Chapter 10: Principles and Practices of Rehabilitation
Opposition
touching the thumb to each fingertip on same hand
The average length of stay for hospitalizations related to pressure ulcers is ______ days, with an average treatment cost of nearly ________ for each affected patient
13.4, $20,000
Serum albumin levels less than ________________ increase the risk of pressure ulcers. Therefore a protein intake of ________________ is recommended to promote ulcer healing.
3g/ml, 1.25 to 1.5g/kg/day
List 12 areas susceptible to pressure ulcer formation.
-Occiput -Ear -Scapula -Elbow -Sacrum -Greater trochanter -Ischial tuberosities -Medial condyle of tibia -Fibular head Medial malleolus -Lateral malleolus -Heel
Suspected Deep Tissue Injury
-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. 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
Alkaline-producing beverages such as ______________________,_____________________,__________________,________________________ and ____________________ promote bacterial growth in the urine and should be avoided for patients who suffer from incontinence.
-carbonated soft drinks -milkshakes -alcoholic beverages -tomato juice -citrus fruit juices
A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor in the patient with a disability attempting to seek employment? A. Substance abuse B. Cognitive ability C. Orientation level D. Self-care ability
A
The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? A. Serum albumin B. Serum glucose C. Prothrombin time D. Sedimentation rate
A
What diet can the nurse recommend to a patient with hypoproteinemia that spares protein? A. A diet high in carbohydrates B. A diet high in fats C. A diet high in minerals D. A diet high in vitamins
A
Prosthesis
A device used to replace a body part
A)Seven nursing diagnosis for patients with impaired physical mobility could be________________________ B) five major goals
A) - Impaired physical mobility - Activity intolerance -Risk for injury -Risk for disuse syndrome -Impaired walking -Impaired wheelchair mobility -impaired bed mobility B) -absence of contracture and deformity -maintenance of muscle strength and joint mobility -independent mobility -increased activity tolerance -prevention of further disability
A patient in rehabilitation has become dependent on family members' assistance with self-care. Which nursing actions will encourage the patient to become independent? (Select all that apply.) A. Motivate the patient to learn and accept responsibilities for self-care. B. Help the patient identify safe limits of independents activity C. Educate the patient in how to perform self-care activities. D. Inform the patient that the family will continue to provide care if self-care is not performed E. Have the patient placed in a long-term care facility until self-care activities are performed independently.
A, B and C
The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply) A. Set a daily defection time that is within 15 minutes of the same time everyday B. Have an adequate intake of fiber-containing foods. C. Have a fluid intake between 2 and 4 L/day D. Take a retention enema daily E. Take a laxative daily
A, B and C
The nurse is initiating a bladder-training schedule for a patient. What interventions can be provided for optimal success? (Select all that apply) A. Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void B. Give up to 3000mL of fluid daily C. Teach bladder massage to increase intraabdominal pressure D. Require the patient to restrict fluid intake during the day to decrease voiding E. Give a diuretic every morning
A, B and C
A(n)_____________ Program is started as soon as the rehabilitation process begins.
Activities of daily living (ADLs)
The nurse has developed an evidence-based plan of care a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve plan of care? A. The healthcare provider B. The patient C. The physical Therapist D. The nurse.
B
What position should be avoided when positioning a patient in bed in order to decrease the incidence of musculoskeletal complications? A. Prone B. Semi-Fowlers C. Side Lying D. Dorsal
B
Two assessments scales that nurses can use to quantify a patients risk for pressure ulcer formation are the _______________________and _______________________scales.
Braden, Norton
The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding? A. Anoxia B. Eschar C. Hyperemia D. Ischemia
C
The nurse is assisting a patient in assuming a side-lying position. Which intervention would be best for the nurse to provide? A. Align the lower extremities in a neutral position B. Extend the legs with a firm support under the popliteal area C. Place the uppermost hip slightly forward in a position of slight abduction D. Position the trunk so that hip flexion is minimized
C
The nurse determines that a patient is at risk for the development of skin breakdown. Which nursing actions would be most effective as a preventative measure. A. Application of powder B. Insertion of an indwelling catheter C. Administration of Vitamin B12 D. Practicing meticulous hygiene measures
D
The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height? A. Use the patients height and add 6 in. B. Use the patients height and add 12 in. C. Use the patients height and subtract 8 in D. Use the patients height and subtract 16in
D
When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury? A. After the patient feels comfortable in the clinical setting. B. After the healthcare provider has prescribed rehabilitative goals. C. When an exercise program has been initiated. D. With initial patient contact.
D
Eschar covering an ulcer should be removed surgically for what reason.
Eschar does not permit free drainage of the tissue
Two common musculoskeletal complications for patients who are in bed for prolonged periods are ___________________________and ___________________________.
External rotation of the hip, planter flexion of the foot (foot drop)
One of the most frequently used tools to assess the patient's level of independence is the ________________________.
Functional Independence Measure (FIM™)
_____________are used to prevent venous stasis.
Graduated compression stockings
Name 3 complications commonly associated with prolonged or impaired physical immobility
Weakened muscles, joint contractures and deformity are common complications associated with prolonged immobility
Two areas that are the most susceptible to the effects of shear and therefore pressure ulcer formation are the ________________and the _______________________.
Sacrum, heels
Name 3 goals of rehabilitation
The 3 goals of rehabilitation are to restore the patient's ability to function independently or at a pre-illness or preinjury level, maximize independence, and prevent secondary disability.
Quality and Safety Nursing Alert
The nurse should avoid massaging reddened areas because this may increase the damage to already traumatized skin and tissue.
To maintain use, a joint should be moved through its range of motion at least __________________ times per day.
Three
Orthosis
an external appliance that provides support, prevents or corrects joint deformities, and improves function
Internal
turning inward, toward the center
Rotation
turning or movement of a part around its axis
External
turning outward, away from the center
Flexion
bending of a joint so that the angle of the joint diminishes
Rehabilitation
making able again; learning or relearning skills or abilities or adjusting existing functions to meet maximum potential
Pulmonary rehabilitation
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 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.
Abduction
movement away from the midline of the body
Plantar flexion
movement that flexes or bends the foot in the direction of the sole
Dorsiflexion
movement that flexes or bends the hand back toward the body or the foot toward the leg
Palmer flexion
movement that flexes or bends the hand in the direction of the palm
Inversion
movement that turns the sole of the foot inward
Instrumental activities of daily living (IADLs)
complex skills needed for independent living, such as shopping, cooking, housework, using the telephone, managing medications and finances, and being able to travel by car or public transportation
Sinus tract
course or path of tissue destruction occurring in any direction from the surface or edge of a wound; results in dead space with potential for abscess formation; also called tunneling
Eversion
movement that turns the sole of the foot outward
Adduction
movement toward the midline of the body
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.
The initial sign of pressure____________________, caused by reactive hyperemia, which normally resolves in less than_____________. Unrelieved pressure results in tissue _________________.
erythema (redness of the skin), 1 Hour. ischemia or anoxia
Activities of daily living (ADLs)
personal care activities, such as bathing, dressing, grooming, eating, toileting, and transferring
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.
Pronation
rotation of the forearm so that the palm of the hand is down
Supination
rotation of the forearm so that the palm of the hand is up
The PULSES profile
s 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).
Slough
soft, moist avascular (devitalized) tissue; may be white, yellow, tan, gray, or green; may be loose or firmly adherent
Four factors that contribute to foot drop are ________________________, _________________________, ________________and _____________________________.
-prolonged bed rest -lack of exercise -incorrect positioning in bed -the weight of the bedding
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.
List four collaborative problems for a patient with impaired physical mobility.
- Impaired physical mobility -Activity intolerance -Risk for injury -Risk for disuse syndrome -Impaired walking _impaired wheelchair mobility _impaired bed mobility
List 10 risk factors for pressure ulcer formation.
-Prolonged pressure on tissue -Immobility, compromised mobility -Loss of protective reflexes, sensory deficit/loss -Poor skin perfusion, edema -Malnutrition, hypoproteinemia, anemia, vitamin deficiency -Friction, shearing forces, trauma -Incontinence of urine or feces -Altered skin moisture: excessively dry, excessively moist -Advanced age, debilitation -Equipment: casts, traction, restraints -Skin problems on admission
Assistive technology
any item, piece of equipment, or product system that is used to improve the functional capabilities of individuals with disabilities; this term encompasses both assistive devices and adaptive devices
Debilitated
impaired strength, weakened, injured, disabled
Extension
the return movement from flexion; the joint angle is increased
The 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.
Four microorganisms that contribute to infection in pressure ulcers are __________________________, ________________,__________________, and _______________.
-Streptococci -Staphylococci -Pseudomonas aeruginosa -Escherichia coli
List eight specialty rehabilitation programs accredited by the commission for the Accreditation of Rehabilitation Facilities (CARF)
-stroke recovery and traumatic brain injury -spinal cord injury -orthopedic -cardiac -pulmonary -pediatric -comprehensive pain management
List 5 major goals for rehabilitation that are associated with the nursing diagnosis of self-care deficit in activities of daily living (ADLs)
-Bathing/hygiene -dressing/grooming -feeding -toileting -Another goal is patient expression of satisfaction with the extent of independence achieved in self-care activities.
The nurse is using a measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting's, transfer, and ambulation. What would be the appropriate tool for the nurse to use. A. Barthel Index B. Patient evaluation conference system C. The PULSES profile D. The Braden Scale
A
Rehabilitation nursing
a branch of nursing focused on providing care to patients who have been incapacitated by illness or injury or are facing potentially life-altering health conditions throughout their lifespan
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.
Assistive device
a type of assistive technology that helps people with disabilities perform a given task
Adaptive device
a type of assistive technology that is used to change the environment or help the person modify the environment
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
Stage III Pressure Ulcer
-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. 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
Stage IV Pressure Ulcer
-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.
Functional Independence Measure (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 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.
Pressure ulcer
localized area of skin breakdown due to prolonged pressure and insufficient blood supply, usually at bony prominences
Impairment
loss or abnormality of psychological, physiologic, or anatomic structure or function at the organ level (e.g., dysphagia, hemiparesis); an abnormality of body structure, appearance, an organ, or system function resulting from any cause
Stage II pressure ulcer
-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 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
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.
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.
unstageable pressure ulcer
-Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed -Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. -Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Undermining
area of destroyed tissue that extends under intact skin along the periphery of a wound; commonly seen in shear injuries; can be distinguished from sinus tract in that there is a significant portion of the wound edge involved, whereas sinus tract involves only a small portion of the wound edge
Stage I Pressure ulcer
-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. 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
List 5 types of therapeutic exercises and describe the nursing activity required to support the exercise
;-Passive; Stabilize the proximal joint and support the distal part; move the joint smoothly, slowly, and gently through its full range of motion; avoid producing pain. -Active-Assistive; Support the distal part, and encourage the patient to take the joint actively through its range of motion; give no more assistance than is necessary to accomplish the action; short periods of activity should be followed by adequate rest periods. -Active; When possible, active exercise should be performed against gravity; the joint is moved through full range of motion without assistance; make sure that the patient does not substitute another joint movement for the one intended. -Resistive; The patient moves the joint through its range of motion, while the therapist resists slightly at first and then with progressively increasing resistance; sandbags and weights can be used and are applied at the distal point of the involved joint; the movements should be performed smoothly. -Isometric or Muscle Setting; Contract or tighten the muscle as much as possible without moving the joint, hold for several seconds, then let go and relax; breathe deeply.
