Flashcards in Chapter 11 Deck (49):
What is rehabilitation?
Making able again; relearning skills or abilities or adjusting existing functions.
What is habilitation?
Patients adjust to disabilities by learning how to use resources and focusing on existing abilities.
What is an impairment?
A loss of function, or an abnormality in structure or function.
What is an adaptive device?
A type of assistive technology that is used to change the environment or help the person modify the environment- eg wheelchair accessible ramp.
What is an assistive device?
A type of assistive technology that helps people with disabilities perform a given task.
What are ADLs?
Self-care activities including bathing, grooming, dressing, eating, toileting and bowel and bladder care.
What are IADLs?
Activities related to independent living, ex cooking, cleaning, shopping, doing laundry, managing personal finances, developing social and recreational skills, handling emergencies.
What is assistive technology?
Any item, piece of equipment or product system used to improve the functional capabilities of individuals with disabilities- includes assistive and adaptive devices.
What is the Americans With Disabilities Act?
Civil rights legislation providing people with disabilities access to jobs in the community.
What are the most commonly reported chronic illness and disability triggered reactions?
Shock, anxiety, denial, depression, anger, hostility and adjustment.
Who are the members of the rehabilitation team?
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.
What are the nurse's roles in rehab?
Caregiver, teacher, counselor, patient advocate, case manager and consultant,
What is included in the FIMTM (Functional Independent Measure)?
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.
What is the PULSES profile?
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).
What is the Barthel Index?
It measures patients' level of independence in ADLs, continence, toileting, transfers, and ambulation.
What is PECS (Patient Evaluation Conference System)?
It contains 15 categories, including medications, pain, nutrition, use of assistive devices, psychological status, vocation and recreation.
What does the nurse assess?
The patient's ability to perform ADLs.
What are some major diagnoses?
Self-care deficit bathing/hygiene, dressing, feeding, grooming, toileting.
What are the major goals in rehabilitation nursing?
Performing ADLs independently or with assistance, patient expressing satisfaction with level of independence in ADL performance.
What are the types of nursing interventions?
Fostering self-care abilities, recommending adaptive and assistive devices, and helping patients accept limitations.
What are some problems commonly associated with immobility?
Weakened muscles, contractures and deformity, altered ambulatory/mobility pattern.
How can deformities and conctractures be prevented?
Proper positioning, and maintaining proper body alignment.
How do you prevent external rotation of the hips?
A trochanter roll from the ilium to mid-thigh.
How do you prevent foot drop?
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.
What are Range of Motion Exercises?
Moving a joint through its full range in all appropriate planes to maintain muscle strength and joint mobility.
What are therapeutic exercises?
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.
How does the nurse assist with patient transfers?
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.
How does the nurse help prepare patients for ambulation?
The nurse supervises exercise necessary to build muscle strength to ambulate, assesses for safety and stability and teaches patients how to use assistive devices.
What are pressure ulcers?
Localized areas of dead soft tissue created by pressure on capillaries.
What are risks for pressure ulcers?
▪️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
What are nursing diagnoses for impaired skin integrity?
Risk for impaired skin integrity and impaired skin integrity.
What are nursing goals related to pressure ulcers?
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.
How can pressure be relieved?
Frequent position changes.
How often must be patient be repositioned?
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.
What are some pressure relieving devices?
Special wheelchairs, special mattresses, and padding devices for bony prominences.
Why should a nurse not massage already reddened areas?
It may increase tissue trauma.
Which nutrients are necessary to improve and maintain tissue health?
Protein, vitamin A, vitamins B, vitamin C, sulfur, zinc.
How can friction be reduced?
By not raising the bed higher than 20° and by lifting instead of pulling the patient.
How do stage one pressure ulcers heal?
The pressure is removed, nutrition and electrolyte and fluid balance are maintained, fiction is reduced, and moisture to skin is avoided.
How do stage two pressure ulcers heal?
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.
How do stage III and stage IV pressure ulcers heal?
In addition to stage one interventions, stage III and stage IV pressure ulcers require debridement, which is painful and requires analgesia.
How can recurrence of pressure ulcers be prevented and why is it so important?
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.
What is the goal in bladder training?
To restore the bladder to normal function.
Which beverages are encouraged during bladder training, and which beverages are discouraged during bladder training?
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.
What are some components of a bladder training program?
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.
What type of urinary catheters are available?
Intermittent self catheterization is preferable to foley/indwelling catheters, and there are also suprapubic catheters.
How is bowel continence promoted?
A regular time for defecation is scheduled, and a suppository or mechanical stimulation may be used.
How can constipation be avoided?
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.