informal caregivers, typically family members, often assume the care and support of the patient. Although the most obvious care tasks involve physical care (e.g., personal hygiene, dressing, meal preparation), other elements of the caregiving role include psychosocial support and a commitment to this supportive role. Thus, the nurse must assess the patient's support system (family, friends) well in advance of discharge. The positive attitudes of family and friends toward the patient, their disability, and the return home are important in making a successful transition to home. Not all families can carry out the arduous programs of exercise, physical therapy, and personal care that the patient may need. They may not have the resources or stability to care for family members with a severe disability. The physical, emotional, economic, and energy strains of a disabling condition may overwhelm even a stable family. Members of the rehabilitation team must not judge the family but rather should provide supportive interventions that help the family to attain its highest level of function. The family members need to know as much as possible about the patient's condition and care so that they do not fear the patient's return home. The nurse develops methods to help the patient and family cope with problems that may arise. For example, the nurse may develop an ADL checklist individualized for the patient and family to ensure that the family is proficient in assisting the patient with certain tasks (see Chart 10-8). (Hinkle 188-189) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing process for patient with lack of physical mobility

The Patient With Impaired Physical Mobility Problems commonly associated with immobility include weakened muscles, joint contracture, and deformity. Each joint of the body has a normal range of motion; if the range is limited, the functions of the joint and the muscles that move the joint are impaired, and painful deformities may develop. The nurse must identify patients at risk for such complications. The nurse needs to assess, plan, and intervene to prevent complications of immobility. Another problem frequently seen in rehabilitation nursing is an altered ambulatory/mobility pattern. Patients with disabilities may be either temporarily or permanently unable to walk independently and unaided. The nurse assesses the mobility of the patient and designs care that promotes independent mobility within the prescribed therapeutic limits. If a patient cannot exercise and move their joints through their full range of motion, contractures may develop. A contracture is a shortening of the muscle and tendon that leads to deformity and limits joint mobility. When the contracted joint is moved, the patient experiences pain; in addition, more energy is required to move when joints are contracted. Assessment Mobility may be restricted owing to pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. Assessment of mobility includes positioning, ability to move, muscle strength and tone, joint function, and the prescribed mobility limits. The nurse must collaborate with physical therapists or other team members to assess mobility. During position change, transfer, and ambulation activities, the nurse assesses the patient's abilities, the extent of disability, and residual capacity for physiologic adaptation. The nurse observes for orthostatic hypotension, pallor, diaphoresis, nausea, tachycardia, and fatigue. In addition, the nurse assesses the patient's ability to use various assistive devices that promote mobility. If the patient cannot ambulate without assistance, the nurse assesses the patient's ability to balance, transfer, and use assistive devices (e.g., crutches, walker). Crutch walking requires high energy expenditure and produces considerable cardiovascular stress; therefore, people with reduced exercise capacity, decreased arm strength, and problems with balance because of aging or multiple diseases may be unable to use it. A walker is more stable and may be a better choice for such patients. If the patient uses an orthosis, the nurse monitors the patient for effective use and potential problems associated with its use. Nursing Diagnosis Based on the assessment data, major nursing diagnoses may include the following: Impaired physical mobility Activity intolerance or risk for activity intolerance Risk for injury Risk for disuse syndrome Impaired walking Impaired wheelchair mobility Impaired bed mobility p. 170 p. 171 Planning and Goals Major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. Nursing Interventions POSITIONING TO PREVENT MUSCULOSKELETAL COMPLICATIONS Deformities and contractures can often be prevented by proper positioning. Maintaining correct body alignment when the patient is in bed is essential regardless of the position selected. During each patient contact, the nurse evaluates the patient's position and assists the patient to achieve and maintain proper positioning and alignment. The most common positions that patients assume in bed are supine (dorsal), side-lying (lateral), and prone. The nurse helps the patient assume these positions and uses pillows to support the body in correct alignment. At times, a splint (e.g., wrist or hand splint) may be made by the occupational therapist to support a joint and prevent deformity. The nurse must ensure proper use of the splint and provide skin care. Preventing External Rotation of the Hip. The patient who is in bed for an extended period of time may develop external rotation deformity of the hip because the ball-and-socket joint of the hip tends to rotate outward when the patient lies on their back. A trochanter roll (i.e., a flannel sheet or bath towel folded in thirds lengthwise and rolled toward the patient or a commercially manufactured roll) extending from the crest of the ilium to the midthigh prevents this deformity; with correct placement, it serves as a mechanical wedge under the projection of the greater trochanter. Concept Mastery Alert Abduction moves the body part away from the body; adduction moves the body part toward the body. External rotation occurs as the leg moves outward. To prevent external rotation deformity, the patient's hip should not be abducted or moved away from the body. Preventing Footdrop. Footdrop is a deformity in which the foot is plantar flexed (the ankle bends in the direction of the sole of the foot). If the condition continues without correction, the patient will not be able to hold the foot in a normal position and will be able to walk only on their toes, without touching the ground with the heel of the foot. The deformity is caused by contracture of both the gastrocnemius and soleus muscles. Damage to the peroneal nerve or loss of flexibility of the Achilles tendon may also result in footdrop. To prevent this disabling deformity, the patient is positioned to sit at a 90-degree angle in a wheelchair with their feet on the footrests or flat on the floor. When the patient is supine in bed, padded splints or protective boots are used to keep the patient's feet at right angles to the legs. Frequent skin inspection of the feet must also be performed to determine whether positioning devices have created any unwanted pressure areas. The patient is encouraged to perform the following ankle exercises several times each hour: dorsiflexion and plantar flexion of the feet, flexion and extension (curl and stretch) of the toes, and eversion and inversion of the feet at the ankles. The nurse provides frequent passive range-of-motion exercises if the patient cannot perform active exercises. Quality and Safety Nursing Alert Prolonged bed rest, lack of exercise, incorrect positioning in bed, and the weight of bedding that forces the toes into plantar flexion must be avoided to prevent footdrop. Patients should be encouraged to wear shoes for support and protection to prevent footdrop. MAINTAINING MUSCLE STRENGTH AND JOINT MOBILITY Optimal function depends on the strength of the muscles and joint motion, and active participation in ADLs promotes maintenance of muscle strength and joint mobility. Range-of-motion exercises and specific therapeutic exercises may be included in the nursing plan of care. Performing Range-of-Motion Exercises. Range of motion involves moving a joint through its full range in all appropriate planes (see Chart 10-4). To maintain or increase the motion of a joint, range-of-motion exercises are initiated as soon as the patient's condition permits. The exercises are planned for individual patients to accommodate the wide variation in the degrees of motion that people of varying body builds and age groups can attain. Range-of-motion exercises may be active (performed by the patient under the supervision of the nurse), assisted (with the nurse helping if the patient cannot do the exercise independently), or passive (performed by the nurse). Unless otherwise prescribed, a joint should be moved through its range of motion three times, at least two times a day. The joint to be exercised is supported, the bones above the joint are stabilized, and the body part distal to the joint is moved through the range of motion of the joint. For example, the humerus must be stabilized while the radius and ulna are moved through their range of motion at the elbow joint. (Hinkle) A joint should not be moved beyond its free range of motion; the joint is moved to the point of resistance and stopped at the point of pain. If muscle spasms are present, the joint is moved slowly to the point of resistance. Gentle, steady pressure is then applied until the muscle relaxes, and the motion is continued to the joint's final point of resistance. To perform assisted or passive range-of-motion exercises, the patient must be in a comfortable supine position with the arms at the sides and the knees extended. Good body posture is maintained during the exercises. The nurse also uses good body mechanics during the exercise session. Performing Therapeutic Exercises. Therapeutic exercises are prescribed by the primary provider and performed with the assistance and guidance of the physical therapist or nurse. The patient should have a clear understanding of the goal of the prescribed exercise. Written instructions about the frequency, duration, and number of repetitions, as well as simple line drawings of the exercise, help to ensure adherence to the exercise program. Return demonstration of the exercises also helps the patient and family to follow the instructions correctly. When performed correctly, exercise assists in maintaining and building muscle strength, maintaining joint function, preventing deformity, stimulating circulation, developing endurance, and promoting relaxation. Exercise is also valuable in helping to restore motivation and the well-being of the patient. Weight-bearing exercises may slow the bone loss that occurs with disability. There are five types of exercise: passive, active-assistive, active, resistive, and isometric. The description, purpose, and action of each of these exercises are summarized in Table 10-1. PROMOTING INDEPENDENT MOBILITY When the patient's condition stabilizes, their physical condition permits, and the patient is able to stand, the patient is assisted to sit up on the side of the bed and then to stand. Tolerance of this activity is assessed. Orthostatic (postural) hypotension may develop when the patient assumes a vertical position. Because of inadequate vasomotor reflexes, blood pools in the splanchnic (visceral or intestinal) area and in the legs, resulting in inadequate cerebral circulation. If indicators of orthostatic hypotension (e.g., drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, dizziness) are present, the activity is stopped, and the patient is assisted to a supine position in bed. Some disabling conditions, such as SCI, acute brain injury, and other conditions that require extended periods in the recumbent position, prevent the patient from assuming an upright position at the bedside. Several strategies can be used to help the patient assume a 90-degree sitting position. A reclining wheelchair with elevating leg rests allows a slow and controlled progression from a supine position to a 90-degree sitting position. A tilt table (a board that can be tilted in 10-degree increments from a horizontal to a vertical position) may also be used. The tilt table promotes vasomotor adjustment to positional changes and helps patients with limited standing balance and limited weight-bearing activities avoid the decalcification of bones and low bone mass associated with disuse syndrome and lack of weight-bearing exercise. Physical therapists may use a tilt table for patients who have not been upright owing to illness or disability. Gradual elevation of the head of the bed may help. When getting patients with SCI out of bed, it is important to gradually raise the head of the bed to a 90-degree angle; this may take approximately 10 to 15 minutes. (Hinkle Graduated compression stockings are used to prevent venous stasis. For some patients, a compression garment (leotard) or snug-fitting abdominal binder and elastic compression bandaging of the legs are needed to prevent venous stasis and orthostatic hypotension. When the patient is standing, the feet are protected with a pair of properly fitted shoes. Extended periods of standing are avoided because of venous pooling and pressure on the soles of the feet. The nurse monitors the patient's blood pressure and pulse and observes for signs and symptoms of orthostatic hypotension and cerebral insufficiency (e.g., the patient reports feeling faint and weak), which suggest intolerance of the upright position. If the patient does not tolerate the upright position, the nurse should return the patient to the reclining position and elevate their legs. Assisting Patients With Transfer. A transfer is movement of the patient from one place to another (e.g., bed to chair, chair to commode, wheelchair to tub). As soon as the patient is permitted out of bed, transfer activities are started. The nurse assesses the patient's ability to participate actively in the transfer and determines, in conjunction with occupational therapists or physical therapists, the adaptive equipment required to promote independence and safety. A lightweight wheelchair with brake extensions, removable and detachable armrests, and leg rests minimize structural obstacles during the transfer. Tub seats or benches make transfers in and out of the tub easier and safer. Raised, padded commode seats may also be warranted for patients who must avoid flexing the hips greater than 90 degrees when transferring to a toilet. It is important that the nurse educate the patient about hip precautions (e.g., no adduction past the midline, no flexion greater than 90 degrees, and no internal rotation); abduction pillows can be used to keep the hip in correct alignment if precautions are warranted. It is important that the patient maintains muscle strength and, if possible, performs push-up exercises to strengthen the arm and shoulder extensor muscles. The push-up exercises require the patient to sit upright in bed; a book is placed under each of the patient's hands to provide a hard surface, and the patient is instructed to push down on the book, raising the body. The nurse should encourage the patient to raise and move the body in different directions by means of these push-up exercises. The nurse or physical therapist instructs the patient how to transfer. There are several methods of transferring from the bed to the wheelchair when the patient cannot stand, and the technique chosen should take into account the patient's abilities and disabilities. It is helpful to demonstrate the technique to the patient. If the physical therapist is involved in teaching the patient to transfer, the nurse and physical therapist must collaborate so that consistent instructions are given to the patient. During transfer, the nurse assists and coaches the patient. Figure 10-2 shows weight-bearing and non-weight-bearing transfers. For example, with a weight-bearing transfer from bed to chair, the patient stands up, pivots until his back is opposite the new seat, and sits down. If the patient's muscles are not strong enough to overcome the resistance of body weight, a polished lightweight board (transfer board, sliding board) may be used to bridge the gap between the bed and the chair. The patient slides across on the board with or without assistance from a caregiver. This board may also be used to transfer the patient from the chair to the toilet or bathtub bench. It is important to avoid the effects of shear on the patient's skin while sliding across the board. The nurse should make sure that the patient's fingers do not curl around the edge of the board during the transfer, because the patient's body weight can crush the fingers as he or she moves across the board. Safety is a primary concern during a transfer, and the following guidelines are recommended: Wheelchairs and beds must be locked before transfer begins. Detachable arm- and footrests are removed to make getting in and out of the chair easier. One end of the transfer board is placed under the buttocks and the other end on the surface to which the transfer is being made (e.g., the chair). The patient is instructed to lean forward, push up with his or her hands, and then slide across the board to the other surface. Nurses frequently assist weak and incapacitated patients out of bed. The nurse supports and gently assists the patient during position changes, protecting the patient from injury. The nurse avoids pulling on a weak or paralyzed upper extremity to prevent dislocation of the shoulder. The patient is assisted to move toward the stronger side. In the home setting, getting in and out of bed and performing chair, toilet, and tub transfers are difficult for patients with weak muscles and loss of hip, knee, and ankle motion. A rope attached to the headboard of the bed enables a patient to move toward the center of the bed, and the use of a rope attached to the footboard facilitates getting in and out of bed. The height of a chair can be raised with cushions on the seat or with hollowed-out blocks placed under the chair legs. Grab bars can be attached to the wall near the toilet and tub to provide leverage and stability. Preparing for Ambulation. Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulation— whether with a brace, walker, cane, or crutches—the patient must strengthen the muscles required. Therefore, exercise is the foundation of preparation. The nurse and physical therapist instruct and supervise the patient in these exercises. For ambulation, the quadriceps muscles, which stabilize the knee joint, and the gluteal muscles are strengthened. To perform quadriceps-setting exercises, the patient contracts the quadriceps muscle by attempting to push the popliteal area against the mattress and at the same time raising the heel. The patient maintains the muscle contraction for a count of five and relaxes for a count of five. The exercise is repeated 10 to 15 times hourly. Exercising the quadriceps muscles prevents flexion contractures of the knee. In gluteal setting, the patient contracts or "pinches" the buttocks together for a count of five, relaxes for a count of five; the exercise is repeated 10 to 15 times hourly. If assistive devices (i.e., walker, cane, crutches) will be used, the muscles of the upper extremities are exercised and strengthened. Push-up exercises are especially useful. While in a sitting position, the patient raises the body by pushing the hands against the chair seat or mattress. The patient should be encouraged to do push-up exercises while in a prone position as well. Pull-up exercises done on a trapeze while lifting the body are also effective for conditioning. The patient is taught to raise the arms above the head and then lower them in a slow, rhythmic manner while holding weights. Gradually, the weight is increased. The hands are strengthened by squeezing a rubber ball. Figure 10-2 • Methods of patient transfer from the bed to a wheelchair. The wheelchair is in a locked position. Colored areas indicate non-weight-bearing body parts. A. Weight-bearing transfer from bed to chair. The patient stands up, pivots until his back is opposite the new seat, and sits down. B. (Left) Non-weight-bearing transfer from chair to bed. (Right) With legs braced. C. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weight-bearing transfer, pull-up method. One of the wheelchair arms is removed to make getting in and out of the chair easier. Typically, the physical therapist designs exercises to help the patient develop sitting and standing balance, stability, and coordination needed for ambulation. After sitting and standing balance is achieved, the patient is able to use parallel bars. Under the supervision of the physical therapist, the patient practices shifting weight from side to side, lifting one leg while supporting weight on the other, and then walking between the parallel bars. A patient who is ready to begin ambulation must be fitted with the appropriate assistive device, instructed about the prescribed weight-bearing limits (e.g., non-weight-bearing, partial weight-bearing ambulation), and taught how to use the device safely. Figure 10-3 illustrates some of the more common assistive devices used in rehabilitation settings. The nurse continually assesses the patient for stability and adherence to weight-bearing precautions and protects the patient from falling. The nurse provides contact guarding by holding on to a gait belt that the patient wears around the waist. The patient should wear sturdy, well-fitting shoes and be advised of the dangers of wet or highly polished floors and throw rugs. The patient should also learn how to ambulate on inclines, uneven surfaces, and stairs. AMBULATING WITH AN ASSISTIVE DEVICE: CRUTCHES, A WALKER, OR A CANE Crutches are for partial weight-bearing or non-weight-bearing ambulation. Good balance, adequate cardiovascular reserve, strong upper extremities, and erect posture are essential for crutch walking. Ambulating a functional distance (at least the length of a room or house) or maneuvering stairs on crutches requires significant arm strength, because the arms must bear the patient's weight (see Fig. 10-4). The nurse or physical therapist determines which gait is best (see Chart 10-5). p. 174 p. 175 Figure 10-3 • Mechanical aids to walking. A. Two types of walkers: pick-up and rolling. B. Three types of canes: C-cane, functional cane, and quad cane. A walker provides more support and stability than a cane or crutches do. A pick-up walker is best for patients with poor balance and poor cardiovascular reserve, and a rolling walker, which allows automatic walking, is best for patients who cannot lift. A cane helps the patient walk with balance and support and relieves the pressure on weight-bearing joints by redistributing weight. Before patients can be considered to be independent in walking with crutches, a walker, or a cane, they should learn to sit, stand from sitting, and go up and down stairs using the device. Table 10-2 describes how patients can ambulate and maneuver using each of the three devices and nursing actions to support using assistive devices. Figure 10-4 • For a person walking with crutches, the tripod stance, with crutches out to the sides and in front of the toes, increases stability. ASSISTING PATIENTS WITH AN ORTHOSIS OR PROSTHESIS Orthoses and prostheses are designed to facilitate mobilization and to maximize the patient's quality of life. An orthosis is an external appliance that provides support, prevents or corrects deformities, and improves function. Orthoses include braces, splints, collars, corsets, and supports that are designed and fitted by orthotists or prosthetists. Static orthoses (no moving parts) are used to stabilize joints and prevent contractures. Dynamic orthoses are flexible and are used to improve function by assisting weak muscles. A prosthesis is an artificial body part that may be internal, such as an artificial knee or hip joint, or external, such as an artificial leg or arm. In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely, or if it is adjusted improperly. The nurse instructs the patient to clean and inspect the skin daily, to make sure the brace fits snugly without being too tight, to check that the padding distributes pressure evenly, and to wear a cotton garment without seams between the orthosis and the skin. If the patient has had an amputation, the nurse promotes tissue healing, uses compression dressings to promote residual limb shaping, and minimizes contracture formation. A permanent prosthetic limb cannot be fitted until the tissue has healed completely and the residual limb shape is stable and free from edema. The nurse also helps the patient cope with the emotional issues surrounding loss of a limb and encourages acceptance of the prosthesis. The prosthetist, nurse, and primary provider collaborate to provide instructions related to skin care and care of the prosthesis. Evaluation Expected patient outcomes may include: Demonstrates improved physical mobility Maintains muscle strength and joint mobility Does not develop contractures Participates in exercise program (Hinkle 173-175) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing process impaired skin integrity

The Patient With Impaired Skin Integrity Pressure ulcers are localized areas of necrotic soft tissue that occur when pressure applied to the skin over time is greater than normal capillary closure pressure, which is about 32 mm Hg. Critically ill patients have a lower capillary closure pressure and a greater risk of pressure ulcers. Patients who are prone to pressure ulcers include those confined to bed for long periods, those with motor or sensory dysfunction, and those who experience muscular atrophy and reduction of padding between the overlying skin and the underlying bone (Sullivan & Schoelles, 2013). The Centers for Medicare and Medicaid Services (CMS) has recently implemented an Inpatient Rehabilitation Facility quality reporting measure related to the percentage of residents with new or worsened pressure ulcers. Based on data from the 2011 International Pressure Ulcer Prevalence Survey, the facility prevalence of pressures ulcers was 11.2% among all facilities surveyed (Wang, Niewczyk, DiVita, et al., 2014). As well as significant pain and suffering, the consequences of developing a pressure ulcer include increased morbidity and mortality and higher medical costs and resource use, and lower odds of discharge to the community. The American Nurses Association tracks hospital-acquired pressure ulcers (HAPU) quarterly as part of the National Database of Nursing Quality Indicators® (NDNQI®). Between the years 2004 and 2011, there was a decreasing trend in the HAPU rate overall, with more improvement beginning in 2008 (He, Staggs, Bergquist-Beringer, et al., 2013). This improvement corresponds to the year the Agency for Healthcare Research and Quality (AHRQ) included data on pressure ulcers as a patient safety indicator in the Healthcare Cost and Utilization Project (HCUP) hospital database. Despite this decrease in overall HAPU rates, development of a pressure ulcer still presents a significant patient safety risk, with increased rates of patient death and longer hospital lengths of stays and readmissions (He et al., 2013). The average length of stay for hospitalizations related to pressure ulcers is 13.4 days, with an average treatment cost of nearly $20,000 for each affected patient (He et al., 2013). All possible efforts to prevent skin breakdown must be made because the treatment of pressure ulcers is costly in terms of health care dollars and quality of life for patients at risk. The initial sign of pressure is erythema (redness of the skin) caused by reactive hyperemia, which normally resolves in less than 1 hour. Unrelieved pressure results in tissue ischemia or anoxia. The cutaneous tissues become broken or destroyed, leading to progressive destruction and necrosis of underlying soft tissue, and the resulting pressure ulcer is painful and slow to heal. Assessment Nursing assessment involves identifying and evaluating risk for development of pressure ulcers as well as assessment of the skin. ASSESSMENT OF RISK FACTORS Immobility, impaired sensory perception or cognition, decreased tissue perfusion, decreased nutritional status, friction and shear forces, increased moisture, and age-related skin changes all contribute to the development of pressure ulcers (DiVita, Granger, Goldstein, et al., 2015; García-Fernández, Agreda, Verdú, et al., 2014). Chart 10-6 lists risk factors for pressure ulcers. Scales such as the Braden scale (see Table 10-3) or Norton scale (Norton, McLaren, & Exton-Smith, 1962) may be used to facilitate systematic assessment and quantification of a patient's risk for pressure ulcer, although the nurse should recognize that the reliability of these scales is not well established for all patient populations. Specific nursing actions related to assessing risk include: Evaluate level of mobility. Note safety and assistive devices (e.g., restraints, splints). Assess neurovascular status. Evaluate circulatory status (e.g., peripheral pulses, edema). Note present health problems. Evaluate nutritional and hydration status. Review the results of the patient's laboratory studies, including hematocrit, hemoglobin, electrolytes, albumin, prealbumin, transferrin, and creatinine. Determine presence of incontinence. Review current medications. (Hinkle 178) Immobility. When a person is immobile and inactive, pressure is exerted on the skin and subcutaneous tissue by objects on which the person rests, such as a mattress, chair seat, or cast. The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur and a pressure ulcer results. Weight-bearing bony prominences are most susceptible to pressure ulcer development because they are covered only by skin and small amounts of subcutaneous tissue. Susceptible areas include the sacrum and coccygeal areas, ischial tuberosities (especially in people who sit for prolonged periods), greater trochanter, heel, knee, malleolus, medial condyle of the tibia, fibular head, scapula, and elbow (see Fig. 10-5). Figure 10-5 • Areas susceptible to pressure ulcers. Impaired Sensory Perception or Cognition. Patients with sensory loss, impaired level of consciousness, or paralysis may not be aware of the discomfort associated with prolonged pressure on the skin and therefore may not change their positions to relieve the pressure. This prolonged pressure impedes blood flow, reducing nourishment of the skin and underlying tissues. A pressure ulcer may develop in a short period of time. Decreased Tissue Perfusion. Any condition that reduces the circulation and nourishment of the skin and subcutaneous tissue (altered peripheral tissue perfusion) increases the risk of pressure ulcer development. Patients with diabetes have compromised microcirculation. Similarly, patients with edema have impaired circulation and poor nourishment of the skin tissue. Patients who are obese have large amounts of poorly vascularized adipose tissue, which is susceptible to breakdown. Nutritional Status. Nutritional deficiencies, anemias, and metabolic disorders also contribute to the development of pressure ulcers. Anemia, regardless of its cause, decreases the blood's oxygen-carrying ability and predisposes the patient to pressure ulcers. Poor nutritional status can prolong the inflammatory phase of pressure ulcer healing and can reduce the quality and strength of wound healing (Thomas, 2015). Serum albumin and prealbumin levels are sensitive indicators of protein deficiency. Serum albumin levels of less than 3 g/dL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers. Prealbumin levels are more sensitive indicators of protein status than albumin levels, but they are more costly to assess. The nurse should assess the patient's prealbumin and albumin values and electrolyte panel. Friction and Shear. Mechanical forces also contribute to the development of pressure ulcers. Friction is the force of rubbing two surfaces against one another and is often caused by pulling a patient over a bed sheet (commonly known as sheet burn) or from a poorly fitted prosthetic device. Shear is the result of gravity pushing down on the patient's body and the resistance between the patient and the chair or bed (National Pressure Ulcer Advisory Panel, 2014). When shear occurs, tissue layers slide over one another, blood vessels stretch and twist, and the microcirculation of the skin and subcutaneous tissue is disrupted. Evidence of deep tissue damage may be slow to develop and may present through the development of a sinus tract, which is an area of destroyed tissue that extends from the edge of a wound. The sacrum and heels are most susceptible to the effects of shear. Pressure ulcers from friction and shear occur when the patient slides down in bed (see Fig. 10-6) or when the patient is positioned or moved improperly (e.g., dragged up in bed). Spastic muscles and paralysis increase the patient's vulnerability to pressure ulcers related to friction and shear. Increased Moisture. Prolonged contact with moisture from perspiration, urine, feces, or drainage produces maceration (softening) of the skin. The skin reacts to caustic substances in the excreta or drainage and becomes irritated. Moist, irritated skin is more vulnerable to pressure breakdown. Once the skin breaks, the area is invaded by microorganisms (e.g., streptococci, staphylococci, Pseudomonas aeruginosa, Escherichia coli), and infection occurs. Foul-smelling infectious drainage is present. The lesion may enlarge and allow a continuous loss of serum, which may further deplete the body of essential protein needed for tissue repair and maintenance. The lesion may continue to enlarge and extend deep into the fascia, muscle, and bone, with multiple sinus tracts radiating from the pressure ulcer. With extensive pressure ulcers, life-threatening infections and sepsis may develop, frequently from gram-negative organisms. Figure 10-6 • Mechanical forces contribute to pressure ulcer development. As the person slides down or is improperly pulled up in bed, friction resists this movement. Shear occurs when one layer of tissue slides over another, disrupting microcirculation of skin and subcutaneous tissue. Gerontologic Considerations. In older adults, the normal aging process leads to diminished epidermal thickness, dermal collagen, and tissue elasticity. The skin is drier as a result of diminished sebaceous and sweat gland activity. Cardiovascular changes result in decreased tissue perfusion. Muscles atrophy and bone structures become prominent. Diminished sensory perception and reduced ability to reposition oneself contribute to prolonged pressure on the skin. Therefore, older adults are more susceptible to pressure ulcers, which cause pain, suffering, and reduced quality of life. Bariatric Considerations. In 2014, an international collaborative comprising members from the U.S. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and the PanPacific Pressure Advisory Panel (PPPUAP) released the Prevention and Treatment of Pressure Ulcers; Clinical Practice Guideline (Dunk & Carville, 2015; National Pressure Ulcer Advisory Panel, 2014). These updated guidelines include recommendations for adults who are obese with specific organization-level considerations, recommendations for the bariatric individual, as well as recommendations for bed and equipment selection and repositioning. Please see the NPUAP Web site link at the end of this chapter to review the quick reference guideline. ASSESSMENT OF SKIN AND EXISTING ULCERS In addition to assessing risk, nursing actions to assess skin include: Assess total skin condition at least twice a day. Inspect each pressure site for erythema. Assess areas of erythema for blanching response. Palpate the skin for increased warmth. Inspect for dry skin, moist skin, and breaks in skin. Note drainage and odor. If a pressure ulcer is seen, the nurse documents its size and location and uses a grading system to describe severity and provides a description of the site (see Chart 10-7). The appearance of purulent drainage or foul odor suggests an infection. With an extensive pressure ulcer, deep pockets of infection are often present. Drying and crusting of exudate may be present. Infection of a pressure ulcer may advance to osteomyelitis, pyarthrosis (pus formation within a joint cavity), sepsis, and septic shock. Nursing Diagnosis Based on the assessment data, nursing diagnoses may include the following: Risk for impaired skin integrity Impaired skin integrity related to immobility, decreased sensory perception, decreased tissue perfusion, decreased nutritional status, friction and shear forces, excessive moisture, or advanced age Planning and Goals The major goals may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. Nursing Interventions RELIEVING PRESSURE Frequent changes of position are needed to relieve and redistribute the pressure on the patient's skin and to promote blood flow to the skin and subcutaneous tissues. This can be accomplished by instructing the patient to change position or by turning and repositioning the patient. The patient's family members should be educated about how to position and turn the patient at home to prevent pressure ulcers. Shifting weight allows the blood to flow into the ischemic areas and helps tissues recover from the effects of pressure. Attention should be paid to patient migration (moving down in the bed) in those on bed rest, particularly when the head of the bed is elevated (Wiggermann, Kotowski, Davis, et al., 2015). For patients who spend long periods in a wheelchair, pressure can be relieved by: Push-ups: The patient pushes down on armrests and raises buttocks off the seat of the chair (see Fig. 10-7). One half push-up: The patient repeats the push-up on the right side and then the left, pushing up on one side by pushing down on the armrest. Moving side to side: The patient moves from one side to the other while sitting in the chair. Shifting: The patient bends forward with the head down between the knees (if able) and constantly shifts in the chair. POSITIONING THE PATIENT The degree of ability to move independently—the comfort, fatigue, loss of sensation, overall physical and mental status, and specific disorder—influences plans for changing position. Patients should be positioned laterally, prone, and dorsally in sequence unless a position is not tolerated or is contraindicated. Generally, those who experience discomfort after 30 to 60 minutes of lying prone need to be repositioned. The recumbent position is preferred to the semi-Fowler position because of increased supporting body surface area in this position. (Hinkle 180-181) Patients able to shift their weight every 15 to 20 minutes and move independently may change total position every 2 to 4 hours. Indications for routine repositioning every 2 hours or more frequently include loss of sensation, paralysis, coma, and edema. Figure 10-7 • Wheelchair push-up to prevent ischial pressure ulcers. These push-ups should become an automatic routine (every 15 minutes) for the person with paraplegia. The person should stay up and out of contact with the seat for several seconds. The wheels are kept in the locked position during the exercise. In addition to regular turning, small shifts of body weight, such as repositioning of an ankle, elbow, or shoulder, are necessary. The skin is inspected at each position change and assessed for temperature elevation. If redness or heat is noted or if the patient complains of discomfort, pressure on the area must be relieved. Another way to relieve pressure over bony prominences is the bridging technique, accomplished through the correct positioning of pillows. Just as a bridge is supported on pillars to allow traffic to move underneath, the body can be supported by pillows to allow for space between bony prominences and the mattress. A pillow or commercial heel protector may be used to support the heels off the bed when the patient is supine. Placing pillows superior and inferior to the sacrum relieves sacral pressure. Supporting the patient in a 30-degree side-lying position avoids pressure on the trochanter. In older adult patients, frequent small shifts of body weight may be effective. Placing a small rolled towel or sheepskin under a shoulder or hip allows a return of blood flow to the skin in the area on which the patient is sitting or lying. The towel or sheepskin is moved around the patient's pressure points in a clockwise fashion. A turning schedule can help the family keep track of the patient's turns. USING PRESSURE-RELIEVING DEVICES At times, specialty beds or alternative bed surfaces may be indicated to help relieve the pressure on the skin (Stifter, Yao, Lodhi, et al., 2015). This is particularly important for patients who cannot get out of bed and who are at high risk for pressure ulcer development. These devices are designed to provide support for specific body areas or to distribute pressure evenly. A patient who sits in a wheelchair for prolonged periods should have wheelchair cushions fitted and adjusted on an individualized basis, using pressure measurement techniques as a guide to selection and fitting. The aim is to redistribute pressure away from areas at risk for ulcers; however, no cushion can eliminate excessive pressure completely. The patient should be reminded to shift weight frequently and to rise for a few seconds every 15 minutes while sitting in a chair. Static support devices (e.g., high-density foam, air, or liquid mattress overlays) distribute pressure evenly by bringing more of the patient's body surface into contact with the supporting surface. Gel-type flotation pads and air-fluidized beds reduce pressure. The weight of a body floating on a fluid system is evenly distributed over the entire supporting surface. Therefore, as the body sinks into the fluid, additional surface becomes available for weight bearing, body weight per unit area is decreased, and there is less pressure on the body parts. Soft, moisture-absorbing padding is also useful because the softness and resilience of padding provide for more even distribution of pressure and the dissipation and absorption of moisture, along with freedom from wrinkles and friction. Bony prominences may be protected by gel pads, sheepskin padding, or soft foam rubber beneath the sacrum, the trochanters, heels, elbows, scapulae, and back of the head when there is pressure on these sites. One group of researchers found that sacral pressure was reduced using a liquid-based pad that covers only the sacral area and can be applied on any bed surface (Duetzmann, Forsey, Senft, et al., 2015). Specialized beds are designed to prevent pressure on the skin. Air-fluidized beds allow the patient to float. Dynamic support surfaces, such as low air-loss pockets, alternately inflate and deflate sections to change support pressure for very high risk patients who are critically ill and debilitated (i.e., impaired strength, weakened, injured, disabled) and cannot be repositioned to relieve pressure. Oscillating or kinetic beds change pressure by means of rocking movements of the bed that redistribute the patient's weight and stimulate circulation. These beds may be used with patients who have injuries attributed to multiple trauma. Specialized beds, which are more expensive than mattress overlays, are no more effective at preventing pressure ulcers than the overlays; there is insufficient evidence to support the choice of one specific bed surface over another (Qaseem, Humphrey, Forciea, et al., 2015). IMPROVING MOBILITY The patient is encouraged to remain active and is ambulated whenever possible. When sitting, the patient is reminded to change positions frequently to redistribute weight. Active and passive exercises increase muscular, skin, and vascular tone. For patients at risk for pressure ulcers, turning and exercise schedules are essential, and repositioning must occur around the clock. IMPROVING SENSORY PERCEPTION The nurse helps the patient recognize and compensate for altered sensory perception. Depending on the origin of the alteration (e.g., decreased level of consciousness, spinal cord lesion), specific interventions are selected. Strategies to improve cognition and sensory perception may include stimulating the patient to increase awareness of self in the environment, encouraging the patient to participate in self-care, or supporting the patient's efforts toward active compensation for loss of sensation (e.g., a patient with paraplegia lifting up from the sitting position every 15 minutes). A patient with quadriplegia should be weight shifted every 30 minutes while sitting in a wheelchair. When decreased sensory perception exists, the patient and caregivers are taught to inspect potential pressure areas visually every morning and evening, using a mirror if necessary, for evidence of pressure ulcer development. IMPROVING TISSUE PERFUSION Activity, exercise, and repositioning improve tissue perfusion. Massage of erythematous areas is avoided because damage to the capillaries and deep tissue may occur (National Pressure Ulcer Advisory Panel, 2014). Quality and Safety Nursing Alert The nurse should avoid massaging reddened areas because this may increase the damage to already traumatized skin and tissue. In patients who have evidence of compromised peripheral circulation (e.g., edema), positioning and elevation of the edematous body part to promote venous return and diminish congestion improve tissue perfusion. In addition, the nurse or family must be alert to environmental factors (e.g., wrinkles in sheets, pressure of tubes) that may contribute to pressure on the skin and diminished circulation and remove the source of pressure. IMPROVING NUTRITIONAL STATUS The patient's nutritional status must be adequate, and a positive nitrogen balance must be maintained because pressure ulcers develop more quickly and are more resistant to treatment in patients with nutritional disorders. A high-protein diet with protein supplements may be helpful. Iron preparations may be necessary to raise the hemoglobin concentration so that tissue oxygen levels can be maintained within acceptable limits. Ascorbic acid (vitamin C) is necessary for tissue healing. Other nutrients associated with healthy skin include vitamin A, B vitamins, zinc, and sulfur. With adequate nutrition and hydration, the skin can remain healthy, and damaged tissues can be repaired (Posthauer, Banks, Dorner, et al., 2015; Saha, Smith, Totten, et al., 2013). To assess the patient's nutritional status in response to therapeutic strategies, the nurse monitors the patient's hemoglobin, pre-albumin level, and body weight weekly. Nutritional assessment is described in further detail in Chapter 5. REDUCING FRICTION AND SHEAR Raising the head of the bed by even a few centimeters increases the shearing force over the sacral area; therefore, the semi-reclining position is avoided in patients at risk. Proper positioning with adequate support is also important when the patient is sitting in a chair. Quality and Safety Nursing Alert To avoid shearing forces when repositioning patients, the nurse must lift and avoid dragging patients across a surface. Lift devices should be used to prevent occupational injuries. MINIMIZING IRRITATING MOISTURE Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly. The soiled skin should be washed immediately with mild soap and water and blotted dry with a soft towel. The skin may be lubricated with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Topical barrier ointments (e.g., petroleum jelly) may be helpful in protecting the skin of patients who are incontinent. Absorbent pads that wick moisture away from the body should be used to absorb drainage. Patients who are incontinent need to be checked regularly and have their wet incontinence pads and linens changed promptly. Their skin needs to be cleansed and dried promptly. PROMOTING PRESSURE ULCER HEALING Regardless of the stage of the pressure ulcer, the pressure on the area must be eliminated because the ulcer will not heal until all pressure is removed. The patient must not lie or sit on the pressure ulcer, even for a few minutes. Individualized positioning and turning schedules must be written in the plan of nursing care and followed meticulously. In addition, inadequate nutritional status and fluid and electrolyte abnormalities must be corrected to promote healing. Wounds from which body fluids and protein drain place the patient in a catabolic state and predispose to hypoproteinemia and serious secondary infections. Protein deficiency must be corrected to promote the healing of the pressure ulcer. Carbohydrates are necessary to "spare" the protein and to provide an energy source. Vitamin C and trace elements, especially zinc, are necessary for collagen formation and wound healing. (Refer to Chart 10-7 for descriptions of stages of pressure ulcers.) Deep Tissue Injury. These tissue injuries may evolve rapidly, and immediate pressure relief to the affected area is indicated. Therefore, the nurse must be vigilant in assessing for these types of injuries (Dunk & Carville, 2015; National Pressure Ulcer Advisory Panel, 2014). Stage I Pressure Ulcers. To permit healing of stage I pressure ulcers, the pressure is removed to allow increased tissue perfusion, nutritional and fluid and electrolyte balance is maintained, friction and shear are reduced, and moisture to the skin is avoided (Dunk & Carville, 2015; National Pressure Ulcer Advisory Panel, 2014). Stage II Pressure Ulcers. In addition to measures listed for stage I pressure ulcers, a moist environment, in which migration of epidermal cells over the ulcer surface occurs more rapidly, should be provided to aid wound healing. The ulcer is gently cleansed with sterile saline solution. The use of a heat lamp to dry the open wound is avoided, as is the use of antiseptic solutions that damage healthy tissues and delay wound healing. Semipermeable occlusive dressings, hydrocolloid wafers, or wet saline dressings are helpful in providing a moist environment for healing and in minimizing the loss of fluids and proteins from the body (Dunk & Carville, 2015; National Pressure Ulcer Advisory Panel, 2014). Stage III Pressure Ulcers. Stage III pressure ulcers are characterized by extensive tissue damage, including slough (i.e., soft, moist avascular tissue), tunneling (i.e., formation of a sinus tract), and undermining (i.e., extensive tunneling under wound edge), to name a few. Given the extensive damage to tissue and necrosis that characterize stage III pressure ulcers, they must be cleaned (débrided) to create an area that will heal, in addition to the measures listed for stage I pressure ulcers. Necrotic, devitalized tissue favors bacterial growth, delays granulation, and inhibits healing. Wound cleaning and dressing are uncomfortable; therefore, the nurse must prepare the patient for the procedure by explaining what will occur and administering prescribed analgesia (Dunk & Carville, 2015; National Pressure Ulcer Advisory Panel, 2014). Stage IV Pressure Ulcers. Surgical interventions are required for these extensive pressure ulcers (National Pressure Ulcer Advisory Panel, 2014). (See the following Other Treatment Methods section.) OTHER TREATMENT METHODS Débridement may be accomplished by wet-to-damp dressing changes, mechanical flushing of necrotic and infective exudate, application of prescribed enzyme preparations that dissolve necrotic tissue, or surgical dissection. If eschar (dry scab) covers the ulcer, it is removed surgically to ensure the wound is clean and vitalized. Exudate may be absorbed by dressings or special hydrophilic powders, beads, or gels. Cultures of infected pressure ulcers are obtained to guide the selection of antibiotic therapy. After the pressure ulcer is clean, a topical treatment is prescribed to promote granulation. New granulation tissue must be protected from reinfection, drying, and damage, and care should be taken to prevent pressure and further trauma to the area. Dressings, solutions, and ointments applied to the ulcer should not disrupt the healing process. For chronic, noninfected ulcers that are healing by secondary intention (healing of an open wound from the base upward by laying down new tissue), vacuum-assisted closure (VAC) or hyperbaric oxygen treatment may be used. VAC involves the use of a negative-pressure sponge dressing in the wound to increase blood flow, increasing formation of granulation tissue and nutrient uptake and decreasing bacterial load. Hyperbaric oxygen therapy involves either the application of topical oxygen at increased pressure directly to the wound or placing the patient into a hyperbaric oxygen chamber. Both methods of hyperbaric oxygen therapy promote wound healing by stimulating new vascular growth and aiding in the preservation of damaged tissue (Dauwe, Pulikkottil, Lavery, et al., 2014). In a recent systematic review, Stoekenbroek, Santema, Legemate, et al. (2014) reported that hyperbaric oxygen therapy improves healing in patients with diabetic leg ulcers; however, more studies are needed prior to routinely introducing this therapy into clinical practice. Multiple agents and protocols are used to treat pressure ulcers; however, consistency is an important key to success. Objective evaluation of the pressure ulcer (e.g., measurement of the size and depth of the pressure ulcer, inspection for granulation tissue) for response to the treatment protocol must be made every 4 to 6 days. Taking photographs at weekly intervals is a reliable strategy for monitoring the healing process, which may take weeks to months. Surgical intervention is necessary when the ulcer is extensive, when complications (e.g., fistula) exist, and when the ulcer does not respond to treatment. Surgical procedures include débridement, incision and drainage, bone resection, and skin grafting. Osteomyelitis is a common complication of wounds of stage IV depth. (See Chapter 41 for more information on osteomyelitis.) PREVENTING RECURRENCE It may take more than a year for healing tissue to regain the strength of pre-injury skin; thus, care must be taken to prevent recurrence of pressure ulcers. However, recurrence of pressure ulcers should be anticipated; therefore, active, preventive intervention and frequent continuing assessments are essential. For example, pressure ulcers are the second most comorbid problem in patients with SCI with 85% of patients with SCI developing a pressure ulcer at least once in their lifetime (Scheel-Sailer, Wyss, Boldt, et al., 2013). The patient's tolerance for sitting or lying on the healed pressure area is increased gradually by increasing the time that pressure is allowed on the area in 5- to 15-minute increments. The patient is instructed to increase mobility and to follow a regimen of turning, weight shifting, and repositioning. The patient education plan includes strategies to reduce the risk of pressure ulcers and methods to detect, inspect, and minimize pressure areas. Early recognition and intervention are keys to long-term management of potential impaired skin integrity. Gould, Olney, Nichols, et al. (2014) suggest immobility and incontinence are among modifiable risk factors that contribute to recurrent pressure ulcer development, particularly in patients with SCI; they suggest the development of structured guidelines to prevent pressure ulcers rests on the identification of factors that differ in patients with SCI who have none, one, or more pressure ulcers. Identifying potentially modifiable risk factors or protective factors may then lead to evidence-based risk assessment tools and interventions customized to patient-specific risks. Evaluation Expected patient outcomes may include: Maintains intact skin Exhibits no areas of nonblanchable erythema at bony prominences Avoids massage of bony prominences Exhibits no breaks in skin Limits pressure on bony prominences Changes position every 1 to 2 hours Uses bridging techniques to reduce pressure Uses special equipment as appropriate Raises self from seat of wheelchair every 15 minutes Increases mobility Performs range-of-motion exercises Adheres to turning schedule Advances sitting time as tolerated Has improved sensory and cognitive ability Demonstrates improved level of consciousness Remembers to inspect potential pressure ulcer areas every morning and evening Demonstrates improved tissue perfusion Exercises to increase circulation Elevates body parts susceptible to edema Attains and maintains adequate nutritional status Verbalizes the importance of protein and vitamin C in diet Eats diet high in protein and vitamin C Exhibits acceptable levels of hemoglobin, electrolyte, prealbumin, transferrin, and creatinine Avoids friction and shear Avoids semireclining position Uses heel protectors when appropriate Lifts body instead of sliding across surfaces Maintains clean, dry skin Avoids prolonged contact with wet or soiled surfaces Keeps skin clean and dry Uses lotion to keep skin lubricate (Hinkle 183-186) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing process patients with self care deficit

The Patient With Self-Care Deficits in Activities of Daily Living An ADL program is started as soon as the rehabilitation process begins, because the ability to perform ADLs is frequently the key to independence, return to the home, and transition into the community. Assessment The nurse must observe and assess the patient's ability to perform ADLs to determine the level of independence in self-care and the need for nursing intervention. Chart 10-2 depicts behaviors that may indicate struggles with function or movement and thus should be assessed. For example, bathing requires obtaining bath water and items used for bathing (e.g., soap, washcloth), washing, and drying the body after bathing. Dressing requires getting clothes from the closet, putting on and taking off clothing, and fastening the clothing. Self-feeding requires using utensils to bring food to the mouth and chewing and swallowing the food. Toileting includes removing clothing to use the toilet, cleansing oneself, and readjusting clothing. Grooming activities include combing hair, brushing one's teeth, shaving or applying makeup, and hand washing. Patients who can sit up and raise their hands to their head can begin self-care activities. Assistive devices are often essential in achieving some level of independence in ADLs. (Hinkle 168) The nurse should also be aware of the patient's medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the family's involvement in the patient's ADLs. This information is valuable in setting goals and developing the plan of care to maximize self-care. Nursing Diagnosis Based on the assessment data, a major nursing diagnosis may include the following: Self-care deficit: bathing, dressing, feeding, toileting Planning and Goals The major goals include performing the following activities independently or with assistance, using adaptive or assistive devices as appropriate: bathing/hygiene, dressing/grooming, feeding, and toileting. Another goal is patient expression of satisfaction with the extent of independence achieved in self-care activities. Nursing Interventions Repetition, practice, and demonstrations help patients achieve maximum independence in personal care activities. The nurse's role is to provide an optimal learning environment that minimizes distractions. The nurse can identify the patient's optimal time to work on activities, encourage concentration, identify endurance issues that may affect safety, and provide cues and reminders to patients with specific disabilities (e.g., hemiparesis or hemineglect) (Hyde & Kautz, 2014). Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. FOSTERING SELF-CARE ABILITIES A patient's approach to self-care may be affected by altered or impaired mobility and influenced by family or cultural expectations. The inability to perform self-care as carried out previously may lead to ineffective coping behaviors, such as social isolation, dependency on caregivers, or depression. The nurse must motivate the patient to learn and accept responsibility for self-care. It helps to encourage an "I'd rather do it myself" attitude. The nurse must also help the patient identify the safe limits of independent activity; knowing when to ask for assistance is particularly important. The nurse educates, guides, and supports the patient who is learning or relearning how to perform self-care activities while maintaining a focus on patient strengths and optimal level of function. Consistency in instructions and assistance given by health care providers, including rehabilitation therapists (e.g., physiotherapists, occupational therapists, recreation therapists, speech-language pathologists, and physicians) facilitates the learning process. Recording the patient's performance provides data for evaluating progress and may be used as a source for motivation and morale building. Guidelines for educating patients and families about ADLs are presented in Chart 10-3. Often, performing a simple maneuver requires the patient with a disability to concentrate intensely and exert considerable effort; therefore, self-care techniques need to be adapted to accommodate the individual patient's lifestyle. Because a self-care activity usually can be accomplished in several ways, common sense and a little ingenuity may promote increased independence. For example, a person who cannot quite reach their head may be able to do so by leaning forward. Encouraging the patient to participate in a support group may also help the patient discover creative solutions to self-care problems. Pre-existing cultural norms may influence the degree of self-care the patient is willing to consider. Cultural and ethnic beliefs about hygiene can vary among individuals and families. The nurse must recognize these beliefs, work through any issues with the patient and family, and communicate pertinent findings to the rehabilitation team. RECOMMENDING ADAPTIVE AND ASSISTIVE DEVICES If the patient has difficulty performing an ADL, an adaptive or assistive device (self-help device) may be useful. Such devices may be obtained commercially or can be constructed by the nurse, occupational therapist, patient, or family. The devices may include built-up handles on toothbrushes or razors; long, curved handles on mirrors or shoe horns; suction cups to hold items in place; shower chairs; raised toilet seats; and universal cuffs to grip self-care items. Some of these are shown in Figure 10-1. To assist premenopausal women with managing menstruation, clothing adaptations (e.g., Velcro crotch flaps for ease of access), mirrors, self-sticking sanitary pads, packaged wipes, and loose underwear may be used. Figure 10-1 • Adaptive and assistive devices. A. Raised toilet seat. B. Shower chair. Quality and Safety Nursing Alert To avoid injury or bleeding, people who take anticoagulant medication should be encouraged to use an electric razor. Women may wish to consider depilatory creams or electrolysis. A wide selection of computerized devices is available, or devices can be designed to help individual patients with severe disabilities to function more independently. The AbleData project (see Resources list at the end of this chapter) offers a computerized listing of commercially available aids and equipment for patients with disabilities. The nurse should be alert to "gadgets" coming on the market and evaluate their potential usefulness. The nurse must exercise professional judgment and caution in recommending devices, because in the past, unscrupulous vendors have marketed unnecessary, overly expensive, or useless items to patients. HELPING PATIENTS ACCEPT LIMITATIONS If the patient has a severe disability, independent self-care may be an unrealistic goal. In this situation, the nurse educates the patient how to take charge by directing their care. The patient may require a personal attendant to perform ADLs. Family members may not be appropriate for providing bathing/hygiene, dressing/grooming, feeding, and toileting assistance, and spouses may have difficulty providing bowel and bladder care for patients and maintaining the role of sexual partners. If a personal caregiver is necessary, the patient and family members must learn how to manage an employee effectively. The nurse helps the patient accept self-care dependency. Independence in other areas, such as social interaction, should be emphasized to promote a positive self-concept. Evaluation Expected patient outcomes may include: Demonstrates independent self-care in bathing/hygiene or with assistance, using adaptive devices as appropriate Bathes self at maximal level of independence Uses adaptive and assistive devices effectively Reports satisfaction with level of independence in bathing/hygiene Demonstrates independent self-care in dressing/grooming or with assistance, using adaptive devices as appropriate Dresses/grooms self at maximal level of independence Uses adaptive devices effectively Reports satisfaction with level of independence in dressing/grooming Demonstrates increased interest in appearance Demonstrates independent self-care in feeding or with assistance, using adaptive and assistive devices as appropriate Feeds self at maximal level of independence Uses adaptive and assistive devices effectively Demonstrates increased interest in eating Maintains adequate nutritional intake Demonstrates independent self-care in toileting or with assistance, using adaptive and assistive devices as appropriate Toilets self at maximal level of independence Uses adaptive and assistive devices effectively Indicates positive feelings regarding level of toileting independence Experiences adequate frequency of bowel and bladder elimination Does not experience incontinence, constipation, urinary tract infection, or other complications (Hinkle 169-170) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Types of urinary incontinence

Urge incontinence occurs when involuntary elimination of urine is associated with a strong perceived need to void. Reflex (neurogenic) incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intra-abdominal pressure is increased (e.g., with coughing or sneezing). Functional incontinence occurs in patients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Overflow urinary incontinence is described as the involuntary loss of urine associated with overdistention of the bladder. Reasons for overdistention and urine leakage vary, but may be related to improper emptying of the bladder, fecal impaction, urethral obstruction, or medication side effect. Total urinary incontinence occurs in patients who cannot control urine because of physiologic or psychological impairment. Management of the urine is an essential focus of nursing care. (Hinkle 186) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Substance abuse in rehabilitation

As in all areas of nursing practice, nurses practicing in the area of rehabilitation must be skilled and knowledgeable about the care of patients with substance abuse. For all people with disabilities, including adolescents, nurses must assess actual or potential substance abuse. Alcohol and drug abuse or dependence has been associated with new occurrence spinal cord and brain injury (Tétrault & Courtois, 2014). Fifty percent of spinal cord injuries are related to substance abuse, and approximately 50% of all patients with traumatic brain injury were intoxicated at the time of injury (Substance Abuse and Mental Health Services Administration, 2014). Substance abuse is a critical issue in rehabilitation, especially for people with disabilities who are attempting to gain employment via vocational rehabilitation. The rates of substance abuse, including alcohol abuse, in people with disabilities are two to four times as high (Glazier & Kling, 2013) as in the general population, and this increased abuse is associated with numerous risks that may have an adverse impact. These risks include medication and health problems, societal enabling (i.e., acceptance and tolerance of substance abuse by key social and cultural groups), a lack of identification of potential problems, and a lack of accessible and appropriate prevention and treatment services. Treatment for alcoholism and drug dependencies includes thorough physical and psychosocial evaluations; detoxification; counseling; medical treatment; psychological assistance for patients and families; treatment of any coexisting psychiatric illness; and referral to community resources for social, legal, spiritual, or vocational assistance. The length of treatment and the rehabilitation process depends on the patient's needs. Self-help groups are also encouraged, although attendance at meetings of such groups (e.g., Alcoholics Anonymous, Narcotics Anonymous) poses various challenges for people who have neurologic disorders, are permanent wheelchair users, or must adapt to encounters with attendees without disabilities who may not understand disability. (Hinkle 167) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Elimination assessment

The health history is used to explore bladder and bowel function, symptoms associated with dysfunction, physiologic risk factors for elimination problems, perception of micturition (urination, or voiding), and functional toileting abilities. Previous and current fluid intake and voiding patterns may be helpful in designing the plan of nursing care. A record of times of voiding and amounts voided is kept for at least 48 hours. In addition, episodes of incontinence and associated activity (e.g., coughing, sneezing, lifting), fluid intake time and amount, and medications are recorded. This record is analyzed and used to determine patterns and relationships of incontinence to other activities and factors. The ability to get to the bathroom, manipulate clothing, and use the toilet are important functional factors that may be related to incontinence. Related cognitive functioning (perception of need to void, verbalization of need to void, and ability to learn to control urination) must also be assessed. In addition, the nurse reviews the results of the diagnostic studies (e.g., urinalysis, urodynamic tests, post-voiding residual volumes). Bowel incontinence and constipation may result from multiple causes, such as diminished or absent sphincter control, cognitive or perceptual impairment, neurogenic factors, diet, and immobility. The origin of the bowel problem must be determined. The nurse assesses the patient's normal bowel patterns, nutritional patterns, use of laxatives, gastrointestinal problems (e.g., colitis), bowel sounds, anal reflex and tone, and functional abilities. The character and frequency of bowel movements are recorded and analyzed. (Hinkle 186) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Altered elimination patterns

Urinary incontinence and bowel incontinence or constipation and impaction are problems that often occur in patients with disabilities. Incontinence curtails the person's independence, causing embarrassment and isolation. Based on structured oral interviews conducted to collect data on bothersome urinary or fecal incontinence in adults aged 50 and older, 20% of women and 6.4% of men reported urinary incontinence (less than once/month, a few times/month, a few times/week or every day/night) (Gorina, Schappert, Bercovitz, et al., 2014; Roe, Flanagan, & Maden, 2015). Fecal incontinence (leakage of gas, mucus, liquid or solid stool at least monthly) was reported by 8.2% of women and 8.4% of men (Wu, Matthews, Vaughan, et al., 2015). Internationally, nearly 55% of nursing home residents will experience bowel and/or bladder incontinence at some point (Mandl, Halfens, & Lohrmann, 2015). For patients with disabilities who experience constipation, complete and predictable evacuation of the bowel is the goal. If a bowel routine is not established, the patient may experience abdominal distention; small, frequent oozing of stool; or impaction. (Hinkle 186) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.