Rehabilitation Nursing/High School (Nurse)

Rehabilitation nursing is part of normal nursing care for P/C (Patient/Client). This term includes a method of care where we use learned P/K movement patterns, thereby maintaining range of motion, restoring function and strengthening their use. The goal is therefore to prevent secondary changes and complications resulting from immobility - Immobilization Syndrome.

Testing in Rehabilitation Nursing

The basic indicator of the state is physiological functions.

Evaluation of self-sufficiency

Gordon test

The Gordons evaluate the test:

• total mobility,
• ability to eat,
• ability to wash,
• ability to bathe,
• ability to dress,
• ability to go to the toilet,
• ability to move in bed,
• ability to maintain a household,
• ability to buy,
• ability to cook.
  • Activities are evaluated by points 1-5

    5 points: Independent, self-sufficient sick.

    4 points: Needs minimal assistance, uses equipment alone, manages 75% of daily activities alone.

    3 points: Needs less help, supervision, advice. He manages 50% of the daily activities himself.

    2 points: Needs a lot of help (from another person or device), can handle less than 25% of daily activities by himself.

    1 point: Completely dependent on the help of others, needs complete supervision. Absolute self-care deficit, no active participation. Needs full assistance or is unable to assist.

Barthel test

Barthel test
Activity	Activity performance	Point score	Evaluation on admission	On discharge
1. eating, drinking	alone without help	10
	with the help of	5
	will not perform	0
2. dressing	alone without help	10
	with the help of	5
	will not perform	0
3. bathing	alone without help	10
	with the help of	5
	will not perform	0
4. personal hygiene	alone without help	10
	with the help of	5
	will not perform	0
5. urinary continence	alone without help	10
	with the help of	5
	will not perform	0
6. stool continence	alone without help	10
	with the help of	5
	will not perform	0
7. use the toilet	alone without help	10
	with the help of	5
	will not perform	0
8. transfer to bed - chair	alone without help	10
	with the help of	5
	will not perform	0
9. walking on the level	alone without help	10
	with the help of	5
	will not perform	0
10. walking up the stairs	alone without help	10
	with the help of	5
	will not perform	0
Overall rating

Evaluation of the degree of dependence in basic everyday activities.

0-40 points = high degree of dependence

41-60 points = moderate degree of dependence

61-95 points = mild degree of addiction

96-100 points = independent

Test modification

Modification of the Barthel test
Actions	Unable to complete a task	Will attempt a task but fail	Requires limited assistance	Requires minimal assistance	Completely independent
Personal hygiene	0	1	3	4	5
He takes a bath himself	0	1	3	4	5
Food	0	2	5	8	10
Toilet	0	2	5	8	10
Stair Walk	0	2	5	8	10
Dressing	0	2	5	8	10
Stool Inspection	0	2	5	8	10
Urine Control	0	2	5	8	10
Walking	0	3	8	12	15
Cart (assessed if P/C learns to control the cart)	0	1	3	4	5
Transfer trolley/bed		3	8	12	15
Total	0				100

Norton rating

Physical condition (general)		Mental Activity		Activity		Mobility		Incontinence
Good	4	Alert	4	Walking	4	Full	4	None	4
Satisfactory	3	Apathy	3	Walking with assistance	3	Slightly limited	3	Occasional	3
Weak	2	Confusion	2	Confined to chair	2	Very restricted	2	Urine only	2
Very bad	1	Sopor and worse	1	Supine	1	Immobility	1	Urine and stool	1

Test of functional independence = ADL

In this test, we evaluate motor skills and mental functions.

• Scoring according to the following parameters:

  7 b = repeated full self-sufficiency,

  6 b = partial self-sufficiency with an aid,

  5b = necessary supervision,

  4 b = minimum aid (75% of activity),

  3 b = Medium help (50% of activity),

  2 b = significant help (only 25% of activity),

  1 b = full help.

Functional independence test = ADL
Area		Points
Personal Care	Food
	External Care
	Bathing
	Dress HK, Hull
	DK Dressing
	Intimate hg.
Continence	Bladder
	Anus
Moves	Bed, chair, trolley
	WC
	Bath, shower
Locomotion	Walking – Wheelchair – Both
	Stairs
Communication	Comprehension of audio – video – both
	Expressing verbal – non-verbal – both
Social Aspects	Social Contact
	Troubleshooting
	Memory
Total Score

Test of instrumental daily activities

Rating:

< 40 b dependent P/C;

45-75 points partly dependent on P/C;

> 80 points independent P/C.

Activity	Rating	Points
phoning	looks up and dials the number	10
	will answer the call	5
	can't handle	0
traveling	travels alone	10
	is only traveling with an escort	5
	special help	0
shopping	shopping alone	10
	shopping with an escort	5
	unable to buy	0
cooking	will cook himself	10
	heats the food	5
	food prepared by another person	0
housework	maintains the household	10
	does light work only, won't keep clean	5
	unable	0
work around the house	done by himself and regularly	10
	supervised	5
	will not perform	0
use of medication	separate	10
	must be prepared	5
	served by another person	0
finance	managed by himself	10
	handles only small expenses	5
	unable	0
Total'

Katz Activity Test

1. part

A	Independent in eating, able to transfer, toilet, dress and bathe.
B	Independent in all activities except one.
C	Independent outside of bathing and one other area.
D	Addicted in bathing, dressing and one other area.
E	Addicted in bathing, dressing, toileting and one other area.
F	Dependent on bathing, dressing, toileting, moving from place to place, and one other area.
G	Addicted in all areas.
Other	Dependent in two areas not classified in the previous points.

2. part

Feature	Independence	Dependency
Bathing	Help only when washing one part of the body or bathes completely by himself.	Help when washing two or more parts, help when entering - exiting in - from the bath, cannot bathe by himself.
Dressing	Takes clothes from the closet or drawer, gets dressed, can fasten a belt, buttons, etc., does not require shoelaces.	Does not dress himself, remains partially undressed.
Toilet	Goes to the toilet, uses it, undresses and dresses again, grooms himself, cleans himself/manages to put a bedpan, urine bottle in his bed at night.	Uses a bedpan, urine bottle bottle, help using the toilet.
Moving	He gets on and off the bed by himself, he moves to the wheelchair.	Help with movement and to the bed, the wheelchair, he can't handle transfers.
Continence	Fully continent.	Incontinence, voiding control with catheters.
Intake of food	Eats from plates or bowls, can cut meat, spread bread.	Needs help, does not eat by himself/intake of artificial nutrition (i.v., RT, VS, PEG).

Activities Test

With a maximum score of 92.

Mental Abilities
1. Level of Consciousness	Wide Awake	8
	Somnolent	6
	Precomatose	4
	Coma	1
2. Orientation in time, space, person	Orient. In all three dimensions	6
	Orient. in two dimensions	4
	Orien. In one dimension	3
	Disorientation	1
3. Verbal communication ability	Normal verbal communication	12
	Slight difficulties in communication	8
	Severe difficulties in communication	4
	Can't communicate verbally	1
4. Psychic activities	Initiative, asks for information	6
	Sometimes proactive, talks to people around him	4
	Not proactive, apathy	3
	Psychic activity cannot be observed	1
Motor activities
1. Right arm	Normal - near normal activity	4
	Activity with functional value	3
	Activity without functional value	2
	No activity	0
2. Right hand	Normal - almost normal activity, independent grasp, movement of individual fingers	4
	Uniform functional grip	3
	Activity without functional value	2
	No activity	1
3. Right lower extremity	Normal - almost normal activity	4
	Activity with functional value	3
	Activity without functional value	2
	No activity	0
4. Left arm	Normal - near normal activity	4
	Activity with functional value	3
	Activity without functional value	2
	No activity	0
5. Left hand	Normal - almost normal activity, independent grasp, movement of individual fingers	4
	Uniform functional grip	3
	Activity without functional value	2
	No activity	1
6. Left lower extremity	Normal - almost normal activity	4
	Activity with functional value	3
	Activity without functional value	2
	No activity	0
Daily Activities
1. Walking	Able to walk	6
	Walking with support - accompanied, independent movement in a wheelchair	4
	Wheelchair bound, able to stand with support	3
	Bed bed, wheelchair, unable to get up	1
2. Personal hygiene	Hg. he does the care entirely himself	6
	Needs help toileting the lower part	4
	Helps with upper and lower body toileting, but helps	3
	Doesn't help with hg. care	1
3. Dressing	He dresses himself	6
	He dresses himself, but needs a little help (putting on socks, etc.)	4
	Helps with small tasks while getting dressed	3
	He doesn't dress himself, someone has to dress him	1
He eats all by himself	6
	Fees with partial help	4
	Must be fed	3
	Nutrition by tube or parenterally	1
5. Emptying - bladder function	Continental	6
	Occasionally urinates	4
	Urinal, toilet aid, bed tray	3
	Introduced urinary catheter	1
6. Defecation - bowel function	Continental	6
	He sometimes makes mistakes	4
	Colostomy, toilet assistance, bed tray	3
	Incontinent	1

Cognitive Function Testing

Neuro-behavioral manifestations

Assessment of behavioral changes due to CNS damage.

	Rating 1-7 points
Inattentiveness
Bodily Manifestations
Disorientation
Anxiety
Disordered expression
Emotional detachment
Conceptual disorganization
Insufficient barriers
Feeling guilty
Memory Failure
Agitation
Inaccurate preview
Depressed Mood
Hostile - Uncooperative
Decline in motivation
Suspiciousness
Fatigue
Hallucination
Motor slowness
Atypical thinking in content
Rough behavior
Irritability
Poor planning
Labile Moods
Voltage
Misunderstanding
Speech articulation disorder
Total

MMSE

Item		Score
1. Orientation	What is the year/season/month/day of the week/date?	0-5 b
	Where are you now? Country/region/city/street/floor in building	0-5 b
2. Repetition and memory	Repetition of three words denoting subjects, number of repeated subjects = points (3 subjects)	0–3 b
3. Attention and Counting	P/K subtracts 7 from 100, ends after 5 answers (1b = 1 correct answer)	0-5 b
4. short-term memory	P/K should name 3 subjects from item 2 (each subject 1b)	0–3 b
5. Recognition of objects	P/K has to name 2 objects (watch/pencil)	0–2 b
6. Repetition	P/K should repeat the sentence	0–1 b
7. Three-step instruction	P/K is to perform the task according to the instructions in the order told by the medic E.g. Take the paper in your hand, fold it in half and place it on the table (each stage 1 b)	0–3 b
8. Reaction to a written instruction	P/K has to perform the task written on the note. He reads it and executes it.	0–1 b
9. Writing	P/K should write a sentence so that it contains both a stimulus and a predicate, a meaningful sentence, tolerance of grammatical errors.	0–1 b
10. Painting according to the template	P/K has to draw 2 pentagons that intersect according to the template

Rating

< 10 points severe cognitive impairment;

11-20 points moderate cognitive impairment;

21-23 points mild cognitive impairment;

more than 24 points is the norm.

Clock Drawing Test

P/K is presented with a clear circle representing the hours. P/K is invited to complete/finish the numbers and hour hands. The finishing method is evaluated.

Blesed Dementia Scale

In this test, we assess P/K's ability to perform normal activities (ADL/IADL), memory and orientation.

Scaling in Pediatrics

In pediatrics, a child's motor development is evaluated based on the maturity of postural functions. Postural functions are evaluated "according to Vojta" and are classified into 9 locomotion stages.

STAGE 0 - LACK OF LOCOMOTION - NEWBORN LEVEL.

• He does not move forward using the upper or lower limbs, there is a complete lack of motor contact with the environment - absence of a grasping reflex, no support function is created.

STAGE 1 - LACK OF LOCOMOTION - LEVEL 3-4 MONTHS OF DEVELOPMENT.

• He does not move forward, but he is able to turn around, functional grip reflex, leans on his elbows if he is on his stomach, lifts his lower limbs when he is on his back. Newborn reflexes are absent.

STAGE 2 - UNDEVELOPED LOCOMOTION - LEVEL END OF 4TH AND BEGINNING OF 5TH MONTHS OF LIFE.

• In the prone position, uses the upper limbs for support, grasps objects by the supports of the other limb, muscle dierence appears, in the supine position there is an effort to grasp the object. It cannot move forward, but attempts to approach are evident.

STAGE 3 - PRIMITIVE LOCOMOCY, CRAWLING - LEVEL 7-8 MONTHS OF LIFE.

• Moving around the room by crawling, rolling from stomach to back.

STAGE 4 – HOPING, EQUAL TO 9TH MONTH.

• This phase does not occur in a healthy child! The child leans on the fist or wrist, the support in the upper limbs is abnormal. The so-called hopping is a homologous movement, it does not take place like normal climbing in a healthy child. They are able to kneel upright and can move to an inclined sitting position.

STAGE 5 - ADVANCED CLIMBING - LEVEL 11 MONTHS.

• Support when climbing is open hands, a crossed (normal) pattern appears when climbing.

STAGE 6 – QUADRUPEDAL LOCOMOTION IN THE FRONTAL PLANE – LEVEL 12-13 MONTHS.

• The child can pull himself up to a standing position and hold it, thanks to the holding he can move sideways.

STAGE 7 - INDEPENDENT WALKING - LEVEL 14 MONTHS - 3 YEARS.

STAGE 8 – STAND ON ONE LEG FOR 3 SECONDS – LEVEL 3 YEARS.

STAGE 9 - STAND ON ONE LEG FOR MORE THAN 3 SECONDS - LEVEL 4 YEARS.

Retardation Quotient

We divide the motor development age by the calendar age. We will get data according to which progress in rehabilitation can be evaluated.

Links

Related Articles

• FIM
• Positioning
• Mobilization
• Basal stimulation
• Rehabilitation
• Rehabilitation Plan
• Practice Unit Song

References

• KOLÁŘ, Pavel. Rehabilitace v klinické praxi. 1. edition. Galén, 2009. ISBN 978-80-7262-657-1.

• KLUSOŇOVÁ, Eva. Rehabilitační ošetřování pacientůs těžkými poruchami hybnosti. 1. edition. IDVPZ, 2000. ISBN 80-7013-319-8.

• VAŇÁSKOVÁ, Eva. Testování v rehabilitační praxi – cévní mozkové příhody. 1. edition. NCO NZO, 2004. ISBN 80-7013-398-8.

• přednáška MUDr. Volejníka, Václava, CSc., ředitele Hamzovovy odborné léčebny pro děti a dospělé Luže - Košumberk