Rehabilitation & Assistive Devices

Rehabilitation

• Assists ill or disabled individuals in achieving their highest possible level of overall functioning

Assists

• With physical, mental, spiritual, social, and economic aspects

Nursing Considerations

• Physical
• Psychological
• Coordination
• Safety
• Resources

Assistive Devices

• Also known as mechanical aids
• Any equipment or product system enhances functional capabilities of individuals with disabilities

Walker: Purposes

• Maintains balance
• Provides increased support via a broader contact area with the floor
• Facilitates some degree of independent mobility

Walker: Advantages

• A very stable mobility aid

Walker: Disadvantages

• Bulky
• Unsuitable in confined spaces, narrow staircases, and crowded environments

Types of Walkers

• Pick-up walker (without wheels)
• Rolling walker (with wheels)

Proper Use of Walkers

• Handgrips at wrist height when arms hang at the side
• Elbows flexed 20-30 degrees when gripping the walker
• Use sturdy, well-fitted shoes

Getting Up and Sitting Down with Walker

• Place both hands on the chair's armrests
• Use arms to push to a standing position before grasping the walker
• To sit, reach back to grasp armrests and sit carefully

Walking with Walker

• Advance the walker
• Lift the affected foot off the ground
• Swing the unaffected foot forward
• Sequence: walker, bad foot, good foot

Going Up Stairs with Walker

• Fold the walker
• Position it opposite the stair railing
• Place the front two legs of the walker on the first step
• Move the stronger leg onto the first step
• Lift the weaker leg to the same step
• "Up with the good, down with the bad" rule

Going Down Stairs with Walker

• Position the walker opposite the stair railing
• Place the front two legs of the walker on the first step
• Move the weaker leg onto the first step
• Lower the stronger leg to the same step

Crutches: Purposes

• Support body weight
• Assist weak muscles
• Offer joint stability
• Relieve pain
• Prevent further injury
• Improve function
• Promote greater independence

Crutches: Types

• Underarm/axillary
• Loftrand
• Platform

Crutch Parts

• Crutch Pad/Axillary Bar: Should be 1.5-2 inches or 3 fingerbreadths below the axilla
• Hand Grip: Should maintain a 30-degree angle to allow elbow flexion
• Crutch Tip/Rubber Tip: Positioning should be 4 inches anteriorly and 6 inches laterally from the toes

Crutch Stance

• Tripod Position: Should be 4 inches anteriorly and 6 inches laterally from the toes

Safety Tips for Using Crutches

• Ensure padding is intact on the top and bottom of the crutches
• Follow doctor's recommendations for weight-bearing on injured leg
• Ensure all nuts are securely tightened after height adjustments
• Wear supportive shoes or go barefoot (avoid loose footwear)
• Avoid walking on wet surfaces

Safety Considerations for Crutch Use

• Remove throw rugs to prevent slips
• Adjust crutch height while standing
• Place crutch tips 6 inches from the toes
• Maintain 2-3 finger width space between armpit and crutch top
• Keep wrist level with handgrip, with a slight elbow bend
• Avoid excessive pressure on axillae when walking
• Stand upright

Four-Point Gait: Indications

• Weakness in both legs
• Poor condition
• Conditions like polio, arthritis, or cerebral palsy

Four-Point Gait: Advantages

• Provides excellent stability with three points of ground contact always

Four-Point Gait: Disadvantages

• Slowest and most stable pattern

Four-Point Gait: Requirements

• Requires both crutches or canes
• Sequence: right crutch, left leg, left crutch, right leg

Three-Point Gait: Indications

• Impairment in one extremity like lower extremity fracture, amputation, or pain
• Must be able to bear full weight on the unaffected extremity

Three-Point Gait: Requirements

• Two crutches, two canes, or a walker is required
• Sequence: both crutches then bad leg, then good leg

Two-Point Gait: Advantages

• Allows for natural arm and leg movements during gait

Two-Point Gait: Disadvantages

• Requires more balance due to two points of support
• Resembles normal walking through progression of four-point gait

Two-Point Gait: Requirements

• Both crutches and canes are required
• Sequence: advance right crutch/left leg, then advance left crutch/right leg

Tripod Gait

• Teaches swing patterns; useful for patients with paraplegia learning to swing

Tripod Gait: Requirements

• Right crutch, left crutch, drag both legs

Swing-To Gait

• Both crutches are advanced together, then weight shifted to hands with legs swung to meet crutches

Swing-To Gait: Indications

• Limited use of both lower extremities and trunk instability

Swing-To Gait: Requirements

• Both crutches and walkers are used

Swing-Through Gait

• Both crutches are advanced and weight shifted, legs swung forward beyond crutch placement

Swing-Through Gait: Indications

• Bilateral lower extremity involvement and trunk instability (paraplegia, spinal bifida)

Swing-Through Gait: Considerations

• Faster gait
• Not as safe as swing-to
• Involves passing of crutches

Key Points for Swing-To and Swing-Through Gaits

• Used for bilateral lower extremity involvement and trunk instability
• Not as safe as swing-to gait
• Fastest gait pattern
• Patient passes through crutches
• Sequence: both crutches, swing both legs (passing through)

Summary of Gait Types: Four-Point

• Slowest and most stable gait pattern

Summary of Gait Types: Three-Point

• One leg affected

Summary of Gait Types: Two-Point

• More difficult and normal walking is imitated

Summary of Gait Types: Tripod

• For paraplegic patients learning to swing

Summary of Gait Types: Swing-To

• Involves no passing through with crutches

Summary of Gait Types: Swing-Through

• Fastest pattern that passes through crutches

Canes: Purpose

• Used to improve balance and support

Canes: Consideration

• Rubber caps to prevent slipping

Types of Canes

• Single tip/standard straight
• Quad cane

Walking with a Cane

• Adjust cane length to greater trochanter level (30 degrees elbow flexion)
• Hold cane on stronger side unless instructed otherwise
• Step forward with cane, followed by injured/weak leg, keeping them aligned
• Advance stronger leg

Walking with a Cane: Sequence

• Cane, bad leg, good leg

Going Up Stairs with a Cane

• Cane goes to opposite side of the injured leg
• Hold the handrail with free hand
• Step up with the strong leg first, then the injured leg
• Good leg, bad leg & cane

Going Down Stairs with a Cane

• Place the cane on the next step, then injured leg, followed by the stronger leg
• Cane, bad leg, good leg

Remember

• Up with the good, down with the bad

Moving Patients: Assessment Needed before Moving a Client

• Physical abilities
• Muscle strength
• Presence of paralysis
• Skin traction
• Cast extremities
• Ability to understand instructions
• Client’s weight
• Medications
• Personal strength and abilities
• Observe proper body mechanics

Moving Patients: Preparation

• Greet and identify client
• Explain procedure
• Adjust IV pole position as well as catheter position
• Arrange hearing aid and glasses
• Lower head of bed
• Lock wheels, pillow near headboard
• Facilitate a supine position, flex knees

Moving Patients: Using Trapeze

• Assist client with grasping; place one arm under thighs and one under trunk
• Have the patient lift when you count to three
• Adjust for comfort

Moving Patients: Using One Nurse

• Place arms appropriately to push shoulders of client as well as the upper back
• Push when client pushes on the count of three

Moving Patients: Rolling Procedures

• Used for spinal alignment and neck maintenance
• Determine staff
• Lower bed
• Use pull sheet to facilitate turning
• Cross arms

Moving Patients: Rolling Procedures (Continued)

• Position nurses to turn the client
• Pull sheet
• All individuals should be turned in synchronization
• Use pillows

Assistive Device: Wheelchair Brakes

• Check for wear and tear regularly
• Engage before forward movements
• Don’t reach
• Don’t tilt

Assistive Device: Wheelchair Straps

• Always use seat positioning
• Maintain course
• Avoid escalators or curbs
• Follow instructions

Assistive Device: Adjustments

• Select a safe speed
• Avoid greasy surfaces

Assistive Device: Ramps

• Switch the wheelchair off

Transferring a Hemiplegic Patient from Bed to Wheelchair Preparations

• Assess for paralysis
• Bed should be wheelchair height
• Locking
• Position wheelchair on the unaffected side

Paralysis: Hemiplegia

• Affects one side

Paralysis: Diplegia

• Affects both sides, with greater impact on legs than arms

Paralysis: Monoplegia

• Only one limb is affected, often an arm

Paralysis: Triplegia

• Three limbs affected

Paralysis: Quadriplegia

• All four limbs are affected

Abdominal Assessment: Health History

• Inquire about abdominal diseases and family history of abdominal disease
• Describe usual bowel patterns and characteristics
• Ask about problems with weight, appetite, food tolerance, belching, nausea, or vomiting

Abdominal Assessment: Health History (Part 2)

• Ask about; pain or indigestion with eating, difficulty swallowing, diarrhea or constipation and bowel incontinence
• Ask about; flatulence, changes in bowel habits or stool, and history of hemorrhoids
• Ask about; rectal pain/itching, pain in the abdomen, ascites, and jaundice

Abdominal Assessment: Key Terms; Emesis

• Vomiting

Abdominal Assessment: Key Terms; Hematemesis

• Vomiting of blood

Abdominal Assessment: Key Terms; Dysphagia

• Difficulty swallowing

Abdominal Assessment: Key Terms; Odynophagia

• Painful swallowing

Abdominal Assessment: Key Terms; Satiety

• Feeling of having had eaten enough food

Subdivisions of Abdomen; Right Upper Quadrant

• Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, and the hepatic flexure of the colon
• Contains parts of the ascending and transverse colon

Subdivisions of Abdomen; Left Upper Quadrant

• Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, and the splenic flexure of the colon
• Contains parts of the transverse and descending colon

Subdivisions of Abdomen; Right Lower Quadrant

• Cecum, appendix, right ovary and fallopian tube, right ureter, and the right spermatic cord

Subdivisions of Abdomen; Left Lower Quadrant

• Parts of the descending colon, sigmoid colon, left ovary and fallopian tube, left ureter, and the left spermatic cord

Nine Abdominal Regions

• To remember the regions, think hypo, lumbar, and iliac

Abdominal Assessment; Right Hypochondriac Region

• Ascending colon
• Gallbladder
• Liver
• Right kidney
• Small intestine
• Transverse colon

Abdominal Assessment; Epigastric Region

• Esophagus
• Liver
• Pancreas
• Right & Left adrenal glands
• Right & Left kidneys
• Small intestine
• Spleen
• Stomach
• Transverse colon

Abdominal Assessment; Left Hypochondriac Region

• Descending colon
• Left kidney
• Liver
• Pancreas
• Small intestine
• Spleen
• Stomach
• Transverse colon

Abdominal Assessment; Right Lumbar Region

• Ascending colon
• Gallbladder
• Liver
• Right kidney
• Small intestine

Abdominal Assessment; Umbilical Region

• Cisterna chyli
• Pancreas
• Right & Left kidneys
• Right & Left ureters
• Small intestine
• Stomach
• Transverse colon

Abdominal Assessment; Left Lumbar Region

• Descending colon
• Left kidney
• Small intestine

Abdominal Assessment; Right Iliac Region

• Appendix
• Cecum & ascending colon
• Right fallopian tube
• Right ovary
• Small intestine

Abdominal Assessment; Hypogastric Region

• Prostate
• Rectum
• Right & left fallopian tubes
• Right & left ovaries
• Right & left ureters
• Seminal vesicle
• Sigmoid colon
• Small intestine
• Urinary bladder
• Uterus
• Vas deferens

Abdominal Assessment; Left Iliac Region

• Left fallopian tube
• Left ovary
• Small intestine
• Descending colon
• Sigmoid colon

Abdominal Assessment; Vascularity Normal

• Scattered fine veins
• Old, silvery, white striae

Abdominal Assessment; Vascularity Abnormal

• Dilated veins
• Red striae

Abdominal Assessment; Skin Characteristics - Normal

• Pale, smooth, minimally raised scars
• Free of lesions or rashes
• Flat moles, surgical scars may be present
• Good skin turgor

Abdominal Assessment; Skin Characteristics - Abnormal

• Non-healing scars
• Redness, inflammation, changes in moles
• Skin glistening and taut, petechiae, cutaneous angiomas

Abdominal Assessment; Skin Color

• Look for Cullen’s and/or Grey Turner’s sign (internal bleeding)

Abdominal Assessment Contour

• Abdominal girth describes the nutritional state
• The abdomen may also be flat, rounded, protuberant or scaphoid or concave

Abdominal Assessment: Key Components

• Inspection
• Auscultation
• Percussion
• Palpation

Abdominal Assessment: Preparation

• Empty bladder
• Short fingernails
• Equipment: Stethoscope, ruler, marker
• Ensure; warm and comfortable environment with warm hands
• Supine patient position with flexed knees and pillow

Abdominal Assessment: Inspection - Normal

• Lighter than the general skin tone

Abdominal Assessment: Inspection - Abnormal

• Purple
• Yellow
• Pale
• Redness
• Bruises

Abdominal Assessment: Auscultation - Normal

• Auscultation of bowel sounds- intermittent, soft clicks cascading and gurgles
• 5-30/min, and stomach growling

Abdominal Assessment: Vascular Sounds(steth) - Normal

• Should be without bruits

Abdominal Assessment: Auscultation - Abnormal

• Auscultation of bowel sounds may be - hypo/hyperactive
• If absent, auscultate for 5 minutes before concluding absent

Abdominal Assessment: Percussion - Normal Finding

• Tympany- Gas in stomach or intestine
• Dullness - fluid or feces

Abdominal Assessment:Percussion - Abnormal Finding

• Hyper-Resonance and Enlarged Area of Dullness or Hepatomegaly

Abdominal Assessment: Percussion Height - Important Note

• Perform Left Lower Border and Ultrasound Border measurements
• Normal findings depend upon if medium or higher level

Palpations - Normal

• Soft, nontender, without masses and bowel sounds are normal

Aorta Characteristics: (Normal)

• Around 2.5-3 wide with a moderately strong and regular pulse

Liver Characteristics

• Liver should not be palpable, it is normal to find mild tenderness there

Spleen Palpations

• Should not be palpable

Kidneys Characteristics: Normal

• Should not be palpable

Appendicitis Test: Bumbergs Sign

• Also known as Rebound Tenderness
• Expect Stabbing Pain when Pressure is Released

Appendicitis Test: Rovsing Sign

• Expect Pain in the RLQ During Pressure in the LLC

Psoas Sign

• Test will check patient’s right leg strength through assisted pressure to the lower thigh

Obturator Sign

• Pain can be expected as the hips and legs are rotated internally.

Nervous System and Cranial Nerves: Perception and Coordination

• Perception: Awareness of stimuli from the environment through the senses
• Coordination: Occurs in the cerebellum; processes of synchronizing contraction of muscles for movement
• Harmonizing parts for a response
• Sight

Sight (Steps Listed

• Sensory cells (rods/black & cones/color)
• Light enters cornea ->aqueos humor->lens->vitreous humor->retina-> rods & cones -> axons of optic nerve -> impulses are carried by nerve fibers -> optic chiasm (fibers cross over) ->nerve fibers called optic tracts -> connect to thalamus and axons form optic radiation which run to the occipital lobe, forming visual interpretation

Smell Process

• Air enters nose -> chemicals in air touch olfactory hairs -> nasal epithelium -> olfactory bulb -> olfactory tract -> olfactory nerve impulses run toward hypothalamus -> connect to the frontal lobe -> smell interpretations

Nervous System Composition and Function

• Neurons are responsible for communicating information through chemical and electrical means
• Sensory neurons: Carry information to the brain
• Motor neurons: Transmit from the brain to muscles
• Interneurons: Communicate different neurons in the body

Neurologic Assessment: Cognitive and Motor Control

• Controls; cognitive and voluntary response
• Affects; involuntary bodily response

Levels of Consciousness: Subtle Deterioration

• Examination for subtlety is required for deterioration
• Monitor

Aspects of Consciousness

• (Arousal and Awareness): includes Orientation vs. Disorientation
• Person, Place and Time

Category of L OC: Full

• Patient is alert/attentive to commands

Category of L OC: Lethargic

• Patient is drowsy but awakens/follows commands
• Question slowly but attentively

Category of L OC: Obtundation

• Difficult to arouse but need constant stimulation

Category of L OC: Stupor

• Arouse to stimulus/pain
• Follow certain commands

Category of L OC: Coma

• Lack of stimulation, no pain, deep state of unconsciousness

Location of Decerebration

• Abnormal posturing in Brainstem patients
• Involves dysfunction of the Brainstem

Location of Decortication

• Is abnormal posturing in lesions in pathways connecting brain to spinal cord.

Neurological Assessments: GlasCow Coma Scale

• Spontaneous Eye Opening score of 4
• Response Eye Opening score of 3
• A response for pain Eye Opening score of 2
• If no eye opening Eye Opening score of 1

Neurological Assessments: GlasCow Coma Scale

• Oriented Verbal response score of 5
• Response score of 4= Confusion, discomfort
• An invalid word Verbal response score of 3
• A Incomprehensible sound verbal response score score of 2
• If there Verbal response is none a verbal response score of 1

Neurological Assessments: Best Motor Response-

• If commands are obeyed: has a score of 6
• Localized pain Motor Response has score of 5
• When withdrawing due to Flexion:Motor Response gets a the score of 4
• Decorticate has score of 3
• Motor Response by flexing Extension gives a score of 2
• A Flaccid response gives score of one.

Glasgow Coma Motor: Important Key Factors

• Highest/Best GCS score possible: 15
• Indicates when coma has occurred < 8
• Lowest score can be: 3

Glasgow Coma w/ Severity

• Injuires range 3-8: Severe
• Injuires range 9-12: Moderate
• Injuires range 13-15: Mild

The Twelve Cranial Nerves

• Is a long list and you should know them all

Mmixed Fxn Cranial Nerves: Trigeminal

• Chewing, face & mouth, touch & pain, corneal reflex
• Sensory

Cranial Nerves: Facial

• A Mixed fnxn: facial expression, tears & saliva, taste.
• Sensory; taste Glossopharyngeal
• Gag reflex Tastes carotid BP

Cranial Nerves: Vagus

• Impulses for sensations to lower pharynx and Larnyx and sensory and motor Fxn for visceral organs.

Cranial Assessment: Olfactory nerve assessment-

• Determine client ability to identify odors!

Cranial Assessment: Nerve Optic

• 2. Test for acuity with a Snellen chart as well to eyesight & Peripheral vision
• Disc with an ophthalmoscope
• Look for pupil symmetry to light
• Note eye assessment to light

Cranial Assessment: Nerves Trochlear Abducens

• Move up and down or laterally following you.
• Six Positions of Cardinal Gaze

Cranial Nerves:

• Motor by performing a cheek and chin touch

Motor C5 is by performing what

• Assess chewing strength to bite.

Cranial Nerve: VII and what

• The symmetry for facial movements to smile frown while clenching Teeth & assess
• Ask about clients ability to different distinct Flavors

Cranial N VII assess what

• Ask client to different Flavors

Cranial Nerve: Glasgow

• Test the clients hearing and listen to the sound

Glasgow Hearing Test

• Webber and River

Cranial Nerve IX

• Motor skill test for range sides tongue. Test gag reflex too by gently pressing tongue with the appressor

Glasgow Nerve: X

• Ask client about vocal cord cord movement and note their speech in regards to Hoarseness
• XI: Ask client’s shoulders while they shrug for resistance and Sternocleidomastoid muscle assess as well.

XI

• Sternocleidomastoid muscular assist & also test tongue XII: For Elevation symmetry tremors elevations side and side

Cerebellar Function & Deep Tendon Reflexes: Finger-To-Nose Test

• With both hands, alternate to nose repeatedly
• Tests for coordination and speed to nose.
• missing mark dysmetria show indicator of disease

Rapid Alternating Hand and And Finger movements

• Hands move towards and from on thigh
• Test with speed and can test other hand
• Dysdiadokinesia indication for Cerebellar

Heel-To-Shin Test

• From one foot on heel to down on Shin
• Note patients ability, and ensure a Straight line
• Test for cerebellum too

Romberg's Test

• Balance assessment test

Tandem Gait

• Assessment by tandem skill and difficult tasks

Deep Tendon Reflexes:

• Biceps = The test with sharp tap

Deep Tendon Reflexes Reflex:Triceps

• Identified the triceps Tendon for tapping just above

Brachioradial is Reflex

• Support Pat’s Elbow. Note Reflex tap
• Fingers for Flex on Finger reflex tap or test there.
• Note ForeArm Extension while on the Leg
• Check for tendon as well & dorsiflex

Reflex Scores

• Scale from 0-1
• With no retest & test clonus
• Check or report Reflex scores if any overactivity to clench there flex

Testing Clonus Assessment

• Sharp Doral Felx from test lower, with dorsalflex note.

Cast Term - Indications of Cast for Fracture for healing:

• Correct if any abnormalities for Fracture.
• Hold the Fracture Bones as heal!
• immobilize is required esp post surgery
• Prevent muscles from constriction when there is limb for mking limbs artificial

Outside and material for types for costs:

• Plaster of Paris(White, gypsum sulphate, take 1-3 days too dry, and is Resonant, Odorless
• Shiny: Lighter in weight), or Fiberglass (Variety, moldable, dries quick)

Cost Application Steps

• Follow and make adjustments, using application, for cost
• Always make sure to: support finger tips!

Cast Application

• Be sure to check the above for any abnormalities

Cast Care While its Dry

• Key factor is to keep cost uncovered!

Cast Care Instructions

• -Report cracks and never pad skin!
• report break or any discomforts!
• Use Hairdryer for cool setting so patient isn’t itchy
• Don’t place powders
• Be attentive too elevation so is reduce of any infection!

Key Nursing terms for medical assessment

• Material/Instruments Cost application
• Always place stockinet, PlasterFiberglass for the materials, gauze
• Have paper to keep the area clean

Cast for Pettaling Assessment

• Use cost tape & follow for correct indications
• Apply and peel and avoid tape for irritation

Assessing a Cast Extremity is very important when assessing pain

• Check if there test is by increased sensation.
• Look side by location, characteristics as assessment is performed
• Elevate the test & any analgesic if prescribed

Blood and Supply

• perform cap refill by assessing what’s on the exterior

Temperature & Assess

• by touch by assessing temp
• Is it by the fingers or toes?

Neuro Func

• Ask clients to know whether what feel side toes are moveable

• Cast Techniques: Performing a Division on it

• Perform Bivalving or portion to half when extremity can be lifted