MEDSURG: CHAPTER 10: PRINCIPLES & PRACTICES OF REHABILITATION:

Assessment of Functional Ability: The Barthel Index:

- 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.

Interventions: Urinary 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.

Nursing Interventions Promoting Mobility: Maintaining Muscle Strength & 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.

Who is the key member of the rehabilitation team? A. Nurse B. Occupational therapist C. Patient D. Physician

C) C.Patient - Rationale: The patient is the focus of the team's effort and the one who determines the final outcomes of the process. The nurse develops the plan of care designed to facilitate rehabilitation. Other team members make a unique contribution to the team effort

Goals:

•Individualize goals to patient •Performing the following activities independently or with assistance -Bathing/hygiene, dressing/grooming, feeding, and toileting •Appropriate use of adaptive devices •Patient satisfaction with level of independence

Areas Susceptible To Pressure Ulcers:

- Occiput - Ears - Scapula - Elbow - Sacrum - Greater Trochanter - Ischial Tuberosities - Medial condyle of tibia - Fibular head - Medial/Lateral malleolus - Heel

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.

Rehabilitation Goals:

- 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 - During rehabilitation, patients adjust to disabilities by learning how to use available resources with a focus on overall health promotion - In rehabilitation, abilities, not disabilities, are emphasized.

Interventions: Urinary Continence: 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.

Assessment of Skin:

- 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

Instrumental Activities Of Daily Living (IADLs):

- Complex skills needed for independent living, including meal preparation, grocery shopping, household management, finances, and transportation.

Interventions: Bowel Continence: Consistency:

- 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.

Assessment of Functional Ability: 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

Interventions: Urinary Continence: 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.

Assessment of Functional Ability: Functional Independence Measure (FIM):

- Most frequently used tool - It's 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.

Nursing Interventions Promoting Mobility: Assisting Patients With Orthoses & 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.

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.

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 - 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.

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) - Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care.

Activities Of Daily Living (ADLs):

- Self-care activities that the patient must accomplish each day to meet personal needs including bathing, grooming, dressing, feeding, and toileting.

Other Treatment Methods: Surgical Intervention:

- 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.

Interventions: Urinary Continence: Bladder Training:

- The 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.

Interventions to Prevent Pressure Ulcer Formation: 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. - 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. - 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.

Interventions to Prevent Pressure Ulcer Formation: 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.

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 - There may be a purple or maroon localized area of discolored intact skin or blood-filled blister. - The area may be preceded in appearance by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue. - Evolution may include a thin blister over a dark wound bed. - The wound may further evolve and become covered by thin eschar. - Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

Stage 1 Pressure Ulcer:

- 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 - Intact skin - Nonblanchable redness of a localized area, usually over a bony prominence - Darkly pigmented skin may not have visible blanching. - Color may differ from surrounding area. - Area may be painful, firm, soft, and warmer or cooler as compared to adjacent tissue.

Risk Factors for Development of Pressure Ulcers: 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

Assessment of Functional Ability: Patient Evaluation Conference System (PECS):

- 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.

Which nutrient is responsible for collagen synthesis? A.Vitamin A B.Vitamin C C.Water D.Zinc

B) Vitamin C - Rationale: Vitamin C promotes collagen synthesis. Vitamin A stimulates epithelial cells and immune response. Water maintains homeostasis. Zinc sulfate is a cofactor for collagen formation and protein synthesis

Nursing Diagnosis:

Based on the assessment data, a major nursing diagnosis may include the following: - Self-care deficit: bathing, dressing, feeding, toileting

Interventions to Prevent Pressure Ulcer Formation: 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 - 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.

Interventions: Urinary Continence: Dependent On Type Of Urinary Incontinence:

- 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. - 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.

Other Treatment Methods: Topical Treatment:

- 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

Risk Factors for Development of Pressure Ulcers: 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.

Interventions: Urinary Continence: Do Not Restrict Fluids:

- 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.

Interventions to Prevent Pressure Ulcer Formation: Using Pressure-Relieving Devices:

- At times, specialty beds or alternative bed surfaces may be indicated to help relieve the pressure on the skin - 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 - 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

Stage 3 Pressure Ulcer:

- 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 - Full-thickness tissue loss - Subcutaneous fat may be visible; however, bone, tendon, or muscle is not exposed. - Slough may be present but does not obscure the depth of tissue loss. - May include undermining and tunneling - Depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage III ulcers can be shallow in these areas. Areas of significant adiposity can develop extremely deep stage III pressure ulcers.

Interventions to Prevent Pressure Ulcer Formation: 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.

Different Roles Nurse Takes On In Rehabilitation Facility:

- 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 care team, including home care nurses, who are responsible for directing patient care after the patient returns home.

Nursing Interventions Promoting Mobility: Ambulating With Assistive Device:

- 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 - The nurse or physical therapist determines which gait is best - 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.

Educating Patients About Activities of Daily Living:

- Define the goal of the activity with the patient. Be realistic. - Set short-term goals that can be accomplished in the near future. - Identify several approaches to accomplish the task (e.g., there are several ways to put on a given garment). - Select the approach most likely to succeed. - Specify the approach on the patient's plan of care and the patient's level of accomplishment on the progress notes. - Identify the motions necessary to accomplish the activity (e.g., to pick up a glass, extend arm with hand open; place open hand next to glass; flex fingers around glass; move arm and hand holding glass vertically; flex arm toward body). - Focus on gross functional movements initially, and gradually include activities that use finer motions (e.g., buttoning clothes, eating with a fork). - Encourage the patient to perform the activity up to maximal capacity within the limitations of the disability. - Monitor the patient's tolerance. - Minimize frustration and fatigue. - Support the patient by giving appropriate praise for effort put forth and for acts accomplished. - Assist the patient to perform and practice the activity in real-life situations and in a safe environment.

Nursing Interventions Promoting Mobility: 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.

Other Treatment Methods: Debridement:

- 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.

Assessment for Risk of Pressure Ulcers:

- Evaluate level of mobility - Assess neurovascular status - Evaluate circulatory status - Evaluate nutritional and hydration status - Review the results of the patient's laboratory studies - Determine presence of incontinence - Review current medications

Interventions: Urinary Continence: External 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.

Nursing Interventions Promoting Mobility: POSITIONING TO PREVENT MUSCULOSKELETAL COMPLICATIONS: 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.

Other Treatment Methods: Vacuum-Assisted Closure (VAC):

- 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 - In a recent systematic review, it was 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.

Interventions to Prevent Pressure Ulcer Formation: 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 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.

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.

Recommending Adaptive/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. - 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. - 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 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.

Stage 2 Pressure Ulcer:

- 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 - Partial thickness loss of dermis, presenting as a shallow open ulcer with red-pink wound bed without slough - May present as an intact or open/ruptured serum-filled blister - May present as a shiny or dry shallow ulcer without slough or bruising; bruising indicates suspected deep tissue injury - Does not include skin tears, tape burns, perineal dermatitis, maceration, or excoriation

Risk Factors for Development of Pressure Ulcers: Age-Related Skin Changes:

- 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

Patient/Family Roles In Rehabilitation Facilities:

- In working toward maximizing independence, nurses affirm the patient as an active participant and essential part of the health care delivery process - 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 - 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.

Interventions: Urinary Continence: Indwelling Catheters:

- 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.

Interventions: Urinary Continence: Intermittent Self-Catheterization:

- 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.

Rehabilitation:

- Is a goal-oriented process that enables people with acute or chronic disorders, including those with physical, mental, or emotional disabilities or impairments

Interventions: Urinary Continence: 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.

Assessment of Functional Ability: PULSE Profile:

- 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).

Risk Factors for Development of Pressure Ulcers: Friction/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 - 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 be 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.

Other Treatment Methods:

- 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.

Nurse's At Rehabilitation Facilities:

- 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 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 - Rehabilitation is a continuous process. - Rehabilitation requires active patient participation. - Rehabilitation is goal directed. - Rehabilitation requires multiprofessional and interdisciplinary teamwork - 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

Risk Factors for Development of Pressure Ulcers: Decreased 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 - 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.

Risk Factors for Development of 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.

Interventions: Urinary Continence: Kegel Exercises:

- 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.

Risk Factors for Development of Pressure Ulcers: 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.

Interventions to Prevent Pressure Ulcer Formation: Reducing Friction/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

Nursing Interventions Promoting Mobility: Maintaining Muscle Strength & Joint Mobility: Performing Range Of Motion Exercises:

- Range of motion involves moving a joint through its full range in all appropriate planes - 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. - 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.

Stage 4 Pressure Ulcer:

- Surgical interventions are required for these extensive pressure ulcers - Ulcer presents with full-thickness tissue loss with exposed bone, tendon, or muscle. - Slough or eschar may be present on some parts of the wound. - Often includes undermining and tunneling - Depth of a stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; stage IV ulcers can be shallow in these areas. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule); osteomyelitis is possible. Exposed bone/tendon is visible or directly palpable.

Interventions: Bowel Continence: Toilet Patients At Same Time Daily:

- 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

Interventions to Prevent Pressure Ulcer Formation: 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.

Interventions: Bowel Continence: Positioning (Elevated Toilet Seat):

- 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.

Nursing Interventions Promoting Mobility: POSITIONING TO PREVENT MUSCULOSKELETAL COMPLICATIONS: 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.

Interventions to Prevent Pressure Ulcer Formation: 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

Interventions: 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.

Nursing Interventions Promoting Mobility: Maintaining Muscle Strength & Joint Mobility: 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.

Assessing Potential Struggles In Function/Movement:

Be alert for the following behaviors: - Holding onto a handrail to pull the body while going up stairs - Holding onto a bedside rail or bedcovers to pull to a sitting position in bed - Leaning to one side and using both hands on the handrail while going down the stairs or a ramp - Holding onto furniture or doorways and watching the feet while walking in the house - Lifting a leg (or arm) by using the other leg (or arm) as support or by lifting with the pants leg (or sleeve) - Tilting the head to reach the back or side of the hair while grooming - Pushing up, rocking forward and back, and/or leaning the body over for momentum ("nose over toes") when rising to stand from a chair - Leaning over from the waist without bending the knees and then placing one hand on the thigh, as if it were a prop, and pushing against the thigh to assist in moving to the upright position - Turning to reach for an object and then using the other arm or an object to support the reaching arm at the elbow or wrist - Positioning a chair before sitting down by using the front or back of the knees and then using the back of the knees to guide sitting down; using the torso and hips to lean against a table or chair - Reaching and leaning with the body rather than with an arm - Walking with a lean to one side, a limp, a waddle, or other variation of a gait - Scanning (i.e., observing or being aware of surroundings) ineffectively while eating or grooming - Rolling or scooting the body, sliding forward in a seat, or other maneuvers to move off a bed or out of a chair

Is the following statement true or false? Rehabilitation is a goal-oriented process that enables people with acute or chronic disorders to identify, reach, and maintain optimal physical, sensory, intellectual, psychological, and/or social functional levels

True - Rationale: Rehabilitation is a dynamic, health-oriented process that helps people with acute or chronic disorders or people with physical, mental, or emotional disabilities to achieve the greatest possible level of physical, mental, spiritual, social, and economic functioning

Outcomes:

•Demonstrates independent self-care in bathing/hygiene or with assistance, using adaptive devices as appropriate •Demonstrates independent self-care in dressing/grooming or with assistance, using adaptive devices as appropriate •Demonstrates independent self-care in feeding or with assistance, using adaptive and assistive devices as appropriate •Demonstrates independent self-care in toileting or with assistance, using adaptive and assistive devices as appropriate

Home & Community-Based Care:

•Plan for discharge is formulated when the patient is first admitted to the hospital •Discharge plans made with the patient's functional potential in mind •Patient/family members are taught how to use equipment •Coordinate a network of support services •Goals: -Independent living -Integration into the community