Chapter 11

Question 0

What is habilitation?

Answer 0

Patients adjust to disabilities by learning how to use resources and focusing on existing abilities.

Question 1

What is rehabilitation?

Answer 1

Making able again; relearning skills or abilities or adjusting existing functions.

Question 2

What is an impairment?

Answer 2

A loss of function, or an abnormality in structure or function.

Question 3

What is an adaptive device?

Answer 3

A type of assistive technology that is used to change the environment or help the person modify the environment- eg wheelchair accessible ramp.

Question 4

What is an assistive device?

Answer 4

A type of assistive technology that helps people with disabilities perform a given task.

Question 5

What are ADLs?

Answer 5

Self-care activities including bathing, grooming, dressing, eating, toileting and bowel and bladder care.

Question 6

What are IADLs?

Answer 6

Activities related to independent living, ex cooking, cleaning, shopping, doing laundry, managing personal finances, developing social and recreational skills, handling emergencies.

Question 8

What is assistive technology?

Answer 8

Any item, piece of equipment or product system used to improve the functional capabilities of individuals with disabilities- includes assistive and adaptive devices.

Question 9

What is the Americans With Disabilities Act?

Answer 9

Civil rights legislation providing people with disabilities access to jobs in the community.

Question 10

What are the most commonly reported chronic illness and disability triggered reactions?

Answer 10

Shock, anxiety, denial, depression, anger, hostility and adjustment.

Question 11

Who are the members of the rehabilitation team?

Answer 11

Nurses, physicians, nurse practitioners, physiatrists, physical therapists, occupational therapists, recreational therapists, speech-language therapists, psychologists, psychiatric liaison nurses, spiritual advisers, social workers, vocational counselors, orthotists and prosthetists, and sex counselors.

Question 12

What are the nurse’s roles in rehab?

Answer 12

Caregiver, teacher, counselor, patient advocate, case manager and consultant,

Question 13

What is included in the FIMTM (Functional Independent Measure)?

Answer 13

A tool used to assess patient’s level of independence. It measures 18 items. The self-care items include eating, bathing, grooming, dressing upper body, dressing lower body, toileting, bladder management, and bowel management. It includes transfer ability, ability to ambulate and climb stairs, communication and social cognition.

Question 14

What is the PULSES profile?

Answer 14

It assesses physical condition (health/illness), upper extremity function (eating/bathing), lower extremity function (transfer/ambulation), sensory function (vision/hearing/speech), bowel and bladder function, situational factors (social/financial support).

Question 15

What is the Barthel Index?

Answer 15

It measures patients’ level of independence in ADLs, continence, toileting, transfers, and ambulation.

Question 16

What is PECS (Patient Evaluation Conference System)?

Answer 16

It contains 15 categories, including medications, pain, nutrition, use of assistive devices, psychological status, vocation and recreation.

Question 17

What does the nurse assess?

Answer 17

The patient’s ability to perform ADLs.

Question 18

What are some major diagnoses?

Answer 18

Self-care deficit bathing/hygiene, dressing, feeding, grooming, toileting.

Question 19

What are the major goals in rehabilitation nursing?

Answer 19

Performing ADLs independently or with assistance, patient expressing satisfaction with level of independence in ADL performance.

Question 20

What are the types of nursing interventions?

Answer 20

Fostering self-care abilities, recommending adaptive and assistive devices, and helping patients accept limitations.

Question 21

What are some problems commonly associated with immobility?

Answer 21

Weakened muscles, contractures and deformity, altered ambulatory/mobility pattern.

Question 22

How can deformities and conctractures be prevented?

Answer 22

Proper positioning, and maintaining proper body alignment.

Question 23

How do you prevent external rotation of the hips?

Answer 23

A trochanter roll from the ilium to mid-thigh.

Question 24

How do you prevent foot drop?

Answer 24

90° positioning in wheelchair with feet flat on foot rests or floor, shoes, padded splits or protective boots when supine in bed and foot exercises.

Question 25

What are Range of Motion Exercises?

Answer 25

Moving a joint through its full range in all appropriate planes to maintain muscle strength and joint mobility.

Question 26

What are therapeutic exercises?

Answer 26

Prescribed by the physician and performed with the help of the physical therapist or nurse. When performed correctly they assist in maintaining and building muscle strength, maintaining joint function, preventing deformity, stimulating circulation, developing endurance and promoting relaxation.

Question 27

How does the nurse assist with patient transfers?

Answer 27

The nurse assesses the patient’s ability to assist and participate in transfer. The nurse or physical therapist teaches the patient how to transfer, and assist weak and incapacitated patients to transfer.

Question 28

How does the nurse help prepare patients for ambulation?

Answer 28

The nurse supervises exercise necessary to build muscle strength to ambulate, assesses for safety and stability and teaches patients how to use assistive devices.

Question 29

What are pressure ulcers?

Answer 29

Localized areas of dead soft tissue created by pressure on capillaries.

Question 30

What are risks for pressure ulcers?

Answer 30

▪️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 and excessively moist
▪️Advanced age, debilitation
▪️Equipment: casts, traction, restraints

Question 31

What are nursing diagnoses for impaired skin integrity?

Answer 31

Risk for impaired skin integrity and impaired skin integrity.

Question 32

What are nursing goals related to pressure ulcers?

Answer 32

Relief of pressure, improve mobility, improved sensory perception, improve nutrition, improved tissue perfusion, minimize friction and shear forces, try surfaces in contact with skin, and healing pressure ulcers, if present.

Question 33

How can pressure be relieved?

Answer 33

Frequent position changes.

Question 34

How often must be patient be repositioned?

Answer 34

If the patient can shift their weight every 15 to 20 minutes, they may be repositioned every 2 to 4 hours. If they cannot shift their own weight, they must be repositioned at least every two hours.

Question 35

What are some pressure relieving devices?

Answer 35

Special wheelchairs, special mattresses, and padding devices for bony prominences.

Question 36

Why should a nurse not massage already reddened areas?

Answer 36

It may increase tissue trauma.

Question 37

Which nutrients are necessary to improve and maintain tissue health?

Answer 37

Protein, vitamin A, vitamins B, vitamin C, sulfur, zinc.

Question 38

How can friction be reduced?

Answer 38

By not raising the bed higher than 20° and by lifting instead of pulling the patient.

Question 39

How do stage one pressure ulcers heal?

Answer 39

The pressure is removed, nutrition and electrolyte and fluid balance are maintained, fiction is reduced, and moisture to skin is avoided.

Question 40

How do stage two pressure ulcers heal?

Answer 40

In addition to stage one interventions, a moist environment should be provided, The wound is gently cleaned with saline and covered with a semi permeable dressing.

Question 41

How do stage III and stage IV pressure ulcers heal?

Answer 41

In addition to stage one interventions, stage III and stage IV pressure ulcers require debridement, which is painful and requires analgesia.

Question 42

How can recurrence of pressure ulcers be prevented and why is it so important?

Answer 42

Recurrence should be anticipated, and the patient should be allowed to increase the time sitting or lying on the healed area in 5 to 15 minute increments.

Question 43

What is the goal in bladder training?

Answer 43

To restore the bladder to normal function.

Question 44

Which beverages are encouraged during bladder training, and which beverages are discouraged during bladder training?

Answer 44

Acid producing drinks such as cranberry and cranapple juice are encouraged, however soft drinks, alcohol, milkshakes, tomato juice, and citrus juices are discouraged because they promote growth in urine.

Question 45

What are some components of a bladder training program?

Answer 45

Planning a voiding schedule, providing privacy, recording bladder voiding successes and episodes of incontinence, pelvic floor exercises, supra pubic tapping, or stroking of inner thigh.

Question 46

What type of urinary catheters are available?

Answer 46

Intermittent self catheterization is preferable to foley/indwelling catheters, and there are also suprapubic catheters.

Question 47

How is bowel continence promoted?

Answer 47

A regular time for defecation is scheduled, and a suppository or mechanical stimulation may be used.

Question 48

How can constipation be avoided?

Answer 48

Increase in dietary fiber and dietary fluids, and physical activity. Patients are encouraged to respond to the natural urge to defecate. Stool softeners, bulk forming agents, mild stimulants, and suppositories maybe prescribed.

Question 49

What are some areas of specialty rehabilitation?

Answer 49

Stroke recovery, traumatic brain injury recovery, spinal cord injury rehabilitation, orthopedic rehabilitation, cardiac rehabilitation, pulmonary rehabilitation, comprehensive pain management programs, comprehensive burn management programs, pediatric rehabilitation programs.