Rehabilitation In Surgical Patients - Prince of Songkla …medinfo2.psu.ac.th/surgery/Edu_be_document/document4...Conditions producing limited joint ROM : •pain •muscle imbalance

Rehabilitation In Surgical

Patients

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OverviewOverview

�� Definition of RehabilitationDefinition of Rehabilitation

�� Disablement processDisablement process

�� Rehabilitation teamRehabilitation team

�� Immobility syndromeImmobility syndrome

REHABILITATIONREHABILITATION

�� A A relearning processrelearning process in which in which

skills and patterns of skills and patterns of

habilitation are reorganized habilitation are reorganized

into relevant and purposeful into relevant and purposeful

activities that can be activities that can be

performed within the limits of performed within the limits of

the patientthe patient’’s potential.s potential.

DISABLEMENT PROCESSDISABLEMENT PROCESS

�� IMPAIRMENTIMPAIRMENT

�� DISABILITYDISABILITY

�� HANDICAPHANDICAP

�� IMPAIRMENTIMPAIRMENT

�� ACTIVITYACTIVITY

�� PARTICIPATIONPARTICIPATION

WHO 1980 WHO 1998

Disease/

Injury

Impairment

��

Disability

��

Handicap

��

WHO : ICF framework, 2001



� Body functions

• The physiological functions of body systems - mental, cognitive and psychological functions.

� Body structures• The anatomical parts of the body -organs, limbs and their components.

IMPAIRMENT

IMPAIRMENTIMPAIRMENT

�� Motor impairmentMotor impairment••weaknessweakness

•• contracturecontracture

�� Sensory impairmentSensory impairment

�� Cognitive impairmentCognitive impairment

�� Structure impairmentStructure impairment•• facial disfigurementfacial disfigurement

•• loss of limbloss of limb


� Activity � Activity Limitation

• The execution of a task or action by an individual and represents the individual perspective of functioning.

� Participation � Participation Restriction

• The involvement of an individual in a life situation and represents the societal perspective of functioning.

The Rehabilitation Team

Physiatry

Patient &

FamilyPatient &

Family

Psychology

Speech

therapy

Social service

Orthotics

Prosthetics

Nursing

Physical

therapy

Occupational

therapy

PhysicianPhysical

therapist

Occupational

therapist

Medical

Social

Workers

DISEASE IMPAIRMENT DISABILITY HANDICAP

NURSE DIETITIANVocational counselors

Recreational therapists

Goals of a Rehabilitation ProgramGoals of a Rehabilitation Program

� To optimise both activity and participation

• To overcome or to work around their impairments

• To remove or reduce the barriers to participation in the person’s chosen environments

• To support their reintegration into society

Principles of RehabilitationPrinciples of Rehabilitation

�� Identify an individualIdentify an individual’’s impairments, s impairments,

activity limitation, and participation activity limitation, and participation

restrictionrestriction

�� Individualized goal settingIndividualized goal setting

�� Educational and learning processEducational and learning process

�� Patient and family centeredPatient and family centered

�� Rehabilitation teamworkRehabilitation teamwork

�� Active and dynamic processActive and dynamic process

RehabilitationRehabilitation InterventionsInterventions

�� Physical Therapy programPhysical Therapy program

�� Occupational Therapy programOccupational Therapy program

�� Prosthesis/Prosthesis/OrthosisOrthosis

�� Mobility aids and adaptive Mobility aids and adaptive

devicesdevices

�� Environmental modificationEnvironmental modification

�� Speech TherapySpeech Therapy

Surgical Patients

Major Operation

Immobility Sequelae of Disease

DEFINITIONDEFINITION

�� Immobilization, ImmobilityImmobilization, Immobility

•• Physical restriction of movement Physical restriction of movement

involving a body segment or the entire involving a body segment or the entire

body.body.

•• Physical restriction or limitation of body Physical restriction or limitation of body

members and of the body in turning, members and of the body in turning,

sitting and ambulationsitting and ambulation

DEFINITIONDEFINITION

�� DeconditioningDeconditioning

•• A reduced functional capacity of A reduced functional capacity of

multiple body systems, especially multiple body systems, especially

the musculoskeletal systemthe musculoskeletal system

•• The multiple, potentially reversible The multiple, potentially reversible

changes in body systems brought changes in body systems brought

about by physical inactivity and about by physical inactivity and

disusedisuse

Common Causes of ImmobilizationCommon Causes of Immobilization

�� Neuromuscular disorders and injuriesNeuromuscular disorders and injuries

�� Orthopedic casts, body jackets, Orthopedic casts, body jackets,

splints after trauma or fracturesplints after trauma or fracture

�� Critically illness requiring bed restCritically illness requiring bed rest

�� Prolonged stays in a recumbent Prolonged stays in a recumbent

position or sitting positionposition or sitting position

Immobilization

Deconditioning

Deconditioning

Musculoskeletal

Cardiovascular

Gastrointestinal

Respiratory

Genitourinary

Integumentary Metabolic Neurological

Musculoskeletal SystemMusculoskeletal System

Muscle Weakness and AtrophyMuscle Weakness and Atrophy

�� With total inactivityWith total inactivity

•• 1010--20% decrease in isometric muscle 20% decrease in isometric muscle

strength per week or about 1strength per week or about 1--3% per 3% per

dayday

�� In 3In 3--5 wks, complete immobilization 5 wks, complete immobilization

can lead to a 50% decrease in can lead to a 50% decrease in

muscle strengthmuscle strength

�� The loss was greatest during the 1The loss was greatest during the 1stst

wk of inactivity and gradually wk of inactivity and gradually

plateauedplateaued at a 25% lossat a 25% loss

Muscle Weakness and AtrophyMuscle Weakness and Atrophy

�� Strength loss varies among musclesStrength loss varies among muscles•• 1 month bed rest caused 81 month bed rest caused 8--13% loss of cross13% loss of cross--sectional area of selected leg muscles by MRIsectional area of selected leg muscles by MRI

•• Quadriceps m. declined 27% with 4 wks cast Quadriceps m. declined 27% with 4 wks cast immobilization by CTimmobilization by CT

�� Antigravity muscles lose strength Antigravity muscles lose strength disproportionately and large ones lose disproportionately and large ones lose twice as quickly as smaller onestwice as quickly as smaller ones

�� Strength that lost in 1 wk may take 4 wks Strength that lost in 1 wk may take 4 wks to regain even with a maximal to regain even with a maximal strengthening programstrengthening program

PreventionPrevention

�� Daily isometric contraction of 20Daily isometric contraction of 20--30 30

% of maximal tension for 10 seconds% of maximal tension for 10 seconds

�� Muscle exertion at 50% of maximum Muscle exertion at 50% of maximum

capacity, 1 sec/day capacity, 1 sec/day �� more more

effectiveeffective

�� Use of electrical stimulationUse of electrical stimulation

�� Early mobilization and ambulationEarly mobilization and ambulation

ContractureContracture

�� The lack of full active or passive range of The lack of full active or passive range of motion (ROM) due to a joint, soft tissue, motion (ROM) due to a joint, soft tissue, or muscle limitationor muscle limitation

�� Conditions producing limited joint ROM :Conditions producing limited joint ROM :•• painpain

•• muscle imbalancemuscle imbalance

•• spasticityspasticity

•• capsular or capsular or periarticularperiarticular tissue fibrosis tissue fibrosis

•• primary muscle damageprimary muscle damage

•• mechanical factors (improper bed positioning, mechanical factors (improper bed positioning, casting or splinting in a foreshortened position)casting or splinting in a foreshortened position)


�� With immobilization as little as 1 wkWith immobilization as little as 1 wk

•• The soft tissue is replaced by more The soft tissue is replaced by more

dense material with more collagen dense material with more collagen

crosscross--linkslinks

•• Adapt to the shortened length by Adapt to the shortened length by

contraction of collagen fibers and a contraction of collagen fibers and a

decrease in muscle fiber decrease in muscle fiber sarcomeressarcomeres


�� With immobilization as 3 wk or moreWith immobilization as 3 wk or more

•• The loose connective tissue in muscles The loose connective tissue in muscles

and around joints gradually change into and around joints gradually change into

dense connective tissue dense connective tissue �� contracture contracture

on the relaxed sideon the relaxed side


�� Most commonly involvement of Most commonly involvement of

muscles that cross two joints in themuscles that cross two joints in the

•• hipships

•• kneesknees

•• anklesankles

•• shouldersshoulders

•• elbowselbows

•• wrists and fingerswrists and fingers


•• Proper positioningProper positioning

•• Active or passive ROM exercisesActive or passive ROM exercises

•• SSplintingplinting

•• Early mobilization and ambulationEarly mobilization and ambulation

TreatmentTreatment

•• Passive ROM with terminal stretch at Passive ROM with terminal stretch at

least twice dailyleast twice daily

•• Prolonged stretch using low passive Prolonged stretch using low passive

tension and heattension and heat

•• Sustained stretch using CPMSustained stretch using CPM

•• Progressive, sustained stretching of 2 Progressive, sustained stretching of 2

hours or morehours or more

•• Treatment of Treatment of spasticityspasticity

•• Surgical releaseSurgical release

LIGAMENTS AND TENDONSLIGAMENTS AND TENDONS

�� Ligaments and tendonsLigaments and tendons

–– longitudinally parallel type I longitudinally parallel type I collagen fiberscollagen fibers

•• While lacking longitudinal stress While lacking longitudinal stress ((immobilizationimmobilization)) newly formed newly formed

collagen iscollagen is

laid down in a haphazard arraylaid down in a haphazard array

�� In primate modelIn primate model

–– ligaments lose ligaments lose 1/31/3 strength in strength in 88wks of immobilizationwks of immobilization

Ligaments and tendonsLigaments and tendons

�� Immobilization causesImmobilization causes•• ↑↑ collagen turnovercollagen turnover

•• ↓↓ collagen masscollagen mass

•• ↓↓ glglyycosaminoglycan and water cosaminoglycan and water contentcontent

•• ↑↑ soft tissue stiffnesssoft tissue stiffness

•• alteration in alteration in fibroblast fibroblast functionfunction

•• ↓↓collagencollagen--bone interface strengthbone interface strength,, bone bone

resorption below insertion siteresorption below insertion site

Disuse (immobilization) osteoporosisDisuse (immobilization) osteoporosis

�� The loss of bone density due to The loss of bone density due to

increased increased resorptionresorption caused by lack caused by lack

of stimulus( of stimulus( egeg. weight bearing, . weight bearing,

gravity, muscle activity) on bone gravity, muscle activity) on bone

massmass

�� Ratio of bone formation to resorption Ratio of bone formation to resorption

isis

influenced by stresses on boneinfluenced by stresses on bone ��

WolffWolff’’s laws law


�� More marked in the More marked in the subperiostealsubperiostealregion, in contrast to senile region, in contrast to senile osteoporosis, which develops from osteoporosis, which develops from the marrow outwardthe marrow outward

�� Initially involves the Initially involves the cancellouscancellous bone bone at the at the metaphysismetaphysis and epiphysis, and epiphysis, later extends to the entire later extends to the entire diaphysisdiaphysis

�� Reduced 40Reduced 40--45% after 12 wks of bed 45% after 12 wks of bed restrest

�� By the 13By the 13rdrd wk, more than 50% of wk, more than 50% of bone density lostbone density lost


�� Osteoporosis of short duration (Osteoporosis of short duration (33 to to

66

monthsmonths)) can be reversed nearly can be reversed nearly

completelycompletely;; longer ones canlonger ones can’’tt..

�� While exWhile exercisingercising might not reverse might not reverse bone lossbone loss,, it will slow its progressionit will slow its progression


�� WeightWeight--bearing standing : bearing standing :

•• standing frame or tilt tablestanding frame or tilt table

•• Standing in parallel barStanding in parallel bar

�� AActive ctive musclemuscle contractioncontraction

�� Early ambulationEarly ambulation

Immobilization Immobilization HHypercalcemiaypercalcemia

�� A condition often associated with A condition often associated with osteoporosis, esp. in adolescent males osteoporosis, esp. in adolescent males who have had traumatic injuries.who have had traumatic injuries.•• symptomatic after symptomatic after 22 to to 44 wks of immobilizationwks of immobilization

•• nauseanausea,, vomitingvomiting,, abdominal painabdominal pain,, lethargylethargy,,

mmuscleuscle weakness and anorexiaweakness and anorexia

•• If not treated, death can occur.If not treated, death can occur.

�� Treatment : Treatment : •• IV furosemide and hydrationIV furosemide and hydration

•• etidronate disodiumetidronate disodium,,

•• IV pamidronate and calcitoninIV pamidronate and calcitonin

Heterotopic Heterotopic OOssificationssification

�� AAbnormal bone growth locationbnormal bone growth location,,

usually around jointsusually around joints

�� NNot caused by immobilizationot caused by immobilization,, but but

generally found in generally found in persons who havepersons who havetrauma Hx trauma Hx ((exex.. SCI or direct mSCI or direct m..

contusioncontusion))

JointsJoints�� Hyaline cartilageHyaline cartilage

•• no vascular blood flowno vascular blood flow

•• receiving nutrition from synovial fluid with imbibition receiving nutrition from synovial fluid with imbibition ((drawing fluid into and out of cartilagedrawing fluid into and out of cartilage))

�� During immobilization During immobilization �� simple diffusion simple diffusion �� not not adequate adequate �� joints begin to deterioratejoints begin to deteriorate �� ccontact ontact areas develop necrosis and erosionsareas develop necrosis and erosions

�� NNoncontact surfacesoncontact surfaces:: fissures and lose fissures and lose

smoothnesssmoothness

�� PProteoglycan imbalance roteoglycan imbalance �� stifferstiffer

–– compensatory cartilage proliferation and compensatory cartilage proliferation and osteophyteosteophyte

formationformation;;

–– fibrofatty infiltration with atrophic synoviumfibrofatty infiltration with atrophic synovium;;

–– subchondral bone deteriorationsubchondral bone deterioration;;

–– extraextra--articular connective tissue contracturearticular connective tissue contracture

The cardiovascular The cardiovascular

systemsystem

Cardiac deconditioningCardiac deconditioning

�� DeconditioningDeconditioning--induced changes occurring induced changes occurring at restat rest•• �� HRHR 1 1 beatbeat//minmin// 2 2 ddaysays for for the the first first 33--44 wks wks of immobilizationof immobilization

•• �� resting stroke volume resting stroke volume up to 15% after 2 wks up to 15% after 2 wks of bed rest of bed rest

•• �� blood volume 7% after 20 days of bed restblood volume 7% after 20 days of bed rest

•• �� Cardiac size Cardiac size by by up to up to 11%11%

•• �� left ventricular end diastolic volumeleft ventricular end diastolic volume

•• CO remains unchanged or slightly decreasedCO remains unchanged or slightly decreased

•• CCardiac ardiac muscle muscle atrophy atrophy may occurmay occur•• Unchanged resting systolic and mean BPUnchanged resting systolic and mean BP,, total total peripheral resistanceperipheral resistance,, VOVO22 at rest and at rest and ArteriovenousArteriovenous oxygen differenceoxygen difference


�� DeconditioningDeconditioning--induced changes induced changes

occurring during exerciseoccurring during exercise•• �� 3030--4040 beatsbeats//min with submaximal exmin with submaximal exerciseercise

after after 33 wkswks

•• �� Stroke volume Stroke volume 30% 30% at maximal and at maximal and

submaximal exsubmaximal exerciseercise

•• cardiac output slightly declines at submaximal cardiac output slightly declines at submaximal

exexerciseercise and and 26%26% mean drop at maximal mean drop at maximal

exexerciseercise

•• �� VOVO22max 27% in maximal and max 27% in maximal and submaximalsubmaximal

exerciseexercise


�� Recovery from deconditioningRecovery from deconditioning

�� It can take up to twice as long or more It can take up to twice as long or more ((with intensive trainingwith intensive training)) to reverse Vto reverse VOO22max max

by by 2020 ddayays of bedrest in previously active s of bedrest in previously active

subjects subjects

�� After After 33--4 4 wks of immobilizationwks of immobilization

•• HR recovery after exHR recovery after exerciseercise is is 50%50% of normal of normal

by by 16 16 ddaysays and is normal by and is normal by 3636 ddayayss

•• submaximal VOsubmaximal VO22 recovers to normal betweenrecovers to normal between

16 16 and and 3636 ddaysays

Orthostatic (postural) HypotensionOrthostatic (postural) Hypotension

�� Impaired ability of the circulatory Impaired ability of the circulatory

system to adjust to the upright system to adjust to the upright

positionposition

�� Prolonged bed rest Prolonged bed rest �� lose this lose this

adaptation adaptation �� tingling, burning in the tingling, burning in the

lower limbs, dizziness, lower limbs, dizziness,

lightheadedness, fainting, vertigo lightheadedness, fainting, vertigo

�� PR ( PR ( ≥≥ 20 beats/min)20 beats/min)

�� SBP (SBP (≥≥ 20 mmHg20 mmHg))

Orthostatic (postural) HypotensionOrthostatic (postural) Hypotension

�� Most of the effects occur in Most of the effects occur in 44--7 7 ddayays of s of

bed restbed rest

�� Developed rapidly in the elderly and Developed rapidly in the elderly and

medicalmedical

illnessillness

�� MMore conditioned before bed rest had ore conditioned before bed rest had

greatestgreatest

deteriorationdeterioration

�� RReversed after remobilization for twice or eversed after remobilization for twice or

moremore

timetime


�� Early mobilization (ROM exercises, Early mobilization (ROM exercises,

strengthening exercises, ambulation)strengthening exercises, ambulation)

�� Abdominal strengthening and Abdominal strengthening and

isotonicisotonic--isometric exercises of the isometric exercises of the

legslegs

�� Use of tilt tableUse of tilt table

�� Use of Ace bandage wraps, full Use of Ace bandage wraps, full

length elastic stockings, abdominal length elastic stockings, abdominal

bindersbinders

�� Adequate salt and fluid intake Adequate salt and fluid intake

Changes in Changes in Fluid balanceFluid balance

Bed restBed rest �� fluids shift from legs to thorax (central fluid fluids shift from legs to thorax (central fluid shift)shift)

�� venous return to the heartvenous return to the heart

��

stretched carotid and aortic baroreceptors stretched carotid and aortic baroreceptors and cardiopulmonary mechanoreceptorsand cardiopulmonary mechanoreceptors

��

�� aldosterone and antidiuretic hormonealdosterone and antidiuretic hormone��

DIURESISDIURESIS

��

�� plasma volumeplasma volume( 10% after 1 wk, 15% by 4 wks, ( 10% after 1 wk, 15% by 4 wks, plateaus around plateaus around 70%70%

of normal plasma volume and of normal plasma volume and 60%60% of normal blood volumeof normal blood volume))

��

�� ViscosityViscosity


�� Isotonic exercise : more twice as Isotonic exercise : more twice as

effective as isometric exerciseeffective as isometric exercise

�� Early ambulationEarly ambulation

Venous Venous ThromboembolismThromboembolism

�� Immobilization Immobilization �� venous stasis, venous stasis,

increased blood viscosity, and increased blood viscosity, and

hypercoagulabilityhypercoagulability

�� VirchowVirchow’’s triad of clot formations triad of clot formation

–– factorfactorss intrinsic to bloodintrinsic to blood

–– blood vessel injuryblood vessel injury

–– stasis of blood flowstasis of blood flow

Assessing Assessing ThromboembolismThromboembolism

�� InflammationInflammation

�� TendernessTenderness

�� AchingAching

�� Positive Positive HomansHomans’’ Sign Sign –– calf pain calf pain

when toes are when toes are dorsoflexeddorsoflexed towards towards

the body.the body.


�� Active exercise : ankle pumpsActive exercise : ankle pumps

�� Use of elastic stockings or elastic Use of elastic stockings or elastic

wrapswraps

�� Proper positionProper position

�� Use of low molecularUse of low molecular--weight heparin weight heparin

in high riskin high risk

Treatment Of Treatment Of ThromboembolismThromboembolism

�� AntiAnti--coagulant therapycoagulant therapy

�� Bed restBed rest

�� AntiAnti--embolic stockingsembolic stockings

�� Avoid Avoid poplitealpopliteal pressurepressure

�� Vital signsVital signs

Respiratory ChangesRespiratory Changes

�� Caused byCaused by

•• Mechanical restriction of breathing Mechanical restriction of breathing (reduced chest excursion due to (reduced chest excursion due to progressive reduction of ROM in the progressive reduction of ROM in the costovertebralcostovertebral and and costochondralcostochondral joints) joints) �� rapid, shallow breathingrapid, shallow breathing

•• Overall reduction in muscular strength Overall reduction in muscular strength and endurance and endurance �� reduced movement of reduced movement of the diaphragmatic, the diaphragmatic, intercostalintercostal, and , and abdominal musclesabdominal muscles

•• CiliaryCiliary malfunction and weakness of malfunction and weakness of abdominal muscles abdominal muscles �� impaired coughimpaired cough


�� ↓↓ Tidal vol., residual vol., and vital Tidal vol., residual vol., and vital capacitycapacity

�� ↓↓ Diaphragmatic and chest wall movementDiaphragmatic and chest wall movement

�� ↑↑ VVentilationentilation/P/Perfusionerfusion ratioratio mismatchmismatch,,

�� ↑↑ RRRR

�� HHypersecretionypersecretion and impaired cough and impaired cough mechanismmechanism

�� RRiskisk for for atelectasisatelectasis and pneumoniaand pneumonia



�� Frequent change in positionFrequent change in position

�� Early mobilizationEarly mobilization

�� Chest PT ( deep breathing, incentive Chest PT ( deep breathing, incentive

spirometryspirometry, assisted coughing, , assisted coughing,

percussion/vibration)percussion/vibration)

�� Adequate fluids intakesAdequate fluids intakes

�� Adequate pulmonary Adequate pulmonary hygieneshygienes

Genitourinary Genitourinary ChangesChanges

�� diuresis and mineral excretiondiuresis and mineral excretion

�� CCalculus formation alculus formation :: 1515--30% due to 30% due to

urinary stagnation, urinary stagnation, hypercalciuriahypercalciuria

�� UTIUTI

�� LongLong--term immobilization decreased term immobilization decreased

GFRGFR

and urine concentration abilityand urine concentration ability

Genitourinary Genitourinary ChangesChanges

�� Adequate fluid intakeAdequate fluid intake

�� Upright position for voidingUpright position for voiding

�� Strict avoidance of bladder Strict avoidance of bladder

contamination during contamination during

instrumentationinstrumentation


Gastrointestinal Gastrointestinal ChangesChanges

�� ConstipationConstipation

–– due to due to �� mobilitymobility,, �� peristalsisperistalsis,, ��

fluid intakefluid intake,, �� loss of plasma volumeloss of plasma volume

•• Embarrassment of using bedpan causesEmbarrassment of using bedpan causes

delayed defecatingdelayed defecating

�� GI secretion and GI secretion and �� GE reflux GE reflux ��

ulcerulcer

�� appetite and appetite and malabsorptionmalabsorption ��

malnutritionmalnutrition


�� Adequate fluid intakes and fiberAdequate fluid intakes and fiber--rich rich

dietdiet

�� Stool softeners and bulkStool softeners and bulk--forming forming

agentsagents

�� Avoid using bedpanAvoid using bedpan and narcotics and narcotics

medicationmedication

�� RegularlyRegularly--timed bowel programtimed bowel program

Neurological systemNeurological system,, emotionsemotions,,

and intellectual functionand intellectual function�� Sensory deprivation : decreased attention span, Sensory deprivation : decreased attention span, confusion, disorientation to time and space, confusion, disorientation to time and space, decreased handdecreased hand--toto--eye coordinationeye coordination

�� intellectual capacityintellectual capacity

�� Emotional and behavioral disturbanceEmotional and behavioral disturbance

�� balance and coordinationbalance and coordination

�� Lack of motivationLack of motivation

�� Critical illness neuropathyCritical illness neuropathy

–– symmetrical axonal sensorimotor neuropathysymmetrical axonal sensorimotor neuropathy

–– mimics weakness of deconditioningmimics weakness of deconditioning

�� Compression neuropathiesCompression neuropathies

–– peroneal nperoneal n.. below fibular headbelow fibular head

–– ulnar nulnar n.. at retrocondylar grooveat retrocondylar groove


�� Encouraging the patient to interact Encouraging the patient to interact

with staff, other patients, and family with staff, other patients, and family

membersmembers

�� Recreational therapy for psychosocial Recreational therapy for psychosocial

integration, integration, resocializationresocialization, ,

adjustment to independent adjustment to independent

functioningfunctioning

�� Proper positioningProper positioning

Integumentary sytemIntegumentary sytem

�� Pressure ulcersPressure ulcers

�� Capillary BP around Capillary BP around 30 30 mmHg mmHg

�� PositionPosition::

•• SittingSitting:: �� ischial tuberosities ischial tuberosities pressurepressure

•• SSupine lyingupine lying:: �� sacral sacral pressure, pressure, heels heels

and occiput and occiput pressurepressure

•• SSideide--lyinglying:: �� greater trochanter greater trochanter pressurepressure

MMetabolic and nutritional changesetabolic and nutritional changes

�� lean body masslean body mass

�� body fatbody fat

�� Disorder of nitrogen balanceDisorder of nitrogen balance

�� Mineral and electrolytes (nitrogen, Mineral and electrolytes (nitrogen,

calcium, phosphorus, sulfur, calcium, phosphorus, sulfur,

potassium) lossespotassium) losses

Determining the Effects of Determining the Effects of

ImmobilityImmobility

�� Duration of inactivityDuration of inactivity

�� Health statusHealth status

�� Sensory awarenessSensory awareness

Deconditioning / Immobility syndrome

Risk to Dead �LOS, Cost �Function

Bed rest, inactivity, disease

�� PulmonarPulmonar

y y

embolismembolism

�� DVTDVT

�� Pressure Pressure

soresore

�� Infection : Infection :

pnemoniapnemonia, ,

atelectasisatelectasis

UTIUTI

• Weakness

• Joint

contracture

• Orthostatic

hypotension

Summary of Preventative Summary of Preventative

TreatmentsTreatments

�� Early mobilizationEarly mobilization

�� StrengtheningStrengthening

�� ROMROM

�� Maintain skin integrityMaintain skin integrity

�� DVT prophylaxisDVT prophylaxis

�� Pain managementPain management

�� Psychological assessment / treatmentPsychological assessment / treatment

�� Aggressive Respiratory managementAggressive Respiratory management

�� B/B assessment & careB/B assessment & care

Documents

Rehabilitation In Surgical Patients - Prince of Songkla …medinfo2.psu.ac.th/surgery/Edu_be_document/document4...Conditions producing limited joint ROM : •pain •muscle imbalance