Rehab Skills

1. Rehab Skills Megan Lynch, MSPT

3. Overview Basic Restorative services Training clients in self care according to abilities Needs of patients with limited functions Speech Physical Basic body mechanics Transfers Use of assistive devices in transferring, ambulation, eating, and dressing

4. Continued Overview Prevention of pressure ulcers Proper Positioning and Mobility in bed and chair Range of Motion (Passive and Active) Exercise programs Use of shower chair

5. Overview Dealing with patients who have one-sided weakness Adapting the environment Feeding

6. Skills Check off: Thursday Basic Body Mechanics Protect yourself from back injury Ambulation Use of Gait Belt Use of Assistive Device

7. Skills Check off: Thursday Transfers Bed to chair Chair to bed Bed to BSC Wheelchair to chair

8. Skills Check off: Thursday Bed Mobility Turning and scoot in bed Positioning in bed Use of Pillows Proper patient positions for comfort Prevention of Pressure Ulcers Skin checks

9. Skills Check off: Friday Active Range of Motion Passive Range of Motion Home exercise program, Theraband Home Adaptations

10. Skills Check Off: Friday Use of DME equipment Hoyer Lift Wheelchair Walker Shower Chair

11. Patient Needs

12. Needs of Patients with Limited Functions Rehabilitation is a slow and painful process Patients become frustrated at their lack of independence Function for many patients may never return HHA should be encouraging but honest with patients

13. Patient Population Patients you assist may have multiple medical issues and disabilities CVA (stroke) TBI (traumatic brain injury) Spinal Cord injury, with para- or quadriplegia Cognitive-impairments (dementia, Alzheimer's) Debilitated individuals (weak, de-conditioned)

14. Physical Needs Stroke (CVA), accidents, muscular and nervous disorders may prevent normal movement of muscles and limbs These patients may require: Assistance with ADLs (activities of daily living, ie: dressing, grooming, eating) Range of motion exercises Frequent rest periods between tasks Placement of items within reach Adjustments to clothing

15. Speech Needs Stroke (CVA), accidents, and dementia may cause speech problems Aphasia: Unable to say correct word or may be unable to speak at all Use of writing tools and pictures Ask Yes or No questions Use simple sentences and commands Use of reality orientation Allow time for patient to gather thoughts

16. Proper Body Mechanics

17. Back Injuries: Occurrence Working in awkward positions and small spaces Sitting or standing too long or prolonged time in same position Heavy Lifting Lifting and twisting Reaching and lifting Lifting objects with awkward or odd shapes

18. Back Injury: Prevention Proper lifting techniques and transfer training Proper body mechanics can greatly decrease the risk for injury for both health care worker and the patient B.A.C.K Back Straight Avoid Twisting Close to Body Keep Smooth

19. Proper Lifting Techniques Stand with shoulders feet hip width apart Squat down to pick up the object keeping back aligned Get as close as possible to the object and secure a good grip on the object Lift gradually using legs, abdominals, and buttock muscle keeping load close to your body

20. Proper Patient Transfer Techniques

21. Types of Patient Transfers Independent One or Two person Supine to sit Stand Pivot Slide board Mechanical lift Slide Sheet Bathroom: commode or tub transfers

22. Tips for Safe Transfers Always use a Gait Belt for added security Provides comfort for patient and a better handle for health care provider Know patient before attempting transfer Read chart to find limitations, precautions, etc get the full picture first Make sure path is clear of clutter and enough space is provided for safe transfer

23. Patient Lifting Transfer technique similar to lifting technique just lifting a person vs an object Keeping center of gravity (COG) low will provide more leverage in performing transfer

24. Transfer: Sliding Patient up in bed Explain to patient what you are going to do Make sure head of bed is lowered fully, move pillow up to where patients head will be Have patient cross arms and lift head Use draw sheet/incontinence pad to decrease shearing force Use proper body mechanics and lift on �3� Make sure you position patient comfortably following transfer

25. Transfer: Supine to Sit To get patient from laying down to sitting at the side of bed Explain the procedure of what you will be doing Use proper body Mechanics Support the patients body and bring them from supine to sitting at the edge of the bed Avoid pain as much as possible Sit with patient to ensure safety, then when ready position them for comfort or prepare for transfer

26. Supine to Sit Dependent patients: Move patient by body segments; lower legs, hips, shoulders, head, etc to scoot them closer to edge of bed, use draw pad for moving trunk Support shoulders while legs are close to EOB, use proper body mechanics and lift shoulders as legs lower Support patient in sitting

27. Supine to Sit Patients who need min/mod assist: Have patients move toward EOB by scooting their legs, have them do bridges to scoot hips and trunk, and lift their neck and shoulders Once close to EOB, support patients shoulders and assist them to sit Patients should use legs to dig into side of bed to help pull to sitting

28. Supine to Sit: Log roll Patients who need supervision: Have patient bend knee and reach arm across body As knee falls across body and arm reaches patient will roll onto their side Once in sidelying, pt will use arm and opposite elbow to push themselves up as their legs come off the side of the bed

29. Sit to Stand Have patient scoot to edge of chair Pull feet back toward them so knees are over the toes Patients will use arm rails/chair rails to push up on Use gait belt for better grasp/safety Can use a count of 1-2-3, have patient lean forward as they push up; �nose over toes� Steady patient and ensure no dizziness

30. Transfer Demonstrations Sit to Stand �nose over toes� Chair to Wheelchair Slide board vs stand pivot Stand Pivot Weight bearing precautions patient CVA

31. Ambulation (AKA walking)

32. Ambulation Use of gait belt Use of an assistive device as appropriate: Walker Cane Crutches Surfaces: Even and Uneven inclines/declines change in surface (tile to carpet to grass)

33. Ambulation Prepare assistive device Assist patient to standing position Walk beside and a bit behind patient with one hand on gait belt for safety Steady walker or patient as needed to avoid falls and unsafe gait

34. Proper use of Assistive Device Walkers: Kept close to the body, patient should stay within the frame of the walker Cane: To be used on the �weak� side (acts as a supporting leg) OR used on strong side to decrease weight bearing (lean away from bad leg) Crutches: Slow paced, not good for the elderly

35. Stair Safety Always use handrail if available Always use gait belt When ascending steps stand behind patient When descending steps, stand beside or behind patient �Up with the Good, Down with the Bad�

36. Assistive Device Lab Walker-Adjusting to proper height Single Point Cane-proper use Gait Belt use

37. Wheelchair Use Managing a curb or step, inclines and declines Parts of WC: Elevated leg rest, removable leg rests Removable arm rest Seat cushions Folding WC

38. Wheelchair transfers Prepare WC: Place WC near bed/chair Remove leg rests, swing them away if needed to remove tripping obstacle Remove arm rests if needed Lock Wheelchair

39. Wheelchair Transfers Stand-Pivot (supervision assist) Stand to side of patient out of the path of the WC Using gait belt, assist in standing; once standing, have patient reach toward far arm rest of wheel chair Hand is placed securely on arm and bottom is turned toward seat, patient reached back with other arm to secure other arm rest and slowly lowers to seat Position patient for comfort

40. Wheelchair Transfers Stand Pivot (min to mod assistance) Remove arm rest closest to patient Stand in front of patient, use good body mechanics Use gait belt to assist patient to perform sit to stand transfer Have patient reach toward arm rest and aim bottom to WC, guide hips with gait belt and slowly lower into seat Replace arm rest, position patient comfortably

41. Wheelchair transfers Slide Board transfer Remove arm rest closest to patient Have them shift their weight to place board under one side of their bottom with the other end of slideboard onto WC Pt will slowly scoot along slideboard with hand on board to secure until in seat, have them shift weight in order to gently remove board Always use gait belt to guide pt and assist with lifting Replace arm rest and position pt comfortably

42. Practice Remove WC leg rests and replace Remove arm rests and replace Lock wheels Practice Wheelchair transfers Stand pivot Stand pivot with assist Slideboard

43. Positioning and Bed Mobility

44. Bony Prominences Name areas on the body you think are at risk for increased pressure??

45. Areas to check for Redness

46. Positioning for Comfort and to Prevent Bedsores Support neck to put spine in correct curvature; use small pillow or rolled towel Place pillow �long ways� to support neck and shoulders Support legs to relieve pressure on hip joints with a small pillow or pad placed under the patient�s ankles and knees to prevent pressure on heels and legs

47. Positioning for Comfort and to Prevent Bedsores **Change position at least every 2 hours** Support body joints using pillows, folded towels, or wash cloths Place a pillow behind back and between knees for side lying

48. Prevent Breakdown Keep skin to skin contact minimal Knees/ankles can be padded to prevent pressure Use draw sheets to minimize friction when moving patient in bed -shearing forces can increase break down Look out for areas of redness

49. Prevent Skin Breakdown: Review Turn at least every two hours Prevent skin- to- skin contact Complete pressure relief for heels Elevate head of bed as little as possible Use lift sheets or trapeze Do not position directly on hip bone Do not rub or massage reddened areas

50. Decrease Pressure and Friction with use of Pillows

51. Bed Positioning

52. Decrease Pressure with Use of Pillows Knees, feet, hands are not touching bed

53. Interventions: Range of Motion (ROM), Therband exercises

54. Range of Motion: Passive Movement within the unrestricted Range of Motion (ROM) for a segment that is entirely by an external force There is no voluntary muscle contraction

55. Passive Range of Motion Goals Passive=patient does not assist in ROM Maintain joint and soft tissue integrity Minimize the effects of the formation of contractures Maintain the mechanical elasticity of muscle Assist circulation and vascular dynamics Decrease or inhibit pain

56. Passive Range of Motion Goals Enhance synovial movement for cartilage nutrition Assist with the healing process following injury or surgery Help maintain the patient�s awareness of movement

57. Range of Motion: Active Active=Patient able to assist moving joint through range of motion Movement within the unrestricted ROM for a segment that is produced by an active contraction of the muscles

58. Active Range of Motion Goals Accomplish the same goals of passive range of motion with the added benefits of muscle contraction Maintain physiological elasticity and contractility of the participating muscles Provide sensory feedback from the contracting muscles

59. Active Range of Motion Goals Provide stimulus for bone integrity Increase circulation and thrombus formation Develop coordination and motor skills for functional activities

60. Active Assistive Range of Motion

61. Demonstration Hand Placement for ROM:

62. Exercise Home Exercise Programs Theraband use

63. Exercise Monitor patient throughout exercises Monitor pain and respirations, facial expressions Always allow for rest periods in between reps and sets Position patient in comfortable position for proper form and comfort when performing exercises In standing, always use gait belt to support

64. Home exercise Program Lower Body http://www.thera-bandacademy.com/exercises/showroutine.asp?erID=53&cat=population&id=1&valname=Older%20Adults%20(50+%20years)&t=10%3A52%3A43+PM Upper Body http://www.thera-bandacademy.com/exercises/showroutine.asp?erID=54&cat=population&id=1&valname=Older%20Adults%20(50+%20years)&t=7%3A52%3A40+AM

65. Working with Patients with CVA Right sided weakness or paralysis The right side of the brain controls the ability to pay attention, recognize things you see, hear or touch, and be aware of your own body Left sided weakness or paralysis The left side of the brain controls the ability to speak and understand language in most people

66. Right Side Weakness Deficits in motor planning or apraxia Aphasia�An communication disorder caused by brain damage Cautious Anxious

67. Left Side Weakness Difficulty regulating emotions or emotions constantly changing Irritable, agitated, hypercritical, and/or intolerant of his or her situation or caregivers Quick and impulsive

68. Left Side Weakness Perceptual problems Visual Body scheme/body image disorder Unilateral neglect Pusher syndrome Strong lateral lean

69. DME Equipment Shower Chair VS Tub bench Hospital Bed Hoyer Lift

70. DME Equipment Shower Chair and tub transfers Use grab bars if they are available Make sure there are non-skid rugs in bathroom to avoid slipping Use assisitve device to provide support Clear path Have patient step into tub with �weak� leg so strong leg is supporting patient Assist patient onto shower chair

71. DME Equipment Tub bench Bench will be half in tub and half out Have patient sit on end of bench and scoot themselves back slowly, using arms to push back and weight shifting to move hips Once legs are in far enough, swing them off bench into tub

72. Adapting the Environment Use of assistive devices for hands Reacher Use of grab bars and other equipment in the home Use of assistive devices for personal care

73. Adapting the Environment Removing clutter and clearing paths Removing throw rugs Re-arranging room for increased space and easy reaching Adjusting seat heights

74. Questions