Presentation on theme: "Rehabilitation Curriculum Course Description This course will focus on rehabilitation and patient care. Topics include complications to inactivity, positioning,"— Presentation transcript:
Course Description This course will focus on rehabilitation and patient care. Topics include complications to inactivity, positioning, transfers, body mechanics, gait, assistive devices, adaptive equipment, fall prevention, wheelchairs, total joint arthroplasty, prosthetics and orthotics, range of motion and exercise.
Course Objectives The general objective of this course are to provide nursing assistance with education concerning rehabilitation and patient care. Upon successful completion of this course, the student should be able to: 1. Describe the role of the rehabilitation team and nursing assistant with patient care. 2. Identify complications from immobility. 3. Demonstrate levels of assistance, patient positioning and transfers. 4.Demonstrate good body mechanics during tasks. 5. Demonstrate the ability to safely assist patients during ambulation and transfers. 6. Demonstrate the proper use of assistive devices with ambulation.
Course Objectives Continued 7. Identify the demonstrate the basic phases of gait. 8. Identify possible factors related to falls in the elderly. 9. Identify wheelchair components and their function. 10. Demonstrate the use of adaptive equipment. 11. Demonstrate and identify through analysis of case studies and laboratory experience compliance with orthopedic precautions. 12. Identify the use of orthotics and prosthetics. 13. Describe the benefits of exercise. 14. Demonstrate the anatomical planes of motion. 15.Demonstrate skilled technique when performing rom.
What is Rehabilitation? A process in which an individual is assisted in reaching their highest level of function and ability.
The Rehabilitation Team PHYSICAL THERAPIST OCCUPATIONAL THERAPIST SPEECH -LANGUAGE PATHOLOGIST RESPIRATORY THERAPIST
PHYSCIAL THERAPIST Evaluate and treat people with health problems resulting from injury or disease. PTs assess joint motion, muscle strength, endurance, balance, mobility and function. Develop a plan of care appropriate for the patients needs. Provide instruction and education to the patient and caregivers. Progress the patients mobility and function to the fullest possible level.
Occupational Therapist Evaluate and treats people with problems arising from developmental deficits, physical illness or injury, emotional or cognitive disorders. Develops a plan of care to restore self care, work and leisure skills. Assists the individual in acquiring the knowledge, skills, and attitudes needed for the performance of activities of daily living (ADL)
Speech-Language Pathologist Evaluate and treat individuals with speech, language, cognition, voice disorders. Evaluate and treat individuals with swallowing disorders. Treatments include, physical strengthening exercises, instructive repetitive practice, use of audio-visual aids and the introduction of strategies to facilitate functional communication and swallowing.
Respiratory Therapist Evaluate and treat individuals with breathing disorders. Disorders include: asthma, bronchitis, emphysema, COPD, heart attach, stroke or trauma, complications at birth, and other disorders.
The Role of the Nursing Assistant and Rehabilitation PROM, AAROM, AAROM POSITIONING PREVENT COMPLICATIONS SUCH AS PRESSURE ULCERS AND CONTRACTURES MOBILITY TO INCREASE THE INDIVIDUALS ABILILTIES OR TO MAINTAIN CURRENT ABILITIES BATHING AND PERSONAL CARE PROCEDURES ENCOURANGE THE INDIVIDUAL TO PERFORM ADLS TO THE FULLEST EXTENT POSSIBLE
Complications from Inactivity Weakness and limitations in mobility Contractures Disuse osteoporosis Pressure Ulcers Decreased cardiovascular and respiratory function Decreased gastrointestinal system function Bladder infections and incontinence Depression
Complications form Inactivity Weakness and limitations in mobility Muscles become weak and atrophy, how can this effect the individual?
Complications from Inactivity Contractures Muscle contractures are a result of prolonged immobility and or improper positioning leading to joint stiffness and decreased range of motion. What can be done to prevent muscle contractures?
Complications from Inactivity Disuse osteoporosis Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue leading to fragility and risk of fracture. How can this effect the individuals mobility?
Complications of Inactivity Pressure Ulcers Pressure ulcers are lesions caused by unrelieved pressure to any part of the body, especially portions over boney areas. What areas of the body could be at risk?
Complications of Inactivity Decreased cardiovascular and respiratory function The heart must work harder to pump blood through the body. The lungs do not expand as fully resulting in decreased efficiency with respiration. How could this prevent an individuals participation during ADLs?
Complications of Inactivity Gastrointestinal system function Appetite may decrease, causing weight loss. Peristalsis slows down, causing indigestion and constipation. Risk of choking and aspiration due to improper positioning. What position would be best during meals?
Complications of Inactivity Bladder infection and incontinence Decreased ability for the bladder to empty completely. Decreased ability to transfer to toilet or commode. How could increased activity benefit an individual during transfers?
Complications of Inactivity Depression Can occur from physical and mental inactivity. How can increased activity benefit an individuals quality of life?
The Nursing Assistant and Patient Care A Study of 599 older adults ( age 85 and above) noted the prevalence of disability, defined as inability to perform one or more ADLs, was 64% for women and 55% for men. The prevalence of disability defined as inactivity was 92% for women and 98% for men. Note the significant difference between ability and functional activity. Resnick 2004
The Nursing Assistant and Patient Care Encourage increased participation in ADLs. Motivate and provide immediate reinforcement for performing a dressing task. Encourage participation in regular care activities. Promote activity, mobility and independence in daily activities. Promote increased involvement and socialization with others.
The Nursing Assistant and Patient Care You are making a difference by encouraging and Supporting your patients! How can you encourage increased participation during ADLs with your patient?
Levels of Assistance Independent Independent with adaptive device Setup Supervision or stand by assistance Cueing
Levels of Assistance Minimum Assistance Moderate Assistance Maximum Assistance
Levels of Assistance Minimum Assistance Patient performs 75% or more of activity.
Levels or Assistance Moderate Assistance Patient performs 50% to 74% of activity.
Levels of Assistance Maximum Assistance Patient performs 25 % to 49 % of activity.
Body Alignment and Positioning of the Patient Body Position Fowler’s Prone Supine Lateral Sim’s Sitting
Body Alignment and Positioning of the Patient Fowler’s Position A semi-sitting position Head of the bed is raised between 45 and 90 degrees Keep the spine straight Support the head with a pillow Support the arms with a pillow
Body alignment and Positioning of the Patient Prone On the abdomen, head to one side with a small pillow under the head Pillow under the abdomen to relieve pressure to the chest and back Pillows under the lower legs to prevent pressure on the toes
Body Alignment and Positioning of the Patient Supine Position The bed is flat Patient positioned on their back The head and shoulders are supported by a pillow Small pillow under lower legs relieves pressure on the ankles and heels Elevate knees to relieve pressure on the low back
Body Alignment and Positioning of the Patient Lateral Position The bed is flat Upper leg is in front of the lower leg supported by a pillow Pillow positioned along the patients back Pillow under the upper hand and arm
Body Alignment and Positioning of the Patient Sim’s Position Left side-lying position Upper leg flexed, not resting on lower leg Pillow supporting upper leg and thigh Pillow supporting head and shoulder Pillow supporting upper arm and hand
Body Alignment and Positioning of the Patient Sitting 90-90-90! Back and buttocks against the back of the chair Feet flat on the floor or footplates of wheelchair Do not allow back of knees to rest against the chair
Body Alignment and Positioning of the Patient Always follow the patients individual plan of care for positioning and mobility.
Body Alignment and Positioning of the Patient Lifting and Moving Patients in Bed Precautions Friction Shearing
Body Alignment and Positioning of the Patient Friction Occurs when the skin is rubbed against another surface. Shearing Occurs when the skin moves in one direction and other structures remain fixed. Give examples of how friction or shearing can happen.
Body Alignment and Positioning of the Patient Before Positioning of the Patient Follow the patients plan of care Ask a coworker for help Practice good hygiene Identify the patient and explain the procedure to the patient Privacy and draping Lock the bed wheels Raise the bed for proper body mechanics
Body Alignment and Positioning of the Patient Turning the Patient Towards You Cross the patient’s far arm over their chest. Bend the elbow of the near arm, bringing the hand to the head of the bed. Place one hand on the patient’s far shoulder and one on the patient’s hip. Gently roll the patient toward you in a smooth motion Put up side rails and utilized pillows for comfort and support
Body Alignment and Positioning of the Patient Turning the Patient Away from You Have the patient bend his knees and cross their arms Place your one arm under the patients head and shoulders The other hand and forearm under the patient’s low back Keep your back straight and bend your body at the hips and knees Gently pull the patient toward you Roll the patient slowly and carefully away from you by placing one hand on the patient’s shoulder and one under the hips.
Body Alignment and Positioning of the Patient Moving the Patient to the Head of the Bed Lift top bedding and expose draw sheet Nursing assistant on each side of the patient Grasp the draw sheet or place one arm under the patient’s thighs and other under the shoulders On the count of three move the patient smoothly towards the head of the bed Use pillows for comfort and positioning
Body Alignment and Positioning of the Patient Logrolling the Patient May be indicated for patient’s that have had spinal injury or surgery Place a pillow between the patient’s legs The patient’s arms are crossed Using a turning sheet Roll the patient towards you Turn the patient as a unit
Transfers Transfer Guidelines Know your patients required level of assistance Know the method of transfer Use a transfer belt unless contraindicated Never pull on a patient’s arms or shoulders Always lock the wheels on the bed and wheelchair Always have the patient wear nonskid footwear Prepare the area…be aware of tubes, orthotics or other equipment in the area
Transfers Transfer Guidelines Continued Transfer the patient to their strongest side Always explain the procedure to the patient and test the patients understanding Stand close to the patient Encourage appropriate body alignment Allow the patient to assist as much as possible
Transfers Transfer Belt Always apply over clothing Tighten the belt snug The belt should not cause discomfort or restrict breathing Be able to slide your open hand under the belt Do not position the buckle over the spine
Transfers Bed to Chair Have the chair positioned along the bed wheels locked Stand in front of the patient Patient seated at the edge of the bed Patients feet flat on the floor Grasp the transfer belt from underneath Brace your knees against the patients knees Ask the patient to push down on the mattress and stand on the count of three. Pull the patient to a standing position
Transfers Bed to Chair Continued Support the patient in a standing position Turn the patient and ask the patient to grasp the far arm of the chair Continue to turn the patient to the front of the chair Gently lower the patient as you bend your knees Make sure the patient is properly positioned and comfortable Remove the transfer belt
Bed to Chair with Two Assistants Nursing assistance on each side facing the patient Patient seated at the edge of the bed Patients feet flat on the floor Each assistant grasps the transfer belt from underneath. The other hand grasps the belt from the back Nursing assistant closest to the chair has room to pivot to allow patient access to the chair Brace your knees against the patients knees Transfers
Bed to Chair with Two Assistance Continued Ask the patient to push down on the mattress and stand on the count of three. Pull the patient to a standing position Both nursing assistance assist the patient to turn slowly and smoothly towards the chair Gently lower the patient as you bend your knees Make sure the patient is properly positioned and comfortable Remove the transfer belt
Transfers Sliding-Board Transfers Slide-boards are used with patients with good upper body strength and sitting balance. Requires wheelchair with removable arm rests and swing away leg rests. Patients must have clothing on their lower body to prevent friction and shearing
Transfers Mechanical lift Used for transfers of heavy patients with decreased ability. Mechanical lifts vary in style and function. Make sure you are trained in the use of the mechanical lift at your facility. Always check slings, straps, hooks and chains for safety. Make sure the patient’s weight does not exceed the recommendation of the manufacture.
Transfers Case study Mr. Jones recently underwent spinal surgery and requires assistance for bed mobility and transfers. Per MD orders Mr. Jones is not to twist or turn his back. Which method would be best to assist Mr. Jones to a side lying position?
Body Mechanics The way we move during an activity. Proper body mechanics involves good posture, balance and using stronger body parts for work. Good body mechanics reduces your risk for injury.
Body Mechanics Body Alignment The way the head, neck, trunk, arms and legs align with each other. Good alignment is essential for efficient safe function and movement.
Body Mechanics Base of Support Is the area in which an object rests. In standing a wide base of support gives you greater stability.
Body Mechanics Rules for Good Body Mechanics It is easier to pull, push or roll an object than to lift Avoid jerky movements Use the larger leg and arm muscles Keep the work as close to your body as possible Keep the work at a comfortable height to avoid bending Keep your body in good physical condition to reduce injury Keep your body in good alignment with a wide base of support
Body Mechanics Lifting Use the strong muscles of the legs for lifting. Bend at the knees and hip, keep your back straight. Lift straight upward in a smooth motion.
Body Mechanics Reaching Stand directly in front of and close to the object. Avoid twisting or stretching. Maintain good alignment and base of support. Be cautious of moving heavy objects.
Body Mechanics Pivoting Place one foot slightly ahead of the other. Turn both feet at the same time, pivot on the heel of one foot and toe of the other. Maintain good alignment and base of support.
Body Mechanics Avoid Stooping Squat Avoid bending at the waist Use the strong muscle of the leg to return to upright position.
Ambulation and Mobility Ambulation The act of walking. Gait The way in which a person walks.
Ambulation and Mobility Normal Gait Pattern Repeats a basic sequence of limb motions that serve to progress the body along a desired path while maintaining weight-bearing stability.
Ambulation and Mobility Gait is divided into two phases Stance – The entire time the foot is on the floor. Swing – When the foot is off the floor.
Ambulation and Mobility Body Alignment and Posture The patient must be able to stand straight on one leg as he swings the other leg to take a step.
Ambulation and Mobility Gait Tips Stand on the patients affected side Use a gait belt if the patient requires assistance Patient should stand as erect as possible Feet should be 4 to 6 inches apart With each step the heel should land on the floor first Proper foot wear Prepare the area, clear walkways Safe use of assistive device
Ambulation and Mobility Gait Tips Continued Allow adequate time Encourage large even steps Allow the patient to do as much as they can When turning, avoid sharp pivots or twisting Make shorter steps when turning
Ambulation and Mobility Gait Tips Continued Avoid letting the upper body get ahead of the lower body Do not lean upper body too far forward Don’t rush If your patient shows signs of illness notify the nurse Never leave your patient unattended
Ambulation and Mobility Assistive Devices for Ambulation Crutches Canes Walkers
Ambulation and Mobility Crutches Typically not recommended for older adults Lofstrand crutches have a cuff that surrounds the forearm Platform Crutches permit weight-bearing on the forearm
Ambulation and Mobility Canes Quad canes have four prongs and offer a wide base of support. Single pronged cane are for assisting with balance Canes are used on the strong side of the body The patient will use a two point or three point gait
Ambulation and Mobility Two Point Gait Cane Affected leg Unaffected leg Three Point Gait Cane, affected leg Unaffected leg When there is no affected leg, weight bearing is equal on both legs.
Ambulation and Mobility Weight bearing is the amount of weight that may be applied on an extremity. Non-weight bearing Toe touch Partial weight bearing Weight bearing as tolerated Full weight bearing
Ambulation and Mobility Non-weight bearing: lower extremity not to bear weight and usually not permitted to touch the ground. Toe touch: the patient can rest the toes of the involved lower extremity on the ground for balance, but not weight bearing.
Ambulation and Mobility Partial weight bearing: A limited amount of weight bearing, such as five pounds, unless a specific amount is confirmed by the MD. Weight bearing as tolerated: The amount of weight bearing may vary from minimal to full, depending on the patients tolerance. Full weight bearing: Full weight bearing is permitted.
Ambulation and Mobility Walkers Standard Wheeled platform
Ambulation and Mobility Disorders Which Can Affect Gait Stroke Multiple sclerosis Huntington’s disease Parkinson’s Arthritis Amputations Orthopedic issues
Ambulation and Mobility Stroke (Cerebral vascular Accident) A blockage or hemorrhage of a blood vessel leading to the brain, causing inadequate oxygen supply and damage to brain tissue. May result in hemiplegia, loss of body control, dysphagia (swallowing issues), Aphasia, speech impairments, Changing emotions, impaired memory, urinary incontinence or frequency
Ambulation and Mobility Multiple Sclerosis A chronic degenerative disease of the CNS which destroys the myelin sheath the surrounds the nerves. May result in muscle weakness, visual impairments, tremors, numbness, speech issues, dizziness, memory and judgment, bowel and bladder dysfunction.
Ambulation and Mobility Huntington’s Disease A hereditary disease of the CNS characterized by brain deterioration and loss of control over voluntary movements, speech impairments, mental deterioration.
Ambulation and Mobility Parkinson’s Disease A progressive nervous disease associated with the destruction of brain cells that produce dopamine. May result in tremors, stiff muscles, slow movement, stooped posture and impaired balance, mask-like expression, swallowing issues, memory and speech, bladder impairments
Ambulation and Mobility Arthritis Acute or chronic inflammation of the joint resulting in pain and stiffness.
Ambulation and Mobility Amputations Patient may have a prosthesis.
Ambulation and Mobility Orthopedic Issues An injury or disorder or recent surgery of the musculoskeletal system.
Fall Prevention, Adaptive equipment, Wheelchairs
Fall Prevention Falls are not part of the normal aging process. But are due to an interaction of factors. Falls are due to: Impairments in mobility Uneven steps, shuffling gait, unsafe use of assistive device
Fall Prevention Falls are due to: Transfers difficulty with moving from sitting to standing Drop sitting Landing too close to the edge of the seat
Fall Prevention Falls are due to: Impaired standing balance Leaning off center Loss of balance when attempting to stand Loss of balance when bending or reaching
Fall Prevention Falls are due to: Multiple medications
Fall Prevention Falls are due to: Postural hypotension Check blood pressure
Fall Prevention Falls are due to: Impaired vision Impaired hearing Impaired position sense Impaired cognition
Fall Prevention Falls are due to: Improper footwear Foot deformities
Fall Prevention Falls are due to: Environmental hazards Objects in walkway Inadequate lighting Unsafe stair management
Adaptive Equipment Devices or equipment designed and fabricated to improve performance in activities of daily living.
Adaptive Equipment Bathing and Toileting Long handled sponge Curved bath brush Hand held shower Grab bars Tub seat/bench Raised toilet
Adaptive Equipment Dressing Dressing stick Sock aids Reachers Button and zipper aid Long-handled shoehorn Elastic shoe laces
Adaptive Equipment Eating Comfort grip curved utensils Scoop dish Plate guards Drinking mugs with large handles or covers
Wheelchair The wheelchair Postural support- The surface that is in contact with the user’s body. Mobility base – Consists of the tubular frame, arm- rests, foot supports, and wheels.
Wheelchair Wheelchair Brakes Brakes must be engaged during a transfer Inspect the brake mechanism for safety
Wheelchair Seat Belts Prevents falls Assists in positioning Check POC for seat belt use
Wheelchair Drive wheels – the large wheels used for propulsion Outer rim – used by the patient to propel the wheelchair Projections – for patients with decrease ability to grasp
Wheelchair Armrests Full length Desk length Removable or fixed Adjustable height
Wheelchair Footrests/Leg-rests Fixed or removable Pivoting or non-pivoting Elevating leg-rests Calf supports
Wheelchair Tilt in Space A fixed back to seat angle Permits changes in orientation for pressure relief and or different activities
Wheelchair One Arm Drive Applying pressure to one rim turns the wheelchair Pump lever to provide propulsion
Total Joint Arthroplasty, Prosthetics and Orthotics
Total Joint Arthroplasty Also know as total joint replacement Over 400,000 procedures a year Primary candidates are people with chronic joint pain from arthritis Purpose of surgery is to relieve pain and restore function
Total Joint Arthroplasty Total Knee Arthroplasty Portions of the knee joint are replaced with metal and plastic Components shaped to allow Continued motion of the knee.
Total Joint Arthroplasty Total Knee Arthroplasty Multidisciplinary team orthopedic surgeon, nursing staff, rehab team
Total Joint Arthroplasty Total Knee Arthroplasty Rehabilitation Phase 1: Inpatient acute care Promotion of ROM Independence with bed mobility, transfers and gait Restoration of safety and independence with ADLs
Total Joint Arthroplasty Continuous Passive Motion (CPM) A machine that performs PROM exercise on the affected knee joint. Often prescribed by orthopedic surgeons Protocol varies always check with patients poc.
Total Joint Arthroplasty Total knee Arthroplasty Rehabilitation Phase II: Skilled Nursing Facility Goals are the same as Phase I Education of family members and caregivers Planning of homecare needs
Total Joint Arthroplasty Total Knee Arthroplasty Rehabilitation Phase III: Outpatient Home Health Focus on safety in home Progression of ROM, transfers, gait and ADLs
Total Joint Arthroplasty Total Hip Arthroplasty The hip joint is preplaced by a prosthetic implant.
Total Joint Arthroplasty Total Hip Precautions Patients should not: Flex the hip more than 90 degrees Cross the affected leg over midline Internally rotate the hip Check weight-bearing precautions
Total Joint Arthroplasty Total Hip Arthroplasty Rehabilitation Phase I: Inpatient acute care Education regarding precautions with transfers and movements Postoperative exercises: Ankle pumps, quad sets, gluteal sets, heel slides.
Total Joint Arthroplasty Total hip precautions Rehabilitation Phase II: Skilled Nursing Facility Reinforce total hip precautions Increase independence with gait and transfers Prepare for safety in home Progress to outpatient home health care
Total Joint Arthroplasty Equipment Needs Raised toilet seat Tub bench or seat Adaptive equipment to assist with ADLs Walker, crutches or cane
Prosthesis - An artificial extension that replaces a missing body part. Orthotic- a device that serves to protect, restore or improve function.
Prosthetics and Orthotics Principal Lower Limb Prosthetics Partial foot Below knee Above knee Knee and hip disarticulation
Prosthetics and Orthotics Partial Foot Trans-metatarsal Amputation Patient bears most weight on the heel Decreased time on the affected foot during gait Plastic socket fixed to a rigid plate Protects amputated ends
Prosthetics and Orthotics Below Knee Tibia and Fibula is transected Knee joint is intact Prostheses include a foot-ankle assembly and socket Limb fits into a custom molded socket
Prosthetics and Orthotics Above Knee Amputation between the femoral epicondyles and greater trochanter Prosthesis consists of foot-ankle assembly, shank, knee unit, socket and suspension device
Prosthetics and Orthotics Hip Disarticulation Amputation of the femur and or part of the pelvis Prosthesis has hip, knee and foot assemblies Plastic molded socket to support weight on remainder of pelvis
Prosthetics and Orthotics The Rehabilitation Team Works closely with the physician and prosthetist Trains the patient to don, use and maintain the prosthesis
Prosthetics and Orthotics Foot Orthosis May be an internal modification in the shoe or external modification Can enhance function by relieving pain and improving the quality of gait
Prosthetics and Orthotics Ankle- foot orthoses orthosis consists of the shoe and plastic or metal component Most AFOs prescribed to control ankle motion by limiting plantar-flexion and or dorsi-flexion, or by assisting motion Provides stability
Prosthetics and Orthotics Knee ankle foot orthoses Consists of shoe, ankle control, knee control and superstructure Most KAFOs include a pair of uprights and knee hinges
Prosthetics and Orthotics Hip knee ankle foot orthoses Addition of a pelvic belt band and hip joints converts the KAFO to an HKAFO Hip joint is usually a metal hinge which prevents abduction, adduction and hip rotation
Exercise Forms of Exercise Aerobic Isometric Active Resistive
Exercise Aerobic- sub maximal, rhythmic, repetitive exercise of large muscle groups, during which the needed energy is supplied by inspired oxygen
Exercise Isometric- Exertion during which the muscle does not change length.
Exercise Active- Exercise that is performed without any assistance.
Exercise Resistive- Training with resistance to movement to increase muscle strength through the use of weights, bands, ones own body weight.
Range of Motion Range of motion exercises are performed to prevent the development of contractures, muscle shortening, and tightness in capsules, ligaments and tendons. Range of motion exercises enhance mobility and provide sensory stimulation with is beneficial to the patient.
Range of Motion AROM – carried out independently by the patient PROM – ROM performed without the assistance of the patient AAROM- Carried out by the patient with assistance to facilitate normal muscle function.
Range of Motion Anatomical Planes of Motions Flexion Extension Abduction Adduction Opposition Internal rotation External rotation
Range of Motion Anatomical Planes of Motion Continued Supination Pronation Inversion Eversion
Range of Motion Range of Motion General Guidelines Check the POC or ask the nurse of rehab team Explain the procedure to the patient Make sure the patient is comfortably positioned Encourage the patient to assist if able and indicated Expose only the body part you are exercising
Range of Motion Range of Motion General Guidelines Continued Support each joint by placing one hand above and one hand below the joint. Watch the patients face for gestures which indicate discomfort. Stop! Reposition or use a lighter touch and or contact the nurse or rehab team Only move the joint within its available range, never push past the point of resistance Perform 3 to 5 repetitions slow and controlled ROM significantly improves joint functioning
Range of Motion Precautions Fractures or dislocations Orthopedic precautions Wounds or pressure ulcers Combative or resistant patients Spasticity or rigidity
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