PHYSICAL MEDICINE AND REHABILITATION • The quality of medical care that can be provided for a patient in a designated rehabilitation service may be dependent to a degree on the quality of nursing care that is available constantly during the restoration process. • The factors that may deserve consideration are 1. The functions and responsibilities that are peculiar to nursing and no other discipline 2. Relationship of nurses to allied professional groups 3. Contributions of nursing towards total rehabilitation care • In rehabilitation nursing the nurse is once a nursing practitioner, a nursing educator, and, at times, a nursing coordinator. • Examples 1. An aphasic hemiplegic patient who is undergoing speech therapy may be aided markedly by rehab nursing person. In ward situation every opportunity can be utilized to promote communication for the patient and thus provide continuity of speech practice not otherwise possible. 2. Ambulation training a part of physical therapy can be carried over into the ward by a coordinating nurse. Nursing practice in rehabilitation • Techniques related to maximum mental and physical health. 1. Basic procedures of all nursing care 2. Provide good hygiene and sanitary environment 3. Wholesome and happy climate 4. Proper rest and sleep 5. Adequate nutrition 6. Diversional occupation Technics to prevent deformities 1. Contractures once developed impede progress of rehab program 2. Institute effective posture technics 3. Apply principles of body alignment and correct positioning of the patient 4. Use of mechanical aids e.g. footboards, bed boards, sandbags, pillows etc. to position patient properly and thus prevent foot drop, wrist drop, claw hand etc. 5. May initiate simple preventive exercises to maintain muscle tone and strengthen muscles 6. May initiate early program of self care activities such as teaching patient to wash his face, comb his hair, brush teethetc. Technics that apply to self care problems • Bed and wheelchair activities • Dressing and undressing • Feeding • Bathing • Toileting • Rehab nurse must possess knowledge and adeptness in use of mechanical devices such as wheelchairs, braces, prosthesis, crutches, canes and self help aids. Technics that apply to elimination of body wastes • Bladder management objectives 1. To determine whether patient can void after the catheter is removed 2. How well the patient empties his bladder 3. Residual urine 4. Obtain better urinary control 5. Obtain maximum cleanliness 6. Alleviate emotional stress associated with incontinence 7. Obtain max comfort 8. aid in prevention of decubitus ulcers Clean intermittent self catheterization • Clean Intermittent Self-Catheterization (CISC) is a way to empty the bladder by using a clean catheter. It involves putting the catheter in and taking it out several times a day. • CISC helps people who cannot empty their bladders the usual way. By emptying bladder regularly, you can help prevent bladder infections. Preparing for CISC • Equipment • Straight catheter . • A new catheter is needed about once a month or when the one you use is brittle. • Soap and water • Clean washcloth • Water-soluble lubricant • Do not use a petroleum-based lubri - cant such as Vaseline. • Plastic bag for used catheters • Plastic bag for clean catheters • Urinal (if measuring urine) Instructions to the patient 1.Gather equipment and place it on a clean towel. 2. Urinate if you can. 3. Prepare your clothing. Make sure your clothes are away from your body and that you have enough light to see well. 4. Wash your hands well with soap and water. This reduces bacteria and prevents infection. 5. Lubricate the catheter's end to ease insertion. 6.Wash the end of the penis thoroughly with soap and water. This reduces bacteria and prevents infection. • 7. Grasp the penis, hold it erect, and insert the catheter slowly about 6 inches. Once urine starts to flow, advance the catheter about 1 inch. If you feel resistance, just stop for a second, take a deep breath, and gently resume insertion. • 8. Place the other end of the catheter into a urinal or container. • 9. Allow all urine to drain. Measure drainage if an output record is needed (see sample record). • 10. After urine flow stops, remove the catheter slowly. Continue to hold the penis and catheter upright. • 11. First, rinse the catheter with cold water to remove any mucous deposits. • 12. Then, wash the catheter with liquid soap and hot water, and allow it to dry completely in the air. Store the catheter in a clean, dry, safe location. Bowel management • Goals 1. To establish periodic pattern of bowel evacuation on a regular time schedule 2. To prevent constipation and bowel impaction
Start bowel training as soon as feasible after admission
Select most suitable time for bowel evacuation Prepare patient for training and elicit his cooperation Instruct the patient concerning his diet and fluid intake Encourage mobility Teach digital stimulation and digital evacuation Digital stimulation • Digital stimulation is a way to empty the reflex bowel after a spinal cord injury. It may also be called a "dil." It involves moving the finger or dil stick around in a circular motion inside the rectum. By doing this, the the bowel reflex is stimulated and the rectal muscles open and allow the stool to leave the body. • This procedure is best done on people who do not have painful sensation in the rectal area. Pressure may be felt in the rectal area, but it should not be painful. The dil should be done at the same time every day or every other day to stay on a schedule and avoid bowel accidents. The time and how often a dil is done depends on the individual. Procedure • Put gloves on both hands or place place dil stick in the hand. • Lubricate pointing finger or dil stick (whichever will be entering the rectum). • Gently put finger or dil stick into the rectum past the muscle. • Gently move the finger or dil stick around in a circular motion. • When the stool begins to empty from the rectum, move the finger or dil stick to one side or remove so the stool can pass. • Do this for at least 20 minutes if no stool is coming. If stool is produced, do the dil as long as the stool is coming dil and for five additional minutes afterward without getting any more stool. • You may need to gently remove stool from rectum with your finger if it does not come out on it's own.(Digital Evacuation) Decubitus ulcers • Most often as a result of prolonged pressure on bony prominences • Tissue ischemia • Early warning signs include reddened skin areas, blister formation • Positioning the patient from side to side and from supine to prone every 2 hours Pressure ulcer prone areas Patient education • Examine skin surfaces thoroughly every day for reddened areas • Bath daily with warm water and soap • Particular attention to lower back, buttocks, hips, feet and heels • Use foam rubber pillow or pad • Change positions frequently • Report signs of broken skin areas • Keep skin dry all times • Examine genital area for redness or ulceration • Watch the braces • Do frequent pushups in the wheelchair • High protein diet Tilt table • To enable paralysed patient assume erect position • To prevent contractures and deformities • To prevent deconditioning effects of prolonged bed rest such as loss of muscle tone, urinary calculi and UTI, decubitus ulcers Community implications of rehab nursing • Educating the patient 1. Fundamental health principles 2. Necessity for cleanliness 3. Moral factor in wearing attractive clothing 4. Need for good grooming 5. Basic elements of mental and physical hygiene 6. Good nutrition 7. Bladder and bowel training 8. Motivate patient to persevere in performing the activities of daily living without assistance from over protective family members 9. Proper care of braces and wheelchair 10. Interpreting patient needs to his family